Medical Peer Review & Blogging

http://blogsurvey.backbonemedia.com

"John: How can you take the concept of peer review and use it in the world of blogging?

George: I think this awaits creative minds to figure out how to do it best, I’ve found that the most important peer review always happens after publication. Peer reviewers may number as many as ten, they are chosen for their expertise, and reviewers advise editors if something should be published. The peer review process has been going on for 300 years, sometimes the peer review process is imperfect, and the real reviews happen in the letters column, the readers tell you about anything they are concerned about very rapidly.

Yes, the letters are as least as important as the review process. I think one area where you can criticize the peer review process, is that it tends to follow a safe route, only publishing the non-controversial articles, while blogging is marvelous in that bloggers are free to publish, as a blogger can get out their piece without the editorial control."

Inherent Conflict Between Doctors & Hospital Administrators

http://doctorrw.blogspot.com/

"There appears to be a burgeoning power struggle between hospital administrators (and their lawyers) and some rank and file physicians. It’s an unintended consequence of the Health Care Quality Improvement Act of 1986, which sought to protect hospital peer review. It provides immunities for hospitals in the peer review process, greatly enhancing their power to discipline physicians. Some physician groups are concerned that this has lead to abuses of peer review as hospitals, for a variety of reasons, increasingly seek to control doctors, setting increasingly narrow boundaries for behavior. "

Contracts & Drug Utilization Review

http://hcrenewal.blogspot.com/

"In particular, Eli Lilly & Co offers its new anti-depressant Cymbalta ( duloxetine HCl) at a discount but with provisions that bar "negative D.U.R. (drug utilization review) correspondence to physicians," and "negative educational counterdetailing." Thus the hospital or insurer would be contractually prohibited from communicating with doctors in ways that might discourage them from prescribing the drug. "

Proscar vs. Propecia - Insurance Ramifications

http://www.recordonline.com/

Yet cracks in the system enable the baldness-fearing man to coast out of the pharmacy with bottles of bright blue Proscar pills instead of small, tan Propecia ones. Some insurers, like Cigna, call for prior authorization, or pre-approval, before such a prescription can be filled. But other insurers acknowledge that they have no way of knowing, or questioning, what a drug is being prescribed for – even when a 23-year-old is receiving medicine for an enlarged prostate, a condition most commonly found in men over 60. "I wouldn't presume the patient doesn't have a prostate condition," said Karen Early, a spokeswoman for Empire Blue Cross Blue Shield in New York. Doctors across the country are divided about Proscar's unintended use.

Doctor Ratings Can Work

http://online.wsj.com/

"Despite these problems with the current approaches to ratings, the idea of objective quality ratings for doctors -- ideally public ratings -- is a good one. I'm involved with a practice-quality research effort that could one day lay the groundwork for an unbiased, reliable system that could help patients and motivate doctors to do better.

The research is conducted through the Practice Partner Research Network, a joint effort whose participants include a medical software company and the Medical University of South Carolina, which designs and conducts the research. The university studies data from my electronic medical record on about 75-80 quality indicators -- things like immunization rates, blood pressure, cholesterol management, diabetes control, and colon, breast and cervical cancer screening rates. My aggregate data -- the data is stripped of patient-identifiable information -- is compared with data from about 100 practices across 37 states."

Utilization Review Defined

http://www.google.com/

The process of assessing the delivery of medical services to determine if the care provided is appropriate, medically necessary, and of high quality. UR may include review of appropriateness of admissions, services ordered and provided, length of stay, and discharge practices, both on a concurrent and retrospective basis.

www.healthinsurecoverage.com/

Evaluation of the necessity, appropriateness and efficiency of the use of medical services and facilities.

www.personal-injury-help-center.org/

A systematic means to review and control patients' use of medical care services as well as the appropriateness and quality of that care. Usually involves data collection, review and/or authorization, especially for services such as specialists, emergency room use and hospitalization. Also known as utilization management or control.

www.insurance.wa.gov/

A general term for an insurance or managed care plan's review of the health care provided to its members. This includes such activities as granting prior approval before hospitalization or doing certain procedures; coordinating a patient's care and rehabilitation once they have left the hospital; and making decisions about whether a second opinion is necessary .

missourifamilies.org/

A mechanism used by some insurers and employers to evaluate health care on the basis of appropriateness, necessity, and quality. For hospital review, it can include pre-admission certification, concurrent review with discharge planning, and retrospective review.

www.gdn.edu

A review and approval of an in-patient hospital service or services provided, or to be provided, to a patient enrolled in a managed care plan. The review determines if the care is Medically Necessary. The utilization review may be performed by the managed-health-care plan or by an organization or entity acting as an agent for the managed-care plan. ...

www.northshorelij.com/

A system to evaluate dental use patterns that helps to identify and prevent program abuse.

pahu.org

A formal review of patient utilization or of the appropriateness of health care services, on a prospective, concurrent, or retrospective basis.

www.woundcare.org/

Genetic Makeup Off Limits For Disability Review

http://www.nj.com/

The Veterans' Disability Benefits Commission has voted unanimously that a veteran's genetic makeup, which might show predisposition to certain illnesses before entering service, is not a reasonable topic for the commission to study in its review of "service connection" and disability payments.

During an Oct. 14 public hearing in Washington, D.C., the commission also rejected, on a 10-1 vote, a proposal to study whether veterans' disability benefits should be reduced at some "normal" retirement age to reflect the typical income drop of most American workers as they retire.

URAC and Health Care Member Portals

http://www.redorbit.com/

High-tech health care and the growth in consumer-directed plans will create greater demand for user-friendly information on both quality and cost. Combined with an increasing interest among consumers for personal health records, there is ample evidence that the companies who provide the best and clearest information will carve the top out of the consumer-directed market.

Alan P. Spielman, chief executive officer of URAC, will connect the dots between growing consumer demand and an emerging consumer-directed health care market as he presents "A Business Case for Website Accreditation as Consumers Demand Evidence-based High-Tech Health Care" Tuesday, Nov. 8 at AHIP's Business Forum 2005 -- New Products and Business Expansion, held in New York. Co-presenting with Spielman will be Bruce Taffel, M.D., chief medical officer for Blue Cross/Blue Shield of Tennessee's Government Business and Emerging Markets and chief medical officer of SharedHealth.

The Problems With Peer Review

http://www.rangelmd.com/

Despite the expense, hospitals should liberally use independent outside review when evaluating a case of reported poor patient care, incompetence, or physician misconduct. This helps to protect the hospital against accusations of trumped up charges and helps to inject some sense of impartiality into the peer review process. Another solution would be to establish independent state peer review committees that would have no professional or personal bias and who's rulings would be binding to both the hospital and the physician.

It's not just that too many good physicians are becoming victims simply because they dared to report poor patient care but the system can't properly deal with truly negligent poor physicians who tend to be protected because of their economic value to the hospital. I'd be willing to guess that many physicians in this country know of at least one other physician who is widely regarded to be a potential threat to patient care but no one is willing to speak up because the physician in question brings a lot of business to the hospital and has considerable political clout.

Technology Can Be Used To Fight Healthcare Fraud

http://www.healthcareitnews.com/

"A national health information network and electronic health records can be used to fight healthcare fraud, which costs the government an estimated $51 billion to $170 billion annually, according to two reports released today.

The reports, commissioned by the Office of the National Coordinator for Health Information Technology and HHS, looked at the role of automated coding software in preventing healthcare fraud and examined ways that a nationwide interoperable health information technology infrastructure could help prevent and detect fraud. Healthcare fraud can include incorrect reporting of diagnoses or procedures to give doctors higher payments, false diagnoses and billing for services a patient never received. "

Hospital Peer Review & Employment Contracts

http://www.aaem.org/casesandcomments/comments13.shtml

"In essence, if you want more than hospital peer review, then you have to negotiate for more in your employment contract. Most important is to realize the fine line drawn between exclusion from a roster and revocation of your hospital privileges. In California, under Fenton, removal from a roster elevates your claim to a revocation of privileges. This is the exception to the rule-in most states your privileges may be left intact but you can be removed from the schedule at the discretion of the "closed" system contract manager. That means no peer review. The majority of states follow an "employment at will" doctrine, which means you can be taken off the schedule for a good reason, a bad reason, or no reason at all. In this scenario without a clause in your contract protecting your shifts, your privileges must be revoked in order to trigger the federal minimum requirements of due process. Once again, that means your situation may controlled by the quasi-judicial powers of a hospital-based peer review committee in regards to the granting or denial of hospital privileges. In the event that the peer review panel upholds the termination of your privileges, the only legal recourse you have in most states is if you can allege and prove malice or tortuous activity on the part of the hospital peer review panel.

Remember, in most contracts that you will be asked to sign, the contract holder can take you off the schedule and leave your hospital privileges intact. In other words, if you accept shifts and credentialing through a contract holder, you can be credentialed at a given hospital and yet not be given any shifts on the schedule if your contract holder deems it his or her will. The net result in this scenario is that you may not even be entitled to hospital peer review, unless your hospital privileges are revoked in the process of being terminated. You have to insert a clause in your contract to assure you of a certain number of shifts and provide for recourse in the event that these are denied."

URAC On Independent Review Organization Accreditation

http://www.urac.org/

"These URAC standards assure that organizations that perform this service are free from conflicts of interest, establish qualifications for physician reviewers, address medical necessity and experimental treatment issues, have reasonable time periods for standard and expedited reviews, and appeals processes. An organization with this URAC accreditation strives for a fair and impartial review process that is of benefit to both patients and physicians with grievances. The National Association of Independent Review Organizations has issued a position statement urging state and federal recognition of the URAC standards to promote consistency and fairness for both patients and employers. "

Hospital Peer Review Tips For Physicians

http://www.miamimed.com/

Being investigated by the peer review committee of a hospital is one of the most stressful things a physician can experience. Yet, knowing a little law and exercising some common sense can help dramatically.

Peer review activity is authorized by both federal and state law. The reason for the laws is to ensure that patients are well cared for in licensed health care facilities. As such, the laws make peer review simple for the reviewing facility. For instance, facilities must provide the affected physician a “fair hearing” with certain procedural benefits like the right to examine and cross examine witnesses and also the right to submit a written statement upon the close of the hearing.

The laws cloak the process in confidentiality in hopes that this will encourage participants to be honest and feel free to actively participate in the process. And if the facilities provide the affected physician a fair hearing by following the procedural requirements of the laws, the facilities and those who testify in the process are immune form liability for antitrust violations. Peer review is intended to resolve quality concerns on an intraprofessional basis. Moreover, it is easy for the health care facility to comply with the applicable laws. Finally, lawsuits against healthcare facilities in connection with peer review have rarely, if ever, been successful. From the affected physician’s perspective, the reviewing facility has a huge advantage.

In truth, practically speaking, peer review is a last resort. It arises typically after multiple committees have reviewed the concern and usually after many discussions with the affected physician.

Nevertheless, affected physicians have a great deal of control in the matter; and the outcome will depend largely on how they view the process and participate in it. For instance, if the doctor views the process as personal attack, it will be difficult to participate meaning fully and positively. The trick for the affected physician is to not take the process personally. If the physician takes the position of “You’re wrong; and I’ll fight you”, the process will be adversarial and the outcome will be painful. If instead, the doctor takes the position of “Help me to understand and address you concerns”, the process can be smooth and the outcome can be positive, even beneficial. This is not to say that affected physicians should simply lie down. In fact, that will be as unhelpful as being combative. Instead, seek to understand and communicate.

Many physicians are motivated in peer review process by fear associated with a report to the National Practitioner Data Bank (“NPDB”). NPDB reporting is basically triggered by peer review activity that involves quality issues. If, however, the doctor allows the fear of an NPDB report to control him or her, it will typically lead to the physician hardening his position in the process. In other words, the fear of an NPDB report often causes a physician to lose his or her best advantages: an open mind and willingness to discuss and compromise. In truth, an NPDB report is not a death knell to physician’s professional career. In fact, the doctor has the right to respond to an NPDB report, and the response will be available to those who query the NPDB. Affected physicians should remember that nearly every doctor who has been sued or who settles a claim has been reported to the NPDB, no matter how ludicrous the claim may be. Still, NPDB reports can raise questions and are upsetting. As such, affected doctors should address the medical staff’s concerns before the matter rises to the level of peer review.

With the foregoing in mind, affected physicians should keep the following tips in mind:

Take committee action and quality concerns seriously before they rise to the level of the MEC or peer review committee;

Seek to understand quality concerns rather than take them personally or attack. The approach for successful litigation does not usually work in peer review matters;

Seek opportunities to meet with the medical staff and address their concerns, even once peer review activity is underway.

© Jeffrey L. Cohen, Esq., 2002. Mr. Cohen is a partner with thee Delray Beach/Ft Lauderdale law firm of Strawn, Monaghan & Cohen, P.A. He is Board Certified by the Florida Bar as a Specialist in Health Law. He may be reached at (561) 278-9400

AllMed Healthcare Management Releases Autumn 2005 Newsletter (Press Release)

AllMed Healthcare Management, an Independent Review Organization (IRO) providing medical review and peer review services to healthcare payers, providers, claims managers, and hospital groups, has released its Autumn 2005 edition of Medical Review News.

The newsletter contains the following articles of interest to Claims Managers, Claims Administrators, and Medical Directors at Health Plans, Third Party Administrators, Utilization Review Companies, and Medical Management Companies.

Outlines of the newsletter articles appear below:

Article #1— Understanding FDA Approval for Medical Devices: Vest Airway Clearance System

* How does FDA approval for a medical device differ from FDA approval for a drug?

* What is the Vest Airway Clearance System and why have doctor’s prescribed it?

* How have the device makers promoted their product to physicians?

* How will an Independent Review Organization (IRO) likely view a claim involving a device with a similar history?

Article#2 — What to Consider for Sleep Apnea Treatment

* What are the different types of sleep apnea and how is apnea medically defined?

* What is the medically necessary treatment for sleep apnea?

* What is the surgical option for sleep apnea treatment?

* How will an Independent Review Organization (IRO) normally view sleep apnea surgery as a sleep apnea treatment alternative?

Article#3—Hospital Peer Review Study Results

* Why do hospitals send out cases for external hospital peer review?

* How often do hospitals typically use Independent Review Organizations (IROs) for hospital peer review?

* Do smaller, regional hospitals use the hospital peer review process differently than larger, urban hospitals?

* How can an Independent Review Organization (IRO) help a hospital improve the quality of care it offers to its patients?

AllMed provides medical opinions that quickly resolve complex problems — saving money while protecting the integrity of patient care. AllMed will review chart notes and operative reports to render objective written opinions; help you reach the right decision while reducing legal risk; apply your plan language to the case, if appropriate, give you direct access to our physicians for questions and follow-up on reviews; and supply clear, professional and easy-to-read documentation. AllMed also applies the same high quality standards to its hospital peer review, pharmacy review, medical bill auditing, and medical director review services.

About AllMed

Allmed reviews claims for issues of medical necessity, standard of care, experimental / investigational, hospital quality management, code unbundling, fraud, and other issues that affect healthcare decision-making.