PEER REVIEW
AND PSRO IN AMERICAN
PSYCHIATRY
Frank W. Sullivan, M.D.
The past 5 years have provided major pressures for and development in the varied areas of peer review of medical services. Organized psychiatry's activities on the national and local levels have been vigorous and responsive. The author traces the development of the mandated, professional and third party payer forms of peer review and the mechanisms and requirements within these programs. The specific programs and projects within the American Psychiatric Association and it's district affilates are also reviewed. The term "peer review," although familiar at present to all of us, was little more than a poorly implemented "paper program" of mandated utilization review with the inception of the Medicare and Medicaid programs of 1965. By 1973, the national health expenditures had reached 104 billion dollars, or 8% of the gross national product. Fourteen percent, or more than 14 billion dollars, was for mental health services with an estimated additional 22 million dollars related to job loss, death, disability, and family disruption. During those 8 years the various and concerned parties, HEW, AMA, APA, private intermediaries, CHAMPUS, FEHB, AHA, J C A H , and congressional committees have each struggled forward with their stylized version of cost containment, utilization, distribution, and review. With these systems came new terms and procedures; utilization review, peer review, medical care evaluation, review coordinator, concurrent review, claims review, retrospective review, quality review, criteria, standards, norms, median length of stay, and the like. At present, peer review and its variations are evolving realities of our practices. The major governmental medical review program, PSRO, was mandated in 1972 along with the sweeping social security amendments of Public Law 92-603. At present this program relates only to inpatient Medicare, Medicaid, and Maternal and Child Welfare recipients. Program implementation of PSRO (Professional Standards Review Organization) has since 1972 suffered all the expected problems of a program implemented by
This paper was presented at the Ninth Biennial Divisional Meeting, Area-II Council, American Psychiatric Association, New York, Nov. 7, 1976. Dr. Sullivan is Chairman of the Commission on Standards and Practice and T h i r d Party Payments of the American Psychiatric Association. Reprint requests should be addressed to 960 Reservoir Ave., Cranston, R.I. 02910. Washington. PSYCHIATRIC QUARTERLY,VOL. 49(4) 1977
33 1
332
PEER REVIEW PSRO
ambivalent and marginally informed physicians, administered by a bureaucracy, and budgeted by a Congress. It is currently emerging from some of its earlier budgetary problems as fiscal year 1977 (beginning October, 1976) will bring a budget of 62 million dollars in program costs and 22 million dollars in review reimbursement costs following the passage of the HEW "money" bill over President Ford's veto. At the end of September 1976, there were 100 conditional and 20 planning grant PSROs in operation and the BQA hopes for contracts with the remaining 83 areas by the end of this fiscal year. The PSRO program itself is now u n d e r scutiny and must set aside funds to study the overall program effectiveness. HEW has therefore established three analyses for the current fiscal year; they will study (1) the impact of concurrent review procedures on hospital utilization; (2) the impact of PSRO on health care expenditures; and (3) the effectiveness of medical care evaluation in assessing quality and utilization of services. The cost containment orientation of PSRO is also being challenged now not only by physicians but by congressional leaders, as in May, 1976, in the House Ways and Means Oversight Committee. Even though reductions in length-of-stay figures have occurred, they are expected to plateau fairly soon and then increase. Although initially mandated to address short-stay hospitalization, the BQA is moving toward development of guidelines for long-term care review with demonstration projects being considered in 15 sites. BQA is also encouraging PSROs to contract with local intermediaries for private care review. Two major review requirements under PSRO deserve at least brief mention at this point; those are utilization review and medical care evaluation. Utilization review, as the name suggests, is primarily for review of utilization of services and is concurrent in timing. Cases are screened at admission by a review coordinator using criteria designed by psychiatrists for that diagnosis or problem. The coordinator can make only a "pass" or "no pass" decision based on the criteria and assign a predetermined length of stay (usually median length of stay) at which time subsequent review will be performed. Physician or committee review is utilized in "no pass" or questionable decisions by the review coordinator or automatically in extended stay cases. Medical care evaluation (MCE) primarily relates to quality assessment. The requirements of PSRO and JCAH are essentially similar and areas of disagreement as to number of reviews required and retrospective review application to utilization review are being resolved by the two bodies. These audit studies are in depth, related to multiple patient study samples, and are retrospective. They are approached in a systematic manner; i.e., there is a study objective, established criteria and standards, specific study design, systematized data collection and reporting, data analysis, and most impor-
333
F.W. SULLIVAN
tantly, development of a corrective plan (educational or administrative change) and restudy as to the effectiveness of the corrective plan. PSRO is currently the most systematized national review program and is viewed as a model peer review program by those looking toward national health insurance, but looked at skeptically by many of the private intermediaries and organized medicine. These latter two groups feel that alternate approaches to medical review are necessary. The APA has repeatedly stressed that PSRO and peer review are not synonymous and has been actively involved in the development of methodologies u n d e r the broader concept. In 1971, the AMA developed a two-volume manual for suggested development and implementation of peer review within medicine. It envisioned systematized peer review as subsuming utilization review, quality review, availability of services, and claims review. The APA in 1972, through its Task Force on Peer Review, developed a position statement on peer review which contained organizational and implementation guidelines for psychiatric review to be considered by the local district branches. These guidelines offered suggestions for activating a local psychiatric peer review committee and establishing liaison with the local medical society. Recommendations were also made for the APA at the national level to coordinate local peer review activity, gather data, distribute information, and integrate peer review with continuing medical education. As is frequently the case with medicine, these guidelines were viewed as interesting and informative but little practical implementation occurred, leaving fertile ground for the PSRO legislation in late 1972. The AMA struggled for the next one and a half years with its constituency's loud resistance and the Board of Trustees recommended an approach of a m e n d m e n t and implementation while the practicing physician, wanting no part of it, recommended the banging of Senator Bennett and the 92nd Congress. The APA's position was one of implementation so long as PSRO did not violate APA's general positions on peer review. With the settling of the dust around the AMA, the APA, through an Ad Hoc Committee on PSRO, collaborated with 30 other national specialty organizations in designing the first set of model criteria sets. This first effort was primarily educational as HEW felt these criteria sets too extensive and cumbersome for PSRO use. A second collaborative effort by the national specialty organizations was launced in 1974 for a revised criteria set development, again u n d e r the sponsorship of AMA. The APA Task Force to Design Screening Criteria developed psychiatry's contribution and these criteria were published by the AMA in 1975, then revised and republished in 1976, in a large volume entitled Sample Criteriafor Short-Stay Hospital Review. There was also a tandem development and inclusion of criteria sets by the American Academy of Child Psychiatry. Recognizing the need for continued effort in the broader aspects of peer review (i.e., in addition to PSRO activity), the APA in 1974, reviewed psychiatry's position on peer review through a task force and established a
334
PEER REVIEW PSRO
standing Committee on Peer Review and a Field Consultant in Peer Review.
This Committee is currently chaired by Don Langsley of Sacramento, California. It has been extremely active in the past year and a half reviewing the PSRO,criteria, coordinating the efforts of the field consultant, sponsoring a workshop at the last annual meeting, developing long-term hospitalization guidelines and criteria, and ambulatory guidelines for claims review, and, most significantly, putting together a practical informational and working manual, the Manual of Psychiatric Peer Review, which was published last month by the APA. This manual can be used as a practical working document by all psychiatrists involved in the review process and its contents should be familiar to every practitioner. Its chapters address the varied and complicated aspects of peer review, including basic definitions and responsibilities; appointment, operations, and funding of the peer review committee; procedures for utilization review and medical audit; appeals processes; confidentiality; and the relationship of peer review to education, ethics, and advocacy. Model criteria sets are offered for short-term inpatient and ambulatory review using the PSRO format. Within the manual also are two additional sections. The first has been developed by the Joint Task Force on Diagnostic Criteria for Analyzability (William Offenkrantz, Chairman) of the American Psychoanalytic Association. This section addresses the general problems of and suggested approaches to a review methodology for analytical patients and contains model criteria sets and practical guidelines. The other section was developed by the Peer Review Committee of the American Academy of Child Psychiatry (Larry Silver, Chairman) and addressed the special problems in the review of children's services, including children's legal rights and confidentiality issues. Appendices to this section give examples of model screening criteria for (1) inpatient short-stay facilities; (2) inpatient intermediate care facilities; and (3) partial hospitalization or outpatient. Currently the Committee on Peer Review is developing ambulatory review criteria for the use of claims review in the offices of the fiscal intermediary where local peer review is either unresponsive or unavailable. A subcommittee is working on another project, i.e., the development of screening criteria for inpatient long-term care. The part-time staff position of Field Consultant in Peer Review is held by Dr. Richard Dorsey of Cinncinnati, Ohio, who served on the first Task Force on Peer Review as a Fatk Fellow and subsequently on the succeeding related task forces and committees. Dr. Dorsey has performed a yeoman's job in traveling to as many of the district branches as possible in his oneyear tenure. He is visiting both the active and inactive areas to gather information on their procedures, activities, and problems; to encourage participation and increased activity, and to further liaison activity between the local review groups and the intermediaries. Central to any effective peer review program, whether of physician,
335 F.W. SULLIVAN
government, or intermediary design, will be the functional capability of the local psychiatric review component, an issue stressed repeatedly by the APA. Although peer review seems currently acceptable in concept by most psychiatrists and a peer review component is identifiable in each APA district branch, local structure, activities, and procedures vary widely. A questionnaire was mailed to all district branches in December, 1975; 46 committees responded. The length of time in operation varied from preparatory stages to six and one-half years, with an approximate mean of three years. For most committees the primary operative affiliation was with the district branch, with 25 having additional working relationships with a medical society, local PSRO, or hospital utilization review component. However, in spite of the varied bases of operations only 14 committees reported their having a formal written plan of operation. Only half the committees reported actual involvement in case review during calendar 1975. Those reviewing cases varied widely as to numbers, with a low of one and a high of 3300. Cases being reviewed were from both inpatient and outpatient settings. Source of case referral was predominately from fiscal intermediaries and approximately 20 and 5% from proriders and patients, respectively. It is assumed that most committees use a consensus model in their review procedures as only 12 of the 46 committees reported the use of guidelines or criteria (six of those committees reviewing cases in 1975 and six not). Nineteen reported that there was a liaison relationship with the continuing medical education component of the district branch. Most of the committees reported their primary function as one of' consultant to the local fiscal intermediary. Of those committees doing case review, most were doing concurrent in addition to retrospective review. Although the limitations of such a brief survey are obvious, it gives at least a rough picture of the local district branch peer review functioning for 1975. Significant progress has been made since 1971 when only 12 local peer review committees were identifiable. A few committees are well advanced in terms of organization and operation. T h e y have formalized written plans of operation and specified roles within their medical and psychiatric societies. They are doing both concurrent and retrospective review of large numbers of cases using written guidelines or criteria. For most committees there is a need to continue to upgrade their functioning. They must formalize their plan of operations and develop specific review guidelines or criteria. They must identify themselves and make themselves available to local fiscal intermediaries, physicians, and patients, as well as specifically identifying their role within the local psychiatric and medical societies, the PSRO component, and appropriate hospitals. They must be willing to review a wide variety of both routine and problem cases and work in liaison with their continuing medical education component to evolve meaningful educational programs. At times they need to act as advocate for both patients and colleagues in negotiations with fiscal intermediaries and government agencies. The APA Peer Review Manual
336 PEER REVIEW PSRO
should prove helpful in many of these areas and theAPA Field Consultant in Peer Review is currently available for consultation to all district branch review components. Viable and responsive review procedures are necessary for continued coverage, meager as it often is, u n d e r existing insurance plans and certainly for expansion u n d e r private plans or variations of national health insurance. Two major governmental insurance programs, CHAMPUS and FEP, are of special importance to psychiatry because they offer coverage for psychiatric illnesses on a parity with other medical illnesses. Because of their broad coverage allowances and the data available through their service years, their successes and failures will provide significant argument for or against psychiatric benefits under the more comprehensive plans under consideration for national health insurance. Considerable concern arose when the percentage of psychiatric expenses u n d e r CHAMPUS increased to 21% by 1973, returning to 18% in 1974. During the late 1960s and early 1970s the percentage of psychiatric expenditures under FEP rose steadily through 1973 to a leveling at 7.5% for the past tWO years. With the significant rises in psychiatric expenses u n d e r both of these programs, serious cutbacks in psychiatric benefits were threatened in 1974. These cutbacks were delayed and benefits continued because of pressure on the Department of Defense and Civil Service Commission, by congressional leaders and program participants and also significantly by the active involvement of the APA Commission on Standards of Practice and Third Party Payment appointed in 1974 and originally chaired by Dr. Robert Gibson. T h e Commission has continued its active liaison with CHAMPUS and Blue Cross FEP in an attempt to negotiate changes in their review procedures to satisfy their accountability needs while maintaining the APA's principles on peer review. The FEP Claims Review Document published and circulated to its local intermediaries in 1974, was viewed by psychiatrists as generally restrictive and unrealistic. The Commission in concert with the Committee on Peer Review suggested significant revisions through a revised document. Further dialogue with Blue Cross FEP resulted in a recently appointed joint task force made up of five members each from APA and FEP charged with the development of a mutually agreeable claims review procedure to be used by the local intermediary for FEP claims under psychiatric benefits. CHAMPUS has been actively evolving more meaningful review procedures over the past two years through three SCOPSE projects under NIMH auspices. The first, SCOPSE I, developed admission and review criteria and methods for children in residential treatment centers. SCOPSE II is currently working on review procedures for inpatient schizophrenic patients. SCOPSE III, recently instituted, wilt address inpatient review methodologies for the remaining adult diagnostic categories. In a recent collaboration by the Commission with the Department of Defense, OCHAMPUS, and NIMH a revised program has been developed for more meaningful review procedures for ambulatory claims and will be
337 F.W. SULLIVAN
instituted over the next 6 to 12 months. Each discipline eligible to submit claims u n d e r C H A M P U S will have a t h r e e - m e m b e r peer review team for review of claims at a specified periodicity. These members will be appointed by C H A M P U S on a state level, based on the r e c o m m e n d a t i o n s of the local district branch peer review committee. Model criteria sets are currently being developed by the APA Peer Review Committee but will be subject to modification by the local committee for their use and the use of the review coordinator. Although there was some initial pressure for a system of interdisciplinary review, it now appears that case review will be the purview of the discipline of the therapist (i.e., psychiatrists reviewing psychiatrists) and interdisciplinary problems and issues will be reviewed by an interdisciplinary policy committee. Like it or not, we are sharing our bed with the federal g o v e r n m e n t a n d the insurance industry. We live and will likely continue to live for some time in an age of bureaucracy. We need to u n d e r s t a n d it and attempt to function within it. We can choose not to involve ourselves in the review of our practice procedures and leave it to others as we have too often done. T h e consumer frequently does not u n d e r s t a n d medical practice procedures and when he does is relatively impotent to deal with medicine or the intermediary. T h e federal g o v e r n m e n t and the intermediary are neither u n i n f o r m e d nor impotent and, if we remain inactive, will continue to arbitrarily set guidelines and restrictions which frequently are at variance with o u r a n d our patients' objectives a n d needs. O u r profession is both viable and vital but we must be willing to prove that t h r o u g h our development of a n d participation in meaningful peer review.
AND PSRO IN AMERICAN
PSYCHIATRY
Frank W. Sullivan, M.D.
The past 5 years have provided major pressures for and development in the varied areas of peer review of medical services. Organized psychiatry's activities on the national and local levels have been vigorous and responsive. The author traces the development of the mandated, professional and third party payer forms of peer review and the mechanisms and requirements within these programs. The specific programs and projects within the American Psychiatric Association and it's district affilates are also reviewed. The term "peer review," although familiar at present to all of us, was little more than a poorly implemented "paper program" of mandated utilization review with the inception of the Medicare and Medicaid programs of 1965. By 1973, the national health expenditures had reached 104 billion dollars, or 8% of the gross national product. Fourteen percent, or more than 14 billion dollars, was for mental health services with an estimated additional 22 million dollars related to job loss, death, disability, and family disruption. During those 8 years the various and concerned parties, HEW, AMA, APA, private intermediaries, CHAMPUS, FEHB, AHA, J C A H , and congressional committees have each struggled forward with their stylized version of cost containment, utilization, distribution, and review. With these systems came new terms and procedures; utilization review, peer review, medical care evaluation, review coordinator, concurrent review, claims review, retrospective review, quality review, criteria, standards, norms, median length of stay, and the like. At present, peer review and its variations are evolving realities of our practices. The major governmental medical review program, PSRO, was mandated in 1972 along with the sweeping social security amendments of Public Law 92-603. At present this program relates only to inpatient Medicare, Medicaid, and Maternal and Child Welfare recipients. Program implementation of PSRO (Professional Standards Review Organization) has since 1972 suffered all the expected problems of a program implemented by
This paper was presented at the Ninth Biennial Divisional Meeting, Area-II Council, American Psychiatric Association, New York, Nov. 7, 1976. Dr. Sullivan is Chairman of the Commission on Standards and Practice and T h i r d Party Payments of the American Psychiatric Association. Reprint requests should be addressed to 960 Reservoir Ave., Cranston, R.I. 02910. Washington. PSYCHIATRIC QUARTERLY,VOL. 49(4) 1977
33 1
332
PEER REVIEW PSRO
ambivalent and marginally informed physicians, administered by a bureaucracy, and budgeted by a Congress. It is currently emerging from some of its earlier budgetary problems as fiscal year 1977 (beginning October, 1976) will bring a budget of 62 million dollars in program costs and 22 million dollars in review reimbursement costs following the passage of the HEW "money" bill over President Ford's veto. At the end of September 1976, there were 100 conditional and 20 planning grant PSROs in operation and the BQA hopes for contracts with the remaining 83 areas by the end of this fiscal year. The PSRO program itself is now u n d e r scutiny and must set aside funds to study the overall program effectiveness. HEW has therefore established three analyses for the current fiscal year; they will study (1) the impact of concurrent review procedures on hospital utilization; (2) the impact of PSRO on health care expenditures; and (3) the effectiveness of medical care evaluation in assessing quality and utilization of services. The cost containment orientation of PSRO is also being challenged now not only by physicians but by congressional leaders, as in May, 1976, in the House Ways and Means Oversight Committee. Even though reductions in length-of-stay figures have occurred, they are expected to plateau fairly soon and then increase. Although initially mandated to address short-stay hospitalization, the BQA is moving toward development of guidelines for long-term care review with demonstration projects being considered in 15 sites. BQA is also encouraging PSROs to contract with local intermediaries for private care review. Two major review requirements under PSRO deserve at least brief mention at this point; those are utilization review and medical care evaluation. Utilization review, as the name suggests, is primarily for review of utilization of services and is concurrent in timing. Cases are screened at admission by a review coordinator using criteria designed by psychiatrists for that diagnosis or problem. The coordinator can make only a "pass" or "no pass" decision based on the criteria and assign a predetermined length of stay (usually median length of stay) at which time subsequent review will be performed. Physician or committee review is utilized in "no pass" or questionable decisions by the review coordinator or automatically in extended stay cases. Medical care evaluation (MCE) primarily relates to quality assessment. The requirements of PSRO and JCAH are essentially similar and areas of disagreement as to number of reviews required and retrospective review application to utilization review are being resolved by the two bodies. These audit studies are in depth, related to multiple patient study samples, and are retrospective. They are approached in a systematic manner; i.e., there is a study objective, established criteria and standards, specific study design, systematized data collection and reporting, data analysis, and most impor-
333
F.W. SULLIVAN
tantly, development of a corrective plan (educational or administrative change) and restudy as to the effectiveness of the corrective plan. PSRO is currently the most systematized national review program and is viewed as a model peer review program by those looking toward national health insurance, but looked at skeptically by many of the private intermediaries and organized medicine. These latter two groups feel that alternate approaches to medical review are necessary. The APA has repeatedly stressed that PSRO and peer review are not synonymous and has been actively involved in the development of methodologies u n d e r the broader concept. In 1971, the AMA developed a two-volume manual for suggested development and implementation of peer review within medicine. It envisioned systematized peer review as subsuming utilization review, quality review, availability of services, and claims review. The APA in 1972, through its Task Force on Peer Review, developed a position statement on peer review which contained organizational and implementation guidelines for psychiatric review to be considered by the local district branches. These guidelines offered suggestions for activating a local psychiatric peer review committee and establishing liaison with the local medical society. Recommendations were also made for the APA at the national level to coordinate local peer review activity, gather data, distribute information, and integrate peer review with continuing medical education. As is frequently the case with medicine, these guidelines were viewed as interesting and informative but little practical implementation occurred, leaving fertile ground for the PSRO legislation in late 1972. The AMA struggled for the next one and a half years with its constituency's loud resistance and the Board of Trustees recommended an approach of a m e n d m e n t and implementation while the practicing physician, wanting no part of it, recommended the banging of Senator Bennett and the 92nd Congress. The APA's position was one of implementation so long as PSRO did not violate APA's general positions on peer review. With the settling of the dust around the AMA, the APA, through an Ad Hoc Committee on PSRO, collaborated with 30 other national specialty organizations in designing the first set of model criteria sets. This first effort was primarily educational as HEW felt these criteria sets too extensive and cumbersome for PSRO use. A second collaborative effort by the national specialty organizations was launced in 1974 for a revised criteria set development, again u n d e r the sponsorship of AMA. The APA Task Force to Design Screening Criteria developed psychiatry's contribution and these criteria were published by the AMA in 1975, then revised and republished in 1976, in a large volume entitled Sample Criteriafor Short-Stay Hospital Review. There was also a tandem development and inclusion of criteria sets by the American Academy of Child Psychiatry. Recognizing the need for continued effort in the broader aspects of peer review (i.e., in addition to PSRO activity), the APA in 1974, reviewed psychiatry's position on peer review through a task force and established a
334
PEER REVIEW PSRO
standing Committee on Peer Review and a Field Consultant in Peer Review.
This Committee is currently chaired by Don Langsley of Sacramento, California. It has been extremely active in the past year and a half reviewing the PSRO,criteria, coordinating the efforts of the field consultant, sponsoring a workshop at the last annual meeting, developing long-term hospitalization guidelines and criteria, and ambulatory guidelines for claims review, and, most significantly, putting together a practical informational and working manual, the Manual of Psychiatric Peer Review, which was published last month by the APA. This manual can be used as a practical working document by all psychiatrists involved in the review process and its contents should be familiar to every practitioner. Its chapters address the varied and complicated aspects of peer review, including basic definitions and responsibilities; appointment, operations, and funding of the peer review committee; procedures for utilization review and medical audit; appeals processes; confidentiality; and the relationship of peer review to education, ethics, and advocacy. Model criteria sets are offered for short-term inpatient and ambulatory review using the PSRO format. Within the manual also are two additional sections. The first has been developed by the Joint Task Force on Diagnostic Criteria for Analyzability (William Offenkrantz, Chairman) of the American Psychoanalytic Association. This section addresses the general problems of and suggested approaches to a review methodology for analytical patients and contains model criteria sets and practical guidelines. The other section was developed by the Peer Review Committee of the American Academy of Child Psychiatry (Larry Silver, Chairman) and addressed the special problems in the review of children's services, including children's legal rights and confidentiality issues. Appendices to this section give examples of model screening criteria for (1) inpatient short-stay facilities; (2) inpatient intermediate care facilities; and (3) partial hospitalization or outpatient. Currently the Committee on Peer Review is developing ambulatory review criteria for the use of claims review in the offices of the fiscal intermediary where local peer review is either unresponsive or unavailable. A subcommittee is working on another project, i.e., the development of screening criteria for inpatient long-term care. The part-time staff position of Field Consultant in Peer Review is held by Dr. Richard Dorsey of Cinncinnati, Ohio, who served on the first Task Force on Peer Review as a Fatk Fellow and subsequently on the succeeding related task forces and committees. Dr. Dorsey has performed a yeoman's job in traveling to as many of the district branches as possible in his oneyear tenure. He is visiting both the active and inactive areas to gather information on their procedures, activities, and problems; to encourage participation and increased activity, and to further liaison activity between the local review groups and the intermediaries. Central to any effective peer review program, whether of physician,
335 F.W. SULLIVAN
government, or intermediary design, will be the functional capability of the local psychiatric review component, an issue stressed repeatedly by the APA. Although peer review seems currently acceptable in concept by most psychiatrists and a peer review component is identifiable in each APA district branch, local structure, activities, and procedures vary widely. A questionnaire was mailed to all district branches in December, 1975; 46 committees responded. The length of time in operation varied from preparatory stages to six and one-half years, with an approximate mean of three years. For most committees the primary operative affiliation was with the district branch, with 25 having additional working relationships with a medical society, local PSRO, or hospital utilization review component. However, in spite of the varied bases of operations only 14 committees reported their having a formal written plan of operation. Only half the committees reported actual involvement in case review during calendar 1975. Those reviewing cases varied widely as to numbers, with a low of one and a high of 3300. Cases being reviewed were from both inpatient and outpatient settings. Source of case referral was predominately from fiscal intermediaries and approximately 20 and 5% from proriders and patients, respectively. It is assumed that most committees use a consensus model in their review procedures as only 12 of the 46 committees reported the use of guidelines or criteria (six of those committees reviewing cases in 1975 and six not). Nineteen reported that there was a liaison relationship with the continuing medical education component of the district branch. Most of the committees reported their primary function as one of' consultant to the local fiscal intermediary. Of those committees doing case review, most were doing concurrent in addition to retrospective review. Although the limitations of such a brief survey are obvious, it gives at least a rough picture of the local district branch peer review functioning for 1975. Significant progress has been made since 1971 when only 12 local peer review committees were identifiable. A few committees are well advanced in terms of organization and operation. T h e y have formalized written plans of operation and specified roles within their medical and psychiatric societies. They are doing both concurrent and retrospective review of large numbers of cases using written guidelines or criteria. For most committees there is a need to continue to upgrade their functioning. They must formalize their plan of operations and develop specific review guidelines or criteria. They must identify themselves and make themselves available to local fiscal intermediaries, physicians, and patients, as well as specifically identifying their role within the local psychiatric and medical societies, the PSRO component, and appropriate hospitals. They must be willing to review a wide variety of both routine and problem cases and work in liaison with their continuing medical education component to evolve meaningful educational programs. At times they need to act as advocate for both patients and colleagues in negotiations with fiscal intermediaries and government agencies. The APA Peer Review Manual
336 PEER REVIEW PSRO
should prove helpful in many of these areas and theAPA Field Consultant in Peer Review is currently available for consultation to all district branch review components. Viable and responsive review procedures are necessary for continued coverage, meager as it often is, u n d e r existing insurance plans and certainly for expansion u n d e r private plans or variations of national health insurance. Two major governmental insurance programs, CHAMPUS and FEP, are of special importance to psychiatry because they offer coverage for psychiatric illnesses on a parity with other medical illnesses. Because of their broad coverage allowances and the data available through their service years, their successes and failures will provide significant argument for or against psychiatric benefits under the more comprehensive plans under consideration for national health insurance. Considerable concern arose when the percentage of psychiatric expenses u n d e r CHAMPUS increased to 21% by 1973, returning to 18% in 1974. During the late 1960s and early 1970s the percentage of psychiatric expenditures under FEP rose steadily through 1973 to a leveling at 7.5% for the past tWO years. With the significant rises in psychiatric expenses u n d e r both of these programs, serious cutbacks in psychiatric benefits were threatened in 1974. These cutbacks were delayed and benefits continued because of pressure on the Department of Defense and Civil Service Commission, by congressional leaders and program participants and also significantly by the active involvement of the APA Commission on Standards of Practice and Third Party Payment appointed in 1974 and originally chaired by Dr. Robert Gibson. T h e Commission has continued its active liaison with CHAMPUS and Blue Cross FEP in an attempt to negotiate changes in their review procedures to satisfy their accountability needs while maintaining the APA's principles on peer review. The FEP Claims Review Document published and circulated to its local intermediaries in 1974, was viewed by psychiatrists as generally restrictive and unrealistic. The Commission in concert with the Committee on Peer Review suggested significant revisions through a revised document. Further dialogue with Blue Cross FEP resulted in a recently appointed joint task force made up of five members each from APA and FEP charged with the development of a mutually agreeable claims review procedure to be used by the local intermediary for FEP claims under psychiatric benefits. CHAMPUS has been actively evolving more meaningful review procedures over the past two years through three SCOPSE projects under NIMH auspices. The first, SCOPSE I, developed admission and review criteria and methods for children in residential treatment centers. SCOPSE II is currently working on review procedures for inpatient schizophrenic patients. SCOPSE III, recently instituted, wilt address inpatient review methodologies for the remaining adult diagnostic categories. In a recent collaboration by the Commission with the Department of Defense, OCHAMPUS, and NIMH a revised program has been developed for more meaningful review procedures for ambulatory claims and will be
337 F.W. SULLIVAN
instituted over the next 6 to 12 months. Each discipline eligible to submit claims u n d e r C H A M P U S will have a t h r e e - m e m b e r peer review team for review of claims at a specified periodicity. These members will be appointed by C H A M P U S on a state level, based on the r e c o m m e n d a t i o n s of the local district branch peer review committee. Model criteria sets are currently being developed by the APA Peer Review Committee but will be subject to modification by the local committee for their use and the use of the review coordinator. Although there was some initial pressure for a system of interdisciplinary review, it now appears that case review will be the purview of the discipline of the therapist (i.e., psychiatrists reviewing psychiatrists) and interdisciplinary problems and issues will be reviewed by an interdisciplinary policy committee. Like it or not, we are sharing our bed with the federal g o v e r n m e n t a n d the insurance industry. We live and will likely continue to live for some time in an age of bureaucracy. We need to u n d e r s t a n d it and attempt to function within it. We can choose not to involve ourselves in the review of our practice procedures and leave it to others as we have too often done. T h e consumer frequently does not u n d e r s t a n d medical practice procedures and when he does is relatively impotent to deal with medicine or the intermediary. T h e federal g o v e r n m e n t and the intermediary are neither u n i n f o r m e d nor impotent and, if we remain inactive, will continue to arbitrarily set guidelines and restrictions which frequently are at variance with o u r a n d our patients' objectives a n d needs. O u r profession is both viable and vital but we must be willing to prove that t h r o u g h our development of a n d participation in meaningful peer review.
