A medical peer review may be initiated at the request of a patient, a physician or an insurance carrier.The term “Peer Review” is sometimes used synonymously with performance appraisal.The first documented description of a Peer Review process is found in the Ethics of the physician written by Ishap bin Alif – Radhani (854 – 931). This is evidence that this process is dated far back in history, for achievement of good and safe clinical care.
Due to the way information is gathered in South Africa, from claims submissions with ICD codes peer review is focused on diagnosis, process measurements and clinical out comes (where the profiling team has the data to assess clinical outcomes).
The entire process is dynamic and has changed over time with a greater emphasis on Quality, process measurements and a decreased weighting on costs. With the introduction of Peer Review committees, the emphasis is on mentoring the reviewed doctor. The statistical report is viewed against the clinical activity, the seriousness of the case and whether the costs are directly due to the physician being reviewed or from referral costs to specialists and hospitals.
The commitment by IPAs to review colleagues is part of our philosophy of attaining the highest possible level of quality within limited resources. The main issue that brings discontent to practitioners is that they believe that allowing costs to influence medical decisions is unethical. They are mistaken in this belief, because “it cannot be ethical to ignore the adverse consequences upon others of the decisions you make, which is what “costs” represent”.
With the limited resources that exists and the inability of a patient to purchase programs that are necessary to meet all his/her needs it is incumbent upon us to assist and review for appropriateness, necessity, choices of the laboratory and radiological investigations (here we need to choose those tests that give the greatest information outside process of a history and good clinical examination), appropriate referral to secondary and tertiary care. Hence choices will be predicated not only on the basis of strictly clinical considerations but also on economic considerations.
The actual “Peer Review” is based on profiling data. Various schemes use different profiling systems. The data is usually retrospective but is risk adjusted for age, gender, co-morbidities and any relevant confounding variables e.g. location and workplace hazards. This in a way allows most times to compare any physician with the average benchmark of his peers. They however may be a “sentinel” case that is far beyond the expected economic spend and this is then credited to the reviewed doctor and he is upgraded to a higher level of performance.
We must review the science behind the profiling and peer review. In essence it has to consider if all the resources are used for one individual what sacrifices must be made to others who also need care. This is the principle of “distributive justice”. Strictly speaking this is very accommodating process and at the peer review it takes into account and is biased towards the reviewed doctors argument on the reasons for why he was not able to achieve a benchmark score.
The medical scheme is simply managing the funds / premiums of their members (our patients). They have a legal, moral and ethical duty to manage these funds to the benefit of all its members and to stay solvent. The other factor is the escalating medical costs which at present run about 5 points above normal inflation.
Physicians who are reviewed have signed a network contract to be assessable to the patient at all time, to manage the clinical care appropriately and safely and subject themselves to Peer Review if necessary.
My personal view is that 90% of all medical practitioners are committed to practicing best care medicine and at a cost that both the patient and scheme can afford. Recently the number of actual peer reviews has dropped to about 80%. This means that 80% of doctors through mentoring and continual medical education are practicing close to “Best Care” practices. There is a small number who charge at a rate that is so-called “market-related”. This is their own decision and democratic right. Then there is a small number of doctors who are forever belligerent, obnoxious and aggressive and feel that their method of practicing which is often evidence based must not be peer reviewed.
There is now also a paradigm shift where the emphasis is not volumes but value. Doctors are profiled to deliver value based outcomes. The problem we have is that some doctors have no intention to manage both the care and costs to their patients.
The categorization of practices is simply to reward doctors who work tirelessly, implement the most appropriate evidence based care for their patients and still save costs without compromising patient care.
The utopia is to achieve Category I and be rewarded appropriately. We are able at times to advise a practitioner who has reached Cat. I that he is withholding certain modalities of care from his patient e.g. mammography, pap smear, HBA1C monitoring, PAS screening, influenza vaccination etc. most often such a doctor will engage in these preventive programs to achieve “wellness” for his patient.
In summary Peer Review that follows profiling is a voluntary program. A doctor is not forced to sign an IPA contract or agree to peer review. This is his/her democratic right and he/she will not participate in the performance based reimbursement (PBR) program for best value outcomes within cost parameters.
In my 20 years of doing peer review it has achieved quality of care and reimbursed those doctors that work as custodians of care and cost.The peer review process has now gained a formal structure. About 35 doctors around the country have attended two “Peer Review” Master Classes. They were taught negotiation skills, ethical issues around healthcare, insight into the Actuarial Management of data and Risk adjustment and various clinical topics aimed at latest guidelines, efficient and cost effective monitoring for response to therapy and a background to the actual profiling tool used. This was a success and the attendees volunteered to attend these formal peer review master classes regularly. This is now evolved as a necessary science to promote value based healthcare outcomes.
Source: Medical Chronicle – November 2014