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Advantages of local UR.

Advantages of Local UR

Physicians recognize that there is a certain amount of waste and inefficiency in the current health care delivery system. They also realize that everyone stands to gain if the areas of waste can be identified and eliminated. Statistics consistently reveal that a small percentage of providers and patients are responsible for a very large percentage of inappropriate care. A properly structured utilization review program is a reasonable way to rid the delivery system of this waste.

All utilization review (UR) programs are based on two premises. First, it is assumed that the practice of medicine can be reduced to a formula, or cookbook. Second, it is assumed that reviewing physicians can accurately determine what constitutes appropriate care for patients without taking histories and examining patients themselves. While these assumptions may prove useful in a large number of cases, they by no means are applicable to all patients and their medical problems. While most UR programs soft peddle these deficiencies in their literature, they are not at all bashful in disclaiming liability for their decisions. They claim that they only deny payment, not treatment. However, these UR firms are fooling themselves, and perhaps their clients, if they don't think that denying payment can and often does have the effect of denying treatment. Next, UR systems all come with built-in biases, depending on who owns them and on their perceived purposes. An insurance company program may be biased to produce lower premiums, even at the expense of quality, in order to remain competitive. A hospital-based system may be biased against decreasing hospitalization. A for-profit UR company may be biased by the profit motive and the competitive environment. Physician-controlled systems can be driven by profit motives or quality of care motives. And on it goes. A UR program basically is selected for its biases. While the ideal UR program, one without biases and based on true and proven ideas, does not exist, we have enough information at our disposal to develop the next best alternative, a properly structured system that minimizes these inherent shortcomings and is dedicated to ensuring that patients receive high-quality care. Everything else--including cost containment--comes in a distant second. The system then should attempt to eliminate inappropriate utilization by identifying the problem and providing education to providers to correct it. Virtually every physician in this country recognizes that health care costs can be trimmed without sacrificing quality. However, quality is an elusive concept that has proved difficult to quantify. Virtually all UR programs pay at least lip service to the assurance of high-quality care. However, they define high-quality care simply as care that complies with their cookbook recipes. Recently, I was looking over the promotional brochure of a large national utilization review service with an excellent reputation. The word "save" or "savings" was used 9 times, "manage costs" two times, and "control costs" once. However, the terms "quality" or "quality of care" were never mentioned. This omission certainly is a reflection of the priorities of the UR company. A good utilization review system must have as a primary goal the identification and modification of inappropriate behavior patterns on the part of both providers and patients. The system should be educational in nature. As a general rule, nonlocal UR systems do a fairly good job in the identification of inappropriate behavior. Where they generally fail is in the educational process necessary to modify this behavior. The vast majority of practicing physicians have a high degree of integrity and concern for their profession. They are willing to change their practice patterns, if--and it is a big if--the changes will benefit their patients in either medical or financial terms. It is much better to have the providers supportive of the UR system and its goals rather than trying to beat the system. Believe me, physicians can beat the system if they feel that the system they are dealing with is unscrupulous or callous. The success of a UR program will be directly related in part to the attitude of practicing physicians toward the program. Finally, the program with the most knowledgeable reviewers will be the best one. Who should these reviewers be? Utilization review nurses are very adept at screening cases and issuing approvals. However, it is totally inappropriate for nurses to deny any patient treatment recommended by a physician. Nurses lack the proper training to deny patients care. All denials must come from physician advisors. Significant physician input in general is an absolute requirement for a UR system to work properly. There have been adequate studies that physician-to-physician contact is the most effective way of modifying inappropriate behavior. Federspell and his colleges, in a series of papers on inappropriate antibiotic usage in children and the subsequent modification of this behavior, demonstrated that physicians are significantly more effective than other professionals in decreasing the number of inappropriate prescriptions. If this type of UR system is applied to a community or group of employees, inappropriate care will be significantly decreased and savings will occur. However, the magnitude of the savings will depend on how much fat there was in the system initially. Some areas practice more efficient medicine than others, and there will be less fat to trim and correspondingly smaller savings.

The Critical Question

Who are the physicians that make the best reviewers? Physicians who become utilization reviewers should have certain characteristics. Their professional reputations, both medical and ethical, should be beyond reproach. They must have the clinical knowledge and practical experience to carry out responsible review. They should be board certified in the specialty that they are responsible for reviewing and should be actively involved in patient care in these same areas. Finally, they must have the respect of the physicians whom they review if they are to be effective in their jobs. While it is possible for nonlocal utilization review physicians to meet the criteria for ethical and professional conduct, appropriate board certification, and active private practice, no utilization review company that I am familiar with makes this type of information available to physicians being reviewed. All that these physicians get is a voice on the phone claiming to be a physician qualified to review their work. One wonders why review companies are hesitant to make this information widely available. Could it possibly be that they are concerned that their reviewing physicians could not pass muster? The vast majority of the nonlocal utilization review physicians with whom I have dealt personally have two serious defects. First, not only are they not board-certified in the specialty under review, but also they usually are not even trained in the specialty. An internist is totally unqualified to make a determination on a treatment plan proposed by a gynecologist for a patient with cervical cancer, just as the gynecologist is unqualified to make a determination on a treatment plan for diabetic ketoacidosis. In fact, the only place in medicine where such absurdities occur is the utilization review process. There is no concern with the quality of care received by the patient in this process. It is true that most long-distance utilization review firms do have some board-certified specialists available for consultation, but most do not utilize them as the initial physician contact. Perhaps they are concerned that these reviewers might better understand the realities of the problem facing the physician being reviewed. Although it would be simple for these firms to require that reviewing physicians be board certified in the same specialty as the physician being reviewed, not a single nonlocal UR system has, to my knowledge, taken this logical step. To be fair, I must comment that, while most local UR systems do follow this procedure, there are some that make the same basic mistake. To be qualified to pass judgment on a medical decision, a reviewing physician must be thoroughly familiar with all of the dynamics that go into clinical decision making. Anyone who is not involved in daily discussions with patients and working with them to make joint medical decisions is totally unqualified to review and reject decisions arrived at by the attending physician. Unfortunately, many of the reviewing physicians who work for nonlocal UR firms lack this qualification and perspective because they are full-time employees or have retired from active practice. In contrast, the vast majority of reviewing physicians for local UR programs are intimately familiar with the constantly changing clinical decision making process because they are in active private practice. Many clinical decisions must be made on the basis of the capabilities of the local medical establishment. This knowledge varies from specific hospital services available to the abilities of individual physicians. Local knowledge is an important consideration in the decision making process and is generally not readily available to long-distance reviewers, thus limiting their ability to make rational and informed decisions. Finally, local physicians being reviewed have no reason to consider those voices on the phone to be those of their peers or to have any respect for reviewing physicians' ethics and professional competence. Usually, the reviewing physician is considered, quite accurately, a hired gun whose job is to place obstacles in the path of carefully thought-out clinical management plans, with no concern for what is best for the patient. Long-distance physician reviewers can do very little to modify the aberrant behavior of certain providers, leaving a large void in the ability of such firms. Local physicians can be much more effective than non-local physicians in bringing this about. They have the respect of their peers, they are available, and they have the backing of the vast majority of the medical community, including referral sources. The most effective method of modifying behavior is face-to-face contact and not a distant voice on the phone or a form letter. When a colleague who is respected by a physician tells him or her that care has been substandard, the physician has no alternative but to listen. With this type of pressure, the physician ignores sound suggestions to modify inappropriate behavior only at significant risk to his or her personal and professional reputation, as well as the financial health of his or her practice. Nonlocal reviewers do not have this respect, the availability for face-to-face discussions, or the community backing so necessary for behavior modification. In a recent survey, 38 percent of physicians stated that they had changed their practice patterns as a result of local utilization review, as opposed to only 26 percent who had changed in response to nonlocal review.

The Local Model

Contrast the usual system of nonlocal review with a system of local utilization review, where the following characteristics occur: * All reviewing physicians are board-certified,

and their review activities

are limited to their specialty. * All reviewing physicians are in the

active practice of medicine. * The backgrounds and credentials of

all reviewing physicians are well known

by the physicians being reviewed, and

they are respected for their clinical

decision making and considered peers. * Reviewing physicians are

knowledgeable of local medical capabilities and

limitations. * Reviewing physicians are available to

actually examine the patient if needed

to resolve a conflict of opinion. * Reviewing physicians are available to

sit down for face-to-face discussions

with physicians who consistently

provide substandard care. The primary argument against local physician review is the old "fox guarding the hen house." In the past, local physician review might have involved many aspects of the "good old boy" network, with transgressions being winked at or swept under the rug. In today's environment, this argument is simply not valid. Physicians do recognize the need to practice cost effective medicine and that the failure to do so, even by a small minority of physicians, reflects on the entire profession. Ample evidence exists that local physicians can and do review their peers in an objective manner and can successfully identify and modify inappropriate behavior. Critics of local review often point to the fear of loss of referrals by the reviewing physicians. In the model local system, physicians are reviewed by physicians in the same specialty, their competitors. It would be extremely unlikely that the reviewing physician would receive referrals from this group. There are equal concerns about reviewing physicians using their UR positions to damage their competition. The Supreme Court, in the case of Patrick vs. Burget, sent a loud and clear message that this behavior will not be tolerated. All things being equal, the final determinant of how successful a utilization review system will be in eliminating inappropriate care and ensuring indicated care will be based on the abilities of the physician reviewers. A properly designed local utilization review program using local physicians as reviewers can achieve excellent results without decreasing the quality of care or rationing care.

William L. Amos Jr., MD, is President of Med-Strategies of Georgia, Inc., Savannah.
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Title Annotation:utilization review; includes related information
Author:Amos, William L., Jr.
Publication:Physician Executive
Date:Jan 1, 1990
Previous Article:Looking ahead.
Next Article:A national perspective on UR.

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