A health economist asked a group of physicians if they knew what was the most expensive piece of medical equipment. Most physicians believed it was a magnetic resonance imager. The economist said they were wrong. "It's this," he replied, waving a pen in the air. The physicians jeered, but they knew where he was coming from. Decisions made by doctors have more impact on health care expenditures than any other factor. Studies have shown that 10 to 20 percent of hospital admissions and 20 to 30 percent of total inpatient days are inappropriate or unnecessary based on accepted medical criteria (1).
Peer review is the most widely used method to curb utilization and ensure appropriate use of clinical resources. From hospital peer review committees to national utilization review organizations, peer assessment has become the cornerstone of medical utilization management as currently practiced. Now that capitation has forced providers to monitor their medical decisions closely, peer review has taken on an even more important role. Whereas accountability in fee-for-service medicine is imposed externally by managed care organizations, capitated arrangements provide physicians with incentives to monitor themselves under the watchful eyes of senior colleagues. Either way, treatment is inspected and controlled to ensure that medical standards are met. Providers at financial risk adopt the same utilization management techniques as the managed care companies they loathe (2).
A good part of my professional life has been spent as a peer reviewer. I have worked on both sides of the river—for managed care organizations and for direct providers of care. In the latter context I was appointed to the "hospital bed police." My own practice has been subject to review as well. I believe that peer review is essential to the practice of medicine, although it shouldn't be as adversarial as it is currently practiced. Modern peer review has turned into a completely one-sided affair, and it was never meant to be that way.
My suggestions for making peer review equitable are discussed in this column. My remarks are limited primarily to inpatient treatment and are intended mainly for physicians conducting reviews. However, many of the guidelines that follow also apply to physicians undergoing review.
Civility and politeness are key to utilization reviewer relations. Disagreements, while inevitable, need not result in heated exchanges between colleagues (3). Profanity and insults serve no purpose. Imperious pronouncements with few details are likewise unproductive. Bite your tongue if you must to avoid negative and hostile interactions.
Competent peer review takes time and cannot be done on the fly. Amazingly, I once saw a review conducted in a lecture hall at an annual meeting of the American Psychiatric Association. The reviewer, crouched in the corner with cell phone in hand, had five minutes to spare before the start of a symposium. Reviews done in one's car are likewise ill advised.
Obtain sufficient information.
The groundbreaking case of Wilson v. Blue Cross of Southern California ruled that insurers and reviewers can be held liable for injuries to patients resulting from a prospective denial of a claim. The court further stated that reviewers have to make reasonable efforts to ascertain the relevant clinical facts to render a sound medical opinion. Decisions made prematurely and in the absence of supporting evidence are likely to be seen as arbitrary and capricious. For example, some reviewers may deny treatment simply on hearing terms such as "borderline" and "noncompliant." Alternatively, buzzwords like "suicidal" and "hearing voices," which normally pass the acid test for hospitalization, should be explored further to determine the true nature of the behavioral disturbance.
Don't micromanage outpatient treatment.
The ability to control inpatient utilization, in particular, is a priority for most managed care companies because hospitalization accounts for 75 percent of behavioral health costs nationwide (4). On the other hand, utilization review in outpatient settings is generally not cost-effective (5). More than 80 percent of patients are seen for fewer than eight sessions, and less than 15 percent are still in treatment after six months (6). Intensive case review of outpatients in psychotherapy places an enormous burden on clinicians and patients and should be streamlined in nearly all circumstances.
There should be clear reasons why a doctor-to-doctor review is necessary. Managed care organizations should attempt to profile providers and focus their efforts on physicians falling outside tolerable limits of quality or utilization.
Review physicians only in your specialty.
Review physicians in the same specialty as yours whenever possible. As a psychiatrist, I would not want to be reviewed by a surgeon any more than a surgeon would want to be reviewed by me. All reviewers should be board certified in their specialty.
Give advice only when asked.
A reviewer's primary task is to determine whether the case in question meets criteria for medical necessity, that is, whether the treatment is effective, consistent with community standards, and delivered in the most appropriate setting. Do not impose your own treatment preferences on the attending physician. Unsolicited advice often borders on preaching and comes across as "one-upmanship."
Use objective criteria and share them with physicians.
Any utilization review organization worth its salt has written utilization review criteria and distributes them to providers when requested. There is a fear that doctors would "game" the system if they were aware of the criteria. In my experience, unlocking the secrets of peer review leads only to trust, not to chicanery.
Don't deny treatment for profit.
Reviewers should never benefit personally or financially from denying medical treatment. Avoid incentives related to utilization targets unless they are also coupled with measurable improvements in quality. Short lengths of stay in the hospital are desirable only if outcomes are improved—for example, if recidivism and patient dissatisfaction decrease.
Offer the opinion of a second reviewer.
Reviewers cannot be judge and jury at the same time. All physicians should be entitled to due process, which includes at the very least the right to appeal a denial and receive a second reviewer's opinion within 24 business hours. In fact, external review, such as by an independent appeals panel, has already been initiated in a few states and could become a national standard (7,8).
Respect your colleague's opinion.
Attending physicians have just as much right to their opinion as you do. Physicians also bring to the table their clinical integrity, sound judgment, and valuable experience. I believe too many reviewers have been co-opted by corporate concerns and have lost sight of what is in the best interest of the patient.
Find ways to certify treatment.
Reviewers have been criticized for making denials more frequently than they certify treatment. Glazer (9) stated, "Faced with unwelcome limits on authority and challenges to clinical judgment, providers may be tempted to throw their hands in the air in surrender, giving utilization reviewers only the briefest of diagnoses and treatment defenses, then accepting whatever their decisions might be." Reviewers must help attending physicians overcome "learned helplessness" and build working relationships that benefit everyone.
It's an understatement to say that utilization review encroaches on patient confidentiality. Although most patients, by virtue of being insured, have given implicit (and sometimes explicit) informed consent for utilization review, they are shielded from this activity as it often occurs without their knowledge. Reviewers must safeguard confidentiality during a review as they would with their own patients.
Recognize treatment limitations.
Reviewers often deny treatment because it seems less than ideal. Keep in mind, however, that most treatment is less than ideal for many reasons. For example, certain services may not covered by the health plan (10), or they may be geographically inaccessible to the patient. Remember that all care is local. The standard of care in the reviewer's area may not be the same as that in the community where the attending physician practices.
Reviewers can become jaded when they conduct reviews day in and day out. Negative, a priori judgments based on bias introduced by case managers and others, however unintended, may occur. Each case must be approached fresh and with an open mind.
Balance objectivity with subjectivity.
Reviewers may fail to recognize that medicine is both an art and a science and that a great deal of subjectivity is involved in reviewing peers. Studies have shown that physician agreement about quality of care is only slightly better than the level expected by chance (11). Moreover, the fact that utilization review organizations tend to approve most patients for the same initial length of hospital stay implies adherence to protocols that do not distinguish among different clinical or patient factors (12). My strict adherence to clinical criteria once angered a physician so much that he questioned whether I was functioning as a clerk or a clinician.
Never get into mind games with another physician during a review. Avoid making psychodynamic interpretations, yet recognize that reviewing peers may have psychodynamic implications (13). Insist that the attending physician communicate clearly and explain his or her treatment plan in terms that are understandable, behavior that is observable, and data that are factual.
Never call anyone a liar.
A reviewer who feels that deliberate misrepresentations have been made during the review should request chart validation. Whether the patient is in treatment or has been discharged, the medical record can be checked for the accuracy of the verbal representations. This approach is much more prudent than calling someone a liar.
Check your ego at the door.
Reviewers have considerable power. Don't let it go to your head. Peer review is not a game of cops and robbers. There are no good guys and bad guys. The reviewer is not being called on to make a moral judgment about treatment. Rather, a reviewer's job is to make a technical, professional assessment of the need for treatment. His or her discretionary authority should not be used for personal gain. Any physician who cannot be objective about these issues need not apply for the job.
Dr. Lazarus is medical director of behavioral health medicine for Prudential HealthCare, 102 Rock Road, Horsham, Pennsylvania 19044 (e-mail, email@example.com) and professor of psychiatry at MCP-Hahnemann School of Medicine in Philadelphia. Steven S. Sharfstein, M.D., is editor of this column.