Third-party Review Research Articles

Subsurface Geology of Hazardous Waste Injection Sands Near Geismar, Louisiana

A third-party review of subsurface geology in the vicinity of Geismar, Louisiana, was conducted as part of the regulatory process for granting exemptions from “Land Ban” statutes that forbid injection of concentrated hydrochloric acid. Radial faults associated with a piercement salt dome displace both injection sands and isolation layers in Darrow Field (T10S R2E) and probably extend upward to the Gonzales aquifer, which is designated as an underground source of drinking water (USDW). A regional normal fault that extends from Laurel Ridge Field (T10S R13–14E) through Darrow Field also disrupts the injection interval. A concern is that these faults provide vertical pathways for transmission of hazardous waste out of the injection zone. The Upper B Sand, which receives hazardous waste from the Geismar Industrial Complex, is stratigraphically equivalent to an important fresh water sand in southeastern Louisiana, the Covington aquifer. Over most of the study area, the base of USDW is in the Gonzales aquifer, which appears to be isolated from the injection zone by the Confining layer. A mass transfer model (EQ6) for irreversible reaction of HCl with injection sands indicates that advective flow beyond the injection field is required for neutralization to occur.

Provider profiling: severity-adjusted versus severity-based outcomes.

Providers will continue to experience increasing pressure to demonstrate cost-effective, high-quality care. For relevant comparisons between providers, outcomes must be evaluated with respect to severity of illness and mortality risk. However, most hospitals use patient classification methods, such as Medicare and Health Care Financing Administration diagnosis-related groups (DRGs), which group together different levels of severity and mortality risk. The most common approach for developing severity-adjusted outcomes for groups of cases with dissimilar severity levels is to divide a statistic by a factor such as the Medicare case mix index, which was not designed or intended for that purpose. As an alternative, providers are increasingly using severity-based methods that classify patients as to severity levels within each diagnosis-related group. The key to severity-based profiling is the classification of cases to similar patient groups and comparison to selected benchmarks for variance analysis at each severity level. Effective provider profiling requires that hospital staff and physicians work together toward the common goal of accurate and complete documentation and coding of all medical conditions. Through use of more accurate severity-based profiling, providers are better able to identify opportunities to improve performance and demonstrate cost-effectiveness and quality to buyers, beneficiaries, and third-party reviewers.

Preliminary clinical evaluation of a high-resolution telemammography system.

The authors designed, assembled, tested, and clinically evaluated a high-quality, fast, and relatively inexpensive telemammography system. The authors designed a telemammography system that uses a high-resolution film digitizer and high data compression (> or = 40:1) to send images over regular telephone lines to a high-resolution laser printer that produces images with the look and feel of the original image and can operate in a hub and spokes mode. The authors then evaluated the system's performance. In a preliminary clinical study, interpretations of the laser-printed system's output of 119 cases were compared with the original interpretations, followed by a review of any clinically significant differences. With the exception of the laser printer, which is a modified off-the-shelf product, all hardware components of the system are commercially available products. The system digitizes (50 microns pixel size), compresses, transmits, receives, decompresses, and prints a 30 MB mammography file in less than 4 minutes. In the clinical study, there were 13 differences (in 13 cases) in the level of concern or recommendations. Seven were found to be clinically insignificant by a third-party review. The remaining six were reviewed by the original interpreter, and three were determined to be significant enough for further action. All were found to result from intra-reader variability rather than differences in visualization of possible abnormalities. Almost real-time, high-quality telemammography without geographic boundaries is possible with the use of high-level data compression. Telemammography with laser-printed film as the display may make it possible to offer mammographic services in remote locations while using commercially available technology.

Psychiatric Care and Patient Confidentiality

To the Editor. —In Resident Forum,1Dr Szigethy writes cogently about the problems with the professional identity of psychiatry in the era of managed care. I would like to briefly elaborate on one of her points, the compromise of patient confidentiality when third-party reviewers are involved. The leaders in psychiatry should take the lead in reexamining the casual manner in which patients are asked to waive their rights to privacy and confidentiality. When psychiatric treatment is involved, managed care companies are either uninterested in or unaware of the impact on patients when they are obliged to waive their or their family member's privacy and confidentiality in order to receive psychiatric services, however limited these services may be. More important, the large problem of the loss of privacy and confidentiality in mental health treatment is just the tip of the iceberg. Physicians routinely send medical information, such as operative reports

Medical professionalism under managed care: the pros and cons of utilization review.

We contend that the full consequences of managed care for American medicine and health care professionals can be more fully understood if strategies for managing care are identified-in particular, strategies for the administrative oversight of professional decision making. In this paper we apply this perspective to the study of third-party utilization review, making use of a national survey of firms contracting to provide prior authorization for hospitalization in 1992. Survey data suggest that (1) existing approaches to utilization review differ greatly among review firms; (2) review practices that might improve agency and accountability seem to be overlooked by most review firms; and (3) a large number of review firms employ practices that undermine professional autonomy in seemingly inappropriate ways.

Could Third-Party Review Make More, Better Devices Available?

Could Third-Party Review Make More, Better Devices Available?

On Doctoring: Stories, Poems, Essays

In today's world of rapid and sometimes frustrating change in the practice of medicine, this anthology of medical stories, poems, and essays is a breath of fresh air. Medicare and Medicaid reform (or lack thereof), the resource-based relative value scale, diagnosis related groups, third-party review, increasing reliance on technology, litigation, decreasing enrollment in medical schools, and the departure of many of our colleagues from the art itself have caused many of us to lose sight of why we originally entered the practice of medicine. These writers, many of them physicians themselves, restore the vision that induced us to go into medicine in the first place. Many of these stories use the prism of medicine to explore the spectrum of human emotions from extreme frailty to unbounded courage. Through poetry, medicine's more poignant moments are portrayed beyond the usual powers of expression. The writers range from the authors of the Old

Charity and community: the role of nonprofit ownership in a managed health care system.

As American medicine has been transformed by the growth of managed care, so too have questions about the appropriate role of nonprofit ownership in the health care system. The standards for community benefit that are increasingly applied to nonprofit hospitals are, at best, only partially relevant to expectations for nonprofit managed care plans. Can we expect nonprofit ownership to substantially affect the behavior of an increasingly competitive managed care industry dealing with insured populations? Drawing from historical interpretations of tax exemption in health care and from the theoretical literature on the implications of ownership for organizational behavior, we identify five forms of community benefit that might be associated with nonprofit forms of managed care. Using data from a national survey of firms providing third-party utilization review services in 1993, we test for ownership-related differences in these five dimensions. Nonprofit utilization review firms generally provide more public goods, such as information dissemination, and are more "community oriented" than proprietary firms, but they are not distinguishable from their for-profit counterparts in addressing the implications of medical quality or the cost of the review process. However, a subgroup of nonprofit review organizations with medical origins are more likely to address quality issues than are either for-profit firms or other nonprofit agencies. Evidence on responses to information asymmetries is mixed but suggests that some ownership related differences exist. The term "charitable" is thus capable of a definition far broader than merely the relief of the poor. While it is true that in the past Congress and the federal courts have conditioned the hospital's charitable status on the level of free or below cost care that it provided for indigents, there is no authority for the conclusion that the determination of "charitable" status was always so limited. Such an inflexible construction fails to recognize the changing economic, social and technological precepts and values of contemporary society. -Circuit Court of Appeals, District of Columbia, Eastern Kentucky Welfare Rights Organization v. Simon (1974).

Long-term intraspinal infusions of opioids in the treatment of neuropathic pain

Long-term intraspinal infusions of opioid drugs are being increasingly utilized in patients with noncancer pain. Despite this, there is a lack of long-term information, including success and failure rates for pain relief and technical problems. During a 5-year period, 18 noncancer patients underwent implantation of programmable infusion pumps for long-term intrathecal opioid infusion. Patients had (a) neuropathic pain, (b) had failed or been ineligible for noninvasive treatments, and (c) obtained greater than 50% pain relief with intrathecal trial infusions of morphine sulfate or sufentanil citrate. A disinterested third-party reviewer evaluated patients at the most recent follow-up. Sixty-one percent (11/18) of patients had good or fair pain relief with mean follow-up 2.4 ± 0.3 years (0.8–4.7 years). Average numeric pain scores decreased by 39% ± 4.3%. Five of the 11 responders required lower opioid doses (12–24 mg/day morphine) and the remaining six patients required higher opioid doses (>34 mg/day morphine). Failure of long-term pain relief occurred in 39% (7/18) despite good pain relief in trial infusions and the use of both morphine and sufentanil. Technical problems developed in 6/18 patients but appeared to be preventable with further experience. Long-term intrathecal opioid infusions can be effective in treatment of neuropathic pain but might require higher infusion doses.

A treatment-team model of managed mental health care.

Many models of managed care have been criticized as inflexible and intrusive, including those in which decisions about level of care are made by third-party reviewers, in-house staff, or other clinicians not involved in the patient's treatment. The treatment-team model of managed care, which has been implemented in the emergency psychiatric service of a midsized, non-profit community hospital in a metropolitan area, addresses these criticisms. Major features of the model are in-person assessment by a clinician who acts as the managed care agent; immediate accessibility of this clinician; referral services with a broad range of intensity, including crisis intervention; and participation of the managed care clinician on the treatment team. The advantages of this model include the incentive to employ qualified managed care clinicians and an increased ability to provide individualized services. Limitations of the model include the diffusion of decision-making power within the treatment team, the potential for overuse of emergency services by primary providers, and the potential for the managed care agent to lose decision-making power due to personal or systems issues.

Legal Precedents Affecting Managed Care: The Physician's Responsibilities to Patients

Managed care, which has become a fait accompli in America, has produced a variety of concerns regarding the physician-patient relationship and the responsibility of physicians to their patients. This article investigates some of the conflicts that develop in this system and reviews important litigation as it relates to managed care. The author makes specific suggestions for how physicians might manage care when they feel they are being put into an ethical double bind by managed care companies or their third-party reviewers.

Forensic social work: Legal aspects of professional practice : by Robert L. Barker and Douglas M. Branson The Haworth Press, Inc. (10 Alice Street, Binghamton, New York 13904-1580), 1993, 139 pp., hardcover—$26.95; softcover—$19.95.

Contents * Preface and Acknowledgments * Chapter 1. Forensic Social Work in a Litigious Society * The Purpose of Forensic Social Work * Law in the Origins of Social Work * Early Affinity of Social Work and the Law * Divergence Between Social Work and the Law * Growth of the Litigious Society * Social Work's Renewed Interest * What Social Workers Must Know About the Law * The Emergence of Forensic Social Work * Chapter 2. The Practice of Forensic Social Work * What Do Forensic Social Workers Do? * Motivations for Forensic Social Workers * Payment for Forensics Experts * Positive Incentives * Forensic Social Work As a Part-Time Occupation * Steps Toward A Forensics Specialty * How Expert Witnesses Become Established * Referral-Building Activities * Forensic Marketing Organizations * Forensic Professional Groups * Forensic Experts in Related Fields * National Organization of Forensic Social Workers * Conclusion * Chapter 3. Testifying in Courtrooms * Types of Courtroom Witnesses * Roles of the Social Work Fact Witness * Distinguishing Fact and Expert Witness * The Subpoena * Presenting Testimony Effectively * Responding to Direct Examination * Responding to Cross-Examination * Hazards in Presenting Testimony * Testifying Against Clients * The Testimony of Children * Recovered or Implanted Memory * Ten Guidelines for the Effective Witness * Chapter 4. Testifying As an Expert Witness * Pretrial Negotiations * Negotiating Payment * Preparation As an Expert Witness * Rehearsing Expert Testimony * Voir Dire: Qualifying As an Expert * Presenting Expert Testimony * Direct Examination of the Expert * Cross-Examination of Expert Witnesses * Tactics to Impeach Expert Witnesses * Conclusion * Chapter 5. Malpractice and How To Avoid It * Some Malpractice Examples * Responsibility for Therapy Outcomes * Alleged Child Abuse: To Report or Not? * The Ramona (ital.) Case * Criteria for Malpractice Liability * Preventive and Defensive Practices * Conduct Leading to Malpractice Claims * Chapter 6. When Laws and Ethics Collide * The Limits of Confidentiality * Child Abuse and Neglect Laws * The Tarasoff (ital.) Case * Rationale of Judges and Legal Officials * Guidelines for Coping * Implementing the Actual Warning * Jaffee vs. Redmond (ital.) * Conclusion * Chapter 7. Preparing for Litigation * Recognizing a Potential Legal Hazard * The Emotional Risks of Litigation * When to Seek Legal Help * Costs of Litigation * Goals in Hiring a Lawyer * Trial or Settlement? * Chapter 8. Professional Review: Judgment by Colleagues * Need for Alternatives to Law Courts * Philosophies of Reviewing Organizations * Types of Sanctions * Disciplinary Action Reporting System (DARS) * Third-Party Review Procedures * NASW Peer Review Procedure * Critique of NASW Adjudication Procedures * Other Professional Review Procedures * Inevitability of Peer Review * How To Avoid or Minimize Sanctions * When Misconduct Is Acknowledged * Chapter 9. Case Recording and Written Contracts * Report Writing for the Litigious Society * Record Keeping for Couples and Families * The Problem-Oriented (SOAP) Record * Accessibility of Case Records * Forensics Reports versus Case Records * The Written Contract * Written versus Verbal Contracts * The Preservation of Contracts and Records * Conclusion * Chapter 10. Legal and Professional Credentials * Practicing Without Credentials * Consequences of Misrepresentation * What Are Credentials? * Origins of Social Work Credentials * Requirements for Professional Credentials * Social Work Licensure * Comparing Credentials with Other Professions * Unresolved Credentialing Problems * The AASSWB Model Social Wo

Diagnosis-Related Groups: Past and Future

Introduction of the diagnosis-related group (DRG)-based Medicare Prospective Payment System is one of a series of major innovations that has occurred in the payment and delivery of health care over the past ten years. Changes such as the increased prevalence of health maintenance organizations, preferred provider organizations, third-party utilization review programs, and the peer review organizations for Medicare patients have all altered the way health care is financed and delivered. The DRG-based Medicare Prospective Payment System is the most visible of these changes, given its breadth of application and its radical departure from the previous retrospective reimbursement for hospital care. The Medicare Prospective Payment System has been in effect since October, 1983. As we approach the fifth anniversary of this program, it is a good time to review its history and to make some judgments as to its future.

Diagnosis-Related Groups: Past and Future

Introduction of the diagnosis-related group (DRG)-based Medicare Prospective Payment System is one of a series of major innovations that has occurred in the payment and delivery of health care over the past ten years. Changes such as the increased prevalence of health maintenance organizations, preferred provider organizations, third-party utilization review programs, and the peer review organizations for Medicare patients have all altered the way health care is financed and delivered. The DRG-based Medicare Prospective Payment System is the most visible of these changes, given its breadth of application and its radical departure from the previous retrospective reimbursement for hospital care. The Medicare Prospective Payment System has been in effect since October, 1983. As we approach the fifth anniversary of this program, it is a good time to review its history and to make some judgments as to its future.

Practicing Accountabilty in Human Service Institutions

Based on observational studies of three kinds of human service institutions, this paper discusses several concerns and reportorial practices of professional caregivers who strive to be accountable to third-party reviewers. It is argued that a conventional understanding of accountability fails to appreciate the situated concerns and practices of caregivers who strive to report not only accurately but also successfully for a variety of organizational purposes. Reporting thus involves social and organizational processes beyond the issues of accurate or objective representation as it is formally conceived in models of technical accountability.

Utilization review conference. Third-party review programs from the Blue Cross vantage point

Utilization review conference. Third-party review programs from the Blue Cross vantage point

Third-Party Review Programs From the Blue Cross Vantage Point

Although utilization review has been underscored by WP.L. 89-97, the subject is certainly by no means new to many physicians or to voluntary systems in general, or Blue Cross in particular. On the contrary, provisions relating to utilization review activity and many other provisions as well in the law are a direct reflection of the fact that these processes have been around long enough to have shown themselves as valuable tools for the development of knowledge, understanding, and progress among physicians, hospitals, third parties, patients, and the various publics. As a subject for national attention and activity, formal utilization and review programs are comparative newcomers to the scene, particularly when one considers the state of the art and the science and the literature. The First National Conference on Utilization, sponsored by the American Hospital Association, the Blue Cross Association, the American Medical Association, and the National Association of Blue Shield