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:
- 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:
- Referring physician
- Cost-effectiveness is measured and considered in assessment of outcome
- Mechanisms for the collection and dissemination of data relative to these measures should be in place.
- 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.
- 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.
Reprinted from Bulletin of the American College of Surgeons
Vol. 79, No. 12, Pages 30-31, December 1994