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Hiding your criteria will never work.

In this era of managed care, the message has been that the health care industry has provided inappropriate or inefficient care, causing the ruination of medicine and ultimately of the U.S. economy. Published research data on small area analysis have demonstrated marked differences in utilization rates for the same surgical procedure in various locations. Researchers and others have logically surmised that criteria used by providers in recommending these procedures have also varied from location to location. Correction, therefore, will require attention to the establishment of logical and defensible criteria.

Payers and policy makers have concluded that providers and patients overutilize available resources and that the need for controls is overwhelming. They have installed mechanisms, such as prior authorization and concurrent review, that are intended to rein in those excesses. Unfortunately, these mechanisms have been impressed on the provider community without its cooperation for the most part. In many instances, especially in the beginning, the criteria used for review purposes represented little more than the professional opinions of the reviewers. Medical policy development was in its infancy, and postpayment review was used in an attempt to preclude payment for "abusive" practices.

Insuring organizations and independent review companies have developed the ability to analyze data to determine the reasons for the performance of medical procedures. Millions of dollars were spent on the development of these criteria and, especially with the explosion in managed care, on computer applications to screen phone requests for prior authorization. Because of the economics of reviews, new and high-cost procedures have been studied the most. These organizations and their work offer individual insurers and review companies the advantage of using "nationally recognized standards" for their own reviews. For the most part, both the information and the logistics of review mechanisms have been proprietary. Providers were restricted from knowledge of the criteria so that they could not "game" the system or "cheat" on their reimbursement requests.

Blue Cross/Blue Shield plans usually used the Appropriateness Evaluation Protocol (AEP) criteria for hospital admissions and continued stays. The criteria were developed during the 1970s with government funding in an attempt to study practice patterns. InterQual's severity of illness/intensity of service (SI-IS) criteria were also widely used and copied and were thought to be in the public domain until the developers recently threatened legal action. These and other criteria were then used by insurers and other intermediaries in adjudicating claims under the federal Medicare and Medicaid programs. Unfortunately for the government, insurers could not admit to using proprietary criteria for fear that they would be discoverable and lost to the public domain. Eventually, the Health Care Financing Administration issued payment guidelines for many procedures, particularly for the rental or purchase of durable medical equipment. Definitions of "skilled care" were developed by HCFA as payment guidelines for nursing and home care. These HCFA guidelines and definitions have often been incorporated into the medical policy and criteria of providers and insurers.

At a November 1991 Medical Utilization Conference in Washington, D.C., the 300 private utilization companies were urged to standardize and release their criteria. Legislative initiatives to monitor or control this exploding industry have been passed or considered in 27 states. The credibility of the industry has been questioned, as several companies seem to be hiding their decision-making processes. Responses of "trust me" are not being accepted by employers, providers, and policy makers.

Preferred Health Care, Ltd., a major utilization review company for the delivery of mental health care, recently published its medical criteria for care and payment. Alex Rodriquez, MD, FACPE, the firm's Corporate Medical Director, says that he is impressed with the high interest of providers in meeting the requirements of national professional practice standards. He calls for an organized approach to reach the necessary consensus and points out that providers, payers, and consumers cannot act independently and be effective. National medical specialty organizations are also very interested in being involved in the adoption of criteria. Preferred Health Care is now working with the American Society of Addiction Medicine and the National Association of Addiction Treatment Providers to create a national consensus for substance abuse therapy.

Criteria have traditionally been developed by studying the practice patterns of providers. Medical students have been taught by core curriculum methods for 20 years. Residents learn through the education processes of their professional and specialty societies. Standards and guidelines for practice are now being published by the American Medical Association. JAMA regularly publishes articles outlining the scientific reasons for practice decisions. Specialty societies have also developed guidelines for physicians.

The reasons for the performance of medical treatments can and must be explained simply and efficiently. Any specialist should be able to explain to a generalist, another specialist, or a patient, in a few sentences or in a phone call, the logic behind a treatment decision. Criteria developed by one review firm list more than 1,800 reasons for a hysterectomy and more than 4,000 reasons for CABG surgery. How many computer screens and how much time woult it take to adjudicate decisions on these procedures? What would be the cost of review? Common sense must be incorporated in the review system. Why can't we publish agreed-upon criteria in algorithms and decision trees, as they do in Patient Care magazine? I believe that the adjudication of most treatments can be described in five or fewer reasons.

Physicians used to maintain their superiority by treating patients in a random manner so that nurses could not second-guess their reasons. Now the team approach of providers, payers, and consumers requires an understanding of the processes and reasons for medical interventions. If providers were given criteria beforehand, the cost of review would be reduced and the quality of care improved. The American College of Anesthesia has adopted standards or monitoring for anesthesia and has reduced the cost of risk and lawsuits by improving patient outcomes.

If you accept the Deming method, working with providers in designing care decisions and improving the processes of care will improve reliability and quality. Listening to the practicing physicians will be much more rewarding than the Delpi approach to teh development of standards, guidelines, and criteria. Publication and acceptance of national standards would reduce malpractice risk for providers practicing in a cost-effective manner. The current medical approach and our historical medical education hold the provider to the standard of "more of the latest" and "most expensive must be better."

With the explosion in new procedures and diagnostic tools, the job becomes even more complicated. Only with cooperation will progress be made. Physician executives must be involved, especially in the expanding outpatient setting. Quality of care requires the we go past the period of episodic approval or denial of individual medical decisions and move forward to individual case management by qualified, informed, cooperative providers. Efficiency is a must.

John J. Saalwaechter, MD, MBA, is Executive Director, American College of Medical Quality Foundation.
COPYRIGHT 1992 American College of Physician Executives
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Author:Saalwaechter, John J.
Publication:Physician Executive
Date:Jan 1, 1992
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