American Journal of Medical Quality

Medical care value purchasing is the latest effort to promote cost containment while maintaining or enhancing the quality of medical care. The fuel driv ing this process is mandated health care cost and quality data disclosure to stimulate competition in oversupplied markets so that the highest quality and lowest cost providers achieve the greatest market share gains. States such as Pennsylvania, pursuant to Act 89, are in the vanguard of this national move ment, sometimes referred to as the "Buy Right Strat egy for Health Care Purchasing."

The measurement of provider quality and cost-ef fectiveness will become a "growth industry" in the 1990s. Medical paternalism will give way to con sumer activism in health care decision making. How ever, there are certain medicolegal pitfalls arising from the promises associated with mandated data disclosure concerning provider cost and quality effec tiveness.

One pitfall is that the unmeasurable quality attri butes (such as compassion and empathy) will fall into even greater disuse. Another pitfall may concern the further inflation of expectations of certain health care outcomes among consumers attending providers with the highest cost/quality ratings. Also, those pro viders losing patients will lose practical skills and any restraint they might have had from overutiliza tion on those few remaining fee-for-service patients left to them. All of these scenarios could result in increased litigation.

Despite these potential pitfalls, medical care value purchasing represents a real advance in promoting quality and cost-effectiveness. Regardless of the un derlying motivation, these two worthy goals should be sought with increasing vigor in the days ahead. The ultimate benefit may well be the rising to prom inence of the "laser-beam" (as opposed to the "shot gun") approach to clinical diagnosis in our academic medical centers and other health care institutions nationwide.

Delegation of Medicare peer review authority to hospital committees contributed to the failure of Professional Standards Review Organizations. The financial incentives of prospective payment under Diagnosis-Related Groups are associated with partic ularly aggressive hospital-based review and ethical tensions between attending physicians, medical staff committees, and hospital administration. Peer Re view Organizations (PROs) are expected to mediate as well as monitor in this environment, but PROs are harshly judged in turn by the "SuperPRO," which finds them too permissive, and by administrative law judges who overturn the majority of their denials on appeal. Although PRO deliberations are held confi dential, release of denial statistics and hospital-spe cific mortality information raises serious concerns.

The Medicare and Medicaid laws were intended to eliminate inferior medical care for the elderly and the indigent. The success of these programs, however, has led to more expense than the government had anticipated. To control this cost, the government has designed several utilization review processes that, by necessity, have also required quality assurance mech anisms. On the assumption that fewer hospital days would cost fewer dollars, discharge planning has evolved. Although physicians may find this somewhat time consuming, they must participate in discharge planning because of the consumers' demand, the legal requirement, the attempt to reduce litigation, and the potential income. All patients need discharge plan ning to some extent. The evaluation of the quality of discharge planning must look at its structure, its process, and its outcome. Most early studies seem to be looking at the in-hospital process, but we must also evaluate process-centered, patient-centered, commu nity-centered, and cost effectiveness-related out comes.

The author examines the concept of a Quality As surance/Utilization Review residency program from the perspective of a program director in an estab lished specialty. Quality Assurance/Utilization Re view could develop into a specialty that is oriented heavily toward administration. In order to maintain a more appropriate orientation toward clinical med icine, the specialty must develop into an attractive practice option for the graduating medical student.

The Medicare database, which is comprehensive, current, and easily manipulated by computer tech nology, contains enormous amounts of information regarding hospital and physician practices. Access to the Medicare database greatly increased with the es tablishment of the Peer Review Organization pro gram. Recent Medicare data releases by the Health Care Financing Administration and the California Peer Review Organization demonstrate the potential usefulness of the Medicare database. Although analy sis of the Medicare database is in the early develop mental stages, the utility of the database will expand as analytic techniques improve.