Reviewing professional practice: Implications for the mental health consumer.

Abstract

Cost containment and quality control are the major purposes of professional practice review (PR). PR appears to more effectively control utilization of services than cost per unit. PR may increase quality of service by establishing a better data base for evaluating treatment and outcome. Quality and cost, however, are interrelated. Optimal quality may raise cost of care. Although PR may decrease costs and increase quality, it may also infringe on the privacy of the clients and narrow their freedom in choosing a provider. Consumers need to be involved to make sure that PR addresses issues of importance to them, such as humaneness of treatment and control of poorly prepared providers.This article discusses some ways in which professional practice review (PR) may affect the consumer of mental health services. PR is used as a generic term for any method that systematically scrutinizes health care, including peer review, quality assurance, medical audit, professional services accounting, Professional Standards Review Organizations (PSROs), Professional Standards Review Committees (PSRCs), utilization review, and claims review. These approaches differ in whether they emphasize cost containment or quality of care; in whether the review is conducted prospectively, concurrently, or retrospectively; and to what extent nonhealth providers participate in the process. However, all of these approaches may be labeled PR.PR standards may be established descriptively or prescriptively. Descriptive standards, alsd called "empirical" or "statistical," are typically used in insurance claims review when determining whether a given practice is "usual, customary, and reasonable" (UCR). Since a descriptive standard "depends upon average clinical practice," an activity may meet the standard "and yet still be below what most persons would agree is minimally adequate" (Zusman & Ross, 1969, p< 353). Professors who grade on a curve are familiar with this phenomenon. In addition, the standards are usually determined on a local rather than on a national basis. As a result consumers living in one area may receive care that is considered inadequate or overpriced in another. Prescriptive standards, also called "clinical," "a priori," or "normative," avoid the relativism of descriptive standards because they are based on the judgment of a select group of experts. This doesjiot necessarily mean, however, that prescriptive standards will lead to more effective or less costly care. In the absence of validating research, such standards may merely reflect the practice prejudices of the experts. Even if valid, prescriptive standards may lead to therapeutic overkill and needless expense (Institute of Medicine, 1974). Effects on CostMuch of PR's impetus in the last decade has come from the desire to control the cost of health services. A crucial question then is, Will PR save consumers money? The experience of one California clinic may provide an answer (Kazanjian, 1982;

APA/CHAMPUS peer review project: Implications for research and practice.

“…The adoption of a peer review system also has a number of implications for the patient (Simon & Rosenberg, 1982). The patient may become a party to an explicit contract rather than to the implicit one that has always existed.…”

Problems, protests, and proposals.

“…Psychologists know that patients who receive good quality treatment should be better off than those who do not, but that factors beyond the clinician’s control may neutralize or enhance the treatment effect. As a result, it is possible to have good quality care and a poor outcome, and the reverse is also possible (Simon & Rosenberg, 1982).…”