Dynamic Chiropractic – September 13, 2004, Vol. 22, Issue 19

Peer Review: Opinion vs. Policy

By Shawn S. Wallery, DC, MBA
A call to all peer reviewers: Please understand that your unsupported individual opinions and "practice guidelines" may be utilized as standard policy and best practices by many of the insurance companies that request them.
As a doctor who has orchestrated, reviewed and performed thousands of utilization reviews with hundreds of practitioners, I understand the benefits and perils associated with the outcomes of these all-too-often "adverse" reviews, both as a reviewer and as a practitioner.

The process of peer review within the chiropractic profession is a necessary function that promotes internal self-governance and quality assurance. However, it is my opinion that most of the chiropractic peer reviews I review utilize independent opinions and implement practice guidelines not supported by any clinical standards or by a preponderance of the chiropractic literature/profession. As this is one article from one practitioner, its sole purpose is not to establish rules, guidelines or policies for an entire profession. It is strictly intended to provide an initial basis for discussion among providers and to assist in formulating real solutions for a system fraught with entropy.

Peer reviews within all health care professions should serve the greater good of the public and the entire profession. It is a process that, if used correctly, will benefit everyone involved. Six potential societal considerations for utilizing peer reviews are to:

  1. promote a higher quality, more effective and efficient health care delivery system;
  2. assure public safety;
  3. promote, develop and assure best standard practices;
  4. assure legal and ethical conduct;
  5. assure case-specific safety, quality, and appropriate patient management; and
  6. promote education, discussion, and potential debate among professional peers on appropriate patient management protocols, standards, and algorithmic development.

Although often a sequela to peer review, the primary purpose is not to provide a denial source for insurance companies or revenue supplementation for the reviewing doctor. These misguided intentions often lead to creative denial standards and a sense of obligation to appease the paying client for the security of future business relationships. As the name implies, these reports and examinations are intended to be "independent."

Ethics of Review

As part of the evolving process of quality assurance in peer review, several basic standards of ethics should be proposed for discussion:

  1. Reviews should measure the documentation submitted against published industry standards of care and refrain from utilizing self-supported statements of denial without basis.
  2. Reviewers should be responsible for supporting their statements of denial with evidence-based published literature, as they require of treating physicians. Statements of denial lacking reasoning or evidence should not be considered valid and are, in my opinion, tantamount to unethical health care.
  3. Reviewers must establish specifically what aspect(s) of the care/treatment are not supported, and why. This should include what is specifically contained or lacking in the presented documentation that is serving to formulate their opinion. Broad-based statements such as "The documentation does not support the care and treatment" should be expanded upon and the areas of concern specifically addressed.
  4. Reviewers should be responsible for responding to all reasonable and logical rebuttals to their reviews. If the rebuttal provides sound reasoning and evidence, the reviewer must reconsider his or her original opinions or provide a proper justification. In my opinion, the statement of "No additional documentation was provided to change my original opinion" may not always suffice. This statement is often utilized irrespective of the evidence or documentation provided by the rebuttal, potentially as a result of reviewers feeling compelled to assure the paying party a reason for denial and avoid embarrassment.
  5. All references must specifically be quoted in correct context as to how they are being utilized as a measurement tool. Unfortunately, many reviewers errantly reference authors, texts and guidelines to support their reasoning for denial. This includes the referencing of the Mercy Guidelines. Many reviewing authors cite this document at the end of their review as their authoritative basis for denial, with no indication as to what specific language from the text was utilized. This text is much more liberal than many reviewers' interpretation of it, if they have even read it at all, and their assumptions as to its content are often false.
  6. Reviewers should refrain from utilizing inappropriate policy references and practice guidelines that do not fit the context of the specific case. For example, utilizing the Center for Medicare and Medicaid Service's payment policy on hot/cold packs for non-CMS claims (private carrier, cash or litigious claims). Care and treatment should only be measured against those laws and established policies specifically related to the case type and geographical area in which the case resides. It is my opinion that the establishment of protocols, guidelines, and payment policies should be for public and private carriers, governmental authorities, or as part of profession majority. This process is certainly not for individual practitioners to act as self-appointed governance on behalf of the whole.
  7. Reviewers should refrain from establishing self-purported usual and customary fee guidelines. Fees should only be measured against the usual and customary fee schedules specific to the case type. Measuring a provider's fees for a workers' compensation claim against CMS's fee schedule may be, in my opinion, a potential violation of anti-trust fee-setting practices, unless the state utilizes CMS as a basis for its fee schedule.

Conclusion

The intention of peer review should be to strengthen the health care system and our profession, not to create a system of self-destruction. If we continue allowing a small number of unelected providers to act as the policy-makers for our entire profession, I believe we will soon find ourselves in a reduced role, more strictly held by our already confined boundaries. It is imperative that we, as a profession, establish regulations, guidelines and controls for the practice of peer review. Laws such as ERISA, organizations such as URAC, and some state workers' compensation/insurance boards have already attempted to establish certain peer-review guidelines and appeals processes. However, for many providers, they are difficult to understand, cumbersome to utilize, and often ineffective. The most effective method of internally managing this paradox is not, in my opinion, another policy guideline or paper trail of appeals forms, but instead, a call to all providers to shift the paradigm in which the standards of our profession are upheld and judged, such that those who judge are held to an even higher level of fiduciary standards.

Shawn Wallery, DC, MBA
Chicago, Illinois

 


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