한정된 자원을 책임있게 운용할 수 있는 의사로 교육하기

(출처 : http://blogs.nature.com/naturejobs/2012/10/17/challenging-the-integrity-of-scientist)

의사들의 진실성(integrity) 교육을 위한 프로그램이 부족한 현실을 해결하기 위해서는 

광범위한 이해관계자들을 포괄하는 해결책이 나와야 할 것이다. 

이 사안는 환자와 사회가 의사집단에 주는 신뢰와 직결되기 때문에 

의사들의 프로페셔널리즘과 윤리에 대단히 중요한 문제이다. 

지불제도의 개혁은 진실성과 인센티브에 대한 지형(landscape)을 변화시킬 것이나, 

의사들의 바른 인식을 대체할 수는 없다. 

연방정부와 주정부도 중요한 이해관계자이지만, 

공공 및 개인의 의료, 환자, 그리고 의사 자신을 지켜내기 위해서는

의학교육, 면허기관, 전문의 인증 등의 분야의 리더들이 함께 힘을 합쳐서 

문제에 대한 인식을 충분히 공유할 수 있도록 노력해야 할 것이다. 

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ABOUT 18% OF THE US GROSS DOMESTIC PRODUCT is consumed by health care—more than that of any other industrialized country—and that number is expected to increase to 20% by 2020

Program integrity—a term frequently used by payers for program losses due to inefficiencies, inappropriate payments, or exploitation—spans the spectrum of waste, abuse, and fraud, which divert health care dollars from the provision of patient care. Waste alone may account for 30% of overall health care costs.1

At the most basic level, documentation and billing are not performed well by many physicians and physician offices

The effects can be substantial. The Centers for Medicare &Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) process identified an overall Medicare fee-forservice error rate of 8.6% of payments for 2011, amounting to nearly $30 billion.3

While defensive medicine is frequently cited as a driver of overutilization, incentives in the fee-for-service payment structure are motivating factors as well.5

This relationship exists for physicians even within the same specialty

Incentive-driven behavior is not just limited to the performing of tests, but also extends to abuse and “gaming” of payment differentials

Numerous studies have documented upcoding of encounters to increase revenue, particularly in certain specialties.7

Factors leading incentive-driven behavior to cross a line into abuse and fraud are complex.

Currently, there are few opportunities for program integrity education. CMS does not mandate such education to participate in Medicare and Medicaid. To our knowledge, no state medical board requires program integrity education for licensure and no specialty board requires it for board certification.

Voluntary instruction is reaching some students and new physicians. According to a 2010 OIG survey of all 160 US medical schools and 660 institutions sponsoring GME programs, only 44% of schools and 68% of institutions offered any instruction in program integrity.9 More than 90% of respondents reported that they would like the government to provide educational materials. In response, OIG developed a booklet titled “A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse” and a presentation to support didactic learning.

Providing educational opportunities is just a first step in raising awareness

Residency and fellowship training are likely the best times for physicians to learn about program integrity given the practical nature of GME training and the immediacy of independent practice

States generally require physicians to certify that they have completed CME during licensure renewal. States could specify that a certain amount of CME be earned in program integrity.

Each specialty board requires physicians to demonstrate knowledge and competence in professionalism and  systems-based practice in order to claim diplomate status

Addressing shortcomings in program integrity education will require a comprehensive solution across numerous stakeholders. This issue is central to medical professionalism and ethics because it speaks directly to the trust placed in the medical profession by patients and society. Payment reformswill no doubt alter the program integrity landscape and shift incentives, but they will not supplant the need for physician awareness. While federal and state governments are vital participants, leaders in medical education, licensure, and specialty certification would ideally work together to ensure that all physicians have sufficient awareness to safeguard public and private health care programs, patients, and themselves.

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JAMA. 2013 Mar 20;309(11):1115-6. doi: 10.1001/jama.2013.1013.

Educating physicians about responsible management of finite resources.

Agrawal S, Taitsman J, Cassel C.

Source

Center for Program Integrity, Centers for Medicare & Medicaid Services, Baltimore, Maryland 21244, USA. shantanu.agrawal@cms.hhs.gov

PMID:

 

23512056

 

[PubMed - indexed for MEDLINE]