Medicare Compliance & Reimbursement

Hospitals can sidestep a major patient safety and compliance nightmare: A physician who's been doing procedures that clearly don't meet established medical necessity criteria.

That scenario occurred recently at a Baltimore,Maryland hospital where a surgeon stands accused of planting stents in people who didn't need them (see the cover story in the last issue of Medicare Compliance & Reimbursement, Vol. 33, No. 1).

"In terms of surgical procedures, the No. 1 safety measure [to help prevent unnecessary procedures] is peer review in hospitals," says attorney Christopher Lucas, in private practice in Camp Hill, Pa. "The hospital has access to the experts and diagnostic data and could evaluate medical necessity, although sometimes the hospital has financial incentives not to look at thatissue too closely."

Not only can the bottom line skew the peer review committee's findings or willingness to take action -- so can fear of confronting a colleague or even getting fired, note experts.

One solution: Hospitals can use an outside objective approach to peer review for certain types of procedures. For example, about 20 hospitals nationwide are using Physician Compliance Network's  "Appropriateness of Cardiovascular Care" program which monitors interventional cardiac procedures, reports Gregory Cohen, MD, MPH, FACC, CEO and founder of the company in Los Angeles.

"The whole basis for forming the company was to get interventional cardiologists ... together to evaluate each other's procedures anonymously" and provide data to the hospital on the appropriateness of the procedures. "At some point we may focus more on quality issues but right now we are focused on appropriateness," says Cohen.

In performing the reviews, the cardiologists in the network, all of whom have ties to academic centers, actually look at the patient's angiogram films and medical record data. The review helps catch situations where the documentation says a patient has an 80 percent blocked artery, which meets the medical necessity criteria for inserting a stent, says Cohen. Yet the patient really only has a 20 percent blockage.

"Most hospitals already monitor for outcomes of the procedure," adds Cohen. But they "don't evaluate whether the procedure was indicated since no one but the performing cardiologist is looking at the films," he points out. And for that reason, "a few cardiologists have abused their privilege to perform these procedures long before it becomes apparent and reported," he says.

A hospital could implement "a similar approach using outside peer reviewers for any surgical procedure for which there are written guidelines or standards," says Cohen. "Hysterectomies, and certain orthopedic and pain management procedures are a few examples that come to mind."

One idea: A hospital could pay outside reviewers from another hospital to examine cases that raise questions about being appropriate or of acceptable quality. The reviewers would have to be people without "a vested interest or axe to grind" and should also be qualified to review the cases, Cohen says.

Cohen predicts we'll see hospitals using more objective approaches to peer review, noting that the business he developed wouldn't have stood a chance of succeeding a decade ago. Hospitals today, however, realize that the government is looking at the procedures that show a "wide geographic variation" in the number performed on patients with similar conditions. Yet "in spite of the increased number and cost of certain procedures performed in these regions and hospitals, there is often no significant difference in overall outcomes for patients."

If that isn't a big enough stick: "Hospitals realize that the government could come after them if a surgeon is doing medically unnecessary procedures," says  Cohen. And "attorneys predict that we will see more whistleblower cases in the future."