Utilization and peer review. Medicine's privilege and responsibility.

Area of Science:

• Medical ethics
• Healthcare quality assurance
• Professional self-regulation

Background:

• Peer review is a privilege and responsibility in medicine.
• Physician involvement is crucial for shaping healthcare's future.
• Current systems require active physician participation in oversight.

Purpose of the Study:

• To emphasize the critical role of physicians in peer review.
• To highlight the dual importance of quality assessment and cost control.
• To advocate for due process and fairness in medical review.

Main Methods:

• Utilization review of professional medical services by physicians.
• Assistance from informed lay personnel and computer-derived data.
• Incorporation of "due process" including discussion and appeals.

Main Results:

• Physicians are essential for accurate utilization review.
• Computer data can assist but not replace physician judgment on medical necessity.
• Peer review significantly impacts healthcare quality and cost.

Conclusions:

• Active physician participation in peer review is imperative.
• Peer review must prioritize patient care quality, with cost control as a secondary benefit.
• A robust peer review system requires due process and appeal mechanisms.