Economic credentialing is here to stay.There is no consensus on the meaning of economic credentialing Economic credentialing is a term of disapproval used by the American Medical Association (AMA). The association defines the term as "the use of economic criteria unrelated to quality of care or professional competence in determining a physician's qualifications for initial or . The American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. defined economical credentialing as "the use of economic criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing hospital medical staff membership or privileges."[1] A less controversial definition is "the evaluation of medical staff member based on resource utilization."[2] This evaluation of economic credentialing indicates that, although there is no common ground or understanding yet, the governing boards Noun 1. governing board - a board that manages the affairs of an institution board - a committee having supervisory powers; "the board has seven members" of health care organizations will have to contend with this new aspect of credentialing in the near future. While a denial of privileges is almost never exclusively done on economic grounds, the questions that are asked are: Has the physician preserved the financial viability of the organization and used resources in an efficient fashion? Has the organization documented efforts to educate him and modify his behavior? Has the organization offered viable, less costly alternatives of care? Thompson states that "medical doctors are the primary determinants of variable health care costs." Thus it is appropriate for the governing board to expect physicians to demonstrate both high-quality services and efficient practice habits.[3] Physicians must be advised of cost-containing avenues in the care of the patient; otherwise their behavior is appropriate. In Edelman v. John F. Kennedy "John Kennedy" and "JFK" redirect here. For other uses, see John Kennedy (disambiguation) and JFK (disambiguation). John Fitzgerald Kennedy (May 29, 1917–November 22, 1963), was the thirty-fifth President of the United States, serving from 1961 until his assassination in Hospital (No.c-2104-80 [N.J. Super. June 25, 1982], cert. denied, 96 N.J. 289 [1984]), there is difficulty in separating physicians' quality of care from economic credentialing. Besides overuse overuse Health care The common use of a particular intervention even when the benefits of the intervention don't justify the potential harm or cost–eg, prescribing antibiotics for a probable viral URI. Cf Misuse, Underuse. of inpatient services inpatient service Managed care A service provided to a hospitalized Pt. Cf Outpatient service. , there were complaints from nursing, social services social services Noun, pl welfare services provided by local authorities or a state agency for people with particular social needs social services npl → servicios mpl sociales , and patients. The physician's inability to work with others was equally important in the final decision.[4] In this case, the physician's being uncooperative and disruptive was probably the main cause of his denial of privileges. The best example of denial on the basis of pure economic reasons is a Florida case, "Rosenblum v. Tallahassee Memorial Regional Medical Center, in which the physician was in direct business competition with the organization within its geographical market. In Alonso v. Hospital Authority of Henry County, 175 Ga., App. 198, 332 S.E.2d 884 (1985), a hospital-based physician hospital-based physician A physician who provides 'clinical support' for Pt management, performing medical services within a hospital/health center Examples Radiologists, anesthesiologists, pathologists, ER physicians– refused to submit bills to Medicare in a form by which the institution could maximize its revenues. The court held that the physician's refusal to cooperate with the hospital's efforts to maximize income constituted just cause for termination of the contract. An appellate court A court having jurisdiction to review decisions of a trial-level or other lower court. An unsuccessful party in a lawsuit must file an appeal with an appellate court in order to have the decision reviewed. reaffirmed the decision (175 Ga. App. at 200-201).[5] Economic common sense indicates that organizations should not be forced to jeopardize their economic survival. Some states concur CONCUR - ["CONCUR, A Language for Continuous Concurrent Processes", R.M. Salter et al, Comp Langs 5(3):163-189 (1981)]. with that principle. Florida law The jurisprudence of this state offers major differences from doctrines prevailing in the United States at either the federal level or that of the various states. Homestead exemption from forced sale, the dangerous instrumentality doctrine, the right to privacy, and the Williams allows hospital boards to consider elements besides the usual training and medical qualifications in credentialing decisions. California statute instructs boards to "provide for the control and use of the physical and financial resources of the hospital." Other states may have similar laws.[6] A hospital that fails to reappoint Re`ap`point´ v. t. 1. To appoint again. reappoint vt → volver a nombrar reappoint vt (to job) → physicians who do not meet revenue projections could be viewed as requesting referrals or money from the medical staff in exchange for privileges. Where medical staff privileges staff privileges Admitting privileges The rights that a health professional has as a member of a hospital's medical staff, which includes hospitalization of private Pts, participation in committees, and in decisions relevant to the hospital's future. appear to be offered to physicians as an incentive to refer patients to the institution, the arrangements will be suspect under the Medicare/Medicaid fraud and abuse law. Furthermore, such credentialing decisions are not protected from liability under federal immunity provisions, as they are construed to violate the Medicare/ Medicaid fraud Medicaid fraud The fraudulent billing of Medicaid by physicians or other health care providers, especially international medical graduates and psychiatrists. See Medicaid. and abuse law.4 If physicians are given clinically valid data that are relevant to their practices, they will self-correct.[7] In the State of Maine, obstetricians, when they were advised that their cesarian section rates deviated from the mean, made efforts to adjust their practices to the mean. Efforts have been made to mediate in these complex situations. California has a mediation panel that renders non-binding decisions. Florida has began a mediation process similar to the one in California.[8] A study of 2,000 chiefs of medical staffs found that more than 95 percent looked at patient outcomes as one of the best ways to determine quality of care; 85 percent considered the degree of compliance with utilization guidelines and protocols as one of the credentialing factors. This is usually a form of economic credentialing. About 65 percent of respondents considered the doctor's admissions generating potential as a criterion.[9] This credentialing criterion can be misconstrued and should only be applied after due consideration of the consequences of a denial on that basis. Payers, such as Southern New England Telephone The Southern New England Telephone Company (commonly referred to as SNET by its customers) started operations on January 27, 1878 as the District Telephone Company of New Haven. It was the founder of the first telephone exchange, as well as the world's first telephone book. Company, are beginning to audit physicians' practices in their preferred provider networks. The audit will check to see if physicians are overusing or otherwise are providing inefficient care. Paul Pietzch, president of the Health Policy Corporation of Iowa, a coalition of employers, states: "Employers don't need to know how hospitals hold the physicians accountable. Employers want accountability from hospitals in terms of outcome data. Once that is done, the dynamics start changing. Suddenly the hospital administrator says: |Hey, my customers are telling me what they want.' He is then empowered to say to the physician, |Do you care about keeping half of our business? If you do, you need to be my partner and see that you do the best job you can.' A job that produces a service that has quality, satisfies the customer and is efficient."[10] Navistar, a truck and bus manufacturer in Chicago, Ill., experienced what it considered high costs for heart surgery. In response, it contracted directly with five centers of excellence. The hospitals were evaluated on many factors: outcomes, resource utilization, and the desire of the hospitals and the physicians to work with Navistar over the long term, including economic credentialing.[11] Hospitals and other health care organizations have exerted a monitoring role with respect to the practice behaviors of the physicians. The scope of this monitoring power has been enlarged by the Sussman v. Overlook Hospital (95 N.J., Super.418, 231 A.2d 389 [1967]) decision, which allows the hospital to monitor "capacity to cooperate ... willingness to abide by To stand to; to adhere; to maintain. See also: Abide the staff organization ... be a cooperative citizen in the medical community." In other jurisdictions, such as in Florida's Harry Rosenblum v. Tallahassee Memorial Regional Medical Center (No. 91-589, Cir. Ct of the second judicial Circuit, Leon Co. Fla. [June 18, 1992]) , the courts are beginning to uphold decisions on credentialing that are related to the good of the institution.[12] Measures Suggested Considering all these points, one must conclude that certain steps are required: * Be proactive. Sell the benefits of economic credentialing to your medical staff as a survival tool during these days of cost crunching. * Sell economic credentialing and the concept of the responsibility of physicians in containing health care costs to the community. * Include economic credentialing as part of your appointment and reappointment reappointment Hospital practice The renewal of medical staff membership and privileges of a practitioner whose previous service on the medical staff has met the staff's standard of Pt care. See Appointment. processes in the medical staff bylaws The rules and regulations enacted by an association or a corporation to provide a framework for its operation and management. Bylaws may specify the qualifications, rights, and liabilities of membership, and the powers, duties, and grounds for the dissolution of an . * Be aware of antitrust implications when dealing with economic credentialing. * Foster and communicate alternatives that contain cost, preserve quality, and are safe medicolegally. The provision of alternatives and education are the keys to riskfree economic credentialing. * Provide in the bylaws for education, counseling, mediation, and binding arbitration prior to denial of privileges. * Demonstrate the relationship between quality and economic credentialing in a positive fashion. * Always consider the public relations public relations, activities and policies used to create public interest in a person, idea, product, institution, or business establishment. By its nature, public relations is devoted to serving particular interests by presenting them to the public in the most and market effects of an economic credentialing denial. * Education and behavior modification behavior modification n. 1. The use of basic learning techniques, such as conditioning, biofeedback, reinforcement, or aversion therapy, to teach simple skills or alter undesirable behavior. 2. See behavior therapy. are the keys. Punitive measures such as denials of privileges are the last resort. References [1.] Andressen, D. Economic Credentialing: Appraising Physician Profitability. Chicago, Ill.: American Medical Association, 1993. [2.] Blum, J. "Study Examines Role of Hospital Boards in Physician Evaluation." Modern Healthcare 20(3)30-1, Jan. 22, 1990. [3.] Thompson, R. "Changing MD Behavior through Continuous Quality Improvement." Trustee 44(10):16-7, Oct. 1991. [4.] Bennesh, K, "Credentialing Criteria puts Hospitals at Risk." New Jersey Law Journal 133(14), April 5, 1993. [5.] Kolb, D., and others. "Economic Credentialing: Financial Analysis and Medical Staff." Topics in Health Care Finance 19(3):58-66, March 22, 1993. [6.] Roth, M. "Factoring in the Financials, Court Gives Nod to Economic Credentialing." Hospitals 67(7):36-40, April 5, 1993. [7.] Johnson, J. "TQM (Total Quality Management) An organizational undertaking to improve the quality of manufacturing and service. It focuses on obtaining continuous feedback for making improvements and refining existing processes over the long term. See ISO 9000. Approach May Help Solve Physician Practice Problems." Trustee 45(4):11, April 1992. [8.] Greece, J. "Florida Groups The Florida group (Sp.: grupo Florida) were a Buenos Aires-based avant-garde literary group in the 1920s, known for their embrace of "art for art's sake". Seek to Form Panel." Modern Healthcare 24(4):8, Jan. 25, 1993. [9.] McCormick, B. "Is Economic Credentialing Really Thriving?" American Medical News 35(46):1,9, Dec. 14, 1992. [10.] Paul Pietzch, President of the Health Policy Corporation of Iowa, personal communication. [11.] Frieden, J. "Should Employers Make Physicians Account for Costs?" Business and Health 10(3):40-50, March 1992. [12.] Bennesh, K. "Economic Credentialing and the Fraud and Abuse Caveat [Latin, Let him beware.] A warning; admonition. A formal notice or warning given by an interested party to a court, judge, or ministerial officer in opposition to certain acts within his or her power and jurisdiction. ." Medical Staff Counselor 6(4):27-35, Fall 1992. |
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