Quality Improvement Organizations
What are QIOs?
CMS contracts with one organization in each state, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands to serve as that state/jurisdiction's Quality Improvement Organization (QIO) contractor. QIOs are private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care. QIO contracts are 3 years in length, with each 3-year cycle referenced as an ordinal “SOW.”
What do QIOs do?
By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS' Program experience, CMS identifies the core functions of the QIO Program as:
- Improving quality of care for beneficiaries;
- Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and
- Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.
Why does CMS have QIOs?
CMS relies on QIOs to improve the quality of health care for all Medicare beneficiaries. Furthermore, QIOs are required under Sections 1152-1154 of the Social Security Act. CMS views the QIO Program as an important resource in its effort to improve quality and efficiency of care for Medicare beneficiaries. Throughout its history, the Program has been instrumental in advancing national efforts to motivate providers in improving quality, and in measuring and improving outcomes of quality.
QIO Program Evaluation
CMS engaged Mathematica Policy Research to develop an independent evaluation of Medicare’s Quality Improvement Organization (QIO) Program’s 9th Statement of Work (SOW), which spanned from August 1, 2008 through July 31, 2011.
CMS requested an independent evaluation of the program in response to the findings of the Institute of Medicine (IOM) in its 2006 report, Medicare’s Quality Improvement Program: Maximizing Potential. In that report, the IOM recommended that that Secretary “periodically commission . . . independent, external evaluation[s] of the QIO Program’s overall contributions.”
The report below is the first completed external evaluation of this type since the IOM made its recommendation.
QIO Reports to Congress
CMS is required to publish a Report to Congress every fiscal year that outlines the administration, cost, and impact of the QIO Program. See the links in the "Downloads" section to read our most recent fiscal year Report to Congress.
Also in the "Downloads" section, read our special Report to Congress in response to the Institute of Medicine's 2006 study on the QIO Program, Medicare's Quality Improvement Organization Program: Maximizing Potential. CMS' response to that report outlines improvements, based on an extensive CMS review and recommendations from the Institute of Medicine, to strengthen Medicare's oversight and evaluation of the QIO Program to better meet the future needs of beneficiaries and health care providers.
- Independent Evaluation of the 9th SOW, QIO Program: Final Report (Nov 2011) [PDF, 844KB]
- Annual Report to Congress: QIO Program - Fiscal Year 2009 [PDF, 1MB]
- Annual Report to Congress: QIO Program - Fiscal Year 2008 [PDF, 1MB]
- Annual Report to Congress: QIO Program - Fiscal Year 2007 [PDF, 1MB]
- Annual Report to Congress: QIO Program - Fiscal Year 2006 [PDF, 99KB]
- Report to Congress: Response to IOM Study on the QIO Program [PDF, 189KB]
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