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CENTER FOR MEDICARE ADVOCACY CONFERENCE DEVELOPS MEDICARE BENEFICIARY COMPLAINT
PROCESS
The Center for Medicare Advocacy, Inc., (the Center), convened a working
conference in January 2007 that designed a model for resolving Medicare
beneficiaries' complaints about quality of care. Sponsored by the Commonwealth
Fund, with assistance from AARP, the conference provided a forum for key
stakeholders to discuss concerns and develop a blueprint for change.
Medicare beneficiaries and their advocates are concerned that this current
process for resolving beneficiary complaints about quality of care has not been
effective in providing fair and timely resolution of complaints. Concerns about
the process include an inadequate resolution of beneficiary complaints about
poor quality, a lack of information about proper care protocols, and the
failure to provide expedited review of denials of care.
Conference Overview
The Center's conference was triggered in part by the national Institute of
Medicine's (IoM) comprehensive study in 2006 of Medicare's current beneficiary
quality of care complaint process. The IoM and others had on many occasions
called for a beneficiary-focused complaint review process. The current process,
operated under a contract with Quality Improvement Organizations (QIOs) has
been found to be primarily provider-focused, assisting providers in quality
improvement activities, rather than beneficiary-focused. The IoM, as a result
of its cumulative findings, recommended removing the function of performing
quality of care investigations from the QIOs and allowing other entities to
perform this work while QIOs continue to focus more specifically on assisting
health care providers in quality improvement.
Prior to the conference, the Center commissioned three background papers to
provide a framework for discussing these topics and others related to quality
review. Forty-two experts in fields ranging from direct patient care to
Congressional staff reviewed these pieces and participated in the day-long
conference to produce a model complaint process.
The Model Complaint Process
An overview of the quality complaint model designed by the conference and a
short description of its elements are provided below:
1. Filing Complaints
Definition of "Complaint" Should be Construed Broadly
Participants agreed that the definition of "complaint" should be construed
broadly. An ideal system would be able to accept and document the broad array
of potential complaints. It would also be flexible enough to allow for an
appropriate method of resolving the complaint, based on its severity and other
factors.
Anyone Can File a Complaint
Participants agreed that anyone should be able to file a complaint. There was
consensus that an ideal system would receive and follow through on complaints
from beneficiaries, family members, advocates, health care workers, and anyone
else with important information. The system would need the means to protect the
anonymity of staff and comply with HIPAA.
Neither Language nor Technology Should Discourage Complaints
The ability to file a complaint should not be constrained by language,
literacy, or technological barriers. The complaint process should utilize
materials that are age-appropriate and should recognize that primarily
Internet-based systems are not effective with the current Medicare beneficiary
population.
2. Goals of the Complaint Process
The Primary Goal is Addressing Beneficiary Concerns
Participants agreed that the primary goal of the complaint process system
should be to address and resolve beneficiary concerns.
A Secondary Goal is Identifying Provider Opportunities for Quality Improvement
In addition to focusing on the beneficiary, it was agreed that the complaint
system is an overarching part of a system's quality control key to the proper
function of any system that delivers a service. Participants agreed that a
well-publicized complaint system that keeps detailed records can identify
problems with specific providers and identify areas where a specific provider
or all providers can improve their quality.
3. There Should be a Single Point-of-Entry for Beneficiaries
There should be a single point-of-entry for beneficiaries and anyone else who
wishes to file a complaint-one number to call regardless of where they live.
The Patient Advocate Link (PAL)
Conferees developed the notion of a PA to help beneficiaries access and work
through the complaint process. The PAL would be an outlet for the beneficiary
for purposes of advice about options or assistance in making preliminary
inquiries about quality of care concerns and to facilitate provider feedback.
Regulatory Capacity of a "PAL" Single Point-of-Entry Entity
The PAL would not investigate and would not make decisions of right and wrong
but would make referrals, listen to the beneficiary, and keep the beneficiary
informed of the progress of the complaint.
4. Qualifications of a Quality Review Entity
Intake and Review
The first person to answer the phone has to be one of the most capable staff
members-efficient, respectful, culturally competent, and patient.
Referral
The referral of the case has to be to the appropriate person or entity for
investigation and/or resolution.
Centralized Database
The complaint information should be entered in a centralized database.
5. Possible Referral and Resolution Entities
Participants discussed, but did not reach a consensus on, which entity or
entities should be responsible for investigating and reviewing complaints.
Providers
State Survey Agencies
State Medical Boards
QIO Retention of Current Role
Other Potential Entities
A Hybrid Approach
6. Data Should be Gathered and Used for Quality Improvement
Data that are gathered by the complaint system should be used for quality
improvement purposes.
7. The Complaint System Should be Evaluated on a Regular Basis
The complaint system itself should be regularly evaluated. Participants agreed
that the system should examine its own interagency communication mechanisms.
The system needs meaningful feedback to be able to know how satisfactorily it
resolves problems both from a beneficiary perspective and that of state and
federal regulators.
Next Steps
The Center for Medicare Advocacy will continue to advance the work of the
Quality Review Conference in a variety of ways. These will include the
following:
Work with CMS staff to (a) expand its approach to the beneficiary quality of
care complaint process to include exploratory models using medical boards and
state licensing agencies, at least on a demonstration project basis, to test
efficacy and efficiency; and (b) to embrace a set of initiatives to provide
more Medicare beneficiary education about the current Medicare beneficiary
quality of care complaint process.
Work with the American Health Quality Association, the organization that
represents all of the QIOs, pending any movement of the complaint process, to
improve their education and outreach efforts toward beneficiaries.
Seek funding for a Public Policy legislative "roundtable" targeting
Congressional staff to alert members and staff to the issues raised at the
conference, highlighting the beneficiary complaint model separate from the
functions of the QIO as a viable legislative goal.
Further Information
Materials from the conference, including the background papers and the
narrative of the conference proceedings are posted on the Center's website at
<www.medicareadvocacy.org/projects_QIOConference.htm>.
Correspondence, questions, or comments regarding this conference should be sent
to: <mailto:[EMAIL PROTECTED]>.
For more information about the QIO beneficiary complaint process, contact
Alfred Chiplin (<mailto:[EMAIL PROTECTED]>) or Toby Edelman (<mailto:[EMAIL
PROTECTED]>) in the Center for Medicare Advocacy's Washington, DC office at
(202) 216-0028.
______________________________________________________________________
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