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A physician's reflections.

A Physician's Reflections

My patient was ninety-three years old and suffering from a fairly advanced case of Alzheimer's disease. With assistance from her elderly daugther, she was able to eat and walk short distances, and, for the most part, she was continent. She made little sense to me, but her daughter was able to communicate with her.

Walking on her own one day, she slipped and fell down the stairway She apparently never lost consciousness, but the rescue squad, following appropriately strict rules, took her to the nearest hospital, not the one where she had been on numerous occasions and where I had privileges. In fact, I first learned of her fall two days after her thirty-six-hour hospitalization. Her daughter called and said the hospital had found nothing wrong except for contusions of her face and scalp. But her mother now was not eating normally, was refusing to walk, and had become incontinent. She had become quite a burden. I made a home visit the next day and confirmed the daughter's observations, drew blood tests, and promised, under pressure, that if she did not pick up in the next few days I would hospitalize her.

Two days later, I called the hospital to schedule admission, citing "altered mental status" as the reason for hospitalization. The admitting office informed me that this particular diagnosis required preauthorization from the local Peer Review Organization (PRO) and that I would have to talk first with hospital utilization review (UR). The UR nurse asked for my proposed diagnostic and treatment plans. I tried, "find out why this patient is deteriorating and then treat accordingly." No good. "How about, CT scan to rule-out a subdural hematoma in an elderly woman who fell the week before?" No good. Out patient procedure. "But the woman's bed-ridden, and her daughter caretaker is not in good health herself." They'll help arrange transportation over the next few days. "But the blood tests show she's becoming dehydrated and is anemic," I stretched. They'll see what they can do.

In total, I spent almost forty minutes on the phone that day, during my regular office practice, trying to achieve preauthorization. At one point the chain of communication had me talking to the hospital UR assistant now my ally, who was talking to her supervisor and to the nurse reviewer at the PRO, who was talking to her physician advisor about my frail patient. At about four in the afternoon, the word finally came down from this nameless doctor that he would grant the preauthorization but that I had better document my medical findings awfully well in the chart. Also the social circumstances, although officially social problems were not recognized for purposes of Medicare preauthorization. Yes, boss.

My planned morning admission occured at dinner time. I examined the patient and could find no obvious explanation for her deterioration. I ordered the CT scan for the next morning acknowledging that I had lost a day because of the admission delay. I was immediately challenged by the patient's nurse, who questioned why I was not obtaining the scan as an emergency. After spending all day arguing that my patient was sick enough to belong in the hospital, I now had to justify why she was not so sick that she needed mobilization of hospital resources at night.

Having crossed the preauthorization hurdle, no one bothered me for days. The CT scan revealed no reversible problem that might have resulted from her fall, such as a subdural hematoma--a collection of blood under the scalp lining that presses on brain tissue. The rest of the workup also did not explain her deterioration. She improved somewhat with intravenous hydration, but never achieved her pre-fall condition. After about 10 days of hospitalization, UR began to ask how long she was going to stay. The hoped-for recovery had not taken place.

After much discussion and a family conference involving nursing social service, relatives and myself, the patient's daughter reluctantly agreed to take her back home, probably the appropriate location for her at this point, but with only limited authorized homecare assistance and no other family help. The patient died in her sleep a few days later. the woman who was not sick enough to qualify routinely for hospitalization was, nevertheless, sick enough to die.

A lot could be said about this case, but the focus here is on DRG incentives and utilization review. The case illustrates the following aspects of public and private efforts to limit health care expenditures through new reimbursement incentives and utilization management that I have experienced:

Utilization review determination often are based in criteria that may apply imperfectly to individual cases; the failure of applicability is more a problem in medical cases than surgical. Reviewer discretion is limited by specific procedures and rules. Obtaining exceptions or waivers for good cause, permitted in all UR systems that I have encountered, may be a time-consuming, often frustrating process. Instead of justifying a clinical recommendation to a peer, the process often requires that I satisfy the reviewer's need to not deviate from the criteria. In essence, I have to help out the reviewer, who is doing me a favor by granting an exception. The Medicare UR process, in particular, has become bureaucratized. Private insurance UR, which does not have to be publicly accountable, in my experience tends to be less bureaucratic, although not necessarily less arbitrary.

UR programs are regulatory, not supportive, in design. In the case described above. I could have used assistance before and during hospitalization, for example, to obtain records or information about the patient's previous hospitalization just a few days earlier. Such assistance, which might have affected subsequent clinical decisions and reduced costs, has generally not been available to me, even though the incentives of the DRG payment system theoretically should result in greater hospital-physician cooperation. The PRO, for its part, was prepared to deny authorization for "altered mental status" but had no responsibility for helping arrange an acceptable alternative in a situation that was difficult for the patient, her caretaker, and her physician.

The one area where UR systems do attempt to facilitate appropriate care is discharge planning. At the end of hospitalization, it is possible to mobilize social service, nursing, physical therapy, home care and other support services to permit timely discharge and necessary follow-up care. Here, the hospital has a responsibility and a DRG payment incentive to promote discharge. With the Medicare program, I have not encountered a similar mechanism designed to avoid hospitalization in the first place. A preauthorization denial protects the hospital from becoming directly involved and forces the physician to seek assistance in a much less structured environment where responsibilities are vaguer.

The UR outcomes for patients depend inordinately upon the willingness and ability of physicians to become adversarial, rather than upon the "merits" of the case, even in the face of presumably neutral criteria and bureaucratic requirements. There is usually a loophole, at least for nonsurgical cases. So far, whenever I have fought a preliminary UR decision, perhaps ten times now, I have won. I have become convinced that the UR outcome is largely determined by my skill as an advocate, the particular tactics I adopt in a given situation, and my persistence. But a lot of time and energy is involved, which has implications for other patients. For example, the time-cost of advocacy is not recognized as a billable item and will be passed on to other patients.

The process is enevitably adversarial, but unlike lawyers, physicians have not been trained in "procedure." In a litigious and cost-containment environment, procedure, for example, appropriately documenting the medical record and complying with UR criteria, necessarily becomes important. Yet medical schools and specialty training programs have not prepared physicians for this aspect of medical care. The practical effect of this kind of system is that the UR outcome for the patient may depend, first, on whether the patient's physician is willing to "take the case," in other words, fight a UR decision and, second, on whether the physician is skilled at UR tactics.

In another case, I tried to obtain preauthorization for a single post-surgery hospital day for an elderly patient with an assortment of chronic conditions undergoing a hernia repair. According to PRO protocol, hernia repair is an out-patient procedure. The hospital UR nurse and PRO nurse had difficulty understanding why a seemingly uninvolved internist, rather than the attending surgeon or anesthesiologist, was pressing the case. None of the patient's chronic conditions alone would justify the in-patient day. I was able to prevail by marshalling arguments about the interaction of his various problems, something that I alone, his long-standing personal physician, could make.

Most physician take the responsibility to act as patient advocate very seriously. It is considered an implicit requirement of the doctor-patient relationship, once established. However, DRGs and utilization review force the advocacy role to be explicit and more onerous. A number of people performing utilization review activities have remarked upon the unanticipated acquiesence of physicians generally to UR determinations--the the invisible third party is the "bad guy." In the case described earlier, after the third or fourth phone call, my strongly considered option was to tell the daughter that, despite reasonable efforts. I could not admit her mother to my hospital, and that she should call the city ambulance and hope that she happened upon a sympathetic emergency room physician wherever the ambulance took her.

Beleaguered Physicians

In American medicine in the 1980s physicians feel beleaguered and unappreciated. As never before, their recommendations and decisions are being questioned, constrained, and even overruled. For decades physicians have prophesied the loss of professional autonomy that would ride in on the coattails of national health insurance. Partly because of opposition from organized medicine, we have managed to remain one of the last developed countries that does not guarantee access to basic medical care for its citizens. We have simultaneously created a crazy-quilt, public/private bureaucratic maze that frustrates patients, doctors, and usually, the bureaucrats themselves. Still worse, nearly 40 million Americans have no health insurance, and millions more face financial impediments to obtaining needed health care. And all the while health care costs continue spiraling.

What is to be done? One option, the favorite of many physicians, would be to turn the clock back to a simpler time. Close down the UR bureacracies. Pay hospital and doctors for their costs of caring for patients. To constrain costs somewhat, led patients pay more out of pocket and hope they forgo some care at the margin. Above all, let physicians be physicians--get off their backs and let them do what they were trained to do, provide medical care.

The obvious problem with this solution is the record of failure. The United States spends more on medical care per capita than any other country, even while nearly 18 percent of the population have no regular source of health care.(1) Turning the clock back also would reinforce the orientation of the health care system to providing limitless care for the sick while ignoring the needs of the relatively well, including children. In a number of clinical areas, such as hypertension, arteriosclerotic heart disease and diabetes, we now have the tools to practice truly preventive medicine. But prevention costs money(2) and insurance programs usually exclude coverage for disease screening and treatment programs that facilitate lifestyle change, such as smoking cessation and stress management. Medications that reduce cholesterol and bring down high blood pressure without side effects are remarkably expensive, certainly beyond the means of many Americans. Yet even with DRG incentives and UR programs in place, there is virtually no limit on what a physician can do for a patient in an acute care, hospital setting.

From this practicing physician's point of view, professional autonomy is not all it is cracked up to be. Certainly, physician frustration and diminished work satisfaction have resulted partly from a loss of professional autonomy and control. In my experience, however, a greater source of frustration is the lack of control caused by patients facing formidable barriers to needed care. Many of the nearly 40 million uninsured do not receive care at all or receive care from publicly funded facilities. Many, however, have long-established relationships with private physicians and then lose their health insurance when they lose or change jobs. In these situations, the physician may be prepared to provide free care but has no authority to command other providers necessary in the care of that particular patient to offer cut-rate services.

Even where patients retain basic insurance benefits for hospital and medical care, the cost of noncovered prescription drugs, home care or other needed service may be prohibitively expensive. The result is that physicians, as a matter of daily medical practice, either promote a style of care that their patients cannot afford or, alternatively, negotiate with patients unsatisfactory diagnosis and treatment compromises. The particular physician approach is colored to a significant extent by how the physician views the threat of malpractice. For many it is easier to adopt a style of care out of economic reach for particular patients but consistent with the community standards of care.

To the extent that savings from inappropriate, wasteful care are plowed back into the system to broaden and deepen coverage, cost containment efforts should promote overall physician job satisfaction as well as patient well-being. For all the concern about DRG incentives and accompanying administrative burdens, it seems clear that Congress was willing to pass catastrophic health care legislation this year--the first major expansion in Medicare in nearly two decades--only because of the budgetary protection provided by the prospective payment reimbursement system for hospitals. That expansion will improve patient care and loosen the bind that physicians caring for the poor and middle class are in.

The second major option to present inadequacies is to rely on financial incentives to providers to reduce expenditures. There then would be no need for regulatory bureaucracies to deny or alter care plans because providers, acting in their financial self-interest, would be attuned to reducing costs. The DRG payment system is such an approach. Since the payment is fixed regardless of actual resource use, it is in the hospital's interest to keep down real expenditures. But physicians make clinical decisions, not hospitals. Thus, the next logical extension of the incentives approach would be to give physicians comparable cost-reducing incentives. The Congress, however, concerned about underprovision of care, has specifically declared illegal attempts by hospitals to directly reward physicians financially for limiting care to Medicare beneficiaries.(3)

A number of health maintainance organizations that contract with private physicians--the independent practice association (IPA) model--have adopted physician payment techniques that directly reward primary care physicians, called gatekeepers or case managers, for lower cost clinical practice.(4) Theoretically, HMO payment systems that share financial risks with physicians correct for the inflationary thrust of traditional fee-for-service billing. The incentives to the physicians are clear. First, keep the patient away from consultants and out of the hospital. Secondly, when these services are needed, select lower-priced providers for routine problems that do not require specialized expertise. And, at all times, scrutinize the care provided by referral physicians and hospitals with an eye to the financial bottom-line.

In practice, the theoretical rationale for placing doctors at financial risks breaks down. For a number of technical and actuarial reasons, most HMOs have not used systems that reward and penalize fairly. In these systems, physicians may do well or badly as a function of the flaws in the payment system, not their own performance.

The more fundamental concern goes to the nature of the doctor-patient relationship. HMO managers take the very same physicians who are criticised for providing unnecessary services in a fee-for-service environment and entrust them not to underserve their captive patients in the face of direct economic incentives to do so. Long accustomed to providing too much of the wrong kind of medical care, physicians now are given powerful incentives to withold the right kind. The Medicare program did not make this leap of faith. In setting up the DRG payment system that rewards less care, Congress also set up the PRO program partly as a watchdog against underservice.

In sum, traditional fee-for-service without constraints has a legacy of spiraling costs. On the other hand, substantial risk sharing with providers promises to undermine the doctor-patient relationship. However unpleasant and burdensome UR programs have become, the Medicare model of hospital prospective payment and utilization review is the favored option for balancing the medical needs of individual patients with the interests of the general population to have health care costs restrained.

The DRG ppayment system was a fundamental change in the way Medicare did business. It changed the incentives for hospitals and, importantly, did not alter physician financial incentives. In matters of utilization review and cost containment, this created a clear tension between physicians and hospitals. Hospitals have a clear obligation to their communities or investors to maintain financial viability. Physicians in salaried or fee-for-service practice can remain the patient's advocate, representing their patient's interests against a system that reasonably wants to limit expenditures and asks physicians to justify their clinical recommendations and decisions. The adversarial model is a reasonable one, certainly preferable to existing alternative models, such as the current capitation/risk systems used by IPA-model HMOs, that give physicians large, direct financial incentives to limit or withold medical care.

It is important to recognize built-in protections against an overly aggressive adversarial system. Hospitals cannot afford to antagonize physicians and patients who can choose hospitalization elsewhere. Physicians, for their part, want their hospitals to succeed financially to secure an acceptable environment in which to practice. The PRO is publicly accountable. For the most part, participants in this process are reasonable and seek accommodation where possible.

In short, my argument is not with the model, but rather with how it is implemented. Without question, this system of cost containment constricts physicians autonomy. More than ever before, physicians must justify their clinical recommendations explicitly and face the prospect that their recommendations will be challenged by an outside party. But such external review could be a positive development. Opening up clinical decisions to peer scrutiny should improve care.

The process of utilization review can and should be improved. At the very least, the criteria used by UR organizations to assign lengths of stay or certify appropriateness of hospitalization should become widely known to practicing physicians. Making public the criteria and rules governing UR determinations would, at least, permit informed communication among the various parties involved in a UR decision, reduce the opportunity for arbitrary service limitations, and promote greater efficiency in processing UR cases. Standardizing criteria and procedures would make UR a more routine part of medical practice, reducing the intrusiveness and burden that it now represents for many physicians. Over time, physicians with good records on utilization review could be exempted from certain review activities and a new emphasis on supporting rather than regulating physicians fostered.

Whatever the refinements in the process, it seems inevitable in a $500 billion industry that those paying the bill will ask for greater accountability of how the dollars are spent. Instead of resisting the inevitable, physicians would better serve their own interests and those of their patients by holding the payers to high standards for their cost restraint activities, not by challenging payers' authority to impose such restraints in the first place. (1)Robert Wood Johnson Foundation. "Access to Health Care." Special Report (Princeton; The Robert Wood Johnson Foundation, 1986). (2)Louise Russell, Is Prevention Better Than Cure? (Washington, DC: The Brookings Institution, 1986). (3)Omnibus Budget Reconciliation Act of 1986, PL 99-509. Sec. 9313. (4)Robert A. Berenson. "Hidden Compromises in Paying Physicians," Business and Health (4 July 1987), 18-22.
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Title Annotation:Cost Containment, DRGs, and The Ethics of Health Care
Author:Berenson, Robert A.
Publication:The Hastings Center Report
Date:Jan 1, 1989
Words:3290
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