Background:
During the last two decades physicians have abdicated their role to CMS and payers fo policing each other. Resident physicians are closely supervised and gradually given more responsibility for decision making as they proceed from PGY 1-PGY4. As a chief resident they are responsible for much of the activity of junior residents. Surgical and/or medical residents in certain specialties have their proposed surgical cases reviewed by either a chief resident, or director of the training program prior to scheduling.
During the first year of practice or if the MD change hospitals medical staff regulatons require providers to have a proctor during a certain number of cases to insure proper judgment and competence.
Following this period they are allowed to operate alone. Further proctoring is usually not necessary unless there is a complication or a death. Usually this takes place in a departmental meeting for review. This often serves as a learning experience and is not a punitive affair. If the difficulties persist the physician will be required to obtain further training or more supervision until he demonstrates competence. The entire process is physician led. It is private and confidential and not discoverable by non-physicians.
During the last two decades physicians have been lax in many regards, and have not required chart reviews prior to surgery nor review of treatment protocols unless there is an untoward event resulting in a morbidity or mortality and after the fact.
Current:
The review and authorization procedure now is conducted by insurers for prior authorization by a non-physician or a medical director for a payer. This occurs away from the clinical setting when the physician submits the case history, and proposed procedure. The intensity of the review by CMS and payers is usually determined by the level of cost and number of procedures that are done. The ultimate goal is not patient safety, nor quality of care. It is to reduce cost. Their benchmark for what is reviewed is a simple algorithm. #of cases X cost/case = total cost. Cases that are done in high volume, or high expense will require prior authorization. Such cases or diagnostics include Cataract removal, Hysterectomy, Spine surgery, Interventional cardiology. Many of these are surgical or advanced medical interventions. Many of the reviews are for expensive imaging, such as MRI or CT imaging.
There has been a gradual erosion of self determination and pre-surgical review by physicians and surgeons, allowing CMS and payers to intrude into physician-patient relationshiphs.
Future:
Physicians will reclaim the role of ascertaining quality control and prevention of abuse and fraud by peer-review of expensive and high volume procedures prior to procedures, both diagnostic and Invasive. It will be required that all pre-surgical cases be reviewed by another member of the department prior to scheduling (except for emergent or urgent need.) The insurance company should not have any role in prior authorization. That will be the purview of medical staff, much like PQRI was performed in the late 1980s for cataract removal.
This system will allow peer and case review for the medical staff and immediate feedback for non-compliant providers.
The insurance system will be simplified. Delays and/or denials could be eliminated for review, authorization and payments. Administrative expense could be reduced. This will require some additonal time and effort by physicians. That is the price for professional freedoms. Freedom takes effort to maintain.
Is this an idealized vision for the future, or will it come to pass? Only you and I can decide.
The time has come to draw a red line in the sands of health care.
