754
PEER REVIEW*
JOSEPH POST, M.D. Professor of Clinical Medicine New York University Medical Center
Research Services Goldwater Memorial Hospital New York, N.Y.
p EER review first consisted in the establishment by physicians of standards for licensure to practice medicine and surgery. This form has continued to be administered by state departments of education. Another type of peer review was developed for appointment to hospital staffs. In time learned societies set up their own higher standards for admission. For many years the latter groups included a small and exclusive portion of the medical profession. However, for the vast majority of physicians it was possible to spend an entire career in practice without ever coming under review, unless one committed some serious breach of trust or etiquette. This quiet was disturbed in the 193OS by demands that physicians who were engaged in certain specialty practices be certified by examination. The specialty boards were organized to set up standards for training qualifications and for examinations which were designed to test professional knowledge. Enforcement was implemented through economic pressure, in that hospitals were required to have board-certified physicians and surgeons in the several specialties in order to maintain accreditation. In the 1930s there were relatively few places in the United States where residency training could be obtained. Until World War II the certified specialist was a member of the elite of medicine. After World War II there was a great expansion of postgraduate training facilities, accompanied by a broadening of the base of the specialty certifications. The exclusiveness of these certifications soon disappeared but was succeeded by the development of subspecialty boards. One wonders what will happen when most of us are certified *Presented as part of a Symposium on Continuing Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 10, 1974.
Bull. N. Y. Acad. Med.
PEER REVIEW PEER R E
VIE
W
75 5 755~~~~~~~~~~~~~~~~~
by these boards. Indeed, we now have certification in general practice! All of these mechanisms were forms of peer review at work. Some physicians were saying to others: "If you do not pass these examinations you are not qualified to practice in these professional areas." The economic impact of these judgments is obvious. We have sold this idea of subspecialty practice so thoroughly that fragmentation and compartmentalization have become the hallmarks of sophisticated medicine. There are physicians who pride themselves on their narrowness of interest and expertise. Several new dimensions have entered this field of peer review during the past 30 to 40 years. The introduction of health-insurance plans brought a new type of peer review in which physicians employed by the paying agency might examine the professional activities of a physician and decide on their appropriateness and hence on reimbursement for services rendered. More recently, with the advent of Medicare and Medicaid, additional reviews were introduced to prevent overutilization and fraudulent practices. At this time too, hospitals organized peer-review committees in order to maintain surveillance over the admission of patients and the duration of their stay. Finally, peer review has become an integral part of medicine with the passage of legislation establishing Professional Standards Regulation Organizations (PSRO). In the winter of 1972 the Committee on Medicine in Society of the New York Academy of Medicine set up a subcommittee to look into some aspects of PSRO and peer review. We wanted to learn how the then-current activities of peer review operated. We avoided the specifics relating to PSROs because even the guidelines were unknown at that time. There are many problems related to this law, including the enormous organizational difficulties thrust upon the medical community and the lack of experience at the grass-roots level. In a sense this is a no-man's land for everyone, the doctors and the administrators. However, I shall pass this by because a PSRO is being put together in Manhattan and the physicians who are involved should speak about it. We spent about six months holding meetings with supervisory representatives of federal, state, and municipal agencies, as well as with those of the insurance carriers. In addition, we met with physicians involved in review activities in the national and local medical societies. Vol. 51, No. 6, June 1975
756
756
J. POST J.
POST
We learned a little about how peer review was functioning. Until now most of the mechanisms for peer review have been concerned with police action in order to minimize medical costs. The techniques which are employed vary with regard to methodology, effectiveness, and diligence, but not in intent. One committee of a county society reviews cases of flagrant abuse which are referred by insurance carriers. The physician appears before a group of his peers to answer charges. After a hearing, a mutually acceptable agreement may be reached by which the physician's behavior or fees are validated or censured, in which case monies may be refunded. In another setting, a physician hired by a municipal agency will review seemingly excessive medical practices and fees referred to him by an auditing unit. He will then examine the records in the medical facility in question-a physician's office or a medical group. Where a question of fraud is involved the matter may be referred to the appropriate legal prosecutor's office. Some of these practices are quasilegal, although so far as we could determine, their legal authority was not defined and their proceedings were not governed by predetermined rules. There is a need for a clearer definition of standards of practice and for their application in a fair and generally reproducible fashion in a prescribed setting. The proportion of physicians whose professional behavior is adjudged to be beyond the range of respectability is approximately 2 to 4%. Obviously, if this were the major problem it would hardly justify all the effort. In all of these considerations we were disturbed by a missing ingredient: quality of care. I am pleased to report that there is now considerable activity in this area. Several groups have established techniques to survey the kinds of care being given to patients in hospitals. Several speakers at this conference will discuss the subject and the 1975 Health Conference of the New York Academy of Medicine is to be devoted to consideration of this topic. Several developments must occur in the hospital if this new broad approach to peer review is to work. First, the staff must have a commitment. This is a far cry from the often perfunctory surveillance seen in the operations of the utilization-review committees. Second, a special staff will be needed to concern itself with these formal audits. This should include paraprofessionals who can be trained to review Bull. N. Y. Acad. Med.
PEER REVIEW
PEER
REVIEW
757
757
charts, as well as nurses and physicians. It also may be essential to have a full-time physician director, immune from the pressures of his colleagues. Third, some source of funding will be needed for all of these activities. During our committee hearings we were impressed by the functioning of such review bodies at neighboring community hospitals. A significant improvement in the care of patients was achieved. The necessity of involvement and commitment by the staff, as well as the immunity enjoyed by a director with qualities of leadership, were obvious and essential ingredients which we noted. I shall mention a by-product of a tight surveillance on admissions and duration of hospital stay. In one of our major hospitals the effectiveness of the surveillance was so great that the census dropped to approximately 8o% from 95%. This had two effects. First, because patients were being discharged earlier, the more profitable time of hospital care, the last few days of a patient's stay, when fewer services are needed, was eliminated. This increased per diem hospital costs. Second, beds were empty and yet the hospital was fearful of the decision to close floors. This would entail reapplication to the hospital council for permission to reopen them at a later time if the need should arise. Hence the hospital continued to maintain empty beds with the complement of supporting staff. This too added to hospital costs. These effects of tight supervision had not been anticipated. Whether one reviews the appropriateness of hospitalization before admission or on the first day after admission, such surveillance is effective in reducing hospitalization. Further, the fact that each hospitalization will be carefully scrutinized will be a deterrent to unnecessary hospitalization. Of course, if the insurance carriers were to liberalize their coverage for ambulatory care services much needless and costly hospitalization could be avoided. As complex as the in-hospital mechanisms of peer review may be, the problems of review of ambulatory care in the physician's office are even more difficult. At this stage, peer review of office practicebeyond that which occurs each time a Medicare, Medicaid, or Blue Shield payment is made-might await the evolution of the in-hospital process. Somewhere in the mechanisms of peer review we must consider a provision for outside review. One day the consumers as well as the Vol. 51, No. 6, June 1975
758
75
J. POST
bureaucrats in our society will not be satisfied with pure peer review, no matter how objective physicians claim to be. Further, it seems reasonable to suggest that institutions which keep themselves under surveillance by internal mechanisms should also have some external source of reviews. Of course one specter looms: the development of a manual of medical practice, through which the physician would become the instrument whereby a set of instructions is carried out and data are fed into computers. Then 1984 could be closer than io years away! Since this conference is devoted to medical education, I shall comment upon one phase of education in relation to the peer review and medical audit within the hospital setting. The advanced training of recent medical-school graduates is the rule today. We have moved rapidly into compartmentalization so that the internship, whether mixed or rotating, is being abandoned. Now a student may go immediately into a specialty without having been exposed to the kind of broadening experience which a good internship once offered. This might not be so dangerous for the future were it not that, especially during the past decade, we have encouraged house officers to take on the major authority of the management of patients as part of their training programs. In some hospitals the referring physician-in whom is vested the trust of the patient, the hospital, the medical community, and the company which issues his malpractice insurance-may not write any orders! He sometimes stands on the periphery as an anxious bystander. In some institutions if the patient is on a floor where he is not under house-officer control he may not be visited by a house officer after admission, except if an emergency should arise! How does one audit such a situation? Are there to be different standards: one set in the so-called teaching setting where it is permissible, nay encouraged, to recapitulate all of the laboratory information which can be retrieved each time a patient presents, especially one with a so-called interesting disease, and another set where one gathers the essential information needed for diagnosis and treatment and gets on with it? Is this good teaching practice? Are two sets of standards to be applied during hospitalization so that it may be prolonged for weeks in the first case while elaborate testing and examination-often not germane to the current illness-are performed? These are not easy questions to answer. In the surgical specialties we have had a different situation. We have often looked the other way while house officers perBull. N. Y. Acad. Med.
PEERPEER REVIEW REVIEW
759 759~~~~~~~~~~~~~~
formed operations and the referring physicians acted as doctors of record. Ironically, we turn to our university hospitals and distinguished voluntary hospitals to set standards for the care of patients, and it is in many of these institutions that the above-mentioned practices are most prevalent. It is clear that what started as the most basic and simplistic type of peer review, medical licensure, has now become a concern as to how a physician conducts his professional life and the results thereof in the population of patients. We are interested not only in the procedures of medical care but also with the outcome. In this time of identity crises and doubts concerning our institutions, the medical profession, one of the last sacred cows, is being led to slaughter. We can react, as many have, with a self-conscious and defensive posture of resistance or we can exploit the opportunities for study, innovation, and exciting constructive change-to the advantage of all concerned.
Vol. 51, No. 6, June 1975
PEER REVIEW*
JOSEPH POST, M.D. Professor of Clinical Medicine New York University Medical Center
Research Services Goldwater Memorial Hospital New York, N.Y.
p EER review first consisted in the establishment by physicians of standards for licensure to practice medicine and surgery. This form has continued to be administered by state departments of education. Another type of peer review was developed for appointment to hospital staffs. In time learned societies set up their own higher standards for admission. For many years the latter groups included a small and exclusive portion of the medical profession. However, for the vast majority of physicians it was possible to spend an entire career in practice without ever coming under review, unless one committed some serious breach of trust or etiquette. This quiet was disturbed in the 193OS by demands that physicians who were engaged in certain specialty practices be certified by examination. The specialty boards were organized to set up standards for training qualifications and for examinations which were designed to test professional knowledge. Enforcement was implemented through economic pressure, in that hospitals were required to have board-certified physicians and surgeons in the several specialties in order to maintain accreditation. In the 1930s there were relatively few places in the United States where residency training could be obtained. Until World War II the certified specialist was a member of the elite of medicine. After World War II there was a great expansion of postgraduate training facilities, accompanied by a broadening of the base of the specialty certifications. The exclusiveness of these certifications soon disappeared but was succeeded by the development of subspecialty boards. One wonders what will happen when most of us are certified *Presented as part of a Symposium on Continuing Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 10, 1974.
Bull. N. Y. Acad. Med.
PEER REVIEW PEER R E
VIE
W
75 5 755~~~~~~~~~~~~~~~~~
by these boards. Indeed, we now have certification in general practice! All of these mechanisms were forms of peer review at work. Some physicians were saying to others: "If you do not pass these examinations you are not qualified to practice in these professional areas." The economic impact of these judgments is obvious. We have sold this idea of subspecialty practice so thoroughly that fragmentation and compartmentalization have become the hallmarks of sophisticated medicine. There are physicians who pride themselves on their narrowness of interest and expertise. Several new dimensions have entered this field of peer review during the past 30 to 40 years. The introduction of health-insurance plans brought a new type of peer review in which physicians employed by the paying agency might examine the professional activities of a physician and decide on their appropriateness and hence on reimbursement for services rendered. More recently, with the advent of Medicare and Medicaid, additional reviews were introduced to prevent overutilization and fraudulent practices. At this time too, hospitals organized peer-review committees in order to maintain surveillance over the admission of patients and the duration of their stay. Finally, peer review has become an integral part of medicine with the passage of legislation establishing Professional Standards Regulation Organizations (PSRO). In the winter of 1972 the Committee on Medicine in Society of the New York Academy of Medicine set up a subcommittee to look into some aspects of PSRO and peer review. We wanted to learn how the then-current activities of peer review operated. We avoided the specifics relating to PSROs because even the guidelines were unknown at that time. There are many problems related to this law, including the enormous organizational difficulties thrust upon the medical community and the lack of experience at the grass-roots level. In a sense this is a no-man's land for everyone, the doctors and the administrators. However, I shall pass this by because a PSRO is being put together in Manhattan and the physicians who are involved should speak about it. We spent about six months holding meetings with supervisory representatives of federal, state, and municipal agencies, as well as with those of the insurance carriers. In addition, we met with physicians involved in review activities in the national and local medical societies. Vol. 51, No. 6, June 1975
756
756
J. POST J.
POST
We learned a little about how peer review was functioning. Until now most of the mechanisms for peer review have been concerned with police action in order to minimize medical costs. The techniques which are employed vary with regard to methodology, effectiveness, and diligence, but not in intent. One committee of a county society reviews cases of flagrant abuse which are referred by insurance carriers. The physician appears before a group of his peers to answer charges. After a hearing, a mutually acceptable agreement may be reached by which the physician's behavior or fees are validated or censured, in which case monies may be refunded. In another setting, a physician hired by a municipal agency will review seemingly excessive medical practices and fees referred to him by an auditing unit. He will then examine the records in the medical facility in question-a physician's office or a medical group. Where a question of fraud is involved the matter may be referred to the appropriate legal prosecutor's office. Some of these practices are quasilegal, although so far as we could determine, their legal authority was not defined and their proceedings were not governed by predetermined rules. There is a need for a clearer definition of standards of practice and for their application in a fair and generally reproducible fashion in a prescribed setting. The proportion of physicians whose professional behavior is adjudged to be beyond the range of respectability is approximately 2 to 4%. Obviously, if this were the major problem it would hardly justify all the effort. In all of these considerations we were disturbed by a missing ingredient: quality of care. I am pleased to report that there is now considerable activity in this area. Several groups have established techniques to survey the kinds of care being given to patients in hospitals. Several speakers at this conference will discuss the subject and the 1975 Health Conference of the New York Academy of Medicine is to be devoted to consideration of this topic. Several developments must occur in the hospital if this new broad approach to peer review is to work. First, the staff must have a commitment. This is a far cry from the often perfunctory surveillance seen in the operations of the utilization-review committees. Second, a special staff will be needed to concern itself with these formal audits. This should include paraprofessionals who can be trained to review Bull. N. Y. Acad. Med.
PEER REVIEW
PEER
REVIEW
757
757
charts, as well as nurses and physicians. It also may be essential to have a full-time physician director, immune from the pressures of his colleagues. Third, some source of funding will be needed for all of these activities. During our committee hearings we were impressed by the functioning of such review bodies at neighboring community hospitals. A significant improvement in the care of patients was achieved. The necessity of involvement and commitment by the staff, as well as the immunity enjoyed by a director with qualities of leadership, were obvious and essential ingredients which we noted. I shall mention a by-product of a tight surveillance on admissions and duration of hospital stay. In one of our major hospitals the effectiveness of the surveillance was so great that the census dropped to approximately 8o% from 95%. This had two effects. First, because patients were being discharged earlier, the more profitable time of hospital care, the last few days of a patient's stay, when fewer services are needed, was eliminated. This increased per diem hospital costs. Second, beds were empty and yet the hospital was fearful of the decision to close floors. This would entail reapplication to the hospital council for permission to reopen them at a later time if the need should arise. Hence the hospital continued to maintain empty beds with the complement of supporting staff. This too added to hospital costs. These effects of tight supervision had not been anticipated. Whether one reviews the appropriateness of hospitalization before admission or on the first day after admission, such surveillance is effective in reducing hospitalization. Further, the fact that each hospitalization will be carefully scrutinized will be a deterrent to unnecessary hospitalization. Of course, if the insurance carriers were to liberalize their coverage for ambulatory care services much needless and costly hospitalization could be avoided. As complex as the in-hospital mechanisms of peer review may be, the problems of review of ambulatory care in the physician's office are even more difficult. At this stage, peer review of office practicebeyond that which occurs each time a Medicare, Medicaid, or Blue Shield payment is made-might await the evolution of the in-hospital process. Somewhere in the mechanisms of peer review we must consider a provision for outside review. One day the consumers as well as the Vol. 51, No. 6, June 1975
758
75
J. POST
bureaucrats in our society will not be satisfied with pure peer review, no matter how objective physicians claim to be. Further, it seems reasonable to suggest that institutions which keep themselves under surveillance by internal mechanisms should also have some external source of reviews. Of course one specter looms: the development of a manual of medical practice, through which the physician would become the instrument whereby a set of instructions is carried out and data are fed into computers. Then 1984 could be closer than io years away! Since this conference is devoted to medical education, I shall comment upon one phase of education in relation to the peer review and medical audit within the hospital setting. The advanced training of recent medical-school graduates is the rule today. We have moved rapidly into compartmentalization so that the internship, whether mixed or rotating, is being abandoned. Now a student may go immediately into a specialty without having been exposed to the kind of broadening experience which a good internship once offered. This might not be so dangerous for the future were it not that, especially during the past decade, we have encouraged house officers to take on the major authority of the management of patients as part of their training programs. In some hospitals the referring physician-in whom is vested the trust of the patient, the hospital, the medical community, and the company which issues his malpractice insurance-may not write any orders! He sometimes stands on the periphery as an anxious bystander. In some institutions if the patient is on a floor where he is not under house-officer control he may not be visited by a house officer after admission, except if an emergency should arise! How does one audit such a situation? Are there to be different standards: one set in the so-called teaching setting where it is permissible, nay encouraged, to recapitulate all of the laboratory information which can be retrieved each time a patient presents, especially one with a so-called interesting disease, and another set where one gathers the essential information needed for diagnosis and treatment and gets on with it? Is this good teaching practice? Are two sets of standards to be applied during hospitalization so that it may be prolonged for weeks in the first case while elaborate testing and examination-often not germane to the current illness-are performed? These are not easy questions to answer. In the surgical specialties we have had a different situation. We have often looked the other way while house officers perBull. N. Y. Acad. Med.
PEERPEER REVIEW REVIEW
759 759~~~~~~~~~~~~~~
formed operations and the referring physicians acted as doctors of record. Ironically, we turn to our university hospitals and distinguished voluntary hospitals to set standards for the care of patients, and it is in many of these institutions that the above-mentioned practices are most prevalent. It is clear that what started as the most basic and simplistic type of peer review, medical licensure, has now become a concern as to how a physician conducts his professional life and the results thereof in the population of patients. We are interested not only in the procedures of medical care but also with the outcome. In this time of identity crises and doubts concerning our institutions, the medical profession, one of the last sacred cows, is being led to slaughter. We can react, as many have, with a self-conscious and defensive posture of resistance or we can exploit the opportunities for study, innovation, and exciting constructive change-to the advantage of all concerned.
Vol. 51, No. 6, June 1975
