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Practice standards use with internal partners.

Department of Defense (DoD) experience shows that inadequate supervision of internal partnerships can result in significant increases in CHAMPUS expenditures. These overruns in the past resulted in a moratorium on new internal partnerships in October 1992. An internal ENT partnership was established prior to the moratorium, in 1990, to augment the sole Air Force provider's service to a population of 54,000. The partnership was established and guidelines were formalized before initiation of the agreement. The partnership providers agreed to work with the federal provider in a group practice model in which the Air Force provider was clinic chief, responsible for monitoring quality and appropriateness of care. A study of services provided by partners under the supervision of the clinic chief was compared to services where no direct supervision was performed. The periods studied covered |90 and |91 CHAMPUS reports. The hope was that direct supervision of services would result in cost containment or even cost reduction when compared to the nonsupervised providers.

Material and Methods

"Medical Practice Guides for the Treatment of Recurrent Ear Infections, Tonsillitis, and Sinusitis" were established, focusing on the use of medical therapies in an attempt to reduce both the short- and long-term requirement for surgical intervention. The guidelines were presented to the active partners, and the initial clinics were closely supervised. The clinic chief gave second opinions at the time of consultation. This supervision was performed for only two clinics per provider. Partner clinic scheduling for the first year was limited to the periods in which the federal provider was also in clinic. This allowed concurrent approval of plans that included surgical intervention.

The CHAMPUS health care summary by primary diagnosis for Offutt Air Force Base was reviewed for all claims, including claims for internal partnerships for 1990 and 1991. A comparison of outpatient professional services included number of patients, number of visits, and government costs for both groups (see figures 1-3, pages 23-24).


The number of noninternal partner encounters drop by 266 patients and 1,147 visits. The patient/visit ratio dropped 0.2, while total government cost per visit went up $116. During this same period, the total cost to the government for nonpartner care went up by $490,239. The total number of internal partner patients increased by 596 and visits by 1,389. The patient/visit ratio increased 0.3, while total government cost per visit went up about $9. The total cost to the government went up $69,687.


The overall effectiveness of closely monitoring the internal partners resulted in limiting cost increases to 20 percent from 1990 to 1991, while the increase in costs for unsupervised providers was more than 270 percent. It should be noted that internal partner average costs per visit for both 1990 and 1991 continued to stay below the 1990 unsupervised levels by $20 per visit, with 1991 levels being $142 less than for the nonsupervised providers. The patient/visit ratio was double on average when comparing unsupervised partners with internal partners.


The use of practice guidelines, along with close supervision of partners by a practicing peer, is clearly an effective tool in controlling government costs in the provision of ENT care. This tool could be used in facilities that do not have peer ENT providers if similar guidelines were employed by an organization's providers. This would ensure that all medical therapies have been tried to the fullest extent prior to referral. It is our recommendation that internal partnerships be fostered only in those institutions that are able to supervise the partners. The enforcement of strict treatment guides by an organization prior to the referring of patients could eliminate this requirement.

All providers should understand that the use of a consultant implies a request to employ his or her method of treatment for that disorder. The practitioner's guidelines for care will be rather broad requirements for special treatments. The consultants are not there to be gatekeepers; that is clearly the function of the referring provider.

Continued development of guidelines for other medical and surgical specialties should have similar results. These guides will result in a delivery system that is both higher quality and more cost effective. It is our hope that, in this age of limited resources, we will be able to maintain even higher standards of care without increasing expenditures.

LTC Salvatore A. Zieno, MC is Clinical Director of Managed Care Research, Medical Society of Saint Anthony Zaccaria, Bellevue, Neb. At the time this article was written, he was Chairman, Department of Surgery, and Clinical Director, Managed Care, Ehrling Bergquist Hospital, Offutt AFB, Meb. The opinions and assertions here are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Air Force or the Department of Defense.
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Author:Zieno, Salvatore A.
Publication:Physician Executive
Date:Oct 1, 1994
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