Quality Improvement Organizations (QIOs) in Medicare
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CMS’ Quality Improvement Organization Program
The Centers for Medicare & Medicaid Services’ (CMS) Quality Improvement Organization (QIO) Program is one of the largest federal programs with a goal to improve health quality at the community level, through greater connectivity and care coordination across all health care settings to improve health care delivery for Medicare beneficiaries.
The QIO program aligns with the CMS Quality Strategy, as well as with the U.S. Department of Health and Human Services’ National Quality Strategy. It contributes to CMS’ goal of achieving the Three-Part Aim for better care, better health and lower costs. The Program collaborates with other national organizations and initiatives dedicated to improving patient safety and population health, including Advancing Excellence in America’s Nursing Homes, the Centers for Disease Control and Prevention, the Home Health Quality Initiative, and Million Hearts®.
CMS redesigned the QIO program in 2014 in an effort to further enhance the quality of services for Medicare beneficiaries. The new program structure focuses on learning and collaboration as a way to improve care, and strives to spread new evidence-based practices and models of care, to achieve the priorities of the National Quality Strategy and the goals of the CMS Quality Strategy.
Types of Quality Improvement Organizations
The QIO program operates through a national network of QIOs, which are independent, mostly non-profit, private organizations staffed by health care professionals and quality improvement experts working to improve the quality and efficiency of health care across all care settings.
There are two kinds of QIOs: Quality Innovation Network-QIOs (QIN-QIOs) and Beneficiary and Family Centered Care-QIOs (BFCC-QIOs). Fourteen QIN-QIOs and two BFCC-QIOs serve the entire United States and its territories.
BFCC-QIOs aim to help Medicare beneficiaries exercise their right to high-quality health care.They provide patients an avenue for submitting complaints about the quality of care they received, and for disputing decisions related to payment, coverage, or a patient’s discharge from the hospital or services. BFCC-QIOs manage all beneficiary complaints, reviews, appeals and other cases to ensure consistency in the review process while considering local factors relevant to beneficiaries and their families. Each state or territory is serviced by one of the two BFCC-QIOs.
The Program’s 14 QIN-QIOs work with providers and other community-based partners on data-driven quality initiatives to improve patient safety, reduce harm, engage patients and families, and improve clinical care at the local level. They work to improve the quality of care for targeted health conditions and priority populations while also aiming to reduce healthcare-acquired conditions and preventable hospital readmissions. Heavily focused on collaboration, QIN-QIOs are meant to serve as conveners of local stakeholders who share a common goal related to improving health care in their community. They also support change initiatives enforced by hospitals, nursing homes, and other providers with the aim of making care more patient-centered, safer, affordable and coordinated. Each QIN-QIO services a region of two to six states or territories.
QIO Program Mission
The mission of the CMS Quality Improvement Organization program is to improve the effectiveness and quality of services delivered to Medicare beneficiaries. The program strives to do this in several ways, including pay for performance, disease management, and accountability measures.
Section 721 of the Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary chronic care improvement programs, now called Medicare Health Support, to improve the quality of care and life for people living with multiple chronic illnesses. Chronic conditions are a leading cause of illness, disability, and death among Medicare beneficiaries and account for a disproportionate share of health care expenditures. Given that Medicare beneficiaries with heart failure account for 43 percent of Medicare spending, CMS has made heart disease a major focus area for improvement through initiatives such as the Million Hearts campaign.
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