Peer review organizations will have a different name and added responsibility following HHS' announcement of a nursing home quality initiative last week. Is it the signal of a major change in the role of what are now called quality-improvement organizations, or just part of their gradual evolution?
The Centers for Medicare and Medicaid Services, which spends more than $300 million annually on policing provider quality, is expected to publish proposed regulations in December that will define the QIOs' responsibilities from 2002 to 2004. Until the draft of the seventh "scope of work" is published in the Federal Register next month, industry observers said it's anybody's guess how the organizations' responsibilities will change.
The CMS has charged QIOs with helping nursing homes improve on quality-of-care measures that will be published for consumers. The CMS also has plans for the organizations to perform the same role for home health providers. Until now, peer review organizations focused primarily on hospital quality enforcement.
Debate among Capitol Hill lawmakers centers around whether QIOs could serve both as quality police and quality improvement agents for the industry. One faction in the U.S. House of Representatives is pushing to have QIOs move away from their regulatory role of reviewing medical cases to focus exclusively on broader quality-improvement projects. Another group is insistent that QIOs keep their medical case review responsibilities.
The QIOs' peer review role is being challenged by a U.S. District Court ruling that requires the organizations to share their complaint investigations with beneficiaries. The July ruling in Washington resulted from a lawsuit brought by Public Citizen Litigation Group on behalf of a Medicare beneficiary. HHS has challenged the decision in the U.S. Court of Appeals and the case is pending.
The CMS wants to "redirect the focus" of QIOs to support community initiatives to improve healthcare quality, according to industry sources familiar with a CMS internal document detailing proposed changes for the program. The "new program" will include less reliance on healthcare professionals and more on members of the public, such as beneficiaries and healthcare purchasers.
The 38 QIOs in the country have 53 separate contracts with CMS to serve each U.S. state and territory.
The American Health Quality Association, which represents the QIOs, said the organizations' role has been changing gradually in the past five years, with more focus on community-based quality improvements. Even the name change has been a long time coming. According to the AHQA, its members began calling themselves quality-improvement organizations in the late 1990s.
The changes are being planned by the CMS even though it is not clear if there will be more money for QIOs in the next contract cycle, a CMS spokesman said.