Peer Review Monthly: Auditing indications for high volume procedures

Dear medical staff leader,

In the best seller book Freakonomics, authors Steven D. Levitt and Stephen J. Dubner pose this question: What do schoolteachers and sumo wrestlers have in common? They link these two seemingly unrelated professions to illustrate how economists can provide statistical proof of behavior patterns. In short, some people, under the right circumstances, will cheat to protect their economic position.

The question for medical staffs today is “How do you know whether all procedures physicians recommend are truly needed?” The vast majority of physicians practice ethically, but just like the few schoolteachers who adjusted test scores so the class would meet state standards (and they would keep their jobs), some physicians push the boundaries of the indications for high-volume medical procedures.

How many medical staff peer review programs look systematically at the indications for high volume procedures? I am not talking about reviewing cases with adverse outcomes to see if a procedure was indicated. I am referring to the routine audit of indications for patterns or practice. Surprisingly, based on our assessment of peer review programs across the country, the answer is that very few medical staffs include such an evaluation when measuring physician competency. When an evaluation is performed, it is often a perfunctory process that is subject to conflict of interest. 

It wasn’t always this way. Twenty years ago, indications for appropriateness were routinely audited internally by the quality department. But now that insurance carriers require pre-approval for procedures, internal audits for indications typically yield very little information because procedures that aren’t indicated aren’t approved in the first place. The Joint Commission surveyors also seemed less interested in these audits. As a result, I believe that over the past 10 years, hospital quality departments with limited resources have turned their attention toward more productive endeavors.

Medicare, on the other hand, did not have a pre-approval process. While it was assumed that hospitals were watching for indications to avoid fraud and abuse, there has been little effort to verify procedural indications.
 
Today, peer review committees need to conduct systematic reviews of indications for two reasons. First, the Office of Inspector General (OIG) has a renewed interest in fraud and abuse as demonstrated by major cases, such as the Tenet Redding Medical Center cardiovascular surgery case, and by the recent initiation of Recovery Audit Contractor demonstration program to recover revenue. OIG’s focus is predominately on cardiovascular, GI, and orthopedic procedures.

Second, plaintiffs' attorneys have discovered the concept of negligent peer review. This allows them to seek corporate damages from the hospital if the peer review process did not function well and allowed inappropriate procedures to go undetected. For example, in one invasive cardiology lawsuit, the plaintiff’s attorney extensively explored whether the hospital and the medical staff peer review process routinely assessed the indications for interventional procedures for a given physician compared to local and national benchmarks. 

Whether we like it or not, it is time to return our attention to systematically measuring procedural indications for the three high volume procedural areas mentioned previously. This could be performed internally with strict criteria. However, wise medical staffs and boards also often use an external source as a component of their process to minimize internal bias.

Hopefully, you will find no issues for concern. But if you do find patterns, it will allow you to address them internally and give the physician a chance to change prior to the regulatory agencies stepping in.

At this point, I believe that not measuring procedural indications is no longer an option.  With the current economic pressures of medicine, it would be naïve to believe that we don’t have a few wayward sumo wrestlers and school teachers among us.

Best regards,

Robert Marder, MD, CMSL
Vice president
The Greeley Company