QIOs Prep for Big Changes

Cheryl Clark, May 15, 2014

By revamping its Quality Improvement Organization program, the Centers for Medicare & Medicaid Services will put an end to a fundamental flaw in the old structure, which exposed contractors to accusations of conflict of interest.

It's taken 10 years, an Institute of Medicine report requested by Congress, two critical evaluations from the Office of Inspector General, and a 2011 federal law. But finally, the albatross of conflict of interest is being removed from the neck of the federal Quality Improvement Organization program.

The network of 53 federally contracted companies, which collectively received $1.65 billion in federal funds over the last three years, will undergo a massive upheaval starting Aug. 1.

The restructuring, announced by the Centers for Medicare & Medicaid Services this month, aims to end an era in which the same QIO performed two conflicting functions:

  • The process of receiving and investigating beneficiaries' complaints about care, malpractice, or fraud, which could lead to notification to federal authorities if the issue involves fraud or "gross or flagrant" provider behavior
  • The recruitment of providers and healthcare systems for voluntary collaborative improvement programs, such as to reduce readmissions or infection rates.

A Wall Goes Up
The restructuring creates two completely separate systems by essentially erecting a wall between the handling of two potentially competing QIO responsibilities.

"Congress has always been uncomfortable with this dual mission, that we're supposed to hold providers accountable on one hand, and then ask them to be recruited for quality improvement initiatives on the other," says Jane Brock, MD, former chief medical officer for the Colorado Foundation for Medical Care, the QIO serving Colorado. She is now with another QIO, Telligen, which serves Illinois.


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