Mr. MAGUIRE. Even in summary, and wouldn't it make sense to make, perhaps not all of the gory details available, but you know, if some distillation of the information that is developed as a result of the PRSO process, let's say hospital X has had a pattern of 25 percent of the care that it delivers being deemed unnecessary or medically not indicated, or what have you, what would be the matter with simply making available that information to consumers saying, hospital X has this pattern and you make your own decision?

Dr. GORAN. I am sure you are aware there is a considerable controversy over how much information needs to be protected and how much needs to be made publicly available. I think the one or two points I would like to make are, first, obviously, we don't feel we have the answer to the best limits but we feel that current policies on confidentiality that govern PSRO operations are reasonable and they are a compromise approach which makes aggregate data available, but protects individual data.

The second thing is in order for PSRO's to function effectively doing peer review, it is clear the PSRO will have to be able to offer to the individuals that it is maintaining profiles on, the protection of privacy so that they can attempt to correct problems through education.

Mr. MAGUIRE. But I want my privacy to be protected, too, and I don't want to go into a hospital and have an unnecessary operation, you know, it becomes a question, doesn't it, of what the need to know really is? Well, I hope this is something we can explore.

What about giving the information to licensing boards and review boards within the hospital, information, that results from these studies, even if you are not prepared to give it now to the public at large?

Dr. GORAN. Well, some of the information that involves the hospital or the practitioners would be given back to the hospital by the PSRO. In fact, this is one of the means by which the PSRO takes action.

Mr. MAGUIRE. Give the whole thing?

Dr. GORAN. It would depend on the individual instance and be up to the local PSRO. One of their responsibilities is to correct the problem and if it involves a hospital practice, the hospital is ultimately responsible for correcting that.

I might add, to clarify one point about data about institutions such as hospitals: aggregate data regarding hospitals will be available to planning bodies and to the public.

Mr. MAGUIRE. By name?

Dr. GORAN. By name of hospitals. That can be used as long as the practitioners are not identified within that group.

Mr. MAGUIRE. I see. So you have no trouble with the idea of identifying hospitals?

Dr. GORAN. Yes, for some purposes. There are some limits I suspect to that where individual practitioners could be identifiable, but generally aggregate patterns indicating utilization practices, et cetera, will be available for planning purposes.

Mr. MAGUIRE. Going back to the hospital you mentioned a minute ago, hospital X, if it had the pattern of 25 percent of the care as not indicated or as being unnecessary, that would be then known publicly, is that what you say?

Dr. GORAN. That kind of information can be made known with the caution that it will take some time before PSRO's are going to be confident that they have accurate data reflecting such a fact. Mr. MAGUIRE. I suspect that will be a problem.

Dr. VAN HOEK. May I make a point?

Mr. MAGUIRE. Sure.

Dr. VAN HOEK. It seems to me that the question of an institution as an entity, having significant deviation from the practice patterns of the community, is less likely than a difference in practice among individual physicians in an institution. In such situations where educational programs are unsuccessful in an attempt to modify inappropriate practices, the institution itself has the incentive to withdraw staff privileges from such physicians. This, in effect, is public information, since the patients then know their doctors no longer have certain privileges in the hospital.

Mr. MAGUIRE. The hospital suffers, in other words, in terms of its image and it will presumably take steps against those physicians which it knows?

Dr. VAN HOEK. The physicians within the institution will have

to answer.

Mr. MAGUIRE. Responsible for that aggregate.

Another question. PSRO's, as I understand it, are now responsible for tissue review, medical review, utilization review and, of course, generally speaking, peer review. There are an awful lot of other concerns that we would have if we were talking about quality assurance. What kind of a schedule, if any, do you have for adding additional responsibilities to those already in place?

Dr. GORAN. The approach we have taken is to give first priority to hospital review, assuring quality within a short-term hospital, and that, as was indicated before, we hope to have completed in 1978, that is, have all Federal beneficiaries under PSRO review that are receiving hospital care.

Before then, actually today, we are conducting some demonstrations in long-term care review. Our next efforts will be, once a PSRO assumes hospital review responsibilities, to go outside the hospital and to incorporate review of all long-term care facilities, mental hospitals, as well as nursing facilities and intermediate care facilities.

Mr. MAGUIRE. Is that prior to 2?

Dr. GORAN. Yes, that is prior to No. 2. Both institutional types of reviews are required. Beyond that, implementation of office review or ambulatory review, which is at the current time at the option of the PSRO, with approval of the secretary, it is likely, at least it has been our early experience, that PSRO's will be requesting the authority to engage in ambulatory review.

So that those that do will then be moving into what we call "community wide review." That is, within their geographic area,

they will be reviewing all services provided to medicare, medicaid, maternal and child health beneficiaries and in addition, we hope simultaneously to expand their review to private patients, as well.

Mr. MAGUIRE. Would they then be getting into questions of fraud and abuse, for example, in the medicare, medicaid programs?

Dr. GORAN. There are separate provisions in medicaid and medicare for investigating fraud and abuse. To a certain extent, PSRO's will have to coordinate their efforts with these separate activities. But PSRO's will not primarily be involved in the issues of fraud and abuse, because there are separate bodies responsible for that.

Mr. MAGUIRE. What about interfacing, if you will-a word I despise, but, nevertheless, it is there-with HSA's and the renal areas and so on; at what point does it become a problem of coordination?

Dr. GORAN. There will be some problems of coordination between the areas, the geographic areas, the renal networks, and the HSA's. In the HSA instance, about one-third of the PSRO areas are not congruent with HSA areas. As HSA's are appointed and established, this will cause the following kinds of problems: PSRO's and HSA's organizations will have to work together and develop agreements in which PSRO's will have input into HSA's findings. In those instances where areas are not congruent, there will have to be more than one agreement, in some instances three or more.

Mr. MAGUIRE. Why can't we have congruent areas if I may ask a nasty question?

Dr. GORAN. Basically two reasons, the statutory processes that led to each set of area designations, use different criteria and there are differences in the chronology of the statutes.

Mr. MAGUIRE. That is, Congress didn't write the law correctly to produce coterminus areas?

Dr. GORAN. I think I would say there are different program purposes which sometimes result in incongruency in terms of defining the areas.

Second, the programs occurred differently in time. Chronologically, we have had PSRO areas for a couple of years now.

Mr. MAGUIRE. What about the second consultations with regard to surgery? Is that something that you expect PSRO's to get into or you will ask them to get into?

Dr. GORAN. Basically, we view the PSRO review system as an alternative and a superior alternative to the second consultation approach to surgery. What PSRO's do, we think more adequately protects both the patient and the physicians.

Mr. MAGUIRE. Could you explain how it works and why you feel justified in making that conclusion?

Dr. GORAN. PSRO's are a first attempt to set standards of acceptable practice and in this regard they would attempt to find standards for procedural, elective procedures and then attempt to review practices within their area to determine whether or not there are deficiencies or discrepancies between a standard and actual practice.

They start out in a neutral manner, not having to assume there is bad practice. They go in as factfinders, setting standards to see

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if there are bad practices and if they identify them, they can then deny payment for the service. However, in so doing, as we indicated before, they provide the patient with an opportunity to appeal, because, after all, the ultimate situation is the patient's.

Mr. MAGUIRE. You have some 100 PSRO's in existence, now operaating; is that correct?

Dr. GORAN. 120.

Mr. MAGUIRE. How many have developed standards that you just described?

Dr. GORAN. The 65 doing review have developed standards. I should indicate many of them have just developed standards and their first set of standards will be less sophisticated than they will be a year from now.

65 have developed some standards.

Mr. SCHEUER. Standards for what?

Dr. GORAN. Quality of care.

Mr. MAGUIRE. Specifically, surgery; that is what I want to know. Dr. GORAN. Surgery and other reasons for hospitalization.

Mr. MAGUIRE. All of the data on unnecessary surgery, you can argue whether this or that study was adequately controlled or what have you, but everything we have seems to indicate substantial improvement from the cost-effective, quality point of view when you have a second consultation, and why wouldn't that be a logical thing to be incorporated, instead of, as you described now, in addition to it?

Dr. GORAN. I should have added that the reason the PSRO system is superior, is because the PSRO can enforce or include within their system, a second consultation, but ordinarily would not do it until they have identified a pattern of deviant practice on the part of an individual practitioner and not do it across the board but focus it on those most needed.

Mr. MAGUIRE. One final point.

Well, semifinal point.

Mr. Chairman, are you still there?

Mr. SCHEUER. Still here, patient, acquiescent and supine.

Mr. MAGUIRE. What about actual inspection of work, of surgery work, do you have any thoughts along those lines?

Dr. GORAN. I do not recall any PSRO in its plan or in conversations having proposed actual inspection of surgery. That begins to go somewhat outside of the realm of review. I think, if I can digress for a second, that that would more likely come up as a recommendation for correctional behavior. That is, a PSRO might identify a surgeon whose technique needed to be improved and recommend that he take a certain course or a certain sort of corrective consultation.

Mr. MAGUIRE. What about inspection for dental work?

Dr. GORAN. I think the same would apply.

Mr. SCHEUER. Will you yield?

Mr. MAGUIRE. Surely.

Mr. SCHEUER. Where you say it would appear that the surgeon's technique needed to be improved, how would you find that out? How would it come to the attention of an official body?

Dr. GORAN. In several ways. The most common way in which it would occur would be the result of a medical care evaluation study, an audit. The PSRO would review retrospectively a series of cases performed by a group of surgeons for a certain sort of diagnosis and through that review, identify that the practices of one, for example, one surgeon, maybe were questionable.

Then we try to determine why there were problems and we surmise that one of the reasons might be that surgical technique was inadequate. Such a judgment can be hypothesized from a review of records and tissue reports. That can be further corroborated by concurrent review if the PSRO chooses.

Dr. VAN HOEK. What happens in hospitals when such a questionable situation arises, the medical staff or the chief of surgery, if there is such a staff member, can ask a surgeon to participate in the procedures for some period of time and actually observe the operative procedure. If there is question of technical competence, it is reviewed by a group of his peers to see what corrective action has to be taken on the performance of that individual physician.

It is a fairly standard procedure within the institution. The PSRO system makes it possible through a more defined, objective system of review on an ongoing basis, rather than situations where some cases may provide only an ad hoc impression that something is wrong, and then it requires a study to confirm it.

Mr. MAGUIRE. One final question.

Dr. Van Hoek, as you indicated, there has been a generalized decrease in the length of hospital stays over the past year.

Now, that is overall, as I understand it. You said that the length of stay in the PSRO hospitals has decreased. But, as I understand it, that is true generally.

Now, my question is this: Has it decreased more under the PSRO process than it has decreased in general?

Dr. VAN HOEK. Up until recently, we did not have good objective data which could answer that question exactly. But we believe that some of the PSRO's, based on further analysis and comparative data, and I believe one of the subsequent witnesses will discuss this with you, can show that PSRO's are shortening the lengths of stay beyond those which would be expected from natural trends in practice patterns.

Mr. MAGUIRE. You said very carefully "some," and does that imply that others decreased less than the trend?

Dr. VAN HOEK. No; what I am saying is this

Mr. MAGUIRE. And some others about the same?

Dr. VAN HOEK. No. What I am saying is one PSRO has done a specific study which substantiates the fact that the decrease is significant and not just part of a national trend, and more PSRO's need to do these kinds of comparative data studies.

Mr. MAGUIRE. You look at PSRO's and that is what it shows and you don't have another PSRO study that shows the opposite. What is the magnitude of the decrease in relation to the trend? Is it, you know, roughly speaking, is it significant? Or how significant is it? Is it 5 or 20 or 50 percent more?