The Arkansas Foundation for Medical Care (AFMC), Arkansas' Quality Improvement Organization (QIO) through July 2014*, worked for several months with a 38-year-old diabetic Medicare beneficiary to ensure he would receive life-saving dialysis services.
Before engaging with AFMC in April 2012, for four years, this beneficiary had only been able to receive emergent dialysis treatments through his local hospital emergency department. As a result, instead of routine dialysis three times weekly, he was limited to emergent dialysis only one or two times weekly, based upon his medical condition. As a result of a previous disagreement with the beneficiary, his physician had discharged him and banned him from receiving services from any facility in either of the two major national providers of this dialysis service. This had essentially eliminated this beneficiary’s ability to obtain life-saving treatments, as 95 percent of dialysis services are provided by one of these corporations.
The beneficiary, being a young father and husband who understood that he was slowly dying because he could not access necessary health care, finally contacted AFMC, his local QIO.
The QIO representative made contact with local End Stage Renal Disease (ESRD) Networks, which work to improve care for patients with kidney failure, as well as the beneficiary’s nephrologist, and the Office of Civil Rights (OCR) federal office in Dallas. The QIO also provided the beneficiary with contact information for his state’s local and federal elected officials. By dealing directly with the OCR’s Deputy Director, the QIO was able to facilitate a decision that the beneficiary had been unfairly discriminated against by his health care provider. The OCR Deputy Director intervened directly with the Centers for Medicare & Medicaid services on the beneficiary’s behalf and, as a result, the beneficiary began receiving regularly scheduled dialysis treatments a few weeks later.
The beneficiary has since stated a goal to become an advocate for other hemodialysis patients as a result of this experience.
*In spring of 2014, CMS determined to separate the consumer type protection activities - case review, beneficiary complaint and appeals - from the quality improvement work for the QIO program going forward. As of August 1, Arkansas is represented by two Quality Improvement Organizations. TMF Health Quality Institute has partnered with the Arkansas Foundation for Medical Care, Primaris in Missouri and the Quality Improvement Professional Research Organization, Inc. in Puerto Rico to form the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) to provide quality improvement work throughout Arkansas, Missouri, Oklahoma, Puerto Rico and Texas. Beneficiary and family centered care services are now provided by KEPRO.