[Congressional Record Volume 153, Number 126 (Thursday, August 2, 2007)]
[Senate]
[Pages S10798-S10799]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRASSLEY (for himself and Mr. Baucus):
  S. 1947. A bill to amend title XI of the Social Security Act to 
improve the quality improvement organization (QIO) program; to the 
Committee on Finance.
  Mr. GRASSLEY. Mr. President, I am pleased to join my good friend and 
colleague Senator Baucus to introduce the Continuing the Advancement of 
Quality Improvement Act.
  The purpose of this legislation is to reform Medicare's troubled 
Quality Improvement Organization, QIO, program. QIOs and their 
predecessor organizations have long been responsible for ensuring that 
the care Medicare beneficiaries receive is medically necessary, meets 
recognized standards and is provided in appropriate settings. They are 
currently tasked with a wide variety of important roles ranging from 
investigating beneficiary complaints of poor quality care to giving 
technical assistance to Medicare providers for improving health care 
quality.
  I have been an advocate of reforming the QIO program for quite some 
time. About 2 years ago, I initiated an investigation into a number of 
the QIOs. Those investigations revealed a program that is in desperate 
need of reform. This program was running with little or no oversight, 
and it was expending more than $1 billion every 3 years with little 
measurable results. In other words, I found trouble. Let me elaborate 
on a few disturbing things that I discovered. I found that one QIO 
leased residential properties for board members and a CEO. That same 
QIO also used Federal funds to lease automobiles for its top 
executives. I also found other QIOs who had board members and staff 
attend conferences, many at lavish resorts.
  I was not the only one to identify serous concerns with the QIOs. 
Others identified concerns too. Specifically, the Institute of 
Medicine, IOM, the General Accountability Office, GAO, and the 
Department of Health and Human Services, HHS, Office of the Inspector 
Geheral (OIG) all identified numerous concerns about the effectiveness 
of this program. These independent organizations also voiced their 
concerns with the manner in which it is operated and have made 
recommendations for major reform. Their findings clearly show the need 
to hold the Centers for Medicare and Medicaid Services, CMS, and the 
organizations that serve as QIOs accountable for the important tasks 
they must perform.
  The Continuing the Advancement of Quality Improvement Act will ensure 
that the QIO program is not only effective in improving the quality of 
care provided to our Medicare beneficiaries, but also that it operates 
in an effective, efficient and accountable manner. Much of this 
legislation is based on the investigations that I conducted and the 
troubling findings that I came across and on the work of the IOM, the 
GAO, and the HHS OIG.
  First, the Continuing the Advancement of Quality Improvement Act 
would focus the mission of the QIO program on quality improvement. QIOs 
currently have many diverse responsibilities. As a result, they served 
conflicting roles of both ``regulator'' and ``technical assistant.'' 
This conflict poses significant barriers to QIOs effectively serving 
either role, and we have come to learn that they really don't perform 
either function particularly well.
  The legislation would also address this conflict by following the 
IOM's recommendation to make the sole purpose of QIOs to be technical 
assistants for quality improvement and performance measurement. The HHS 
Secretary would be required to transfer all other QIO: responsibilities 
to other entities called Medicare Provider Review Organizations, MPROs, 
in a manner that will support the needs of beneficiaries and be 
accountable to them.
  Second, the legislation would improve the beneficiary complaint 
review process that I think is in desperate need of reform. You may 
recall that in 2006 we read about the plight of Mr. Schiff. Mr. Schiff 
went to a QIO and filed a complaint about the care provided to his 
wife, who died. The QIO in that case was unresponsive to Mr. Schiff. He 
was forced to take legal action to learn what the QIO found out about 
his wife's death. He should not have had to do that. After all, he was 
the one who filed the complaint with the QIO in the first place because 
he thought that someone did something wrong that lead to his wife's 
death. It was at that juncture that I learned that the beneficiary 
complaint review process was too opaque and ineffective. More 
importantly, beneficiaries were not being properly served. In fact, I 
came to learn that complainants often do not receive the findings of 
the investigation conducted by the QIO. Now I ask; what sense does that 
make?
  The Continuing the Advancement of Quality Improvement Act would 
require MPROs to report the investigational findings to the complainant 
and refer the provider to a QIO for technical assistance and/or the 
appropriate regulatory body for sanctions. In other words, this part of 
the bill would bring transparency to a process now shrouded in a cloud 
of silence.
  Third, the Continuing the Advancement of Quality Improvement Act 
would ensure that limited resources go to providers that need them the 
most. The GAO recently found that QIOs prioritized their assistance to 
providers who would be easiest to help rather than the providers who 
were most in need of help. In other words the QIOs decided it was 
easier to take a B plus student and make them into an A student rather 
than putting their resources into the D student to bring them up to 
par. I guess that way they thought that they would look better and more 
successful. But if you ask me; that is not the best way to spend 
limited taxpayer resources. Now, this bill will insure that if demand 
for technical assistance exceeds available resources, the QIOs would 
give priority to providers that are in rural or underserved areas, in 
financial need, have low performance measures or have a significant 
number of beneficiary complaints. In other words the help is going to 
go to those who need it most.
  Fourth, the Continuing the Advancement of Quality Improvement Act 
would make QIO data more available to CMS and providers for quality 
improvement and patient safety purposes. Amazingly enough, QIOs are 
currently restricted from sharing such data despite the obvious value 
of this data for improving health care quality. This legislation would 
permit the sharing of QIO data with providers for quality improvement 
and patient safety purposes and require CMS to make recommendations on 
how to improve the data sharing process.

  Fifth, the Continuing the Advancement of Quality Improvement Act 
would promote competition in the QIO program. This is a giant leap 
forward. These organizations are currently not subject to significant 
competition because of limitations on who can be a QIO and the 
availability of noncompetitive contract renewals. This lack of 
competition has led to a gross lack of accountability and stagnation in 
the QIO program. This legislation would promote competition by allowing 
other types of organizations to serve as QIOs and eliminate 
noncompetitive renewals.
  Sixth, the Continuing the Advancement of Quality Improvement Act 
would enhance governance at the QIOs. During the course of my 
investigations I identified repeated failures in governance. I exposed 
board members who were more interested in helping themselves than 
helping others.
  This bill will also address board member conflicts of interest. My 
investigations identified numerous incidents of questionable QIO 
governance practices and board member conflicts of interest. Since the 
QIO program receives over $400 million in taxpayer funding every year, 
it is reasonable for us to expect not only that QIOs are governed in an 
ethical manner free of conflicts of interest, but also that CMS 
appropriately oversees the program. This

[[Page S10799]]

legislation would require QIOs to comply with board governance 
requirements and would require CMS to establish procedures to address 
conflicts of interest and follow those procedures.
  Finally, the Continuing the Advancement of Quality Improvement Act 
would increase much needed accountability in the QIO program. The I0M, 
the GAO and the HHS OIG have all questioned the effectiveness of the 
QIO program. This legislation would require the Secretary to perform 
interim and final evaluations of program effectiveness not only at the 
individual QIO level, but at the overall QIO program level as a whole. 
Also, high performing QIOs would receive financial rewards while low 
performing QIOs would receive financial penalties. Finally, the 
Secretary would be required to submit a more detailed annual report 
showing performance results of QIOs and MPROs and details on how 
taxpayer dollars are spent.
  We have been placing more emphasis on the quality of care that our 
Medicare beneficiaries receive from providers. You see this as we 
require more transparency in the Medicare program with the public 
reporting of provider quality measures. You also see this as we 
transform Medicare from being a passive payer of services of any 
quality to a value-based purchaser. These are important reforms that 
will help improve the quality of care provided in the Medicare program 
and work toward ensuring that limited resources are used more 
efficiently and wisely.
  As we move toward a payment system based on quality, the reforms in 
this bill will position the QIO program to support that transformation 
in Medicare to a quality-based purchaser by making the tools and 
assistance available to help Medicare providers improve the quality of 
the care they provide. The Continuing the Advancement of Quality 
Improvement Act would ensure the QIO program's ability to provide this 
assistance in an effective, efficient and accountable manner and 
correct the problems currently plaguing the program.
  Mr. BAUCUS. Mr. President, today I am pleased to join Senator 
Grassley in introducing the Continuing the Advancement of Quality 
Improvement Act of 2007.
  This bill represents another step in our commitment to improving the 
quality of care provided for Medicare beneficiaries and all Americans.
  The Medicare program funds Quality Improvement Organizations, known 
as QIOs, in part to work with health care providers to help them 
improve the quality of care they provide.
  QIOs have played an evolving role in Medicare. Recently, the QIO 
program has received a great deal of attention. Not only did Senator 
Grassley and I have the Senate Finance Committee look into aspects of 
QIO operations, but the Institute of Medicine, the Government 
Accountability Office, and the Health and Human Services' Inspector 
General have all opined about QIOs as well. It seems there is a 
consensus that the QIO program could be doing more to help improve the 
quality of care.
  That is not to say that QIOs have not been doing good work and 
providing valuable services up until now. Quite the opposite. However, 
over the course of time, QIOs have been tasked with a number of 
responsibilities and the program's mission has become blurred.
  What Senator Grassley and I found, as well as the IOM, the GAO, and 
the HHS, OIG, is that the QIO program needs a sharper focus. Its 
mission to improve quality must be clear and unambiguous. Therefore, 
the Continuing the Advancement of Quality Improvement, or CAQI, Act 
would focus QIOs on providing technical assistance for quality 
improvement and performance measurement.
  The bill would separate the beneficiary complaint process from QIOs 
and give this responsibility to Medicare Provider Review Organizations, 
which will be required to report to the complainant and refer the 
provider to a QIO for technical assistance and/or the appropriate 
regulatory body for sanctions. This will make the complaint review 
process stronger.
  The CAQI Act would ensure that QIOs devote their attention to the 
health care providers that need help the most. It would also permit 
sharing QIO data with providers for quality improvement and patient 
safety purposes.
  The Finance Committee investigation of the QIO program led Senator 
Grassley and I to include certain provisions we believe will enhance 
the integrity of the program. So, the CAQI Act would promote 
competition by allowing other types of organizations to serve as QIOs 
and eliminating noncompetitive renewals.
  To ensure ``corporate'' integrity, the CAQI Act would establish 
requirements for governance and boards of directors at the QIOs, as 
well as requiring CMS to establish ways to avoid conflicts of interest.
  The CAQI Act aims to ensure greater accountability for individual 
QIOs, and the QIO program as a whole. It would require the Secretary to 
perform evaluations of the effectiveness of each QIO and the whole 
program. QIOs would be evaluated on consistent measures that are based 
on nationwide priorities for quality improvement. The Secretary would 
be required to report to Congress annually on QIO performance, 
including how program funds were spent.
  The QIO program is an asset to the Medicare program and the health 
care system in general. We have an opportunity to improve its 
effectiveness. We can make it a more useful tool as we continue 
advancing toward quality improvement. We have a duty to make the 
Medicare program as strong and robust as it can be. The Continuing the 
Advancement of Quality Improvement Act presents an opportunity to do 
just that. Senator Grassley and I urge our Colleagues to support it.
                                 ______