Once Health Regulators, Now Partners

William C. Rollow, a physician who oversees the QIO program for Medicare, acknowledged that the program has "shortcomings, as any program does." But he said that QIOs provide "a very valuable service in return for the taxpayers' investment" and that their role is "more educational today than regulatory."

In 2003 and 2004, QIOs received about 3,100 complaints from Medicare patients -- or about one for every 14,000 beneficiaries. Rollow agreed that the number appears small considering the swelling ranks of Medicare members and evidence of widespread hospital mistakes and deficient care.

Patients and relatives who do complain have less than a one in four chance of having their complaints upheld, a Washington Post analysis of complaint data found. QIO sanctions against doctors and hospitals around the country have plummeted in the past two decades from an average of 31 a year to one a year. When families do manage to pry out a few details, as Shipp did, they are warned that the findings are confidential.

"The way the QIOs treat the [Medicare] beneficiaries is almost like a Third World country," said David A. Swankin, president of the nonprofit Citizen Advocacy Center in Washington. "It's a culture that says, 'Make as little public as you have to.' "

QIO executives say they are hamstrung by Medicare's decades-old rules, which place a premium on secrecy. Those rules even prohibit them from publicly naming the hospitals they work with unless the facilities agree. Few do.

The private groups also are hindered from releasing the results of their collaborations. That means potentially valuable information that could help patients pick a hospital or nursing home stays locked in the groups' computers.

The president of the trade group representing QIOs said he does not know why more hospitals and nursing homes don't publicize their involvement. "I don't know why they don't shout it from the rooftop," David Schulke said.

Schulke defended the provider-friendly approach of the QIOs, saying most examples of poor care stem from systemwide problems, not a few bad physicians or hospitals. He said the American Health Quality Association, the QIO trade group, does not track complaints or sanctions.

"I can't make a value judgment about the number of complaints," Schulke said. "The process is advertised. I don't know why there aren't more or there aren't fewer."

Each state has a QIO, and there is one each for the District, Puerto Rico and the U.S. Virgin Islands. There is little public accountability. Congress rarely examines the groups' operations. Medicare is supposed to file an annual report about their activities with Congress but hasn't for years. Instead, the insurer includes a few pages in an annual report.

Medicare officials do audit QIO performance but declined to provide copies of the audits and haven't responded to a Freedom of Information Act request submitted 17 months ago.

A Question of Impact

The use of outside contractors to monitor quality dates to the early years of Medicare, when Congress authorized the creation of scores of local groups charged with determining whether care was medically necessary and cost-effective.