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CMS to launch $25 billion quality initiative

The CMS wants to consolidate several Medicare quality programs in an effort to identify the highest performing organization and have them scale their efforts under a contract that's worth up to $25 billion.

Quality Improvement Networks and Organizations (QIN-QIOs), End Stage Renal Disease (ESRD) Networks, and Hospital Improvement Innovation Networks (HIINs) will now fall under one large contract that focuses on educating and training stakeholders that could affect quality of care for Medicare patients. These organizations include hospitals, clinicians and long-term care facilities that work together to reduce hospitalizations, readmissions and poor care outcomes.

The effort will allow the CMS to "establish a pool of quality improvement contractors that are capable of rapid national, regional, state and local level quality improvement," an agency spokesman said.

Among those affected by this move are Health Services Holdings, TMF Health Quality Institute and HealthInsight. HIINs now under contract include providers Atrium Health and Dignity Health and group purchasing organizations Premier and Vizient, among others.

These groups can apply to be part of what will now be known as the Network of Quality Improvement and Innovation Contractors (NQIIC). Applications will be accepted through June 26 and will be awarded Dec. 1. The contracts will last for five years, with the option of a five-year renewal. The budget for the new quality initiative is up to $25 billion.

The CMS will provide guidance and funding and NQIIC contractors will be expected to gather providers, patients and other stakeholders to address a care or quality problem. For instance, if a certain region in the country is struggling with hospital acquired infections or a spike in the number of falls, a group could be called to come up with a solution, identify best practices or rapidly test quality improvement efforts to address the problem in question.

NQIIC vendors must also seek ways to harmonize measures across care settings and eliminate those that aren't useful.

"The proposed new structure addresses legitimate provider complaints about too many measures and too many rules on how to meet those measures, it maintains a clear focus on outcomes and on vulnerable populations," said Michael Millenson, president of consulting firm Health Quality Advisors.

The various quality contractors used by different providers can create variances that could affect Medicare patients who require care across primary, acute and post-acute settings, said Dr. Rahul Koranne, chief medical officer at the Minnesota Hospital Association, which has been a HIIN since 2016. The CMS requires HIINS to work with hospitals to decrease instances of patient harm and preventable 30-day readmissions.

"If care in the hospital is the only thing that improves, and not in a nursing home or clinic, that's not servicing a patient," Koranne said.

The new structure will concentrate on proven approaches, said Ellen Gagnon, interim CEO of Network for Regional Healthcare Improvement, a national network health improvement collaboratives. "Clinicians, especially in rural areas, could benefit from reduced administrative burden and a more coordinated support system to navigate the emerging pay for value environment," Gagnon said.

There is some controversy about the effort since the new effort may mean that QIOs will no longer be able to conduct claims audits due to new duties under NQIIC , according to said Emily Evans, a health policy analyst at Hedgeye Risk Management. The CMS has been relying more on QIOs to audit hospital claims instead of Recovery Audit Contractors (RACs).

Hospitals prefer QIOs over RACs, which are paid by the CMS to comb through providers' medical records to ensure Medicare payments are accurate. RACs receive a cut of each overpayment they find. QIOs tend to be run by clinicians making them better suited to judge these claims.

In a FAQ document released by the CMS, it said it won't announce terms of QIO contracts until next year.

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