Peer Review: Protecting Your Investment So Hospitals will be paid - - PDF document

Peer Review: Protecting Your Investment

 Incentive payments  Funded by 1% cut in base DRG payment

So… Hospitals will be paid less unless:

 Meeting 17 clinical processes (aspirin, antibiotic timing, Dx instructions)  Patient-centeredness (HCAHPS)  Soon, mortality data

Good scores on …

What is at stake when peer review fails?

• Potential for patient harm
• Recruitment/relocation investment
• Hospital reimbursement tied to

performance

• Morale/turnover
• Vicarious liability
• Hearing
• Litigation
• Recruit replacement
• Criminal, licensure issues

Costs:

In the Matter of

Mark G. Midei, M.D.

 Unprofessional conduct in the practice of medicine  Willfully making a false report or record in the practice of medicine  Gross overutilization of health care services  Violations of the standard of quality care  Failure to keep adequate medical records

Licensure Action

• Dr. Midei was present for

the proceedings and was represented by nine attorneys.

 Implanted cardiac stents unnecessarily  Falsified the extent of blockage of the patients’ coronary arteries by reporting that it was 80% when it was in reality lower – much lower  Falsely reported that they suffered from unstable angina

“Dr. Midei was not paid per stent inserted…was employed under circumstances in which any employee would feel at least some pressure to produce a high volume

• f stents.”

License revoked July 13, 2011. May not apply for reinstatement for two years.

How Did the Board Know?

Anonymous letter from Hospital employee.

• Dr. Midei claimed he was

suspended by hospital to deflect attention from its own fraud investigation.

The outside reviewer was impressive to the state board hearing officer.

• Dr. Chacko was subjected to

unacceptable harassment and intimidation by [Dr. Midei’s attorney].

Throughout Dr. Chacko’s testimony, Mr. Snyder repeatedly interrupted, attempted to confuse, demean, and bully him, and made subtly threatening comments to him. Mr. Snyder’s many attempts to rattle Dr. Chacko were unsuccessful. I found Dr. Chacko to be extremely knowledgeable and thoroughly

• professional. He never became agitated, no

matter how many times Mr. Snyder insulted

• him. When Mr. Snyder asked Dr. Chacko a

question which assumed facts not in evidence

• r misstated his testimony, …
• Dr. Chacko quickly and dispassionately

corrected him. When a lawyer asking the questions became confused about the symptoms and treatment of the five patients at issue, Dr. Chacko had complete, accurate recall of all of the relevant facts. Dr. Chacko did not exhibit any animus toward [Dr. Midei], and he acknowledged [Dr. Midei’s] status in the medical community. For all of these reasons, I have given Dr. Chacko’s testimony great weight.

Midei claimed Dr. Chacko’s report was “paid for.”

• Dr. Chacko was paid $1,400 for his

report and expert testimony. (Dr. O’Neill (Dr. Midei’s expert) was paid more than twenty times that much.)

Disciplinary proceedings against a physician are not intended to punish the offender but rather to protect the public.

The violations proven were repeated and

• serious. Although none of the patients

suffered any adverse consequence, such as bleeding or blood clots, as a result of [Dr. Midei’s] care, one of the patients suffered a tear in an artery, requiring the placement of another stent, and the patients were required to take Plavix for a year and aspirin for life after their stents were inserted. [Dr. Midei] unnecessarily exposed patients to risk of harm. This factor warrants a severe sanction. [Dr. Midei’s] practice of inserting stents increased the cost of the patients’ medical care to the health care system. PCI is much more expensive to a patient, the Medicare program, and insurers than medical therapy.

…before these charges became public, [Dr. Midei] was a recognized leader in the medical and cardiology communities in Maryland. He has a body of work over a professional lifetime that, before this case, any doctor would be proud to own.

[Dr. Midei] was a salaried employee at SJMC; he had no apparent financial motive for his conduct. He was devoted to his profession, respected by his peers and co- workers, and had a loyal following of referring physicians.

Traditional “peer review”:

• Retrospective
• Subjective
• No sufficient interaction
• Novice reviewers
• Personal
• No end point/trend
• Fear of litigation

The Joint Commission calls it: OPPE FPPE We call it: Professionalism/ Lifelong learning

It must start earlier

Continuous Professional Performance Process

Orientation Set clear, high standards* Preceptor/mentor Replace “lost” hours of training *Requires bylaws change/contract language

Mutual Benefits

 Gives each physician the best chance to be successful  Maintain currency  Reviewers’ CME

How?

• Multiple input process
• Physicians
• Employees
• Patients (www.cahps.ahrq.gov)
• Protocol/guideline compliance
• Medical necessity (compare with

Dartmouth/Dx statistics)

• Sentinel events/never events
• Specialty-specific indicators

What?

• System issues
• Conduct
• Health
• Quality

What?

• Triage: Identify system issues
• Share data/information with physicians

(de-identified)

• Educational letters/follow-up
• PIPS
• Progressive discipline (bylaws

change)

Role of Board

• Ultimate responsibility
• Assure
• a good process
• participants are trained and diligent
• system issues identified and correction plan

implemented

• Require conformance to quality and safety

initiatives

• Require reports on unusual or long-standing

problems

Role of Management

• Assure resources for ongoing process
• Determine if it is contract/employment

issue

Role of Medical Staff

• Accountable
• Well trained
• Compensated?

Participants must be:

Who serves on committee?

• Physician leaders with training
• Quality Director
• MSP
• PMG CMO

What if problem is with PMG physician?

Peer Review Privilege

• Attaches to Medical Staff, but to

PMG?

• Documentation matters – keep out of

employment files

Required Documents to Clarify and Guide Process

• Information Sharing Agreement
• Release
• Contract Language
• Bylaws Language
• Policy on Performance Review Based
• n Established Benchmark Data

Who finally acts?

Employer? PPEC?

→ Tweaking current system won’t work → Bylaws/contracts must require compliance → Standards must be clear → PPEC must be trained, vigilant

Beneficiaries

 Patients  Physicians  Hospital