Economic credentialing may be defined as the use of economic criteria, unrelated to quality assurance, to determine a neurosurgeon’s qualification for the grant or renewal of medical staff membership or privileges. This type of credentialing is inappropriate. The need to prevent economic considerations from affecting medical determinations regarding quality care is critical. The introduction of economic factors into medical staff credentialing is particularly threatening. Patients will be denied hospital services if qualified physicians are denied medical staff membership because of the economic mix of their practices and patients.
Physician Profiling
In its day-to-day management, a hospital administration utilizes information systems to gather data necessary for billing, payroll, personnel and planning. Given the constant flux in healthcare financing in both the private and public sector, hospital billing and collection data systems are becoming particularly complex and have spawned a variety of data to assist hospital accountants. The data collection has led to the creation of physician profiles.
Physician profiling, i.e., accumulating data separate from medical staff quality assurance systems on the physician’s admission and treatment decisions, already has created the potential for economic pressures to affect the care provided the hospitalized. How physician-specific economic information is utilized in the hospital is key for quality assurance. Appropriately utilized, some profile information has or could play a positive role in assessing care quality. Conversely, the inappropriate use of profiles for economic reasons in the credentialing system can have devastating, long-term effects on quality and access to care.
A review of the literature and of the data systems available to hospitals was summarized last year in CMA ON-CALL (the California Medical Association’s online library) Document 1212. It shows that some data may serve a purpose related to patient care and other data commonly collected by hospitals clearly does not. According to the CMA Document 1212, criteria that could be used by hospitals can be grouped into three categories:
- criteria that are valid for quality assurance purposes,
- those that may have validity for quality assurance,
- those that have no quality assurance validity.
Examples of criteria that have validity for quality assurance purposes include length of stay, number of ICU days, excessive and redundant testing, fraud and abuse, health status, office proximity and disruptions of hospital operations, as they pertain to patient care and excessive number of denial letters.
Examples of economic data that may have quality ramifications depending upon the clinical context include comparison of resources used (variation studies), number of tests ordered, comparative profiles of physician outcomes and resources utilization within the same DRG category, number of hospital admissions vis-à-vis outpatient services utilization and number of consultants/referrals.
Selected examples of criteria that do not apply to quality include personal referral patterns, resource utilization in dollars, physician profit by reimbursement, physician profit by cost, revenue per physician, commercial payor profiles, market need for particular type of physician, comparative use of inpatient services and operating room underutilization.
Although the use of the above fiscal information may appear to be sound business practice, straight application of sheer business motives in the delivery of healthcare, most particularly in a hospital, is not acceptable in public policy or law. Selection of medical staff members based on the relative profit by cost or reimbursement level, or other criteria wholly unrelated to the quality of care provided, creates innumerable hazards. The ultimate problem is the unavoidable negative affect of economic credentialing on patient care. Physicians whose patiient base generates less profit for the hospital may be refused medical staff membership. People who have the misfortune to contract an inefficient disease will go without hospital care. The use of, or sanctioning of, economic credentialing may convert the medical staff to a listing of those practitioners who generate profit rather than high quality medicine.
The Exclusive Contract
Exclusive contracts have existed for a long time throughout the nation. Traditionally, these contracts were entered into to assure access and quality of care. More recently, financial considerations have grown in importance as reasons for exclusive contracting. The exclusive contract has the potential for abuse by circumventing the quality improvement mechanisms of the medical staff. The contract may put the physician or physician group in a position of being controlled by the hospital’s financial plan. Neurosurgeons need to recall that the negotiation position of a single doctor or small group of doctors versus the hospital corporate entity is rarely one of equal bargaining power, particularly where there is a surplus in the specialty and no other local facility in which to practice.
John A.Kusske, MD, is former Chair of the AANS Mananged Care Advisory Committee.