Medicare peer review organization preprocedure review criteria: an analysis of criteria for three procedures

Article Abstract:

One of the many attempts to curtail health care expenditures in the US, which currently average slightly over 11 percent of the gross national product, is the development of prior or preprocedure review programs which evaluate the necessity of medical care before it is delivered. The federal government is an active participant in such programs because it administers Medicare funds. Medical care criteria are the standards used by review groups in their evaluation, and 48 Medicare Utilization and Quality Control Peer Review Organization (PRO) programs currently apply them to decisions affecting the 32.4 million Medicare recipients. The PROs perform preprocedure review for several specific medical procedures (gallbladder removal, joint replacement, removal of the uterus, and others); however, review criteria are not, at present, standardized. To explore the variability in the PRO preprocedure review for the three most commonly reviewed procedures, a study of review criteria was undertaken. The procedures were carotid endarterectomy (removal of fatty plaque from the carotid artery, which carries blood to the brain); cataract removal; and implantation of a cardiac pacemaker (to control disorders of heart rhythm, or arrhythmias). PRO review criteria were compared with each other and with practice guidelines developed by physicians' groups (American College of Physicians, American Academy of Ophthalmology, American College of Cardiology). The results showed extensive variability among PROs in review criteria for all three procedures, particularly for carotid endarterectomy and cataract removal. In addition, differences were found between PRO criteria and those developed by physicians' associations. Examples are provided concerning this variability. The results illustrate the importance of establishing firm prior review criteria. Four recommendations are presented for improving the preprocedure review criteria, including: the criteria should be publicly available; their content needs scrutiny; existing practice guidelines should be considered in formulating criteria; and practice guidelines should be developed with an eye to their relevance for review criteria. (Consumer Summary produced by Reliance Medical Information, Inc.)

Surveys, Medicare

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Unwanted variations in the rules of practice

Article Abstract:

A research study presented in the March 13, 1991 issue of The Journal of the American Medical Association shows that considerable geographic variation exists in the criteria accepted by professional review organizations (PROs) as indications for three surgical procedures: carotid endarterectomy (removal of fatty plaque blocking a carotid artery, which carries blood to the brain); cataract removal; and implantation of a cardiac pacemaker. PRO approval is necessary for Medicare payment of such bills. Moreover, the study found that PRO guidelines are often quite different from practice guidelines (standards to which physicians are expected to adhere). PRO standards are, at least, visible and subject to analysis: other private review programs have invisible standards that cannot be evaluated so openly. Rather than being designed as absolute standards, perhaps by private managed-care companies, practice guidelines should outline reasonable options for treating a specific condition. They should take into account all relevant outcomes, and should be able to evaluate the probability of particular outcomes, based on the patient's characteristics. All such guidelines should be based on science, and should be subject to evaluation by physicians who are familiar with the clinical problem under consideration. For many conditions, patients will choose different treatments depending on their own goals and values: no single set of formalized treatment guidelines is appropriate for all patients. No third party is equipped to make treatment decisions for the doctor and patient involved. Guidelines can do no more than clarify treatment options: they cannot dictate treatment. (Consumer Summary produced by Reliance Medical Information, Inc.)

Standards, editorial

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A view from out there

Article Abstract:

The author writes of his experiences while pursuing a part-time endocrinology practice in Boise, Idaho, after retiring from 27 years as a clinician-teacher-administrator in a large midwestern hospital. In contrast to common criticisms of the medical profession that characterize many physicians as greedy, uncaring and incompetent, the author concludes that the medical community in Boise is, as a group, conscientious, well-informed, generous with professional time, and strongly committed to scholarly activities. Eighteen percent (56) of the physicians in Boise are family practitioners and 12 are internists. The remainder represent various medical subspecialties, and only a few physicians are general practitioners. The local Veteran's Administration (VA) Hospital is university-affiliated and is an accredited teaching hospital. The two private hospitals in the Boise area, while making some efforts to apportion functions between them, have a relationship that the author describes as 'an uneasy mixture of wary cooperation and fierce competition.' The author attributes the favorable medical climate in Boise to the fact that it still consists primarily of the old-fashioned fee-for-service medical practices. Salaried physicians are employed mainly by the VA Hospital, and health maintenance organizations have not yet gained a foothold in the Boise area.

Health aspects, column, Medical cooperation, Boise, Idaho

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