HHS: Medicare quality groups go easy on low performers

The QIOs counter that harsh action is seldom necessary, because doctors and others take steps on their own to correct problems.

By David Glendinning, AMNews staff. July 9, 2007.

Washington -- Special contractors hired by Medicare to enforce sanctions against physicians and others providing low-quality care are imposing the minimum penalties in the majority of cases, according to a new report.

A review of Medicare quality improvement organizations by the Dept. of Health and Human Services Office of Inspector General found that QIOs rarely took the toughest actions possible against practices that were deemed to be in violation of professional standards. Twenty-eight percent of the time, the organizations took no action after confirming a quality-of-care concern.

Between 2003 and 2006, the organizations selected 318,018 cases for review, completed full reviews on 34,768 and confirmed one or more quality concerns in 6,439 cases. They recommended no action in 1,794 cases with a confirmed concern and 5,125 corrective actions in the other 4,645 cases.

"QIOs have long had the potential to be an essential frontline mechanism through which Medicare can oversee the quality of care for which it pays," the report states.

"However, QIOs assigned more than 80% of confirmed quality concerns to one of the two least serious classifications, 'care could reasonably have been expected to be better' or 'care failed to follow generally accepted guidelines or usual practice.' "

The organizations very seldom found that the "care provided was a gross and flagrant violation," the most severe classification.

When QIOs decided to take corrective actions against physicians or others between 2003 and 2006, they took the harshest actions -- initiation of sanctions or referral of the cases to licensing boards -- less than 2% of the time.