Administrative Memos

200210

FROM: Theodore O. Will, Chief Executive Officer
DATE: Nov 01, 2002
SUBJECT: Medicare 7th Scope Of Work - Overview
IPRO CONTACTS:

Spencer Vibbert, Vice President, Communications & Corporate Development, Ext. 588

IPRO's new Medicare Quality Improvement Organization (QIO) workplan, known as the Seventh Scope of Work (7SOW) went into effect on August 1, 2002. This three-year Scope of Work provides us with many opportunities to further our work in ensuring quality care to Medicare beneficiaries and directs IPRO to do the following:

• Improve the quality of care for Medicare beneficiaries by ensuring that care meets professionally recognized standards of care,
• protect the integrity of the Medicare Trust Fund by ensuring that Medicare only pays for services and items that are reasonable and medically necessary and that are provided in the most appropriate setting,
• protect beneficiaries by expeditiously addressing individual cases such as beneficiary complaints, hospital-issued notices of non-coverage (HINNs), EMTALA violations and other statutory responsibilities.

Below you will find an overview of the specific tasks that will be undertaken for the new Scope of Work. We have also attached a list of Medicare's inpatient and outpatient quality measurement specifications effective August 1, 2002.

IPRO is currently working with members of the Provider Relations Committee to finalize a Memorandum of Agreement (MOA). We will shortly be sending the MOA to you for signature.

Task 1: Improving Beneficiary Safety and Health Through Clinical Quality Improvement

Task 1 involves designing quality improvement projects and improving clinical health outcomes for Medicare beneficiaries in nursing homes, home health agencies, hospitals, physician offices, underserved individuals and those residing in rural areas, and enrollees in Medicare + Choice Organizations (M+COs).

Task 1a - Nursing Home Quality Improvement

IPRO and skilled nursing facility providers will collaborate on improving performance on clinical quality indicators for all nursing homes in the state and for an identified sub-set of homes participating in an intensive improvement effort. Task 1a goals include:

1. statewide improvement on the set of 3-5 publicly reported quality of care measures selected in consultation with stakeholders;
2. improvement by 10% on selected publicly-reported quality of care measures for nursing homes in the state;
3. NH satisfaction - The Centers for Medicare & Medicaid Services (CMS) will survey identified participant NHs. CMS asks that at least 80% of the identified participant NHs will be mostly or fully satisfied with the assistance given it by IPRO.

Task 1b - Home Health Quality Improvement

IPRO and providers will develop partnerships to improve Outcome and Assessment Information Set (OASIS) quality of care performance measures for Home Health Agencies (HHAs) in the state and for identified participant HHAs. Specific goals include:

1. improvement on targeted OASIS quality of care measures for at least 30% of HHAs in the state;
2. HHA satisfaction - CMS will seek feedback from the HHAs who participated in HH OBQI training and/or were identified participants. CMS asks that at least 80% of the HHA respondents be mostly or fully satisfied with the assistance given it by IPRO.

Task 1c - Hospital Quality Improvement

IPRO and the hospital community of New York State will work together to sustain and enhance the quality of care delivered to Medicare beneficiaries. The clinical conditions that CMS has chosen to focus on for this Scope of Work include acute myocardial infarction, congestive heart failure, pneumonia and reduction of post surgical infections.

IPRO 's goals regarding Task 1c include:

1. Statewide improvement on inpatient quality of care measures;
2. Hospital satisfaction - CMS will seek feedback from the hospitals the State. CMS asks that at least 80% of the respondents be mostly or fully satisfied with the assistance provided by IPRO.

Task 1d - Physician Office Quality Improvement

This subtask focuses on care delivered in outpatient settings and builds upon work conducted in the 6th Scope of Work. The conditions that this task applies to include breast cancer, diabetes and immunization.

Goals include:

1. Statewide improvement on quality of care measures;
2. improvement on diabetes and breast cancer screening quality of care measures for identified participant physicians;
3. physician satisfaction - CMS will elicit feedback from the physicians in the state who participated with IPRO. CMS asks that at least 80% of the respondents be mostly or fully satisfied with the assistance given by IPRO.

Task 1e - Underserved and Rural Beneficiaries Quality Improvement

IPRO and the New York provider community will work together to eliminate disparities between medically underserved seniors and the general Medicare beneficiary population.

IPRO's work on this task will be evaluated based on the following:

1. IPRO must seek a relative improvement in the chosen underserved population and quality of care measure of at least 2% greater that theverall statewide improvement achieved by IPRO on the same task 1(c) or Task 1 (d) indicator(s);

Task 1f - Medicare + Choice (M+COs) Quality Improvement

IPRO will collaborate with M+C plans to implement Quality Assessment and Performance Improvement (QAPI) projects to improve health outcomes and enrollee satisfaction. In addition, IPRO will be expected to have made a concerted effort to include M+COs in Tasks 1a to 1e.

IPRO will be evaluated qualitatively by the project officer, as well as by M+CO satisfaction - CMS will seek feedback from the M+COs who participated in a quality improvement project and/or received technical assistance provided by IPRO. CMS asks that at least 80% of the respondents be mostly or fully satisfied with the assistance given by IPRO.

Task 2: Improving Beneficiary Safety and Health Through Information and Communications

In this scope of work, communication between IPRO, providers/practitioners, beneficiaries and caregivers will be encouraged.

Task 2a - Promoting the Use of Performance Data

CMS is committed to public release of institution - specific performance data involving nursing homes throughout the U.S., beginning in the fall of 2002.

IPRO's efforts to promote the publicly reported performance measures should contribute to the following outcomes:

1. additional hits to the performance measure data posted at Nursing Home Compare on www.medicare.gov;
2. an increase in Nursing Home Quality Initiative-related telephone inquiries made to 1-800-MEDICARE and to IPRO; and
3. additional requests by nursing homes to the QIO for technical assistance with their quality improvement efforts.

Task 2b - Transitioning to Hospital Generated Data

The purpose of this task is to encourage hospitals to abstract and collect their own clinical data. IPRO will assess the current reporting capabilities of NYS hospitals and provide technical assistance to hospitals as they take on this responsibility.

Throughout the contract, CMS will use data collected by IPRO to measure the proportion of hospitals within the State that have implemented a data abstraction system to abstract quality of care measures.

CMS will conduct a Customer Satisfaction Survey of the appropriate personnel in all facilities where IPRO supports the ongoing use of the CMS-approved abstraction tools. CMS asks that at least 80% of the respondents be mostly or fully satisfied with the assistance given it by IPRO.

Task 2c - Other Mandated Communications Activities

This task addresses:

1. The establishment and use of a Consumer Advisory Council to advise and provide guidance regarding consumer related activities;
2. IPRO's concerted effort at broadening consumer representation on its Board of Directors;
3. the successful development and implementation of provider and beneficiary outreach plans;
4. the successful operation of a Beneficiary helpline, as reflected in such measures as documented responses to inquiries within established reasonable time frames and efforts to ensure that responses are clear and substantive.

Task 3: Medicare Beneficiary Protection Program

IPRO will work with hospitals to ensure the health and safety of Medicare beneficiaries as well as to protect the integrity of the Medicare Trust Fund.

Task 3a - Beneficiary Complaint Response Program

While still responsible for reviewing beneficiary complaints regarding care decisions, IPRO may now offer mediation between the beneficiary and the provider/practitioner to resolve those concerns when directed by CMS (target date 2003). IPRO is encouraged to work with providers to identify systems improvement opportunities.

IPRO's success on this task will be assessed by based on the following elements:

1. Beneficiary satisfaction with complaint reviews. IPRO will conduct surveys of beneficiary complaints, once their complaint process has been completed. IPRO will be expected to asses complainant satisfaction and demonstrate that we have improved it, or undertaken appropriate improvement activities;
2. proportion of complaint review for which quality improvement activities have been recommended to providers/practitioners;
timeliness of completed reviews. CMS expects reviews to be completed within the prescribed timeframes at least 90% of the time;
3. reliability of review. CMS expects IPRO to assess and continuously improve the reliability of its case review program.

Task 3b - Hospital Payment Monitoring Review Program

As in the 6th SOW, IPRO will continue to review all cases referred by the Clinical Data Abstraction Centers (CDACs) as part of a random sample to produce national and state specific payment error rates for coding and medical necessity.

IPRO will also monitor hospital admissions and coding patterns by conducting hospital profiling and trend monitoring, target identification activities to determine for errors and inappropriate utilization by providers. IPRO will develop project proposals to address identified and potentially significant utilizations and coding problems. All projects must be approved by CMS prior to implementation. In addition, IPRO may be directed by CMS to conduct specific error prevention projects.

CMS will evaluate IPRO's success under this task in relation to the following criteria:

• IPRO must complete the expected reviews, accomplish this within expected timeframes at least 90% of the time, identify opportunities for improvement, and communicate and report on findings in accordance with CMS requirements.

In addition, IPRO must meet one of the following criteria:

• With respect to the absolute payment error rate, IPRO will be judged successful if the follow up payment error rate is no greater hat 1.5 standard deviations above the baseline payment error rate; or
• If IPRO makes substantial and effective effort and makes acceptable progress in improving provider performance in relation to any and all payment monitoring projects approved or directed by CMS

Task 3c - Other Beneficiary Protection Activities

IPRO will respond to beneficiaries' requests for case review to ensure that Hospital- Issued Notices of Non-coverage (HINNs)/Notice Of Discharge & Medicare Appeal Rights (NODMARS) given to Medicare beneficiaries or their designated representatives are correct and that those beneficiaries are not discharged from hospitals prematurely. In addition, IPRO must monitor content and accuracy and take HINN appropriate action to correct any identified deficiencies.

EMTALA is more commonly known as the "anti-dumping" law. IPRO will provide independent review for cases CMS determines have violated the EMTALA. QIO review is a requisite step prior to the imposition of civil monetary penalties or a provider's termination by the Office of the Inspector General (OIG).

IPRO will make medical necessity, quality of care, and/or DRG validation determinations (applicable to the kind of case under review). IPRO will also monitor the hospital's compliance in securing physician acknowledgement statements.

IPRO will exercise its authority to reopen initial determinations and DRG changes when necessary.

IPRO's success on this task will be assessed in relation to the following elements:

1. Timeliness of completed reviews. CMS expects reviews to be completed within the allotted timeframes at least 90% of the time.
2. Reliability of review. CMS expects IPRO to assess and improve the reliability of its case review.

Task 4: Improving Beneficiary Safety and Health Through Developmental Activities (Special Studies)

During the course of the 7th Scope of Work, IPRO may be asked to perform work that is not specified in Tasks 1-3, under "Special Study" designation.

Should you need additional information on the 7SOW, please do not hesitate to contact me or Spencer Vibbert at 516-326-7767, extension 588.