Quality credentialing: Boon or boondoggle?
Article Outline
In a good hand every sword cuts well. Montenegrin proverb
As a surgeon in a private practice surgical group, you have just been informed that an emergency meeting has been called this evening for your group to discuss a crisis with a major private insurance payor. Several members of the group, including a vascular surgeon, a general surgeon, and an orthopedist, have been excluded from future reimbursements because they were not credentialed as higher-quality specialists. The higher-quality specialists were designated as such because of their lower admission rates, lower readmission rates, shorter lengths of hospital stay, and fewer complications according to the insurance company’s practice screens. Those surgeons not included will, by not being on the preferred list, become known to the other insurers. This particular insurer accounts for a double-digit share of the group’s income and your income. Otherwise, this payor has paid well, and transactions have been relatively hassle free. What should the group’s response to this latest intrusion be?
Physician compensation has taken many turns and twists over the past three decades, and the economic landscape of private health care insurance is shifting once again. At the onset of managed care, private and governmental insurers had considerable economic data to suspect that physicians, as a profession, were oversupplying health care.1 Payors sought to control the physician side of the equation; ergo, managed care. Managed care has had varying degrees of success in controlling physician behavior, less in controlling costs, and it has produced a backlash of patients, physicians, and health care institutions responsible for an industry-wide rethinking of strategic focus, product design, and pricing policies.2 There remains much interest on every side in improving the quality of care, although definitions may vary considerably between physicians and patients on one side and hospital administrators and payors on the other.
Quality is a human product or service’s standard of acceptability; it is a descriptor of how well something was done. The determination of quality requires comparisons of similar endeavors after deciding on what constitutes a desirable outcome. The confusion seems to result from the notion that value is interchangeable with quality. Value is the cost of quality.
Historically, quality was exclusively the concern of the physicians, and finance was left to the hospital administration. This long-standing tradition faded when cost-plus reimbursement systems were replaced by diagnosis-related groups and other tactics designed to reduce hospital reimbursements.3 Quality of care, once measured only by clinical outcome, became surrogate financial variables, such as average hospital or intensive care unit days, operating room cost, total cost of hospitalization by diagnosis, or even the time it takes a particular surgeon to do a procedure. With the rapid expansion during the 1990s of the managed care paradigm, payors began to use the quality word as a standard of excellence of both cost and good clinical outcome, but mainly cost. They abdicated specifically pinning down clinical outcomes as practical standards because physicians remained the experts in defining clinical quality, and clinical outcomes should, after all, parallel cost. Patients were the last to be concerned about quality until their rock-solid trust was somewhat eroded by the landmark 1999 report on medical errors by the Institute of Medicine, changes endorsed by the Leapfrog Group, and generally the attached publicity.4 Patients were significantly more concerned about the quality of their medical care than physicians.5
It also seems that what is meant by higher quality is not raising the apogee of the normalized curve but reducing the rightward tail where the worst outcomes often reside. The cost-savings from reducing the worst outcomes would seem an admirable ethical goal. In contrast, reducing services to bare-bones care for the sole purpose of decreasing costs by providing only essentials is less ethical (particularly when the insured does not know they have a coach policy).
There is little mystery about what “quality” of medical care means; it means adherence to standards of medical care based on the best available evidence. This should not be caricatured, as it often is, by the counterclaim that there aren’t many randomized, controlled clinical trials for everything that physicians do. This may be true, but it is an irrelevant retort, because quality concepts are applied only to therapies common enough to have sufficient data to analyze. Moreover, randomized trials are but one, not the sole, level of evidence.
Evidence-based medicine involves mastery of the discipline of applying the best available evidence to reduce uncontrolled and therefore unjustified variation in the processes and outcomes of medical care. Not only has uncontrolled negative variation in the processes of medical care and therefore in their outcomes caused preventable mortality and morbidity, but it has also resulted in preventable, high rates of cost increases. Physicians are obligated, therefore, to conform clinical judgment and decision making to the best available professional standards, because this is the only basis for becoming and remaining scientifically and clinically competent. Becoming and remaining scientifically and clinically competent is the bedrock component of fiduciary responsibility or medical professionalism, concepts introduced into the history of medical ethics in the 18th century by John Gregory (1724-1773) and Thomas Percival (1740-1804).6, 7
As noted in our study case, private medical insurance is being modified. Government payers and private health care insurers are busy developing new products that transition from a managed care focus on controlling the cost of physician behaviors to altering the patient side of the equation with “customer-driven” health care systems. The products thus far consist of health savings accounts, high-deductible preferred provider policies, and policies limited to “high-quality providers.”8, 9
The latter is a targeted attempt to switch compensation to physicians providing higher-quality care or more specifically away from bottom-dwellers. The result should be to align the financial self-interests of insurance payors with fiduciary responsibility to patient care. Not only can there be no persuasive ethical objection to such a change, but it should be actively embraced by physicians as a means to strengthen their commitment to fiduciary responsibility. Medical institutions, for various reasons including lack of authority, legal liability, and guild restraints, do little to control the worst doctors.10 The basic stated purpose is to make patients more knowledgeable and therefore motivated and effective consumers of quality medical care, rather than having medical care directed by cost considerations disconnected from fiduciary responsibility. Not everyone considers consumer-driven health care to be a good thing. Burda11 fumes,
One of the greatest public-relations coups in the history of the healthcare industry is the creation of the term “consumer-driven healthcare.” Anyone who follows healthcare knows that consumers had nothing to do with this latest cost-saving invention from the minds of employers and health insurers. And the only “movement” attached to the term is the transfer of money from the pockets of patients into those of employers and insurers and, potentially, healthcare providers.
Nevertheless, the rate of increase of health care costs slowed in 2005 to 9.2%, which is the lowest rise since 1999 but still exceeds the rise in wages by threefold. Either the employee or the employer of those with private insurance has to make up the difference, and without some economic solution, physicians will price themselves out of reach or the “big brother” regulatory arm of the government will become the undesired but unavoidable solution.
We are concerned in this article with one of leading edges of the new movement toward pay for performance joined to educated patients, exemplified by the Aexcel program of the Aetna insurance company. The above higher-quality specialist designation is probably no surprise to surgeons in the Jacksonville, Dallas, and Seattle areas; Aetna has instituted its Aexcel program denying participation to the lesser-quality specialists there, according to Dr. John Rowe, the physician CEO of Aetna insurance.8 Twenty additional urban markets are primed to follow by the time this issue of the Journal appears in your mailbox. The concept is appealing from a marketing perspective. As explained above, it is to be applauded from an ethical perspective, provided that the selection process is truly resulting in better clinical outcomes. Higher-quality specialists are selected who will provide better clinical quality care that will cost less because they are more skilled, and their patients will, as a rule, therefore have better outcomes. All surgeons are equal only under the law, a chafing awareness. And those most incompetent sometimes slip through the system’s cracks.10 Having oneself or a close family member faced with need for a serious operation, it would be a rare surgeon indeed who was nonselective in the choice of an attending surgeon. Why should not the same selectivity be available to all patients? Aetna claims to offer aid for patients to do just that, thus saving patients from choosing lower- or poor-quality surgeons by a policy permitting them to have operations done only by “high-quality” surgeons.
Answer A is an unthinking, petulant response to the threat. It is also self-defeating, because recent experience with managed care should have convinced everyone that the power of big money trumps individual physicians. Moreover, it indicates that the first loyalty is to members of your group, a “guild mentality” that both Gregory and Percival attacked as antithetical to professional integrity. Gregory’s language is harsh when he describes the guild mentality as “a narrow, selfish, corporation-spirit.”12 p. 237 Your unwavering loyalty to associates should follow your being wholly convinced that they deserve it from an objective professional perspective.
B is a worse choice still. Asking patients to alter their insurance at perhaps greater expense for your group’s continued care involves the raw assertion of individual and guild self-interest and is therefore wrong on its face. Using your professional influence for such base purposes is destructive of professional integrity.
Expecting the courts, geared for administration of justice, to give one mercy when one really wants mercy can be an expensive, masochistic learning experience. In this case, your associates would be climbing into a ring with the metaphorical 800-pound gorilla and a horde of his primate lawyer friends. Answer C should await your associates’ showing that their results are within acceptable standards, that they actually have been defamed by being excluded from the higher-quality group, and that financial losses were incurred. In other words, the issue of the quality of care provided by colleagues must be addressed, as a matter of strict, shared fiduciary responsibility to the group’s patients.
Discharging your partners out of hand because they cannot meet the criteria of a single payor without data to show they are below the standards of the group practice would be impulsive, unwarranted, and unfair. There should be a well-defined understanding as to what constitutes a serious enough violation in a group practice to constitute a partner’s leaving. Also, this behavior does not consider that group practices differ considerably in financial structuring. Option D is thus ruled out.
In the case of the Aetna program to panel higher-quality specialists, the ethics depend on the selection criteria primarily being markers of clinical excellence with cost savings an epiphenomenon. The Aexcel program uses three types of criteria for identifying high-quality surgeons: (1) criteria from the Ambulatory Care Quality Alliance (the American College of Surgeons and Society of Vascular Surgery are members); (2) general inpatient criteria such as bleeding and infection rates; and (3) criteria from societies of each specialty. Dr. Rowe was contacted and agreed to supply the specific criteria for vascular surgeons but at this writing has not done so. Few could argue that, provided that data as described are accurately collected and objectively applied, the worse and better surgeons could be identified. This leaves option E as the preferred method of dealing with this challenge. Industry-originated quality-improvement methods have long been established to work in medical care as well as manufacturing products. Objective scrutiny that fairly compares surgeons is a gut wrenching, but ethically essential, part of practice. It is not foreign to surgeons who are held responsible in morbidity and mortality reviews from the moment they enter residency training. Option E also insulates the quality surgeons in the group from risk of injury to their professional integrity, risk that will occur if they put the group’s economic self-interest ahead of shared fiduciary responsibility for patients. Rising financial water can be a useful stimulus for seeking higher professional ground.
References
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- . Lectures on the duties and qualifications of a physician . Edinburgh: W. Strahan and T. Cadell, 1772 In: McCullough L editors. John Gregory’s writings on medical ethics and philosophy of medicine . Dordrecht, The Netherlands: Kluwer Academic; 1998;p. 161–248
James W. Jones, PhD, MHA, Surgical Ethics Challenges Section Editor
PII: S0741-5214(06)00311-9
doi:10.1016/j.jvs.2006.02.030
© 2006 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
