Quality Improvement Organizations
What is the QIO Program?
The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services' National Quality Strategy for providing better care and better health at lower cost. 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's 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.
What are QIOs?
A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare.
There are two types of QIOs that work under the direction of the Centers for Medicare & Medicaid Services in support of the QIO Program:
Beneficiary and Family Centered Care (BFCC)-QIOs
BFCC-QIOs help Medicare beneficiaries exercise their right to high-quality health care. They manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. They also handle cases in which beneficiaries want to appeal a health care provider’s decision to discharge them from the hospital or discontinue other types of services. Two designated BFCC-QIOs serve all 50 states and three territories, which are grouped into ten regions.
Quality Innovation Network (QIN)-QIOs
The QIO Program’s 14 Quality Innovation Network-QIOs (QIN-QIOs) bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality. By serving regions of two to six states each, QIN-QIOs are able to help best practices for better care spread more quickly, while still accommodating local conditions and cultural factors.
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. The QIO Program is an important resource in CMS’s 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 Transformation
CMS redesigned its QIO Program to further enhance the quality of services for Medicare beneficiaries. The new program structure maximizes learning and collaboration in improving care, enhances flexibility, supports the spread of effective new practices and models of care, helps achieve the priorities of the National Quality Strategy and the goals of the CMS Quality Strategy, and delivers program value to beneficiaries, patients, and taxpayers.
The QIO Program changes include separating case review from quality improvement, extending the contract period of performance from three (3) to five (5) years, removing requirements to restrict QIO activity to a single entity in each state/ territory, and opening contractor consideration to a broad range of entities to perform the work.
Now, one group of QIOs (BFCC-QIOs) addresses quality of care concerns and appeals, while another group (QIN-QIOs) works with providers, stakeholders, and Medicare beneficiaries to improve the quality of health care for targeted health conditions. QIOs will have new skills for transforming practices, employing lean methodologies, assisting Medicare providers with their transition to the Quality Payment Program, and developing innovative approaches to quality improvement.
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.