Continuous Improvement in Hospital Quality of Care

Hospitals like any other business are under continuous pressure to improve their quality of care, and focus on improving outcomes and overall patient safety. Most hospital organizations today have adopted quality management best practices to ensure that services for their patients are uniform, consistent and meet the highest quality standards possible.

We work with many of the largest hospital chains across the country and see their dedication and commitment to continuously improve quality. Patients of the heath care system should be pleased to know that most hospitals are in fact working very hard to evolve and improve their quality standards.

There are however exceptions. Some hospitals have nagging problems related to specific sentinel events and negative outcomes. Often what we find is that there's a correlation between high incidence of bad outcomes and a poor quality management process. Sometimes times the missing ingredient in a quality management system is leadership. When a hospital or medical provider is consistently suffering from a high number of sentinel events, typically it is because there is a lack of quality management accountability inside their system and a lack of follow-through on corrective or disciplinary action which is necessary in order to ensure the highest standards.

How can this be resolved? The starting point is for the leaders in these problem hospitals that are suffering from this problem to take notice and engage the necessary resources in order to create real, lasting change. The leaders can set up and commit to making changes and go through a change management process.

Certainly an Independent Review Organization can be brought in to help overcome any conflict of interest or other issues related to protection of certain physicians who are misbehaving or underperforming. The role of an Independent Review Organization in exposing misdiagnosis, mistreatments or a physician’s underperformance can be a very important one. The reason is because an Independent Review Organization can provide an objective, unbiased, decision making that helps hospitals clearly understand when they have underperforming physicians instead of making these decisions based hearsay, personal grudges, insinuations or guess work.

The Independent Review Organization plays a vital role in taking the guesswork out of making sure that physicians are held accountable and exonerated when they have done nothing wrong.

Helping Third-Party Administrators Manage Healthcare Claims Costs

Independent Review Organizations work with Third Party Administrators across the nation to deliver better care decisions and allocate healthcare resources more effectively.

Why is an Independent Review Organization so important to this process of working with Third Party Administrators? It's simple. First of all, third-party administrators are called upon to ensure that effective claims decisions are made for each patient and that benefits are allocated according to plan language, medical necessity as well as standard of care. Yet third-party administrators typically do not have the in-house medical staff to perform this function. So they need to rely upon the services of an outsourced medical review company, or Independent Review Organization, to make these determinations effectively. As a result, third-party administrators depend heavily on Independent Review Organizations for allocating medical and healthcare resources regarding the most expensive and most complex medical treatments.

Usually should a Third Party Administrator have a medical director on staff, typically they are generalists and cannot be expected to have medical knowledge across a whole spectrum of different types of healthcare treatments and medical specialties. This is where employing the services of an Independent Review Organization can make a huge difference in terms of improving an organizations ability to make those decisions. This is also why third-party administrators today rely heavily on Independent Review Organizations to get their medical reviews done fast and efficiently.

Evidence-Based Medical Review Determinations

There is much debate about the role of evidence-based medicine in making effective healthcare decisions. We’re strong supporters of using medical evidence to determine whether or not a patient should receive a suggested treatment.

However, the debate about evidence-based medicine sometimes goes beyond the practical. One cannot generally apply evidence based medical principals to every case without understanding the specific context of an individual patient diagnosis and treatment. This is where using a panel of board certified specialists who actively perform the procedures that they're reviewing and pairing up those specialists with specific case circumstances is the most effective way to make a decision. It makes sure that not only is the medical evidence taken into consideration when making a patient case, but also that the situation of the patient based on the information in their medical chart.

We believe that evidence based medicine needs to be balanced against the knowledge and experience of doctors who are performing certain treatments and their practical experience in determining what the best treatments are and what the standard of care is.

Optimizing Your Request for Medical or Peer Reviews

If you're a claims manager, utilization management nurse or case manager and you're sending cases to an Independent Review Organization for medical peer review, here are some important tips that can make your next review easier and maybe cost less.

1. Your request should clearly state exactly the issues that you want us to review about your case. Point out the defining issues which are most important to consider.

2. Ask clear questions that get to the heart of the matter or the issue that you're trying to get a determination about. From time to time, clients send us vague questions or ask redundant or extraneous questions that don't get to the heart of the matter. Framing your questions properly is very important when you're requesting an independent medical review.

3. Don’t overstate the number of questions you want answered, because the cost of an independent medical review is directly a function of the number of questions that you want us to review. The cost of course is also driven by the number of pages that we're requested to review. When we look at thousand pages on a case, obviously it's going to cost a lot more than hundred pages.

4. Another way that you can reduce the cost of your medical reviews is to make sure that you only send us the pages that are really relevant to your questions. Of course we don’t want our clients to skim through and eliminate pages that could provide good background information on the case. On the other hand, it does make sense to eliminate any extraneous internal communications that are not germane to the case before they're prepared and sent to us.

If you are considering sending cases into an Independent Review Organization for medical review, make sure that you frame your questions properly and succinctly and that you reduce the questions to the ones that are most important to rendering a determination.

Our Nation’s Healthcare Costs are Spiraling Out of Control

Almost every day we read in the newspapers how healthcare costs continue to rise at a double digit pace. As employers each year we are chagrined to hear from our health insurance carriers that they're passing on 12 to 15 to 17 percent increases in health care premiums. We respond by shifting costs over to our employees by increasing the deductibles and co-pays hoping to stem the tide of uncontrollable healthcare costs. Yet, they continue to rise.

We want to do something about this. Clearly one of the things that we can be done is to make sure that in the healthcare system today, the resources are allocated only to those people who deserve and qualify for the treatment that they're seeking on the basis of medical fact. AHIP commonly estimates that 30% of all healthcare treatments are unnecessary. We believe this to be the case because it mirrors our own statistical denials of healthcare benefits on the cases that we review for major health insurance carriers, Third Party Administrators and other clients.

The point is allocating health care resources an important part of medical cost containment equation and something that we should all be concerned about? Certainly our company is not at the forefront of this. Our role is to simply provide independent medical review services that help payers allocate their resources more effectively. We believe there are many other ways o to solve this problem, and Independent Review Organizations are adding increasing value by helping to contain medical costs.

As a member of the National Association of Independent Review Organizations (NAiro), we’ve banded together to press for changes in legislative and regulatory areas at the state level and to seek to unify the bureaucratic regulations that are tangling up our healthcare system at the state level and leading to increasing costs. We also are pushing for better ways to improve the overall healthcare system by advocating standards for credentialing Independent Review Organizations.

All of the NAiro members are accredited by URAC which has helped us to improve our overall quality and to insure our clients that we meet high standards of performance when it comes to medical review quality, turn around time, objectivity and evidence based decision-making. NAiro is pursuing an aggressive agenda among its members to improve the overall responsiveness of the industry to changing healthcare trends, as it relates to emerging treatments. We're also working actively as members of the URAC board to push forward an agenda that will make it easier for healthcare organizations to select credentialed organizations as their healthcare vendors.

What other ideas do you have that could be implemented on this subject for our national advantage. We'd love to hear you at info@allmedmd.com.

Online Service versus Faxing

Why does it make sense for us to push patient health information through a secure Web application as opposed to sending or faxing charts? Obviously there are cost reduction reasons for this. And with the advent of new electronic health records, more and more information is being stored digitally by healthcare organizations. There's a great opportunity to take advantage of this in order to store and move electronic health records and medical review cases through the system in a digital format.

We believe that our PeerPoint software will enhance this process and that Allmed will emerge as the leader in independent review software for Independent Review Organizations. Why is this? We've been spending the last year working on a customized and highly optimized, Web-based work flow application that mimics the way we work today. Effectively our PeerPoint software will collapse the myriad of client server software programs that we currently use in our office into a single fully integrated solution for your independent medical reviews.

We expect to launch this application in the next couple of months and are confident that our clients will see immediate benefits like being able to swiftly and securely transact business with us.

Healthcare Workflow Software Makes Great Sense

If you are a hospital or health insurance payer today, there are a myriad of workflow applications available to help improve efficiency and reduce cost in your organization. Everything from inscription software, to case management systems to finance and accounting software has been specialized for clinical practices. Those are just some of the examples of the way organizations can use software to perfect their business processes, reduce their costs and improve the overall viability of their organizations and its competitiveness.

A good example of workflow software in the healthcare arena is the use of Web applications for conducting reviews. Whether it is a independent medical review for health plans or hospital peer review, today there are new cutting-edge applications that support the Independent Review Organization review process and allow for the exchange of critical, confidential patient information (PHI) in a secure, Web based work flow.

We're developing a Web-based application at Allmed called PeerPoint. This software will allow us to transact with our business partners, clients and specialist doctors across the country securely and greatly enhance our ability to efficiently track and manage cases as they move through the medical review process. We're excited about this software and the benefits that it's going to offer to you, our clients. You will have the ability to check the status of cases online. We will benefit from internal cost reduction and improve the scalability of our company.

If your company is considering deploying Web applications in a healthcare environment, in particular if you're thinking about deploying a custom Web application, we can give you some advice and ideas, because we've spent the last year developing experience and perspective by building ours.

Taking Corrective Action After Peer Review

We perform quality management reviews for many of the top hospitals across the United States. When we talk to risk managers and quality managers involved in these cases, one of the questions we commonly ask is, "How do you use the determinations that we provide to you? When we perform a hospital peer review, what do you do with the information? How do you integrate that information into a corrective action plan?"

The fact is we get various answers from different people on this subject. If necessary, some quality managers use our hospital peer reviews for disciplinary action with physicians who have engaged in things like misdiagnosis, mistreatment or outright provider fraud.

Other hospitals haven’t integrated their peer review and their corrective action process to close the loop on these subjects. Hospitals that have a disconnection between their peer review function and taking effective corrective action are missing a great opportunity to improve quality. In fact, one of the things we ask ourselves is: "Why would they have us conduct a peer review if they don't plan to do anything with the information?"

Because large organizations take on their own culture and politics, we believe that’s one of the reasons why peer reviews aren’t sometimes converted into corrective action. If large hospital organizations scrutinized the work of one of their top physicians, it’s very easy for them to avoid conflict arising from a discovery of wrong doing by that physician. Many times it's easier to suppress these conflicts than it is to deal with them in a healthy, open and fair way. This is one of the dilemmas for any large organization when it comes to self-policing and pressing for continuous improvement. Certainly, it is one of the key issues that hospital organizations face with respect to improving quality management today.

Cost Pressures on Healthcare

Like everyone else today, cases managers and health care professionals are being pressured to reduce costs and eliminate treatments wherever possible in order to control the double-digit increases in healthcare costs across the nation.

How can you as a case management or utilization review professional be sure that you’re reducing cost while still effectively ensuring that patients and members of your health plan consistently get what they're supposed to?. One of the most common solutions for this today is to bring in external medical review resources to look at cases that are either very complex or that require a specialist’s review before making a final decision.

Do you have specialists available to your organization to perform these reviews? If you do, you're among the few because most organizations today can't afford to employ or retain advanced physician specialists. For those case managers and utilization review nurses who don't have those kinds of specialist resources at their disposal, the best answer is to outsource those cases to an Independent Review Organization.

External Quality of Care Reviews for Provider Organizations

If your hospital or a medical group has doctors seeing patients on a regular basis, you need to perform quality management functions to determined and verify the proper quality of care. Traditionally organizations do this internally using their own nursing resources and physician peer panels.

Increasingly, companies are outsourcing this type of activity to an Independent Review Organization which can assign a specialist to look at specific cases and determine root cause analysis of any care deficiencies. This makes sense when the hospital or medical group has a shortage of specialist availability to look at cases that are complex and require a specific specialist to review a sentinel event. Outsourcing this function is becoming more common among leading medical organizations and hospitals.

We're working with the top three hospital chains in the country and they are increasingly viewing peer review as a non-core activity that can be cost effectively and easily outsourced. They understand that this makes sense, because they can get it done faster using and Independent Review Organization then they can internally. They also understand that when sentinel events occur, and their organization risks expensive lawsuits or sanctions, the cost of actually performing these external hospital peer reviews is miniscule in comparison. That’s why providers are looking more and more to outsource quality of care reviews to Independent Review Organizations like Allmed.

Managed-Care Nursing Made Easy

If as a utilization review or utilization management nurse or a case manager, your job is to pre-authorize complex claims and treatments, one thing that you can do to make your job easier is to outsource your most difficult cases to an Independent Review Organization. We work with hundreds of organizations across the United States that do this. They have found great benefit in terms of cost reduction, and speedier decision making when it comes to preauthorizing expensive or complex treatments. Managed care nurses typically have many years of health care experience. Often they have many years in clinical practice that’s also supplemented by years of case management reviewing many different types of cases and treatments.

Despite these years of experience, case management nurses and Utilization Review nurses cannot be expected be up to date on all the newest medical treatments and diagnoses. In fact, the standard of care continues to change. What was once viewed as a cosmetic treatment can now be diagnosed as medically necessary because those standards change.

This is why an Independent Review Organization is so important to a managed care nurse. What it allows you to do is extend your reach by allowing you to tap into the up to date knowledge of top specialist physicians across the country to make preauthorization decisions more effective. It’s widely considered a best practice today.

Some manage care organizations and medical management firms have their own panel of physicians, yet increasingly the best Managed Care Organizations and Utilization Review companies are outsourcing this function. Why? They can't compete with the services of an Independent Review Organization for cost, credentialing, availability or turn around.

Claims Management Made Easy

If you're a claims manager or adjuster workers comp, auto, health or disability insurance, one of the scarcest resources you have is your time. When you have complex and costly cases, your time gets eaten up adjudicating claims and consulting others for opinions. If you find yourself in positions where you're stretched too thin, a great way to extend your capabilities and to move your most difficult cases through your organization is to use the services of an Independent Review Organization. Independent Review Organizations are dedicated to providing medical decision support to claims payers of all types on healthcare benefits or on medical benefits related to specific treatments. An Independent Review Organization provides an external, objective medical review service for insurance carriers, Third Party Administrators, and other types of payers. Independent Review Organizations help them allocate their resources effectively and provide decisions about the approval and denial of treatments.

Independent Review Organizations are typically accredited by a URAC (at least the good ones are). They provide a panel of external peer physicians in all specialties and sub-specialties who are capable of providing standard or expedited reviews of health care cases by determining their medical necessity, standard of care, whether they are experimental or investigational, whether they indicate an appropriate length of stay in hospitals and other types of questions that a doctor must review.

The Independent Review Organization always matches the case with a specialist having the same background as the referring specialist. Independent Review Organization specialists are always board certified, licensed and in active practice. This insures is that you will be able to use the same expert knowledge to make your claims decision as was originally applied to the treatment being considered. It allows you to speed up your claims decision making, eliminate unnecessary medical treatment, reduce premium costs for disability and workers comp and ensure that your claims resources are being allocated to members who deserve the care, and not those who don’t.

So if you're a claims manager and you're not using an Independent Review Organization today to evaluate claims inside your organization, consider one.

Improve Your Appeals Decision-Making Process

Many health care organizations have appeals units that are set up to review appeals for benefits denied their health plan members. Often they struggle under the heavy workload related to responding according to state-mandated deadlines for these appeals. Many of these organizations have built up large case management and medical claims departments in order to meet those requirements. They are trying to respond to their case load, but in fact, these health plans are really in another business—and it’s not case review.

When health plans want to improve the quality and speed of their appeals decision-making, they should consider outsourcing these decisions to an Independent Review Organization. Because an Independent Review Organization is much effectively set up to handle large volumes of appeals in a way that is more expeditious and lower cost than a health plan can do so internally. The issue isn’t whether or not Independent Review Organizations have lower cost physicians. They don’t. In fact, we employ many of the top physicians and specialists in the country. The point instead is health plan providers can outsource medical decision making highly qualified physicians on a pay as you go basis—and only pay for a fraction of the doctor’s time at a reasonable hourly rate.

Independent Review Organizations assist a large number of the biggest health insurance carriers today with their appeals decision-making support. Is it time that your organization consider outsourcing this? If you're keeping this kind of work in house and are staffing your organization with a group of doctors to review these appeals, you might want to consider whether it makes better sense for you to send these cases to an Independent Review Organization for external review.

An Independent Review Organization can help you to match each case with a board certified, actively practicing specialist or sub-specialist for every case that comes through your appeals process. This is something that’s very difficult for organizations to handle internally. Even if your organization has a provider arm locating, tracking down, and retaining the services of a specialist to review a case, often times it's very cumbersome them. And it’s not really the business they are in. Instead sending these cases out to an Independent Review Organization that has a pre-selected specialist and sub-specialist panel makes more sense. And it can be done at lower cost and with much speedier turn around times.

Turn around time is a key concern for complying with state insurance regulations, which typically call for an expeditious appeal process. If your organization hasn't begun outsourcing to an Independent Review Organization yet, you should consider investigating the benefits of doing so. You'll find that you'll reduce your cost and you'll improve your regulatory compliances as a result.

State Regulations Make Healthcare More Expensive

Healthcare is regulated to a large degree at the state level, not the federal level. This adds incredible levels of cost to the healthcare delivery system. In particular, it makes health plans, Third Party Administrators and other types of healthcare payers and delivery organizations spend more on administration in order to credential meet state licensing and regulations for each state where their patients and member reside. One way for organizations to circumvent some of this and become more responsive and provide medical decision making support that their case managers need is by outsourcing some medical decision making to an Independent Review Organization. An Independent Review Organization easily provides medical decision support across state lines for a host of different constituents. This way organizations can quickly and efficiently allocate healthcare resources according to need and plan language without being encumbered by state regulatory processes. An Independent Review Organization plays a fundamental role in speeding up and overcoming some of the state regulatory requirements that we’re facing today.

Health plans, health insurance carriers, Third Party Administrators and other managed care organizations and medical management firms encounter a myriad of regulations when they are managing members who reside in multiple states. We believe that with respect to health core organizations, the state regulatory environment amounts to nothing more than state-mandated protectionism and simply adds additional layers of cost and bureaucratic difficulty for most health care organizations doing business in several states.

Often state regulations require that care decisions be made by physicians and specialists licensed in that state. In our opinion, this is wasteful and unnecessary. In fact, national standards do exist about the education of physicians and specialists. So why don't national credentialing standards also exist? These are the questions we ask ourselves as an Independent Review Organization that is trying to deliver value across multiple states and across multiple client constituencies.

Independent Review Organizations Meets State Managed Care Regulations

When it comes to patient care, licensing and certification, and credentialing of their providers, managed care organizations are called upon to meet rigorous state regulations. Independent Review Organizations ease their burden by providing managed care organizations (Managed Care Organization) with a flexible means for outsourcing their medical reviews and pre-authorizations to an entity which is capable of providing credentialed, state-licensed physicians for all specialties and subspecialties. Increasingly this is important as organizations work across state lines to provide pre-authorizations for expensive and complex treatments and manage patient populations in a several states.

An Independent Review Organization provides great value because it can work across states lines and is set up to recruit and credential specialists in multiple states to meet state regulatory requirements more easily than an Managed Care Organization can. This is why an increasing number of Managed Care Organizations turn to Independent Review Organizations for outsourcing their preauthorization approvals to get specialty matches of complex and costly medical treatments. Whether it’s for group health, workers comp, disability Third Party Administrators, re-insurers or self-insured organizations, an Independent Review Organization provides the flexibility to respond to the complexity of state regulations.

State Regulations and the Independent Medical Review Process

When it comes to health plan administration, appeal of denied benefits, and other types of regulations that effect the healthcare industry, it’s no secret that healthcare is regulated primarily at the state level. This state focus on health care regulation adds of complexity to the independent review process. For health plans operating across multiple states and multiple regions of the United States, it adds costs as well.. We believe that there needs to be a streamlined set of national regulations that will make it easier for health insurance carriers and other companies administering health plan benefits to do business in multiple states without having to have multiple and redundant peer review panels. Operating in multiple states also increases the infrastructure to support, administer and track state regulations.

For an Managed Care Organization or a Third Party Administrator or an Independent Review Organization, working in multiple states as can be an administrative and bureaucratic nightmare. It shouldn’t be this way. We believe that streamlining state regulations and unifying them under national standards would go a long way toward making it easier for healthcare organizations to do business in more than one state and reduce the overall cost to their members. Healthcare regulations are far to complex and the regulatory burden that most healthcare organizations are under adds unnecessary costs. Those costs are passed on to consumers and have a negative impact on everyone.

As an Independent Review Organization, we do business in more than 40 states. In many states, our clients require that we have board-certified physicians in active practice who are licensed in the state where the health plan operates or where a case is being reviewed. To respond to this we have developed a peer specialist panel of over 300 physicians across the country. We add and credential physicians in specific states only to meet state regulatory requirements and this adds costs to the independent review process. Ultimately, these costs are born by the health plan or by the consumer. If there are national medical standards when it comes to medical education, why aren’t there national standards when it comes to licensing physicians?

Other professions have national credentialing organizations and national licensing requirements. But in the medical area, states still feel that it’s their responsibility to license and credential medical personnel practicing within their borders. This turf protection adds no value and doesn’t improve the overall quality of medical care in the United States today. Instead, it adds more burden. We would like to advocate for single, national, licensing requirements for physicians that would greatly simplify the ability of physicians to work across state lines, while still ensuring effective standards advocate the highest quality care and patient safety.

Creating an Electronic Independent Review Process

As Independent Review Organizations work to mesh with their clients medical decision making processes, it’s apparent that what’s needed is an electronic interface that allows an Independent Review Organization to connect its work flow to its clients whether they are Third Party Administrators, manage care organizations, health plans, reinsures or self-insured companies. All clients want to be able to send their cases and medical charts with patient hospital information (PHI) to their clients in an easy, seamless and secure fashion. Using Web technology makes perfect sense. As a result, many leading Independent Review Organizations are developing electronic, Web-based applications that will allow them to transact business by receiving and sending clients’ cases seamlessly.

AllMed is developing its own Web portal for independent medical reviews and hospital peer reviews. Over the next several months, we will deploy this portal. Already we’re in the process of testing the platform to ensure its quality and plan to start beta tests with existing clients in October or November. We believe that using the Web for performing independent medical reviews and transacting in a secure HIPAA compliant environment makes perfect sense for our company and our clients. Most of our clients are moving in this direction as well and demanding this type of application when selecting an Independent Review Organization.