has the potential of jeopardizing the public's acceptance of our voluntary system.

We must make it abundantly clear to the public that, for the most part, the increased cost of medical care can be identified with the better care and services that have resulted from progress in medical science. On this basis we must persuade the American people to place a higher priority on expenditures for medical care, on the theory that they are getting real value in the form of better health for each dollar spent in this area. We believe an informed public will accept this premise provided that they have our assurance we are

aware of wasteful practices, and that we are taking aggressive steps to eliminate them. The initiative here rests with the medical profession. The solution however, can only be achieved, in our opinion, with the cooperation of the doctor, hospital and insuring organizations. The Nassau County Medical Society in recognition of this responsibility has developed a program to conserve the public's health care dollar.

It is in a sense a form of preventive medicine in the field of medical economics which will assure the survival and continued healthy growth of our voluntary system of providing and financing medical care.

HE PROGRAM shall be carried out under the direction and guidance of the medical society.

The following committees shall be formed and directed to assume responsibility for operation of the program:

A. Coordinating Committee (Present Voluntary Health Insurance Committee of Nassau County Medical Society)

B. Review Committee

C. Medical Staff Liaison Committee

D. Individual Hospital Utilization Committees

The Coordinating Committee shall be composed of a Chairman and representatives of the A.A.G.P. and various medical specialties appointed by the Pressdent of the Nassau County Medical Society. Invitations to participate in meetings of the Coordinating Committee shall be extended to representatives of the voluntary and private general hospitals in Nassau County, the insurance industry (through the Health Insurance Council), Blue Cross-Blue Shield and Independent plans (through G.H.I.). Problems or complaints of individual physicians with health insurance or prepayment plans may be submitted to the Coordinating Committee for discussion with or referral to the insurance organization involved.

It will be the function of the Coordinating Committee to lay out an initial blueprint to deal with the specific problems of inefficient use of hospital facili

ties and overcharging. The committee will also be responsible for development and dissemination of initial and continuing publicity on the program for referral to members of the Nassau County Medical Society and the general public where appropriate.

The Review Committee of the Coordinating Committee shall be appointed by the President of the Nassau County Medical Society, and shall include general practitioners and specialists. This committee will review specific cases involving a physician's fee submitted by an insurance organization or policyholder to determine whether the fee charged is consistent with the "usual" or "customary" charge for such services in the community.

The Medical Staff Liaison Committee of the Coordinating Committee will be composed of one representative of the medical staff of each voluntary and general hospital in Nassau County. Invitations to serve on this liaison committee shall be extended by the Chairman of the Coordinating Committee to the chief of staff in the hospital with the suggestion that the hospital's staff representative on the committee be selected from the members of the hospital's utilization committee.

It will be this committee's responsibility to adapt the information in Section III on Hospital Utilization Committees to encourage and assist individual hospitals in establishing and operating the utilization committees. The liaison committee will periodically review the functioning of the utilization committees and give guidance or direction where necessary and will serve as a permanent liaison between the Coordi

nating Committee and the individual hospital utilization committees.

A Utilization Committee will be established within the medical staff of each hospital to assure that the in-patient service given is necessary and could not be provided as effectively in the home, office, hospital out-patient department or some other more appropriate, available facility. The committee shall analyze

3.

and identify factors that may contribute to unnecessary or inefficient use of in-patient services and facilities and make recommendations designed to minimize ineffective utilization.

NOTE: SEE ORGANIZATION CHART, Page 5

The following sections 3, 4 and 5 contain detailed information on the operation of the program:

HE UTIlization CommiTTEE is a fact-finding

instrument of the medical staff without authority directly to effect changes in procedures or lessen the responsibility and privileges of other medical staff committees or individual members of the medical staff. It operates to strengthen the responsibility and authority of existing medical staff and administrative structure by making practical recommendations to the appropriate body for consideration and action.

The Utilization Committee devotes particular attention to the following areas which generally account for ineffective utilization:

Unnecessary admissions.

Excessive length of in-patient stay.

Delay in use or over-use of x-ray, laboratory and
other diagnostic and therapeutic services.
Delay in consultation and referral.

In each of these categories, the Utilization Committee provides answers to such questions as the following:

How many of such cases are there?

What factors contribute to these conditions?

What practical recommendations can be made to the medical staff, chiefs of clinical and non-clinical services, administration, prepayment plans and to the community to avoid these situations?

A. Organizing The Utilization Committee

1. Appointment of Members

Appointment of the chairman and Committee members should be made by the President of the Medical Board in accordance with existing bylaws governing the organization of medical staff committees. Generally, appointments

should be for a three year period; one-third of the committee should be rotated each year. Reappointments may be made after a lapse of one year.

2. Size of the Committee

The actual number of members of the Committee will be influenced by the size and organization of the medical staff and the number of hospital admissions. For effective functioning, however, the Committee should usually number no less than five.

3. Composition of the Committee

Membership on the Committee should include either the chief or a representative of each major department.

It seems advisable that the departments of pathology, radiology and anesthesiology be represented on the Committee.

The hospital administrator, or his designated assistant, should attend the meetings. The administrator should be responsible for the minutes of the meeting and for furnishing information on administrative procedures and policies which the Committee may request. Members of the medical staff who are not on the Utilization Committee may be invited to serve temporarily on the Committee when specific areas of study are selected in which they have special competence. The chief resident, the medical record librarian, the chief social worker and other hospital department heads should sit in at meetings, on invitation from the Committee.

4. Meetings

The Utilization Committee should meet as a

group once a month to conduct its activities. More frequent meetings may be held if deemed necessary by the chairman. Review of cases and records will be done by Committee members prior to the regular meeting. Presentations of findings should then be made to the full Committee for discussion and disposition. If the size of the medical staff and the extent of its organization warrant, the Utilization Committee may be divided into medical and surgical sub-committeess which will be concerned with cases relating to their respective services. Such sub-committees may meet independently for initial case review; however, analyses and findings should always be presented before the full Utilization Committee for review and recommendations.

B. Relationships

1. With Chiefs of Service

The Committee will need to maintain liaison with the chiefs of service for referral of particular situations indicating questionable or inappropriate utilization.

2. With Other Committees of the Medical Staff The Utilization Committee should work closely with other medical staff committees, seeking their assistance when indicated,

(a) Medical Record Committee

The work of the Utilization Committee is largely dependent upon the availability in the hospital of up-to-date charts which contain sufficient information to justify the decisions made by the attending physician in charge of the case and to permit objective review. The analyses of the Utilization Committee may point up inadequacies in the charts not revealed by review from the standpoint of accrediting bodies, legal requirements or quality control. Recommendations for improvement of medical records, including possible revision of forms, should be referred to the Medical Record Committee for appropriate action. In conjunction with its work, the Utilization Committee may wish to recommend various changes in forms and record procedures to the Medical Record Committee.

(b) Tissue Committee

In general, the Utilization Committee will need to maintain closest liaison with the Tissue Committee which is responsible for establishing the justification for surgery done in the hospital. The chairman of the Tissue Committee should have a standing invitation to attend meetings of the Utilization Committee.

(c) Operating Room, Admissions, Pharmacy and Other Medical Staff Committees Many of the recommendations of the Utilization Committee will be referred to the Operating Room, Admissions, Pharmacy and other medical staff committees for review and action, thus requiring liaison with them.

C. Functioning of the Utilization Committee 1. Review of Charts

In general, the Committee will function by reviewing and evaluating charts of discharged in-patients. The Utilization Committee may also concentrate on daily screening of cases admitted to the hospital. It must be recog nized, however, that information available at the time of admission is sometimes insufficient for objective evaluation of the need for hospitalization. In addition, this approach does not consider the problem of excessive length of stay. For these reasons, it is desirable that the Utilization Committee devote its major efforts to consideration of completed charts of discharged in-patients.

It is obviously not possible or even desirable for the Committee to examine the chart of each in-patient. The work-load should be divided among the Committee members and the review should be based upon selection in advance of the most appropriate categories of

cases.

Each member of the Committee should be assigned responsibility for reviewing charts in advance of each meeting and should be prepared to discuss those charts which raise specific questions. To the extent possible, each committee member should review those types of cases in which his judgment would be best, based on experience and training.

(b) Short-stay Cases

About 10 per cent of all cases admitted to general hospitals are discharged after one day. Included among these cases may be a significant number admitted for diagnosis or other procedures which might have been provided as effectively without admission. Each short-term case where the need for admission is questionable should be reviewed.

(c) Cases Questioned or Rejected for Payment by Prepayment or Insurance Plans Prepayment and insurance plans complaints involving questionable use of hospital facilities or services may be directed to the Nassau County Medical Society Coordinating Committee for

review.

Review of such cases may provide a basis for development of better understanding with such plans, improvement of their procedures and better service by physicians to the insured public.

(d) Cases in a Specific Diagnostic or Opertive Category

Usually, the work of the Committee will be carried out by study of all of the recently discharged cases with a specific diagnosis or operation. A different diagnosis or operation can be studied each month. Special attention should be given to identifying the different characteristics, if any, of the patients with the same diagnosis who had the longest stays in comparison with those who had the shortest stays.

3. Use of Check-list or Review Form

A check-list or review form should be used by members of the Utilization Committee in reviewing charts. The administrator and medical record librarian should assist in designing a general form. Special forms may be designed for use in studying specific classes of cases. Suggested check-lists are attached as Exhibits I and II. The first form is completed by the medical record librarian. The second form, which is completed by the member of the Utilization Committee, reflects the opinion of the reviewing physician and includes a number of items to be marked "yes" or "no," with space for detailed explanation where indicated. The reverse side of the form is to be used for recording any action to be taken by the Utilization Committee, together with recommendations made and the final disposition. To keep the records confidential, the patient should be identified by hospital number only, while the names of the attending physician (s) and member (s) of the Utilization Committee reviewing the record should be in code. Initially, it is advisable to become familiar with the various questions and explanatory comments on the check list and thus gain a general understanding of the points covered. The check-list can be completed most rapidly if the medical record is reviewed first in its entirety and management of the case studied. 4. Obtaining Additional Information from the Attending Physician

In some instances, the Committee member reviewing the chart may feel a need for additional information. Discussion with the attending physician should be encouraged in such circumstances. The Committee should develop a general policy on the conditions under which these consultations are held. In some instances, the attending physician may be requested to meet with the Utilization Committee in order to provide additional information.

5. Records

The Utilization Committee should maintain adequate summary records of its activities. In general, these summaries can be developed from the data recorded by the Committee members on the check-list forms and should be incorporated as part of the Committee min