Opinion: Adhering to Standards of Care Helps Manage Risk

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Medicare and other third-party payers have started predicating reimbursement on adherence to standards of care. Post hoc chart reviews have resulted in substantial take-backs for failure to adhere to those values in cardiology, pulmonology and expanding to other areas. Outpatient medicine is also being subjected to such scrutiny.

The question of standards and who sets them can be debated. After all, the product of a committee may not fully reflect the intent/perspectives of its members. The result is sometimes a range for such matters as monitoring medication safety. Such is the case with respect to disease-modifying anti-rheumatic drug (DMARD) safety surveillance.

The published safety surveillance range is one to three months, the latter representing the longest interval that the American College of Rheumatology and the 3E (Evidence, Expertise, Exchange) Initiative committee members recognized as safe—although most favored monitoring at the shorter interval.^1,2 At some point, the insurance industry will demand adherence to that standard for DMARDs, as the legal system already has in malpractice cases.³

Prescribe & Monitor

Primary care physicians receive very little training/experience in musculoskeletal disease during medical school and postgraduate education, even less in how to prescribe and monitor medications in a manner that minimizes patient risks.

Does a rheumatologist new to a region or a facility have the responsibility to educate colleagues or should they simply modify their practice habits (related to their specialty by compromising standards) to fit in? Might acquiescing to an area’s practice habits (e.g., performing medication safety evaluations at six-month or yearly intervals and by performing incomplete examinations) be considered a form of Stockholm syndrome? And is it not another form of response to bullying to acquiesce to compas­sionate demands (e.g., it’s inconvenient for the patient to be seen more than twice a year, or the patient does not want to pay for more frequent visits)? And they are demands. We should not assume that patients and their families who talked/bullied a physician into monitoring outside of established standards will have compassion for the physician when morbidity or mortality results. The courts are replete with malpractice cases filed after a physician failed to follow medication monitoring standards.

Adherence to standards of care provides a safety net for both patients and physicians.

Patients with psoriasis were recognized early on to be at risk for hidden liver disease when treated with DMARDs. Request for liver biopsy after 1,500–2,000 mg cumulative methotrexate dosing is the standard of care, a standard more recently found appropriate for all patients receiving methotrexate. When a patient is found with cirrhosis (despite history of normal liver function tests), we all feel bad, so much more so when it could have been prevented by timely liver biopsy.