Postgrad Med J: first published as 10.1136/pgmj.69.810.306 on 1 April 1993. Downloaded from Postgrad Med J (1993) 69, 306-307 © The Fellowship of Postgraduate Medicine, 1993

Special Article - From the 'learned leech' Medical police in the twenty-first century George A. Silver Emeritus Professor ofPublic Health, Yale University School ofMedicine, 590 Ellsworth Avenue, New Haven, CT06511, USA

American physicians may be envied for the size of parallel cost increases for the rest ofthe population, their financial reward, but not for the burdensome strenuous efforts at cost control have been under- conditions of American medical practice. The taken. There were measures aimed at limitation of physician in the USA is under more severely capital expenditures, reductions of length of stay in restrictive regulation than colleagues in most other hospital, planning principles to reduce overall ex- countries. This is paradoxically the result of the penditures, and specific reductions in reimburse- strenuous efforts of the organized medical pro- ments, whether diagnosis related groups (DRGs) or fession to resist control by a governmental fee schedule cutbacks. Nevertheless, whatever the bureaucracy. Costs have multiplied, apparently approach over the years, the inflation of costs, well uncontrollably. The multiplication of individual above the general index of inflation, continued insurance plans, parallel governmental insurance inexorably. plans, employer participation plans and the Other measures having failed, sterner steps were

associated institutional efforts at cost control gave taken to limit the doctor's freedom to prescribe - not copyright. rise to a blizzard ofpaperwork. It also gave rise to a only medications, but diagnostic and therapeutic bureaucracy in both the private and public sectors measures of all kinds. Government, along with and the public and private insurance regulations employers and the private insurance industry have that were required to manage the paper flow and set their sights on severe limitations of use by financial transactions. patients, reduced payments to doctors and hospitals, Doctors and hospitals have been called to and restriction of use of expensive technological account as inflation of costs, obstacles to access machines. Within the past few years, a number of and receipt ofcare has aroused anger and fear. For devices have been employed to accomplish these http://pmj.bmj.com/ their sins, it seems that the medical police are about ends. 'Managed care', for example, allows the to be called in. patient access to a service other than in the doctor's Actually, the need for the development of strin- office only by that office doctor's permission. For gent control measures is only about 25 years old. elective procedures, the doctor must receive prior Government-sponsored and -supported insurance approval by telephone from the insurance company. for the elderly (Medicare) and government- 'Preferred providers' have agreed to a prearranged provided medical insurance for the eligible poor reimbursement with the insurance company. A (Medicaid) became law in 1965. Before that, the patient who elects to use someone other than the on September 28, 2021 by guest. Protected physician was in fairly complete command of preferred provider will not receive the full benefit of medical decision-making. Charges were set by the the insurance - or perhaps none at all. doctor, with some deference to the patient's finan- To enforce the regulations, further steps were cial situation, of course, but with little regard for necessary. Collection of data had to be improved, the private insurance fee schedule. Laboratory in order to clarify charges and payments. Com- studies, X-rays or specialty consultations were puterized systems had to be put in place. The Office ordered as the doctor saw fit. Hospitalization was ofthe Secretary ofHealth and Human Services has the doctor's prerogative. an Inspector-General with a staff designed for Since then, as the cost of the two programmes investigation and enforcement. has ballooned, from an estimated few hundred The activities of every practising physician are million dollars in 1966 (never held down to that!) to now coded for reporting purposes, to measure the present nearly $150 billion, together with the conformity and for comparison. CPT (current procedural terminology), for example, was intro- duced to permit comparisons when the physician Correspondence: G.A. Silver, M.D. reported reimbursable procedures; and the ICD-9 Accepted: 29 October 1992 (International Classification of Diseases, ninth Postgrad Med J: first published as 10.1136/pgmj.69.810.306 on 1 April 1993. Downloaded from MEDICAL POLICE IN THE TWENTY-FIRST CENTURY 307 edition) became the associated bible for comparing out whether it was (a) correct behaviour and (b) if physician diagnosis with the procedure. Computer so, his reimbursement. This will be forwarded, on efficiency requires the UPIN (unique physician line of course, to the Inspector General's Office, identification number). where the information will be filed under the The only step lacking to assume absolute control UPIN. From this file, his and her 'profile' of of physician behaviour is a standardized descrip- behaviour will be analysed and if his or her tion of diagnosis and treatment. There are now behaviour is too frequently (more than 2 sigma) underway studies on medical services outcome, incorrect, some disciplinary action will be taken: a statistical studies of the effectiveness of certain monetary fine; perhaps return to hospital training; procedures and under what conditions these proce- or loss oflicensure. Malpractice suits will be a thing dures can be applied. When these 'outcome of the past. Either the doctor or the patient will measures' resulting from the studies have been receive benefit from the computer's judgment. completed, a manual can be prepared in which the European physicians may be watching the proper diagnostic measures and suitable thera- unfolding of this process with a mixture of horror peutic measures for specific diagnoses will be and satisfaction, the comeuppance oftheir wealthy coded. The resulting 'clinical guidelines' will then American colleagues. The schadenfreude may be be published. quickly dissipated as the politicians and adminis- In the computerized future, with a numerical trators in their own countries undertake similar formula representing the selected clinical guideline control measures. European physicians should for the diagnosis (ICD-9), ajudgment can be made keep in mind that it was American physicians of the appropriateness of the procedure (CPT), themselves who brought this loss of independence prescribed by the physician (UPIN). The coded on themselves by stubborn opposition to taking factors will complete the circle in evaluating leadership in reform measures that might have led physician behaviour, and the computer will spew to a more cooperative alliance with government. copyright. http://pmj.bmj.com/ on September 28, 2021 by guest. Protected