Administrative Memos

200408

FROM: Theodore O. Will, Chief Executive Officer
DATE: Oct 27, 2004
SUBJECT: MEDICARE SPECIAL STUDY - ALTERNATIVES FOR RESOLUTION OF BENEFICIARY COMPLAINTS - ALTERNATIVE APPROACH IMPROVEMENT METHODOLOGY (A2IM)
IPRO CONTACTS:

Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364

The purpose of this memorandum is to make you aware that IPRO has been awarded a special study by the Centers for Medicare and Medicaid Services (CMS) to test alternative methods for resolution of beneficiary complaints. Our approach, the Alternative Approach Improvement Methodology (A²IM), detailed later in this Memorandum, will be implemented by IPRO on November 1, 2004 and offered to complainants, as appropriate, through the end of April 2005. We encourage you to consider participation in this alternative approach to complaint resolution should you be contacted by IPRO subsequent to our receipt of a Medicare beneficiary complaint. If successful, this type of approach may be implemented by CMS on a national basis in the Medicare - QIO 8th Scope of Work that begins August 1, 2005.

IPRO's initial handling of a Medicare beneficiary complaint in the pilot mirrors the traditional review process, i.e., the complaint is initiated via a call to IPRO's Helpline with subsequent submission of a written complaint, or as the result of written communication. However, unlike the traditional complaint review process, A²IM proceeds from IPRO first level physician medical record review directly to complaint resolution. In addition, as the concerns will be mutually resolved by the involved parties, the end result will be an agreement focused on quality and/or process improvement(s).

BACKGROUND:

As the Quality Improvement Organization (QIO) for New York State, IPRO conducts review of all written beneficiary complaints about the quality of services that may be paid for under Title XVIII of the Social Security Act. This complaint process, which IPRO has conducted since program inception in 1987, provides Medicare beneficiaries and their families a forum to have quality of care concerns addressed across the continuum of care.

Within the last two years, the Centers for Medicare and Medicaid Services (CMS) has implemented many changes to improve the Medicare beneficiary complaint process. QIOs, including IPRO, have implemented a case management approach for handling beneficiary complaints. In addition, when appropriate and with concurrence of all involved parties, mediation may also be offered as an alternative method to traditional case review. CMS would now like to systematically evaluate the potential for incorporating other such practices into the Medicare beneficiary complaint process as they believe there is a significant potential for a QIO to meet its statutory obligation (referenced above), improve satisfaction for both beneficiaries, practitioners and providers and take advantage of opportunities to improve the health care delivery system.

IPRO'S SPECIAL STUDY APPROACH:

IPRO's "Alternative Approach Improvement Methodology (A²IM)" that has been funded by CMS, tests a voluntary, alternative complaint resolution process that offers involved parties the option of either early provider/practitioner involvement in resolution of a Medicare beneficiary complaint or IPRO facilitation of direct provider and/or practitioner/beneficiary resolution. IPRO believes that our approach, in addition to offering Medicare beneficiaries a timely and cost effective alternative to traditional medical record review also helps allay physician/ provider concerns about liability and confidentiality. Equally important, A²IM strengthens our ability to improve health care quality by encouraging physicians and/or providers to actively participate in the complaint resolution/improvement process. Thus, building upon the lessons learned in implementing mediation, IPRO will continue to promote complaint resolution as an opportunity for improving Medicare service and care, one person at a time.

IPRO will utilize the decision protocols outlined in the table below, to determine whether a complaint case is more appropriately resolved through traditional medical record review, mediation or if "A²IM" may be offered. The decision protocols are based upon the results of IPRO's initial physician review of the medical record(s) pertinent to the case.

Table. IPRO Complaint Resolution Decision Protocols


IPRO Physician Review Determines	Mediation	A²IM	Traditional Case Review
No quality of care concerns associated with case - no opportunities for improvement	Yes	Yes	Fallback
No quality of care concerns associated with case - care could have been better	No	Yes	Fallback
Quality of care concerns are associated with case - related to systemic issues	No	Yes	Fallback
Quality of care concerns are associated with case - related to clinical issues but no adverse impact	No	Yes	Fallback
Quality of care concerns are associated with case - related to clinical issues but adverse or potential adverse impact	No	No	Yes

Once deemed appropriate for alternative case resolution, IPRO's plan allows the beneficiary to choose one of the following two (2) approaches:

Option 1: Self-Resolution: This first option allows for early provider/practitioner involvement in resolving the complaint through self-resolution. IPRO will contact the complainant to solicit his/her interest in participation. Subject to their agreement, we will then contact the physician/provider to obtain their agreement for participation. Subsequent IPRO involvement will then be limited to helping arrange for an initial meeting (face-to-face or telephonically) between the involved parties, although, as noted below, provider/practitioner agreements regarding follow-up steps to be taken are expected to be formulated and reported to IPRO.

Option 2: Facilitated Resolution: This second option relies on IPRO to serve as the intermediary between the complainant and the practitioner/provider, thus avoiding direct confrontation through an iterative process of discussions. As above, IPRO will contact the complainant to solicit their interest in participation. Subject to their agreement, we will then contact the physician/provider to obtain their agreement for participation. Unlike Option 1, IPRO will continue to work with all involved parties to help them reach a satisfactory complaint resolution.

In addition, the following program elements are applicable to both Option 1 and Option 2:

Voluntary consent to participate must be obtained from all involved parties.
The case may revert to traditional medical review at any time by participant request or if the complaint cannot be resolved by either optional approach.
Retrospective complaint cases must be resolved with 30 days; concurrent complaint cases (beneficiary still a patient or receiving care) must be resolved within two (2) work-days.
Provider/practitioner agreements regarding follow-up steps to be taken are expected to be formulated and reported to IPRO. Suggestions for quality/process improvements that would help to prevent a similar complaint in the future, will also be solicited.
All participants will be requested to complete a satisfaction survey as well as an optional, A²IM process improvement feedback form.

SUMMARY:

IPRO's initial handling of a Medicare beneficiary complaint in this pilot mirrors the traditional review process, i.e., the complaint is initiated via IPRO's Helpline with subsequent submission of a written complaint, or as the result of written communication. However, unlike the traditional complaint review process, A²IM focuses on the use of the complaint as an opportunity for quality and/or process improvement; concerns are mutually resolved by the participants and the end result is an agreement focused on process improvement(s) not a final determination letter in regard to standards of care that were met or not met.

Should you have any questions in regard to this special study, please feel free to contact Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment or Elizabeth Hall, Assistant Director, Mediation, CQI and Special Studies at (516) 326 - 7767, extension 364.