[ST-20] Statement of Recommendations to Ensure Quality of
Surgical Services in Managed Care Environments
[by the American College of Surgeons]
Health care delivery systems in the United States have
undergone major changes in recent years. There has been a strong
trend toward managed care organizations because purchasers of
health care services perceive them to be less expensive than
traditional fee-for-service systems. In these vertically integrated
organizations, an administrative entity coordinates or "manages"
the delivery of health care services in ambulatory and hospital
settings. Central to the cost containment mission of these organizations
is the utilization control of physician services. Primary care
physicians are put into the role of "gatekeeper" for
their patients, regulating if and when specialty consultation
and treatment is made available to them. In many managed care
organizations, the primary care physician is paid under a capitation
system--that is, the physician receives an annual salary based
on the number of lives served, rather than services rendered.
In such systems, there may be a financial disincentive for the
primary care physician to refer patients for specialist care
("risk sharing"), since specialist care is thought
to be more expensive.
To address the important issue of how the quality of surgical
services can be maintained in a managed care environment, the
College...convened a group of 12 Fellows in various surgical
specialties, all of whom work in some form of managed care system.
This working group developed a series of recommendations for
surgeons and managed care organizations, with the aim of ensuring
that appropriate and timely quality surgical care is readily
available to patients in the system. Although directed at managed
care, these recommendations are widely applicable to all surgical
services regardless of the health care delivery system.
The following statement was approved by the College's Board
of Regents at its October 9, 1994, meeting.
In seeking to ensure the maintenance of high-quality surgical
care for patients enrolled in managed care systems, the American
College of Surgeons makes the following recommendations:
1. Managed care organizations should document the quality
of surgical care provided to their patients.
Through national organizations such as the American College
of Surgeons, surgeons must participate in determination of the
measures used.
These measures include documentation that:
- --Referrals to surgeons are timely and appropriate, regardless
of financial incentives
- --Surgical response and treatment is timely and appropriate,
regardless of financial incentives
- --Facilities and personnel available are consistent with
the surgical workload and quality goals
- --Risk-adjusted morbidity and mortality rates of the managed
care organization and the individual surgeon are within established
limits
- --Quality of life and performance capability of patients
following surgical care is considered as a critical component
of the measurement of outcome
- --Satisfaction is measured and used in assessing and improving
performance of the system
--Measurements should include surveys of the:
· Patient
· Referring physician
· Surgeon
- --Cost-effectiveness is measured and considered in assessment
of outcome
2. Mechanisms for the collection and dissemination
of data relative to these measures should be in place.
3. Surgeons should participate in programs designed
for the training and continuing education of primary care physicians
(gatekeepers) so that timely referral will guarantee patients
access to high-quality, cost-effective surgical care.
4. The surgeon must be the patient advocate so that
all patients will be ensured access to high-quality and the appropriate
range of surgical care, regardless of disincentives, financial
or otherwise, employed by the managed care organization.
Statements
menu
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Reprinted from Bulletin of the American College
of Surgeons
Vol. 79, No. 12, Pages 30-31, December 1994
