Peer Review: Protecting Your Investment Peer Review: Protecting - PDF document

Peer Review: Protecting Your Investment Peer Review: Protecting Your Investment So… Hospitals will be paid less unless: Good scores on …  Incentive payments  Meeting 17 clinical processes  Funded by 1% cut in base (aspirin, antibiotic timing, Dx DRG payment instructions)  Patient-centeredness (HCAHPS)  Soon, mortality data Costs:  Potential for patient harm  Recruitment/relocation investment  Hospital reimbursement tied to What is at stake when peer performance  Morale/turnover review fails?  Vicarious liability  Hearing  Litigation  Recruit replacement  Criminal, licensure issues K:/Pres/Handout/EPI/1112/01SanDiego/Linda/PeerReview_Investment.ppt 1

Peer Review: Protecting Your Investment Licensure Action  Unprofessional conduct in the practice of medicine In the Matter of  Willfully making a false report or record in the practice of medicine Mark G. Midei, M.D.  Gross overutilization of health care services  Violations of the standard of quality care  Failure to keep adequate medical records  Implanted cardiac stents unnecessarily Dr. Midei was present for  Falsified the extent of blockage of the proceedings and was the patients’ coronary arteries by represented by nine attorneys. reporting that it was 80% when it was in reality lower – much lower  Falsely reported that they suffered from unstable angina  Failed to obtain the Active Thus, although Dr. Midei was not Coagulation Time (“ACT”) and paid per stent inserted, he was instead simply administered heparin employed under circumstances in while inserting the catheter which any employee would feel at least some pressure to produce a high volume of stents. K:/Pres/Handout/EPI/1112/01SanDiego/Linda/PeerReview_Investment.ppt 2

Peer Review: Protecting Your Investment How Did the Board Know?  Received a letter from a new employee of the SJMC License revoked July 13, 2011.  Employee wanted anonymity May not apply for reinstatement  Listed 36 patients with “insignificant blockages” who received stents for two years. Claimed he was suspended by hospital to deflect attention from its own fraud Dr. Midei’s defense was first investigation. to blame the hospital. Dr. Chacko was subjected to The outside reviewer was unacceptable harassment and impressive to the state board intimidation by Mr. Snyder, [Dr. hearing officer. Midei’s] attorney. K:/Pres/Handout/EPI/1112/01SanDiego/Linda/PeerReview_Investment.ppt 3

Peer Review: Protecting Your Investment Throughout Dr. Chacko’s testimony, Mr. Dr. Chacko quickly and dispassionately Snyder repeatedly interrupted, attempted to corrected him. When a lawyer asking the confuse, demean, and bully him, and made questions became confused about the subtly threatening comments to him. Mr. symptoms and treatment of the five patients at Snyder’s many attempts to rattle Dr. Chacko issue, Dr. Chacko had complete, accurate were unsuccessful. I found Dr. Chacko to be recall of all of the relevant facts. Dr. Chacko extremely knowledgeable and thoroughly did not exhibit any animus toward [Dr. Midei], professional. He never became agitated, no and he acknowledged [Dr. Midei’s] status in matter how many times Mr. Snyder insulted the medical community. For all of these him. When Mr. Snyder asked Dr. Chacko a reasons, I have given Dr. Chacko’s testimony question which assumed facts not in evidence great weight. or misstated his testimony, … Dr. Chacko was paid $1,400 for his Midei claimed Dr. Chacko’s report and expert testimony. report was “paid for.” (Dr. O’Neill (Dr. Midei’s expert) was paid more than twenty times that much.) 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 Disciplinary proceedings suffered a tear in an artery, requiring the against a physician are not placement of another stent, and the intended to punish the offender patients were required to take Plavix for but rather to protect the public. a year and aspirin for life after their stents were inserted. K:/Pres/Handout/EPI/1112/01SanDiego/Linda/PeerReview_Investment.ppt 4

Peer Review: Protecting Your Investment …before these charges became [Dr. Midei] unnecessarily exposed public, [Dr. Midei] was a recognized patients to risk of harm. This factor leader in the medical and cardiology warrants a severe sanction. communities in Maryland. He has a [Dr. Midei’s] practice of inserting body of work over a professional lifetime stents increased the cost of the patients’ that, before this case, any doctor would medical care to the health care system. be proud to own. He was considered PCI is much more expensive to a patient, one of the top ten interventional the Medicare program, and insurers than cardiologists nationally, in terms of the medical therapy. number of invasive procedures he performed. Traditional “peer review”:  Retrospective [Dr. Midei] was a salaried employee at  Subjective SJMC; he had no apparent financial  No sufficient interaction motive for his conduct. He was devoted  Novice reviewers to his profession, respected by his peers  Personal and co-workers, and had a loyal following of referring physicians.  No end point/trend  Fear of litigation The Joint Commission calls it: We call it: OPPE Professionalism/ FPPE Lifelong learning K:/Pres/Handout/EPI/1112/01SanDiego/Linda/PeerReview_Investment.ppt 5

Peer Review: Protecting Your Investment Continuous Professional Performance Process Orientation Set clear, high standards* It must start earlier Preceptor/mentor Replace “lost” hours of training *Requires bylaws change/contract language How? Mutual Benefits  Multiple input process  Physicians  Employees  Gives each physician the  Patients (www.cahps.ahrq.gov) best chance to be successful  Protocol/guideline compliance  Maintain currency  Reviewers’ CME  Medical necessity (compare with Dartmouth/Dx statistics)  Sentinel events/never events  Specialty-specific indicators What? What?  Triage: Identify system issues  System issues  Share data/information with physicians  Conduct (de-identified)  Health  Educational letters/follow-up  Quality  PIPS  Progressive discipline (bylaws change) K:/Pres/Handout/EPI/1112/01SanDiego/Linda/PeerReview_Investment.ppt 6

Peer Review: Protecting Your Investment Role of Board Role of Management  Assure resources for ongoing process  Ultimate responsibility  Assure  Determine if it is contract/employment  a good process issue  participants are trained and diligent  system issues identified and correction plan implemented  Require reports on unusual or long- standing problems Who serves on committee? Role of Medical Staff  Physician leaders with training Participants must be:  Quality Director  Accountable  MSP  Well trained  PMG CMO  Compensated? Peer Review Privilege  Attaches to Medical Staff, but to PMG? What if problem is with  Documentation matters – keep out of PMG physician? employment files K:/Pres/Handout/EPI/1112/01SanDiego/Linda/PeerReview_Investment.ppt 7

Peer Review: Protecting Your Investment Required Documents to Clarify Who finally acts? and Guide Process  Information Sharing Agreement  Release Employer?  Contract Language PPEC?  Bylaws Language  Policy on Performance Review Based on Established Benchmark Data Beneficiaries → Tweaking current system won’t  Patients work  Physicians → Bylaws/contracts must require compliance  Hospital → Standards must be clear → PPEC must be trained, vigilant K:/Pres/Handout/EPI/1112/01SanDiego/Linda/PeerReview_Investment.ppt 8