Table of Contents

Executive Summary..............................................................................Page 5

Physician Office......................................................................................Page 9

Nursing Home.......................................................................................Page 17

Home Health..........................................................................................Page 21

Hospital...................................................................................................Page 25

Beneficiary Review................................................................................Page 31

Appendix................................................................................................Page 33

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Executive SummaryThe Centers for Medicare & Medicaid Services (CMS) operates a nation-

wide quality improvement organization (QIO) program to ensure that peo-ple on Medicare receive high-quality healthcare services.

QSource has worked alongside various organizations and providers inTennessee for 34 years. As the Medicare QIO for Tennessee, QSource is ded-icated to helping healthcare providers deliver quality services by workingwith them to protect the Medicare program and beneficiaries.

With our breadth of experience in the field of quality improvement (QI)and our collaborative skills in working with healthcare providers, we bringquality improvement expertise to nursing homes, home health agencies,physician offices, hospitals, managed care organizations, pharmacies andprescription drug plans.

The QIO Program works with providers to achieve the vision of the“right care for every person every time” by assisting with measuring andreporting performance, guiding providers along the path of adopting healthinformation technologies, redesigning care processes and helping healthcareprofessionals and organizations with transforming organizational culture,and improving the quality of care and services to Medicare beneficiariesthrough statutorily mandated case review activities.

To achieve this goal, we have adopted the six aims of the Institute ofMedicine (IOM) for healthcare services as a tool to help guide our efforts in

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statewide QI activities. Throughout this publication you will see data comparing Tennessee to

other states on some of these quality measures, demographic trends and sta-tistics, and data representing performance improvement over time. Thisinformation is used to identify areas most in need of improvement and to seewhether current efforts are working.

QI specialists work in four distinct care settings. Dedicated staff in eachsetting, along with clinical experience and administrative expertise provideunique insight into the intricacies of that setting. These team members travelstatewide to provide consultation and troubleshooting support. We also pro-vide regional conferences and continuing education opportunities.

Our quality improvement specialists also collaborate on the developmentof tools that help healthcare providers improve patient self-management,such as educational booklets, posters and handouts for patients, and self-stick reminders for patient charts to let staff know when specific screeningtests are due.

While QSource quality improvement projects and related products andservices are too numerous to list comprehensively, this report offers a snap-shot of each setting's goals, accomplishments and challenges, and howQSource is working to help improve specific aspects of care. In addition toassisting healthcare professionals across the state in implementation of inter-ventions and programs that improve care, our staff also helps identify trendsand specialized interventions to meet the diverse and ever-changing charac-teristics of our state.

This report highlights the advances QSource and its partnering providershave made since the last reporting of this information in 2006. This reportoffers a snapshot of progress made by all, along with answers and explana-tions to the reasons for and barriers to that progress.

It is our hope that this information acts as a catalyst for quality improve-ment discussion across our state, and that QSource continues to be a vitalpartner in assisting local, state and federal organizations in driving changeamong the healthcare communities that we serve.

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7

Implementation of Technologyto Improve Care

Physician Office SnapshotAccording to a recent survey of Health Information Management

Systems Society (HIMSS) Leadership, 48 percent felt that health informa-tion technology (HIT) is one of the most significant drivers in reducingmedical errors and promoting patient safety over the next 12 months.Survey respondents also stated that implementation of an electronic healthrecord (EHR) (48 percent) and connecting information technology at hos-pitals and remote locations (33 percent) were key drivers of success overthe next calendar year10.

When asked in a survey by the Commonwealth Fund to rate the mosteffective ways to improve patient care, an overwhelming 92 percent of sur-vey respondents stated that EHRs were the preferred choice in leading thecharge in improving patient safety11.

Further, more than half of physicians polled in the Booz AllenHamilton Physician Survey conducted in 2006 view consumer-directedhealthcare as having the greatest impact on their practice in the next threeto five years12.

When asked about their exposure and use of quality information, 12percent of physicians stated that they had seen quality information withinthe past year. When asked a similar question regarding their use of thatdata, 7 percent of survey respondents stated that they had seen and actedon quality information. As HIT continues to evolve as a tool in improvingquality of care, these numbers should see increases nationally13.

QIO Impact and EffectivenessAs the national trend towards a more streamlined, efficient and

patient-centered care model evolves, the Tennessee QIO will be at the cen-ter of this change. QSource works with physician offices across the state tohelp them prepare for the national transition to electronic health recordsand implementation of Cultural Competency standards.

QSource's priorities are aligned with CMS's public reporting and pay-for-performance initiatives as well as a national emphasis on providingculturally competent care. CMS has outlined the following topics of prior-ity for quality improvement:

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• Promotion of Health Information Technology andElectronic Health Records (EHRs)

- Redesign Processes to Support Quality Improvement- Improve Quality Related to Prescription Drug Benefits

• Improve Care for Patients with:- Diabetes- Coronary Artery Disease- Heart Failure- Hypertension- End Stage Renal Disease

• Increase Preventive Care- Adult Immunization- Blood Pressure Measurement- Breast Cancer Screening- Colorectal Cancer Screening- LDL Cholesterol Level- Tobacco Use Counseling

• Improve Cultural Competency

QSource efforts to date have assisted 200+ primary care practices andmore than 1,500 physicians with various stages of electronic health recordimplementation. The QSource team has developed an EHR roadmapprocess that has successfully transitioned over 50 practices from a paper toan electronic environment.

The highlights of work to date show that our efforts in the electronichealth record arena have not been in vain. Thirty eight percent of practicesworking with QSource have either implemented (33 percent) or have con-tracted (5 percent) for an EHR product. As our assistance to Tennesseepractices continues, we look towards 100 percent of our participating prac-tices adopting electronic health records or other systems such as patientregistries that will allow for better tracking of patients and overall betterdocumentation of services. As technology adoption evolves within ourstate, we look for improved performance on the CMS preventive care andpatient care measures.

Opportunities for ImprovementA 2007 Citrix Systems, Inc. survey showed that the most important

EHR requirements are: ease of use (78 percent), security (62 percent) and

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interoperability (58 percent) as the top three elements to consider whenmoving forward14. QSource looks to continue our efforts with assisting thestate, trade associations, and health information technology vendors withmomentum in our state to address issues such as ease of use, security andinteroperability. Our involvement with the regional health informationorganizations (RHIOs), the Governor's Council on e-Prescribing and otherstatewide initiatives will allow us to continue to push technology as theprimary tool in improving care for Tennessee's Medicare beneficiaries.Although we still have many of our participants that have not implement-ed systems, we believe that our current progress will achieve even greatersuccess next year.

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Implementation of CulturalCompetency Training to ImprovePatient Care

Physician Office SnapshotThe National Health Disparities Report highlights disparities in

healthcare access and quality of care. This report showed that racial andethnic minorities fared far worse than whites in access to and quality ofhealth care. These findings were similar among African Americans,Hispanics, Asians, American Indians and Alaska Natives15.

Hispanics and African Americans experience delays in getting caredue to cost, and both populations experienced higher failures in obtainingcare due to cost compared to whites (non-Hispanic)16.

According to research conducted by the Research Triangle Institute,Hispanics had a more difficult time than other ethnic or racial groups get-ting needed, urgent and routine care17.

The diverse ethnic and racial make-up of Tennessee is one considera-tion when looking at the care provided and how language barriers mayimpact care decisions. Although ethnic and racial components are driversto be considered, the most disadvantaged population within our state con-tinues to be dual eligibles (people with both Medicare and Medicaid).

In Tennessee, dual eligibles represent the largest underserved popula-tion. According to national dual eligible figures, 57 percent live below thepoverty level, and 93 percent live below 200 percent of the poverty level.Compared to non-duals, dual eligibles are more likely to: be female,African American or Hispanic; lack a high school diploma; have greaterlimitations in activities of daily living; reside in a rural area; and live in aninstitution, alone, or with persons other than a spouse, which furtheremphasizes the need for increased diversity training within our communi-ties18.

Dual eligibles cost Medicare about 1.6 times as much as non-dual eli-gibles18. Dual eligibles are more likely than non-dual eligibles to be dis-abled or over 85 years old18. In Tennessee, the underserved population lagsbehind the general population for each of the quality measures evaluatedby CMS.

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QIO Impact and EffectivenessAs our state becomes more and more diverse, the manner in which we

provide care must also change. All indicators point towards a TennesseeMedicare population in the future that is culturally diverse and may expe-rience difficulties in accessing care because of language, disability, access,cultural differences or other barriers. In an effort to aid physicians inTennessee with learning about the changing patient mix of tomorrow,QSource has been providing cultural competency training to providersand office staff across the state free of charge.

CMS has contracted with QSource to help reduce healthcare dispari-ties among Medicare beneficiaries. To date, QSource has distributed theOffice of Minority Health's National Standards for Culturally andLinguistically Appropriate Services (CLAS) materials and tools statewideto Tennessee's primary care practices. QSource provides technical assis-tance, web-based tools, and educational programs to assist Tennesseeproviders in completing the training.

Sixty-seven practices and 200 individual practitioners have enrolled ina cultural competency program. CMS expectations are for 80 percent ofparticipating practices to have completed cultural competency training by

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November 2007. In return, participants will receive up to nine ContinuingMedical Education (CME for physicians) or Continuing Education Units(CEUs for nurse practitioners) in relation to their licensing.

Opportunities for ImprovementIn addition to increasing awareness of cultural competency in health-

care, we will continue to work with trade associations, medical groups,health plans, and state insurance/malpractice carriers/providers to imple-ment standards and educational curricula while providing incentives forsuccessfully completing the healthcare diversity and cultural competencytraining.

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Implementation of StatewideMedication Therapy ManagementEducational Program

Physician Office SnapshotAccording to the 1999 Institute of Medicine report "To Err is

Human: Building a Safer Health System,” more than half of themedical errors that occur in the United States are medication relat-ed19.

Nearly one-fourth of all hospital admissions result from peoplenot being able to take their medications properly because of misin-terpretation of directions.20

As many as 55 percent of older adults fail to comply with theirmedication regimen and nearly 28 percent of hospital admissionsfor people age 65 or older are due to medication-related problems.20

The U.S. Food and Drug Administration estimates that approxi-mately 1.3 million people are injured annually following so-called"medication errors."20

Medication errors are one of the top five causes of death in peo-ple age 65 or older.20

More than $200 billion is spent each year to correct medication-related problems, according to the Medicare Rights Center.20

QIO Impact and EffectivenessWorking under the direction of our Medication Therapy

Management (MTM) Advisory Panel, QSource and the TennesseePharmacists Association (TPA) will launch a statewide provider andbeneficiary educational campaign in July 2007. The bulk of the pro-gram will consist of distribution of patient and provider education-al materials explaining MTM benefits and services. Current plansare to distribute brochures to all Tennessee-based pharmacists. Theplan also includes access to additional materials and tools free ofcharge via an online ordering system. The goal is to increase MTMknowledge among beneficiary and provider communities.

Stimulating Change ThroughCollaborative Efforts

Nursing Home SnapshotNational trends illustrate that from 1999 to 2003, there was a 7 percent

average annual increase in the Medicare skilled nursing facility (SNF) use.The number of admissions has increased significantly over this five yearperiod. In addition to the increase in admissions, the number of skillednursing facility days grew 9 percent within the same period.

As with the increase in Medicare SNF use, the overall annual increaseof skilled nursing facilities also illustrated a 7.4 percent increase from 1996to 20051.

The increasing trend in SNF admissions, coupled with the increase inthe number of skilled nursing facilities and days is similar to national esti-mates indicating that the number of people who need long-term care in thenext 15 years will increase by 30 percent and that the number who may usepaid long-term care services could double between the years 2000 and20502.

Total Medicare spending for skilled nursing facilities has increasedfrom 5 percent in 1995 ($9.05 billion) to 6 percent in 2005 ($19.74 billion)1.

In Federal Fiscal Year 2004, Tennessee spent over $1 billion in Medicaidfunds for nursing facility services2.

QIO Impact and EffectivenessQSource works with nursing home professionals to help them improve

specific aspects of care identified by CMS as quality measures. Individualnursing home’s performance on these measures is reported to the publicon the Nursing Home Compare section of Medicare’s Web site(www.medicare.gov).

QSource, as a federal Medicare contractor working intensively with 45of the state’s nursing homes, is responsible for those homes meeting andexceeding the CMS-defined public reporting and pay-for-performance ini-tiatives. For the long-term care industry, CMS has defined the publiclyreported measures in Table 1 for quality improvement.

QSource efforts, along with the support and the dedication of the 45partnering nursing homes as well as all nursing homes across the state,have been instrumental in improving resident care, quality of life, andimplementing changes that work to improve Tennessee’s national rankingon quality of care indicators. As indicated in Table 1, nursing homes across

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Tennessee have shown improvement in 12 of the 15 CMS defined nationalquality indicators. The movement in these indicators illustrates positivetrending for our state as more and more homes identify ways in whichthey can implement culture changes and quality improvement methodolo-gies. Under our contract with CMS, QSource is responsible for workingdirectly with nursing homes across the state on four of the 15 measuresoutlined in Table 1. Our efforts to date have documented improvementover the past two years for all four quality measures. We have seen signif-icant improvement in our statewide ranking for depression (14th to 11th),pain (37th to 31st) and restraints (44th to 42nd). Although the nationalranking for high-risk pressure ulcers has declined (28th to 34th), thestatewide percentages have decreased from 13 percent to 12.53 percent,and continue to be a focus of our quality improvement efforts. The nation-al rankings for low-risk pressure ulcers and bed fast indicators did notimprove in reference to national ranking, but both measures did show

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For all measures, lower ratesindicate better performance

documented decreases in statewide percentages. The use of physical restraints in U.S. nursing homes has dropped dra-

matically since the 1990 implementation of federal regulations severelylimiting their use. According to The Gerontologist (Vol. 44, No. 2), an esti-mated 12 percent of the nation’s nursing home residents are physicallyrestrained, down from 40 percent in 1990. During the fourth quarter of2004, the national restraint average was 7.3 percent. Tennessee's rate wasslightly higher at 10.6 percent and had opportunities for improvement.

In 2005, QSource partnered with 15 nursing homes in a pilot toimprove the quality of care measure related to restraints. Utilizing the col-laborative model based on the Institute of Healthcare Improvement's (IHI)Breakthrough Series, QSource developed a collaborative focusing onrestraint reduction. Upon completion, this initiative resulted in the 15 facil-ities going from a collective 10 percent restraint rate to 4 percent, a relativeimprovement of 60 percent compared to a statewide average relativereduction of 10 percent for the same timeframe. After the pilot was over,all participating facilities except one maintained their improvements andcontinued to decrease their restraint rate. Several went on to becomerestraint-free.

The success of this effort led to additional collaboratives with 45 nurs-ing homes during 2006. The topics were:

• Reducing physical restraints. The restraint rate for the group was 9.65 percent in Q4 2004 which decreased to 4.35 percent by Q4 2006.

• Reducing high-risk pressure ulcers. The high-risk pressure ulcer rateof 13.80 percent according to Q4 2004 data was reduced to 11.34 per-cent by Q4 2006.

• Managing depressive symptoms. Results showed an improvement from 12.69 percent in Q4 2004 to a rate of 10.31 percent for Q4 2006.

• Reducing chronic pain. The measure improved from 5.48 percent inQ4 2004 to 4.61 percent in Q4 2006.

As these collaboratives continue, the national ranking on these pub-licly reported measures should improve.

Opportunities for ImprovementTennessee continues to have opportunities for improvement on many

of the CMS publicly reported quality measures. QSource continues towork with Tennessee nursing homes to improve statewide percentagesand national ranking on all CMS measures.

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Stimulating Change ThroughCollaborative Efforts

Home Health SnapshotMost frail and elderly patients desire and prefer to stay home whenev-

er possible. Hospitalizations can unnecessarily create financial and emo-tional burdens for patients and their families, and can negatively impactthe healthcare delivery system. According to CMS, currently, more than aquarter of Medicare's 2.9 million home health patients are admitted to thehospital every year. Home health quality improvement interventions canbe effective in reducing avoidable hospitalizations and overall costs for theMedicare program3.

Although the number of home health providers drastically decreasedfrom 1996 to 2002, the more recent data shows a trend toward more homehealth providers as the numbers have climbed 17 percent from 2002 to20054.

Spending for home health care services grew at an average annual rateof 20 percent from 1992 to 1997. Spending began to fall in 1997, concurrentwith the introduction of the interim prospective payment system, andreached an all time low in 1999. From 1999 to 2005, there has been a steadyincrease in the number of users, the number of episodes, and the amountof spending on home health care services1.

QIO Impact and EffectivenessQSource is working with home health agencies statewide to reduce

avoidable acute care hospitalization (ACH), which is a CMS national pri-ority measure. CMS has also requested that each state select a group ofagencies for more intensive intervention on this measure. Therefore,QSource is working with 20 percent of state agencies to reduce avoidableACH by implementing evidence-based best practice strategies, improvingagency culture and encouraging the use of technology. QSource has alsobeen tasked with improving one statewide publicly reported measure.Improvement in managment of oral medications was chosen. In addition,CMS reports each agency’s performance on an additional eight measuresto the public on www.medicare.gov.

QSource efforts, along with the support and dedication of partneringagencies across the state, have been instrumental in improving patient careand quality of life. They also have been effective in working to improve

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Tennessee’s national ranking on quality of care indicators. As indicated inTable 2, home health agencies across Tennessee have shown improvementin seven of the 10 CMS defined national quality indicators. The movementof these indicators illustrates positive trending for our state as more agen-cies identify ways in which they can implement quality improvementmethodologies and make changes in agency culture.

In January 2007, CMS, in conjunction with the Home Health QualityImprovement Organization Support Center (HHQIOSC) and QIOs acrossthe nation, launched a national intervention and educational campaigndesigned to make significant strides toward improvement of ACH rates.Tennessee and QSource are playing an active role in the campaign as ACHcontinues to be the major focus of our quality improvement efforts.

Our efforts to date have documented improvement over baseline num-bers on the management of oral medications measure. As a result, ourranking nationally has improved from 27th in the nation to 13th (38.29 per-cent to 43.74 percent). Although our national ranking for ACH has notchanged, our partnering agencies have reduced their ACH rates collective-ly by 2.41 percentage points from baseline to February 2007.

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Quality MeasuresFor the first two measures, lower rates

indiate better performance.For all other measures, higher rates

indicate better perfomance.

Opportunities for ImprovementTennessee is one of the highest utilizers in the nation of home health

services. Almost one-third of all acute care discharges are made to homehealth, skilled nursing or inpatient rehabilitation services.

QSource, along with partnering home health agencies across the state,will continue to work together on projects designed to reduce statewideACH rates. CMS data indicates if the nation's home health communitycould reduce the country's acute care hospitalization rate by 3 percent,32,205 fewer patients would be hospitalized and more than $802 millionMedicare dollars could be saved each year. In Tennessee alone, this 3 per-cent reduction would amount to $23.7 million and 953 fewer patients hos-pitalized.5

Statewide, Tennessee’s efforts to reduce ACH have not shownimprovement. To address the lack of reduction, QSource will broaden itsscope of work across settings next year to include working with case man-agement/discharge planning staff in hospitals. We also will be focusing onsoliciting increased assistance from the physician community in an effortto improve the lives of home health patients and reduce avoidable acutecare hospitalization.

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Stimulating Change ThroughCollaborative Efforts

Hospital Snapshot (State and National)According to the United Health Foundation report titled "America's

Health RankingsTM 2006," Tennessee ranks 47th among all states in regardsto overall health, with one of the major contributors being a high rate of car-diovascular deaths6.

Among Tennessee adults, nine out of 10 reported at least one risk factorfor heart disease and stroke. Almost two-thirds reported two or more riskfactors, including 9 percent who reported four or more risk factors7.

According to hospital discharge data system (HDDS) data, the numberof inpatients in Tennessee with a primary diagnosis of disease of the heart(DOH) increased by 13 percent from 61,803 in 1997 to 69,628 in 20027.

National DataMedicare payments for inpatient costs associated with DOH for the gen-

eral population increased 57 percent from $845 million in 1997 (in 2002 dol-lars) to $1.3 billion in 2002. The costs paid by other insurers increased by 44percent from $362 million in 1997 (in 2002 dollars) to $523 million in 2002. In2002, myocardial infarction accounted for 23 percent of the DOH inpatientcosts among the general population and 5 percent of DOH physician serv-ice costs among the elderly. In 2002, congestive heart failure (CHF) account-ed for 17 percent of DOH inpatient costs for the general population and 14percent of the DOH physician services costs among the elderly7.

Every year, more than 927,000 Americans die of cardiovascular disease.In addition, more than one-fourth (70 million) of Americans live with a car-diovascular disease. More than 6 million hospitalizations each year are dueto cardiovascular disease. Costs for cardiovascular disease in 2005 are esti-mated at $394 billion, including healthcare expenditures and lost productiv-ity from death and disability8.

Surgical site infections (SSIs) account for 14 to 16 percent of all hospital-acquired infections and are among the most common complications of care,occurring in 2 to 5 percent of patients after clean extra-abdominal operationsand up to 20 percent of patients undergoing intra-abdominal procedures.Among surgical patients, SSIs account for 40 percent of all such hospital-acquired infections. By reducing SSIs, hospitals, on average, could recognizea savings of $3,152 per patient and a reduction in extended length of stay byseven days on each patient developing an infection9.

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Adverse cardiac events are complications of surgery occurring in 2 to 5percent of patients undergoing non-cardiac surgery and as many as 34 per-cent of patients undergoing vascular surgery. Certain perioperative cardiacevents, such as myocardial infarction, are associated with a mortality rate of40 to 70 percent per event, prolonged hospitalization and higher costs.Studies suggest that appropriately administered beta-blockers reduce peri-operative ischemia, especially in patients considered to be at risk. Nearlyhalf of the fatal cardiac events could be preventable with beta-blocker ther-apy9.

Postoperative pneumonia occurs in nine to 40 percent of patients andhas an associated mortality rate of 30 to 46 percent. Many of the risk factorsfor this event respond to medical intervention and thus are preventable. Aconservative estimate of the potential savings from reduced hospitalizationsdue to postoperative pneumonia is $22,000 to $28,000 per patient admis-sion9.

QIO Impact and EffectivenessQSource works with hospitals in the state to help them find and address

opportunities for improvement in specific aspects of care, designated asquality measures by CMS. Individual hospital performance on most ofthese measures is reported to the public on the Medicare web site,www.medicare.gov, Hospital Compare section.

QSource efforts, along with the support and the dedication of partner-ing hospitals and the Tennessee Hospital Association (THA), have beeninstrumental in improving patient care, quality of life, and implementingchanges that work to improve Tennessee's performance on quality of careindicators. Since implementation of QSource's 8th Scope of Work qualityimprovement programs in 2005, hospitals have improved overall statewideaverages for all of the CMS national quality indicators.

For the hospital industry, CMS has outlined the publicly reported topicsin Table 3 as priorities for quality improvement. The movement in theseindicators illustrates positive trending for our state as more and more hos-pitals identify ways in which they can implement culture changes and qual-ity improvement methodologies. For example, our efforts to date have doc-umented improvement compared to 2005 in the areas of adult smoking ces-sation for all topics, 20 percentage point increase in pneumococcal vaccina-tions (pneumonia measure), 13 percentage point increase over baseline forACEI or ARB for LVSD-AMI (acute myocardial infarction measure), and a10 percentage point increase in beta blocker at discharge (acute myocardial

26

infarction measure).

Special QIO FocusDuring the past four years, many hospitals in Tennessee have worked

collaboratively with QSource and each other to improve surgical care. Theimprovements in these four measures are displayed on the "Snapshot"graph on page 20.

SCIP Infection 1: Prophylactic Antibiotic Received within One HourPrior to Surgical Incision (SCIP-INF-1) shows a steady improvement overtime, but approximately 15 percent of eligible patients are not receiving

27

Quality Measures

what they need. This suggests that awareness and coordination of thisaspect of care across the patient care team still has room for improvement.

SCIP Infection 2: Appropriate Prophylactic Antibiotic Selection (SCIP-INF-2) is at a fairly high rate of compliance and suggests surgeons are cog-nizant of the current recommendations for prophylactic antibiotic selectionfor their patients.

SCIP Infection 3: Prophylactic Antibiotics Discontinued within 24 Hoursof Surgery End Time (SCIP-INF-3) shows a steady improvement, butapproximately 25 percent of eligible patients are not receiving what theyneed. With what is known about this measure, the finding for Tennesseesuggests that surgeons are either not familiar with, or are resistant to, thecurrent recommendations for prophylactic antibiotic discontinuation.Administration of unnecessary antibiotic therapy has been linked to theincreasing problem of antibiotic resistance.

The fourth measure - the SCIP All-or-None metric (SCIP-INF-4)- is thenew way of looking at patient care delivery; how many surgical patientsreceived all three aspects of care? Roughly 64 percent of the state's surgicalpatients are receiving all eligible care elements.

Opportunities for ImprovementTennessee has opportunities for improvement in most of the CMS pub-

licly reported and surgical care quality measures.

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Monitoring Quality of Care andServices Provided to MedicareBeneficiaries

Beneficiary Protection Services SnapshotIn addition to its population-based quality improvement activities

in various clinical settings, QSource also improves the quality of careand services provided to Medicare beneficiaries through statutorilymandated case review activities. During the retrospective review ofmedical records primarily selected by CMS to review appropriatenessof setting, utilization, coverage and Diagnosis Related Group (DRG)validation issues, Tennessee physician and non-physician reviewersmay discover care events that represent a departure from medical andhealthcare standards. When these opportunities for improvement areidentified, the QSource case review staff works with providers andpractitioners to correct the noted deficiency and improve future careand services provided to Tennessee Medicare beneficiaries. Statutorilymandated review selections include cases related to the EmergencyMedical Treatment and Active Labor Act (EMTALA), cases where hos-pitals have requested a higher weighted DRG payment and caseswhere program coverage of care and services may be at issue. Otherareas for review include beneficiary complaints and review of noticesof non-coverage.

Among other responsibilities assigned to QSource by CMS is theeffort to assure that only proper reimbursement is disbursed to hospi-tals billing Medicare for care and services under the InpatientProspective Payment System (IPPS). This obligation is primarilyachieved through the Hospital Payment Monitoring Program (HPMP).The purpose of this program is to measure, monitor, and reduce theincidence of improper fee-for-service inpatient payments, includingerrors in DRG coding; provision of only medically necessary services;and appropriateness of setting, billing and prepayment denial in thestate.

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Appendix:

1. Medicare skilled nursing facility use increased between 1999-2003.(MedPac. A Data Book: Healthcare spending and the Medicare program, June 2006).

2. April 2006 Improving Long-Term Care Services in Tennessee: Meeting the Changing Needs of a Growing Population Prepared for AARP Tennessee Auerback Consulting, Inc. Roger Auerback, Inc. AC Maximizing independence, quality and resources in long term.

3. http://www.acponline.org/journals/news/may07/homehealth.htm andhttp://www.homehealthquality.org/hh/about/default.aspx

4. The number of post-acute care providers generally continues to grow.(MedPac. A Data Book: Healthcare spending and the Medicare program, June 2006).

5. Can Physicians Reduce Hospitalizations among Patients Receiving Home Health Services?”Unpublished article authored in 2007 by QSource Medical Directorates Dr. Manoj Jain,Dr. Steven Winbery, QSource analyst Madhuri Annam and Home Health Program ManagerMarian Boxer. Data compiled from CMS Data Compendium.

6. United Health Foundation - America's Health RankingsTM 2006.www.unitedhealthfoundation.org

7. The Burden of Heart Disease and Stroke in Tennessee: 2006.8. Centers for Disease Control and Prevention. Documented within the Healthy States Trends

Report - CSG's partnership to promote public health.9. Quality Source November/December 2004. 10. HealthcareITNews.com Graphs 0507. 18th Annual 2007 HIMSS Leadership Survey.11. HealthcareITNews.com Graphs 0507. Commonwealth Fund Survey of Public Views of the U.S.

Healthcare System, 2006.12. HealthcareITNews.com Graphs 0507. Booz Allen Hamilton Physician Survey 2006.13. HealthcareITNews.com Graphs 0507. Kaiser Family Foundation Agency for Healthcare

Research and Quality, 2006.14. HealthcareITNews.com Graphs 0507. 2007 Citrix Systems, Inc. Survey based on a survey of pri-

vate sector health IT executives.15. National Healthcare Disparities Report: Summary. February 2004. Agency for Healthcare

Research and Quality. Documented within the Healthy States Trends Report - CSG's partnershipto promote public health.

16. Ethnic and racial disparities in delaying or failing to obtain care, 2004.(MedPac. A Data Book: Healthcare spending and the Medicare program, June 2006).

17. Georgetown University Center on an Aging Society.http://ihcrp.georgetown.edu/agingsociety/pubhtml/hispanics/hispanics.html

18. Demographic differences between dual eligibles and nondual eligibles, 2003.(MedPac. A Data Book: Healthcare spending and the Medicare program, June 2006).

19. 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System".20. Quality Source Spring 2007.

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These materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & MedicaidServices (CMS). Contents do not necessarily reflect CMS policy. 8SOW-TN-TASKALL-2007-03