QIOs Helping to Prevent Readmissions and Improve Quality

When Quality Improvement Organizations (QIOs) and providers work together, the rate of hospital readmission is less than in areas where QIOs do not work with providers, according to the American Health Quality Association (AHQA). The data provided by the AHQA shows that this collaboration has prevented more than 95,000 hospitalization and 27,000 hospital readmissions among Medicare beneficiaries resulting in a cost savings of nearly $1 billion.  In addition, recent data shows that QIOs have helped improve care at nursing homes as well by reducing the uses of restraints and the rate at which pressure sores develop.

Readmission Reduction

From October 2010 to March 2013 readmission rates among Medicare beneficiaries declined by 13.22 percent when the provider worked with a QIO, reported the AHQA.  The readmission rate for Medicare beneficiaries for providers who did not work with a QIO declined by 12.55 percent.  Similarly the AHQA reported that overall hospital admissions for Medicare beneficiaries declined by 8.39 percent when the provider worked with a QIO as opposed to 8.12 percent reduction in hospital admissions for Medicare beneficiaries when the provider did not work with a QIO.

An earlier study in the Journal of the American Medical Association (JAMA) came to similar conclusions. That study found that rehospitalizations were cut in half when providers worked with QIOs. In these cases QIOs implemented strategies aimed at (1) developing effective community coalitions that work to help keep patients healthy; (2) develop standard transition process as patients move from one care setting to another; (3) transferring patient clinical information between providers in a timely fashion; and (4) helping patients and their family members become actively engaged in the transition from one care setting to another.   The study involved 6,800 hospitalizations and averted 1,800 rehospitalizations.


A QIO is usually a non-profit organization staffed by doctors trained in medical review;  ensures that services provided to Medicare beneficiaries are medically necessary, reasonable, effective, and economical; and that the services meet professionals accepted standards of care. QIOs have been around since the 1980’s and there is generally one QIO per state. QIOs, among other things, are required to establish Memoranda of Agreements with providers and health plans that are consistent with the goals of the Health Care Quality Improvement Program.  They are  also to implement quality improvement projects on a standardized set of quality indicators and initiate local projects to improve quality.

“QIOs work in close partnership with physicians, nurses, and other members of the interdisciplinary team across settings–forming a network that helps patients remain healthy long after they leave the hospital,” said Adrienne Mimms Vice President and Chief Medical Officer of Atlanta-based Alliant GMCF, the QIO for Georgia and president of the AHQA.

HAIs. A greater reduction in hospital acquired infections (HAIs) has been reported in areas where QIOs work with providers as well, according to the AHQA.  From February 2011 to August 2013, QIOs’ efforts resulted in a 53 percent reduction in central line associated blood stream infections.  In addition, hospitals that work with QIOs have reduced the total number of Medicare patient days in which a catheter was used by more that 85,000 days. A major source of HAIs is catheter associated urinary infections.

Improvements at Nursing Homes

In another QIO project the rate of pressure sore development in nursing homes has been dramatically reduced according to a report in McKnights. Nursing homes working with QIOs have achieved a 38 percent reduction in the rate of pressure sore development from 2011 to 2014.  The use of restraints in nursing homes working with QIOs has been reduced by 76 percent under a separate initiative involving 1,000 nursing facilities working with QIOs.

“As the rates of chronic disease increase and the baby boom generation ages, it’s essential that we improve the quality of health care provided to  America’s seniors,” said Todd Ketch, executive director of AHQA. “Quality Improvement Organizations have driven major improvements in the quality of care across the nation, and in the years ahead, our work with QIOs will focus on  coordinating patient care across settings, reducing health care associated infections, improving care for common conditions like diabetes and heart disease, and more,” said Patrick Conway, MD, MSc, Chief Medical Officer for CMS, and Deputy Administrator for Innovation and Quality.


Quality Improving, Sepsis Still a Problem, Fist-Bump Not to Replace Handwashing

Since before the Affordable Care Act (ACA) (P.L. 111-148) CMS has been placing on emphasis on paying for the quality of care provided rather than the amount of care provided.  The ACA accelerated that initiative by adding even more quality of care reporting requirements and tying a portion of some payments to the reporting on improvements in quality of care measures.  Those efforts seem to be paying off, according to the 2013 National Healthcare Quality Report  and the National Healthcare Disparities Report from the Agency for Healthcare Research and Quality (ARHQ). This good news, though, has been offset by another study conducted for the American Thoracic Society, which shows that sepsis contributes to as much as 50 percent of all hospital deaths.  In the end, it looks like good old fashioned hand washing will be the most effective way of preventing the spread of infection in the hospital setting as recent studies have shown that patients expect a handshake and not a fist-bump from their physicians.  Fist-bumping became popular after it was studied last year by the University of West Virginia as a way to reduce the spread of infections from medical personnel to patients.

Quality Improving

The ARHQ reported that hospitals had showed significant improvement in 75 percent of the quality indicators that they reported on, while home health and skilled nursing facilities showed improvement in only 60 percent of the quality measure they report on, and ambulatory surgical settings showed improvement in only 50 percent of their quality measures.  “Hospitals are clearly engaged in the efforts to improve health care quality in the United States, ” said AHRQ Director Richard Kronick, Ph.D.  The AHRQ has been reporting on quality improvements and disparities in healthcare every year since 2003.

The public reporting of quality measures seems to be having a positive impact, AHRQ’s report stated.  Fourteen of the 16 quality measures that reached a 95 percent performance level were publicly reported by CMS, and another four measures that CMS reports on were improving at the fastest pace.  The ARHQ report found that the rates of healthcare-associated infections are falling and processes to reduce hospital readmissions are increasing.  The ARHQ noted that this finding is consistent with a number of other national reports, including a May 7 CMS report.

Sepsis Problem

While the quality of care overall is seen as improving, sepsis infections still continue to be a major concern.  A report by the American Thoracic Society found that as many as half of all deaths  in a hospital have sepsis as a contributing factor even though only ten percent of patients have sepsis. According to the Mayo Clinic sepsis occurs when chemicals released into the bloodstream to fight infection trigger inflammation throughout the body which can lead to a number of other complications that result in organ failure. The study prepared for ATS by the Kaiser Permanente Northern California Division of Research examined 6.5 million hospital discharge records and found that mortality rates for patients with sepsis was 10.4 percent compared to only 1.1 percent among non-sepsis patients.  The study’s author said, “we were surprised to find that as many as one in two patients dying in U.S. hospitals had sepsis.”


One novel method studied last year to reduce the rate of infection in hospitals was to replace the patient provider handshake with a fist-bump.  A West Virginia University study found that a fist-bump had one-third as much skin contact as a handshake and that the time the skin of the two people was in contact was 2.7 times greater with a handshake. A number of studies, though, have shown that the handshake is expected by patients. A 2007 study found that 78 percent of patients said they wanted a handshake when being greeted by their physician. Other studies conducted in 2013 and 2009 came to similar conclusions.  The logical conclusion is that proper hand hygiene is necessary and the most effective way to improve care. The lead investigator of the fist-bump study agrees.  “The overall goal of the study was to do one thing: to bring attention to the importance of hand washing. It’s a funny way to raise attention, I know, but my goal wasn’t to get rid of handshaking and supplant it with fist bumping,” said W. Thomas McClellan.

Skilled Nursing Facility 2015 Payment Rates Proposed

On May 6, 2014, CMS will publish a Proposed rule updating the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2015.

The Proposed rule also includes: (1) a proposal to adopt the most recent Office of Management and Budget (OMB) statistical area delineations to identify a facility’s urban or rural status for the purpose of determining which set of rate tables would apply to the facility and to determine the SNF PPS wage index including a proposed one-year transition with a blended wage index for all providers for FY 2015; (2) a revision to policies related to the Change of Therapy (COT) Other Medicare Required Assessment (OMRA); (3) amendment to the regulations governing the use of civil money penalties (CMPs) as required by Section 6111 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

The Proposed rule also discusses (1) observed trends related to therapy utilization among SNF providers, (2) accelerating health information exchange in SNFs, and (3) the SNF therapy payment research currently underway within CMS.

2015 Changes to Payment Rates

Based on proposed changes, CMS projects that aggregate payments to SNFs will increase by $750 million, or 2.0 percent, from payments in FY 2014, which represents a higher update factor than the 1.3 percent update finalized for SNFs last year. This estimated increase is attributable to 2.4 percent market basket increase, reduced by the 0.4 percentage point multifactor productivity adjustment required by law.

Wage Index Update / New Labor Market Delineations

CMS had delayed implementing new OMB statistical area delineations, set forth in the February 28, 2013 OMB Bulletin No. 13-01, to allow for sufficient time to assess the new changes. Because it now believes that these OMB delineations accurately reflect the local economies and wage levels of the areas in which hospitals are currently located, CMS is proposing to implement the new OMB delineations for the SNF PPS wage index effective beginning in FY 2015. In addition, CMS is proposing to implement a one-year transition with a blended wage index for all providers in FY 2015 to assist providers in adapting to the new OMB delineations.

Change of Therapy (COT) and Other Medicare Required Assessment (OMRA)

On October 1, 2011, CMS introduced the COT OMRA, which is an assessment designed to capture changes in the therapy services provided to a given SNF resident during the past 7 days. Effective for services provided on or after October 1, 2011, CMS required facilities to complete a COT OMRA for patients classified into a Resource Utilization Group, Version 4 (RUG-IV) therapy category, whenever the intensity of therapy changes to such a degree that it would no longer reflect the RUG-IV classification and payment assigned for a given SNF resident based on the most recent assessment used for Medicare payment. CMS proposes to revise the existing COT OMRA policy to permit providers to complete a COT OMRA for a resident who is not currently classified into a RUG-IV therapy group, or receiving a level of therapy sufficient for classification into a RUG-IV therapy group, but only in those rare cases where the resident had qualified for a RUG-IV therapy group on a prior assessment during the resident’s current Medicare Part A stay and had no discontinuation of therapy services between Day 1 of the COT observation period for the COT OMRA that classified the resident into his or her current non-therapy RUG-IV group and the ARD of the COT OMRA that reclassified the patient into a RUG-IV therapy group.

Under the proposed policy, while a COT OMRA may be used to reclassify a resident into a therapy RUG in the circumstances described above, it may not be used to initially classify a resident into a therapy RUG. CMS believes it is appropriate to revise the COT OMRA policy in this manner to provide for more accurate payment for services provided to those residents who have qualified for a RUG-IV therapy group during their Medicare Part A stay and continue to receive skilled therapy services during their Medicare Part A stay.

CMPs Under the ACA

Section 6111 of the ACA amended sections 1819(h) and 1919(h) of the Social Security Act to incorporate specific provisions pertaining to the imposition and collection of CMPs. These sections specify that some portion of CMPs collected may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes or is decertified, projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by CMS.

The Proposed rule would amend the regulations at 42 CFR Sec. 488.433 to require that 90 percent of the CMPs collected must be used entirely for activities that protect or improve the quality of care for SNF residents. The Proposed rule would also requires that: (1) all activities and plans for utilizing CMP funds, including any expense used to administer grants utilizing CMP funds, must be approved in advance by CMS; (2) at a minimum, proposed activities submitted to CMS for prior approval must include a description of the intended outcomes, deliverables, and sustainability; and a description of the methods by which the activity results will be assessed, including specific measures; (3) CMP funds may not be used for activities that have been disapproved by CMS; and (4) states must maintain an acceptable plan for the effective use of CMP funds.

Observations on Therapy Utilization Trends

In the FY 2014 SNF PPS Final rule, CMS discussed its monitoring efforts associated with the impact of certain policy changes finalized in the FY 2012 SNF PPS final rule (76 FR 48486). In that 2012 rule, CMS noted that it would continue these monitoring efforts and report any new information as appropriate. In this 2015 Proposed rule, CMS does not propose new Medicare policy in the discussion of observed trends but merely highlights that it will continue to monitor these observed trends which may serve as the basis for future policy development.

Accelerating Health Information Exchange in SNFs

In the Proposed rule, CMS states it commitment to accelerating health information exchange (HIE) through the use of electronic health records (EHRs) and other types of health information technology (HIT) across the broader care continuum. Specifically, CMS expresses support for a number of initiatives, including: (1) alignment of incentives and payment adjustments to encourage provider adoption and optimization of HIT and HIE services through Medicare and Medicaid payment policies; (2) adoption of common standards and certification requirements for interoperable HIT; (3) support for privacy and security of patient information across all HIE-focused initiatives; and (4) governance of health information networks.

SNF Therapy Research Project

CMS has contracted with Acumen, LLC, and the Brookings Institution to identify potential alternatives to the existing methodology used to pay for therapy services received under the SNF PPS. In this Proposed rule, CMS updates the public on the current state of this project. According to CMS, in September 2013, it completed the first phase of the research project, which included a literature review, stakeholder outreach, supplementary analyses, and a comprehensive review of options for a viable alternative to the current therapy payment model. During the second phase of the project, which began in September 2013, CMS plans to further develop their options and perform a more comprehensive data analysis to determine which of these options would work best as a potential replacement for the existing therapy payment model.

For a look at our coverage of the FY 2014 payment rates, see here.

Official Testifies About HRSA’s Health Workforce Investments, Goals, Successes

On April 9, 2014, Rebecca Spitzgo, Associate Administrator of the Bureau of Health Professions in the Health Resources and Services Administration (HRSA), testified before a Senate Subcommittee on Primary Health and Aging regarding the nation’s primary care workforce needs and HRSA’s activities and in this area. In light of recent investments from the American Reinvestment Recovery Act of 2009 (ARRA) (P.L. 111-5) and the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), Spitzgo’s testimony focused on: (1) recent investments to strengthen the primary care workforce; (2) new efforts to build a primary care workforce; (3) diversity programs; and (4) training for comprehensive primary care.

HRSA’s Mission and Focus

An agency of HHS, HRSA is the primary federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. HRSA was created in 1982, when the Health Resources Administration and the Health Services Administration were merged. Its stated mission is to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs. In its efforts to strengthen the health care workforce, HRSA’s workforce programs emphasize the training of the next generation of primary care providers, strengthening up the primary care training and development infrastructure, providing incentives for students to choose primary care and to practice where the Nation needs them most, and repaying loans for primary care providers willing to work in some of the Nation’s most underserved areas.

Recent Investments to Strengthen the Primary Care Workforce

In her testimony, Spitzgo stated that, to date, ACA and ARRA investments have resulted in:

  • the training of an additional 1,700 primary care providers, including physicians, advanced practice nurses, and physician assistants, as well as 200 behavioral health providers;
  • the doubling of the numbers of clinicians in the National Health Service Corps (NHSC) from 3,600 in 2008 to nearly 8,900 in 2013; and
  • nearly 1,600 advanced practice nurses in the NHSC and nearly 2,600 nurses in the NURSE Corps working in high need communities.

Spitzgo also noted that the ACA provides $230 million over five years to fund the Teaching Health Center Graduate Medical Education (GME) program, which has expanded residency training for primary care residents and dentists in community-based ambulatory patient care settings, including HRSA-funded health centers. According to Spitzgo, this program supported more than 300 primary care resident full-time equivalents (FTEs) in 21 states in academic year 2013-2014, and is expected to support nearly 600 FTEs in academic year 2014-2015.

New Efforts to Build a Primary Care Workforce

Spitzgo testified as to the several new programs and initiatives to build a better primary care workforce contained in the President’s FY 2015 Budget, including:

  • A workforce initiative to support the training of 13,000 new physicians by 2024 and grow NHSC clinicians from 8,900 in 2013 to 15,000 in by FY 2015.
  • A new residency program, the Targeted Support for GME program, will build on the Teaching Health Center GME program, focusing on residency training in ambulatory, preventive care delivered in team-based settings. This new program includes a $100 million set aside for children’s hospitals in FYs 2015-2016, to be distributed via formula that will continue to support the same types of disciplines currently funded through the Children’s Hospitals GME Payment program.
  • Continued support of the NHSC.
  • A new $10 million Clinical Training in Interprofessional Practice program, which will support community-based clinical training in interprofessional, team-based care setting.
  • $4 million for the Rural Physician Training Grant program to provide support for medical schools to recruit and train students interested in rural practice.

Diversity Programs

In her testimony, Spitzgo stressed HRSA’s success in facilitating a diverse healthcare workforce. She offered the following statistics:

  • Underrepresented minorities and individuals from disadvantaged backgrounds accounted for approximately 45 percent of those who completed HRSA’s health professions training and education programs during 2012-2013.
  • More than half of the nearly 1,100 NHSC scholars and residents in the pipeline are minorities.
  • In FY 2013, African American physicians represented 17.8 percent of the Corps physicians, which exceeds their 6.3 percent representation within the national physician workforce.
  • In FY 2013, Hispanic physicians represented 15.7 percent of the Corps physicians, exceeding their 5.5 percent representation in the national physician workforce.

Training for Comprehensive Primary Care

Spitzgo’s testimony focused on HRSA investments to support the behavioral health disciplines and the integration of oral health into primary care. With regard to behavioral health, she noted that:

  • NHSC providers (including health service psychologists, licensed clinical social workers, licensed professional counselors, marriage and family therapists, and psychiatric nurse specialists) have increased from 700 in 2008 to 2,440 in 2013.
  • If they count psychiatrists, psychiatric physician assistants, and psychiatric nurse practitioners, more than 2,800 out of nearly 8,900 clinicians in NHSC (as of September 30, 2013) provide behavioral health services.
  • A partnership between HRSA and the Substance Abuse and Mental Health Services Administration (SAMHSA) will train and provide placement assistance for approximately 1,800 additional behavioral health professionals and 1,700 behavioral health paraprofessionals.

Spitzgo further testified that HRSA funds several programs that support training and education necessary to improve the integration of dental care into primary care. Sptizgo also noted that approximately 75 percent of the more than 1,300 dentists and dental hygienists in NHSC work at health centers or health center look-alikes.