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Contending with PSRO
Because the PSRO's initial responsibility in evaluating health care services paid for by Social Security programs is limited to those services provided by or in institutions, most dental services are excluded at present. However, review of ambulatory care can be authorized by HEW, and dental care undoubtedly will come under review in time. As the program is currently structured, dentists whose work will be reviewed by the PSRO are excluded from membership in the reviewing groups.
Contending with PSRO John F. O'Donnell, AB, Chicago
Proponents have called it a program with "the potential for having a greater favorable impact on health and the health care system in this country than any other ever enacted.” Critics have denounced it as “massive government intervention into private medicine.” Al though in most areas organized medi cine is working diligently in its behalf, in some, medical societies are demand ing repeal and refusing to cooperate in its implementation. The law establishing professional standards review organ izations (PSROs) to determine the qual ity and appropriateness of health care services paid under Social Security is— to understate the case—a most contro versial one. Because of the controversy, it also has been the most widely reported and editorialized health program since the Medicare bill. But the news media, with few exceptions, have viewed the PSRO program solely in terms of its effects on the practice of medicine, leading their audience, including many dentists, to conclude that it is “the physicians’ problem.” Examination of the program suggests that this conclusion is decid edly shortsighted. 836 ■ JADA, Vol. 89, October 1974
PSRO OPERATION The PSRO program was established by PL 92-603, the Social Security Amend ments of 1972, to evaluate health care services provided under Social Security programs, primarily Medicare and Medi caid, to ensure that these services con form to appropriate professional stan dards, are medically necessary, and are provided in the most economical set ting appropriate for effective care. Preparatory to implementation, the Department of Health, Education, and Welfare has divided the country into 203 PSRO areas and has begun the process of selecting organizations to be desig nated as conditional PSROs or award ed planning grants to establish PSROs. PSROs will operate on a trial basis and will be required to review only those Social Security health care ser vices provided by or in institutions. As a consequence, most dental care is ex cluded from the scope of a PSRO’s ini tial responsibilities. This, however, is not a permanent condition. In fact, there is no assurance that this exclusion will continue even through the trial period, which cannot exceed 24 months. As
soon as a PSRO considers itself cap able, it may petition the HEW secretary to broaden its review authority to include ambulatory care. Since continuation of its status is contingent on its satisfac tory progress, the incentive to expand activity is clear. Consequently, it may be expected that all dental services paid for under Social Security programs will be subject to review in the relatively near future. When this occurs, a basic discrimina tory aspect of the law will become evi dent. Dentists, whose work is subject to review, are precluded from member ship in the reviewing organization. DENTISTS EXCLUDED FROM REVIEWING GROUPS In May 1974, the American Dental Asso ciation addressed this discrimination in testimony before the Senate Finance Committee and submitted corrective amendments to the law. What effect this action will have is unknown, but, as the program is now structured, mem bership in the PSROs themselves, that is, the local reviewing groups, is open only to physicians and osteopaths. The same is true of the National Profession al Standards Review Council, the advi sory group to the HEW secretary, and, for practical purposes, the statewide Professional Standards Review Coun cils, which coordinate activities in states
Council chairman comments No extraordinary vision is needed to see that the PSRO concept stands on dentistry’s horizon. It is an immedi ate reality for federally funded insti tutional health care and is designed to expand to include ambulatory care as well. When the federal government speaks of PSRO, it is speaking of peer review. When the sponsors of the myriad national health insurance bills speak of quality assurance, they are speaking of peer review. The fed eral government intends to demand peer review of the practice of den tistry. In the private sector, the demands are no less real. Insurers continue to seek local professional mechan isms, capable of evaluating matters which are in dispute and reaching impartial decisions about them. Thus, from within the profession and from outside it, comes the call for effective peer review. If this call is ignored, what then? What will happen if organized dentistry re fuses to establish peer review mech anisms where none now exists and refuses to continue operating those committees already established? Will patients stop asking for assurance that treatment is appropriate and fees fair? Will the government? Will the insurers? The answer is obvious: they will not stop asking. Rather, if dentistry fails to respond forcefully and effec tively, they will turn to others out side the profession. When that hap pens, the opportunity to demonstrate the high quality of care being deliv ered every year in this country will be lost. With this lost opportunity, the pro fession's internal control may be lost. For the evaluation of dental ser vices is as much the business of den tists as is the accomplishment of any dental procedure. A dentist can no more turn away from doing it—and doing it to the best of his ability— than he can turn away from provid ing dental care itself. Robert B. Hughlett Chairman Council on Dental Care Programs
with three or more PSROs. Dental ex pertise within the program is available only through the state advisory groups comprising health care practitioners other than physicians, and in the gov erning boards of PSROs, on which in dividuals not eligible for membership may serve. The law implies that PSROs will seek this expertise and that services provid ed by health care practitioners other than physicians will be reviewed by practitioners of the same discipline. PSROs are authorized to arrange to have this accomplished. Furthermore, the Senate Finance Committee's report accompanying the law states: “It is ex pected that PSROs would make speci fic arrangements with groups represent ing substantial numbers of dentists for necessary review of dental services." From this, it seems safe to assume that appropriate dental peer review will be conducted in the PSRO program. Nevertheless, this statutory discrim ination is most significant, entirely apart from any considerations of professional status, because it creates a situation in which dentists contribute their talent, knowledge, and experience to a pro gram over which they have virtually no control. When one considers the con tinuing debate of the program’s merits, PSRO is most certainly “the dentists’ problem,” too. Charges that the program is nothing more than a federal cost-control mech anism, that it will violate the privacy of patients and, through the establishment of standards, will promote second-rate, “cookbook” health care, cannot be dis missed lightly. Even the strongest PSRO advocate will admit to the potential with in the program for these and other abuses. No immediate resolution will be forthcoming. Such charges will be proved or discredited only through the operational record of the program. Or ganized dentistry seeks ways to influ ence that record.
ADA VIEWPOINT Recognizing the implications of the law and the inevitability of its exten sion to ambulatory care, the Association has been presenting the profession's concerns to elected officials, HEW rep resentatives, and representatives of or
ganized medicine. Although it has taken no position regarding approval or disap proval of the law itself, the Association readily acknowledges its responsibility for dental peer review, in both private health insurance programs and public plans such as Medicare and Medicaid. But it points out that unless dentists are involved in the planning and admin istration of PSROs, a sound system for reviewing dental care will not be pos sible; unless dentists have proper rep resentation on the national and state wide review councils, the vital data need ed to improve dental review procedures will not emerge, and unless dentists make final determinations on the qual ity of dental services in hospitals and private offices, there can be no effec tive evaluation of these services. A number of state dental societies have established close liaisons with medical counterparts and with the applicant organizations seeking PSRO designation on a planning or condi tional basis. To facilitate this effort, the Council on Dental Care Programs has initiated a system through which dental societies are notified of HEW actions with respect to PSRO designations with in their respective states. As of August 1974, applicant organizations had been awarded planning or conditional con tracts in half the PSRO areas. Across the nation, then, as the law makers weigh dentistry’s quite funda mental objection and as debate contin ues in the health care community, the fact of PSRO is inescapable. Organiza tions are formed, appointments are made, contracts are signed. The law moves, inexorably it seems, toward im plementation. Regardless of one’s opinion of it, PSRO must be acknowledged as a mechanism of considerable force, one which will profoundly influence the health care of 40 million Medicare and Medicaid recipients. At the same time, in considering PSRO, it is difficult not to look beyond Social Security pro grams to the mounting congressional interest in national health insurance. In this context, the prospects are formid able indeed.
Mr. O'Donnell is assistant secretary of the Council on Dental Care Programs.
O 'D onnell: CONTENDING WITH PSRO ■ 837
Contending with PSRO John F. O'Donnell, AB, Chicago
Proponents have called it a program with "the potential for having a greater favorable impact on health and the health care system in this country than any other ever enacted.” Critics have denounced it as “massive government intervention into private medicine.” Al though in most areas organized medi cine is working diligently in its behalf, in some, medical societies are demand ing repeal and refusing to cooperate in its implementation. The law establishing professional standards review organ izations (PSROs) to determine the qual ity and appropriateness of health care services paid under Social Security is— to understate the case—a most contro versial one. Because of the controversy, it also has been the most widely reported and editorialized health program since the Medicare bill. But the news media, with few exceptions, have viewed the PSRO program solely in terms of its effects on the practice of medicine, leading their audience, including many dentists, to conclude that it is “the physicians’ problem.” Examination of the program suggests that this conclusion is decid edly shortsighted. 836 ■ JADA, Vol. 89, October 1974
PSRO OPERATION The PSRO program was established by PL 92-603, the Social Security Amend ments of 1972, to evaluate health care services provided under Social Security programs, primarily Medicare and Medi caid, to ensure that these services con form to appropriate professional stan dards, are medically necessary, and are provided in the most economical set ting appropriate for effective care. Preparatory to implementation, the Department of Health, Education, and Welfare has divided the country into 203 PSRO areas and has begun the process of selecting organizations to be desig nated as conditional PSROs or award ed planning grants to establish PSROs. PSROs will operate on a trial basis and will be required to review only those Social Security health care ser vices provided by or in institutions. As a consequence, most dental care is ex cluded from the scope of a PSRO’s ini tial responsibilities. This, however, is not a permanent condition. In fact, there is no assurance that this exclusion will continue even through the trial period, which cannot exceed 24 months. As
soon as a PSRO considers itself cap able, it may petition the HEW secretary to broaden its review authority to include ambulatory care. Since continuation of its status is contingent on its satisfac tory progress, the incentive to expand activity is clear. Consequently, it may be expected that all dental services paid for under Social Security programs will be subject to review in the relatively near future. When this occurs, a basic discrimina tory aspect of the law will become evi dent. Dentists, whose work is subject to review, are precluded from member ship in the reviewing organization. DENTISTS EXCLUDED FROM REVIEWING GROUPS In May 1974, the American Dental Asso ciation addressed this discrimination in testimony before the Senate Finance Committee and submitted corrective amendments to the law. What effect this action will have is unknown, but, as the program is now structured, mem bership in the PSROs themselves, that is, the local reviewing groups, is open only to physicians and osteopaths. The same is true of the National Profession al Standards Review Council, the advi sory group to the HEW secretary, and, for practical purposes, the statewide Professional Standards Review Coun cils, which coordinate activities in states
Council chairman comments No extraordinary vision is needed to see that the PSRO concept stands on dentistry’s horizon. It is an immedi ate reality for federally funded insti tutional health care and is designed to expand to include ambulatory care as well. When the federal government speaks of PSRO, it is speaking of peer review. When the sponsors of the myriad national health insurance bills speak of quality assurance, they are speaking of peer review. The fed eral government intends to demand peer review of the practice of den tistry. In the private sector, the demands are no less real. Insurers continue to seek local professional mechan isms, capable of evaluating matters which are in dispute and reaching impartial decisions about them. Thus, from within the profession and from outside it, comes the call for effective peer review. If this call is ignored, what then? What will happen if organized dentistry re fuses to establish peer review mech anisms where none now exists and refuses to continue operating those committees already established? Will patients stop asking for assurance that treatment is appropriate and fees fair? Will the government? Will the insurers? The answer is obvious: they will not stop asking. Rather, if dentistry fails to respond forcefully and effec tively, they will turn to others out side the profession. When that hap pens, the opportunity to demonstrate the high quality of care being deliv ered every year in this country will be lost. With this lost opportunity, the pro fession's internal control may be lost. For the evaluation of dental ser vices is as much the business of den tists as is the accomplishment of any dental procedure. A dentist can no more turn away from doing it—and doing it to the best of his ability— than he can turn away from provid ing dental care itself. Robert B. Hughlett Chairman Council on Dental Care Programs
with three or more PSROs. Dental ex pertise within the program is available only through the state advisory groups comprising health care practitioners other than physicians, and in the gov erning boards of PSROs, on which in dividuals not eligible for membership may serve. The law implies that PSROs will seek this expertise and that services provid ed by health care practitioners other than physicians will be reviewed by practitioners of the same discipline. PSROs are authorized to arrange to have this accomplished. Furthermore, the Senate Finance Committee's report accompanying the law states: “It is ex pected that PSROs would make speci fic arrangements with groups represent ing substantial numbers of dentists for necessary review of dental services." From this, it seems safe to assume that appropriate dental peer review will be conducted in the PSRO program. Nevertheless, this statutory discrim ination is most significant, entirely apart from any considerations of professional status, because it creates a situation in which dentists contribute their talent, knowledge, and experience to a pro gram over which they have virtually no control. When one considers the con tinuing debate of the program’s merits, PSRO is most certainly “the dentists’ problem,” too. Charges that the program is nothing more than a federal cost-control mech anism, that it will violate the privacy of patients and, through the establishment of standards, will promote second-rate, “cookbook” health care, cannot be dis missed lightly. Even the strongest PSRO advocate will admit to the potential with in the program for these and other abuses. No immediate resolution will be forthcoming. Such charges will be proved or discredited only through the operational record of the program. Or ganized dentistry seeks ways to influ ence that record.
ADA VIEWPOINT Recognizing the implications of the law and the inevitability of its exten sion to ambulatory care, the Association has been presenting the profession's concerns to elected officials, HEW rep resentatives, and representatives of or
ganized medicine. Although it has taken no position regarding approval or disap proval of the law itself, the Association readily acknowledges its responsibility for dental peer review, in both private health insurance programs and public plans such as Medicare and Medicaid. But it points out that unless dentists are involved in the planning and admin istration of PSROs, a sound system for reviewing dental care will not be pos sible; unless dentists have proper rep resentation on the national and state wide review councils, the vital data need ed to improve dental review procedures will not emerge, and unless dentists make final determinations on the qual ity of dental services in hospitals and private offices, there can be no effec tive evaluation of these services. A number of state dental societies have established close liaisons with medical counterparts and with the applicant organizations seeking PSRO designation on a planning or condi tional basis. To facilitate this effort, the Council on Dental Care Programs has initiated a system through which dental societies are notified of HEW actions with respect to PSRO designations with in their respective states. As of August 1974, applicant organizations had been awarded planning or conditional con tracts in half the PSRO areas. Across the nation, then, as the law makers weigh dentistry’s quite funda mental objection and as debate contin ues in the health care community, the fact of PSRO is inescapable. Organiza tions are formed, appointments are made, contracts are signed. The law moves, inexorably it seems, toward im plementation. Regardless of one’s opinion of it, PSRO must be acknowledged as a mechanism of considerable force, one which will profoundly influence the health care of 40 million Medicare and Medicaid recipients. At the same time, in considering PSRO, it is difficult not to look beyond Social Security pro grams to the mounting congressional interest in national health insurance. In this context, the prospects are formid able indeed.
Mr. O'Donnell is assistant secretary of the Council on Dental Care Programs.
O 'D onnell: CONTENDING WITH PSRO ■ 837