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Our work with Medicare

One of AFMC’s primary responsibilities is serving Medicare as a Quality Improvement Organization (QIO). In this role, AFMC works under contract with the federal Centers for Medicare & Medicaid Services to improve and ensure the effectiveness, efficiency, economy and quality of services delivered to Arkansans who are on Medicare.

QIOs across the nation are charged with:

  • Improving the quality of care for people on Medicare
  • Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and medically necessary and that are provided in the most appropriate setting
  • Protecting those on Medicare by speedily addressing individual complaints, notices and appeals, including beneficiary complaints; provider-issued notices of non-coverage (Hospital-Issued Notice of Non-Coverage [HINN], Notice of Discharge and Medicare Appeal Rights [NODMAR] and Medicare Advantage appeal); and Emergency Medical Treatment and Labor Act (EMTALA) violations

9th Statement of Work

The QIO program is currently in the 9th three-year contract cycle with Medicare (August 2008 – July 2011). Under the 9th statement of work, AFMC is focusing on three main themes: Beneficiary protection, patient safety and prevention. All QIOs will also help Medicare promote the adoption of value-driven health care; support the adoption and use of health information technology; and reduce health disparities in their communities.

As part of this new contract cycle, QIOs are required to offer help to specific nursing homes and hospitals that have not recently performed well on important quality measures.

Beneficiary Protection:
Meeting needs for those on Medicare

Part of AFMC’s work for Medicare is reviewing the health care provided to Arkansans and responding to concerns and complaints about health care quality. AFMC handles these responsibilities under our contract with the federal Centers for Medicare & Medicaid Services.

Review
Our reviewers work to ensure that care provided under Medicare meets accepted medical standards, is medically necessary and is delivered appropriately. Clinical reviewers also conduct case reviews for certain notices issued by providers and appeals from beneficiaries.

Complaints
AFMC reviews and responds to complaints about quality of care from all sources, including:

  • Medicare beneficiaries and their representatives
  • Health care providers
  • Anonymous sources
  • Those referred by CMS

AFMC determines and takes appropriate action on complaints. Such action might include mediation, quality improvement activities or sanctions if deemed necessary.

Education
AFMC also works to educate Arkansans about their rights under Medicare and how to exercise those rights. For more information, see:

 

 

Patient safety: Preventing harm resulting from care

Health care should heal people, not harm them. Providing health care as safely as possible has always been a high priority, and has taken on new urgency in recent years.

In 1999, the Institute of Medicine issued a report, titled “To Err is Human: Building a Safer Health System,” calling for a reduction in preventable medical errors and “adverse events” that harm patients. At that time, the IOM estimated preventable medical errors in hospitals alone claimed at least 44,000 lives each year — and perhaps as many as 98,000. The IOM also reported that more than 1.5 million Americans are injured each year by medication errors.

In more recent years, the spread of antibiotic-resistant infections — in health care settings and the community — has caught the attention of the general public and the mainstream media.

The Centers for Medicare and Medicaid Services has taken note, launching the National Patient Safety Initiative for Nursing Homes and Hospitals. The idea is that the best way to make care safer is to improve processes and systems, building in safeguards to prevent human error, surgical infections and other possible causes of harm to patients.

AFMC and other quality improvement organizations across the nation are working with health care providers and educating people on Medicare to help:

  • Prevent health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections
  • Reduce rates of pressure ulcers in nursing home residents and hospital patients
  • Reduce the use of physical restraints in nursing homes
  • Make surgery safer
  • Improve hospital treatment of heart failure
  • Improve prescription drug safety
  • Help specific nursing homes improve the quality of care

AFMC has been working with health care providers on most of these measures for years. For instance, nursing homes in Arkansas have successfully reduced the percentage of residents with pressure ulcers, as well as dramatically reducing the use of physical restraints. Hospitals have improved their performance in accepted standards for heart failure treatment. The Surgical Care Improvement Project (SCIP) has helped hospitals increase the number of patients who receive antibiotics in keeping with national guidelines and improve in other standards of surgical care.

Together, we are helping to build a safer and more effective health care system for ourselves, our children and future generations.

Prevention:  A cornerstone of health care

Health care, as its name implies, means caring for patients’ health — not simply treating their illnesses and injuries. Preventive care is not only good medicine; it is cost-effective. It saves lives, improves quality of life, relieves strain on the health care system and conserves limited resources.

For more than 30 years, AFMC has worked with physicians to improve health care quality and ensure that every patient receives the right care at the right time. AFMC promotes preventive measures in medicine and encourages Arkansas physicians to track their patients closely, to ensure that these patients appropriate preventive services, including:

Health information technology — electronic health records, e-prescribing, electronic reminders and other applications — allows physicians to effectively track patients and the preventive services they have received. Used effectively, health information technology can also help prevent missteps and miscommunication, increase efficiency and improve care in other ways.

AFMC actively promotes care management using EHRs. The Physician Office Team at AFMC can work directly with individual practices and providers to help them make the most effective use of EHRs and other health information technology and to increase the likelihood that patients will receive the preventive care they need, when they need it.

For more information, see: Health Information Technology (HIT) Assistance