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CQI in Medicare

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Medicare’s Essential Features

Medicare has emerged as one of the best health insurance program for the elderly, making it withstand various challenges and demands of health insurance for Americans at the age of 65 years or those with certain health conditions. The Federal government created the Medicare program as an answer to the vulnerability of old people above the age of 65. It also considered the challenges of people who are not yet over 65, but suffer from disabilities or other terminal forms of illness (Esterson, 2005). This meant that according to Medicare, the Federal government funds could provide insurance cover to persons who were blind or having renal failure. The usefulness of the Medicare program rest on several essential features that make the program unique and effective in meeting the insurance cover of all people listed as beneficiaries of this program. The essential features of Medicare make up the four groups that Medicare operates under, which are: Hospital insurance, Medical insurance, Medicare Advantage Plans, and Prescription Drug Coverage. Thus,

a)The first part of Medicare is the Hospital insurance, which provides insurance cover for beneficiaries who receive inpatient care. Under this cover, patients who receive services from hospice, home healthcare, and skilled nursing facility will receive payment from Medicare as payments for their charges.

b)Medical Insurance is the second essential feature of Medicare. This feature provides cover to patients who receive treatment in outpatient care or doctors (Leavitt, 2009). In addition, this cover can cater for some preventative services that patients may receive to maintain their health and reduce deterioration of their health. Patients pay for this insurance as a premium service that cost about $96.40 as at 2009 (Leavitt, 2009).

c)Medical Advantage Plans is the third feature of Medicare. This plan allows patients to receive health cover from private health care providers that Medicare has approved. This plan is also unique as it caters for cost incurred in the plan under (a) and (b) above, as well as those under the prescription drug coverage.

d)The Prescription Drug Coverage is the last feature of Medicare, which provides insurance cover for cost incurred through the purchase of prescription drugs. This feature of Medicare help patients lower the cost of drugs and protect against future increase in prices of drugs.

Article Summary

The article “Quality Improvement Organizations and Continuous Quality Improvement in Medicare” provides a concise summary of evolution in the Quality Improvement Organizations and how Continuous Quality Improvement continues to address issues of quality in health care. In this article, Schenck, McArdle and Weiser (n.d) argue that Medicare program, just like other programs, faced issues of quality. However, the introduction of Quality Improvement Organization not only helped Medicare, but it also stirred the development of other healthcare quality measures.

In the article, Schenck, McArdle and Weiser (n.d) reported that Professional Standard Review Organization and Peer Review Organization were created to improve the quality of care in a healthcare setting. The Center for Medicare and Medicaid Service later improved the above agencies by introducing other measure that allowed reporting on the quality of care.

For instance, the article reports that the government urged providers to adopt new initiatives, such as the ‘pay for performance’. The article also provides a succinct summary of how the Quality Improvement Organization works. In particular, Schenck, McArdle and Weiser (n.d) mention that QIO use contractors and other expertise to accomplish their tasks. Most important, the article highlights the role of QIO in improvement of quality in Medicare. In this section, the article mentions that QIO’s role is to improve on quality using approaches such as education, training, and availing resources. Towards the end, the article underscored the value of measuring the effectiveness of the QIOs and at the same time, it mentions the possible tools that evaluators can use.

Why CMS Created QIOs and Widened Roles of PRO?

The Center for Medicare and Medicaid Service (CMS) created Quality Improvement Organization to address issues of quality in healthcare. The introduction of Quality Improvement Organization signified the CMS’s realization that quality was crucial to the success of Medicare and Medicaid. The creation of the QIOs broadened PRO as CMS focused on the use of increasing knowledge on the philosophy, process and applicability of the Continuous Quality Improvement in various facets of healthcare (Schenck, McArdle, & Weiser, n.d). To date, the CMS has made slow but meaningful improvement that has helped create more quality within Medicare.

Recommendations from the Article

Schenck, McArdle and Weiser (n.d) recommend that Quality Improvement Organization should focus on providing technical assistance to providers who have performance issues, unlike before. This will be a shift to a more pressing need, because some providers are still performing below their expectations. The article also recommends that QIOs should improve the availability of data to hasten the decision-making process. This recommendation comes against the backdrop of lateness in releasing of data critical in correct issues affecting the quality. Another recommendation calls for the removal of the review processes in QIOs, which have in the past consumed a lot of time, slowing down the process of correcting quality issues.

Effectiveness of the QIOs

I believe that QIOs have made significant progress in promoting quality in healthcare, but it has not achieved its mandate to the fullest as quality gap still exists and requires filling. For example, some healthcare providers still have lower performances, despite the increased use of technologies that can help in improving the quality. In addition, the lack of consistencies in quality within the healthcare community points to shortcomings, which QIOs must address. Indeed, fixing these loose ends will contribute to the full realization of QIOs.

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