Hospitals monitor resource consumption.
The prospective pricing system enacted into law for the Medicare system in 1983 and increasingly adopted in one form or another by other third-party payers places a high premium on knowing per patient costs and being able to control them. Controlling the costs of patient care depends largely on physicians' prudent utilization of resources. We were interested in determining the degree to which hospitals had established formal mechanisms for monitoring and controlling physician-directed resource consumption, and so me undertook a survey of the hospital-based members of the Academy, using one of the Academy's InterCOMs. Of the 1,140 questionnaires mailed, 178 were returned, a 15.6 percent response rate. Responses were obtained for hospitals of aU sizes. No attempt was made to generate data on the basis of geography. The survey results are summarized in the accompanying table. About a third of the hospitals have physician/administration committees, including the medical director, to study physician-directed resource consumption on a per patient basis. Larger hospitals are more likely to have such committees, and no hospital with fewer than 100 beds reported a committee. Those hospitals with committees for the most part reported that they were effective in reducing costs per case without sacrificing quality. Hospital size did not appear to have any relationship to the effectiveness of the committee. Slightly fewer than half of the hospitals measure resource consumption by physician on a per case/per diagnosis basis. Again, hospitals with more than 500 beds were most likely to do so, and hospitals with fewer than 100 beds reported no such measurements. Just over half of the hospitals factored in patient acuity level in these measurements, and the most frequent response was that the acuity level was generated by nursing services. Respondents were asked how they compare the performance of physicians in terms of resource comsumption for the same type of cases on a cost per case basis. The majority made such comparisons, using cases of the same diagnosis. Larger hospitals were more likely than smaller hospitals to use this technique. Other criteria used to make these comparisons were length of stay and major diagnostic category. About two-thirds of the hospitals gave special attention to antibiotics and other expensive drugs in their monitoring activities. The pattern of responses was mixed when viewed on the basis of hospital size, but the largest hospitals showed the highest usage of special programs for controlling the use of these medications. "Gatekeeper" techniques for monitoring and controlling the ordering of procedures and drugs were less prevalent, with less than one-third of respondents reporting them. Hospital size seems to have little relation to the use of these techniques. Where "gating" is practiced, the pharmacy is the most likely site. For most hospitals, the next most likely "gatekeeping" mechanism was a "computer." About one-third of the institutions with residency programs indicated that educational programs were in place to help control the costs of patient care teaching programs. Larger hospitals were more likely than smaller hospitals to have such programs. Surprisingly, fewer than one-quarter of the hospitals that are attempting to monitor and control physician-directed resource consumption have established ways to keep such programs from becoming cookbook medicine. The largest hospitals were the most likely to have such controls. The results of this survey and further communication with physicians who claim they are busily involved in monitoring and controlling resource consumption show that hospitals have not yet acquired the data and the techniques necessary to deal successfully with the DRG-based prospective pricing system. It is also apparent that there is no single approach that has served the needs of all hospitals. As payment mechanisms become more and more tight, and hospitals are squeezed not just by the federal health programs but by third-party payers in general, the results of surveys such as this one should become skewed more obviously in the direction of greater institutional control over physician-directed utilization of resources in the provision of patient care. a
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|Author:||Davis, Tracy L.|
|Date:||Jan 1, 1989|
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