Peer review and healthcare reform

I typically use my crystal ball to gaze into the future of my hometown baseball teams, the White Sox and the Cubs, but this spring, I thought I could use it for something less predictable—namely, the impact of healthcare reform on peer review. In general, the potential affect of the recently passed legislation on our social and economic systems has sparked a debate unlike few other subjects in recent memory. While I did not expect my crystal ball to give me all the answers, I did hope that it might shed some light on the area in which do much of my work: peer review.

As we all try to sort through the rhetoric and realities of this new bill, a couple of themes emerge that would affect how healthcare is evaluated and who gets to evaluate it:

• The majority of our healthcare reimbursement system will remain in the private sector. 
• With the expansion of Medicaid and maintenance of Medicare, there'll still be a significant public component.
• To make any of these changes happen, healthcare costs need to be reduced.
• Regulators will increasingly scrutinize healthcare outcomes in an effort to prove that the cost justifies the result

How will these themes affect peer review? Healthcare providers will continue to be reimbursed by the private sector and the public sector. The private sector evaluates appropriateness of care through the preauthorization process and increased scrutiny of individual services provided, using denials as the primary tool. The public sector (Medicare and Medicaid) rely largely on retrospective review and overall patterns, using audits and penalties as a primary tool.

Both public and private systems also are moving into pay-for-performance models based on patient outcomes. Pay-for-performance models encourage healthcare providers to perform patient care processes reliably (think core measures) and achieve better-than-expected outcomes for similar types of patients.

Where does peer review enter into the equation? My crystal ball says:

• Payors will more heavily scrutinize healthcare providers based on indications for procedures and treatments, not just adverse outcomes. 
• Healthcare providers will need to be more aware of the guidelines or standards payers are using and consider them in the evaluation of physician care. 
• Healthcare providers will need to more proactively measure their compliance with payers. 
• Physicians will need to comply with evidence-based medicine through rate measures of key processes. 
• In relation to outcomes, healthcare providers will need to be willing to look more deeply into improvement opportunities rather than automatically accepting adverse results as simply due to patient factors.

Why should medical staffs take on this burden? There is no question that external reviewers will be increasingly involved in evaluating physician care. Many of these systems rely on computer algorithms and non-physician reviewers using predetermined guidelines. However, to the extent that we create strong internal peer review systems that identify physician improvement opportunities early on, we will do a service to our medical staff members by preventing them from falling into patterns that would be identified by external sources. If we are more proactive in our evaluation and improvement activities, we will spend less time reacting to the findings of the extra forces around us.

I also see the potential for a judicious increase in hospital-requested external peer review to help medical staffs deal with those peer review issues that the internal systems struggle with, such as conflict of interest and lack of expertise. Also, as patterns of care come under greater scrutiny through Recovery Audit Contractor (RAC) audits, proactive external assessment for appropriateness will help identify patterns earlier and prevent potential penalties.

My crystal ball says that peer review does not need to change fundamentally. It just needs to step up to the plate and be sure it gets the job done. And if it does, the cost-quality equation will justify the need for staff and information system support that the medical staff requires to do the job well.

Robert Marder, MD, CMSL, is the vice president of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.