CARE GUIDELINES: Doctors Sue Milliman & Robertson
Maintaining that they were "falsely linked" to pediatric care guidelines, two Texas pediatricians are suing the consulting and actuarial firm Milliman & Robertson -- the publisher of guidelines used by insurance companies to help determine the length of hospital stays and whether to pay for treatments. The Houston Chronicle reports that the lawsuit, which might be the first to "directly attack the credibility of such guidelines," contends that the guidelines have "no basis in sound medical practice, and raises the specter that Milliman & Robertson tried to buy scientific legitimacy by giving $100,000 to the pediatrics department at the University of Texas-Houston in exchange for the school's stamp of approval." The suit also raises questions about whether the pediatrics department "manipulated its own faculty into becoming 'contributing authors'" to accept the money.
Too Little, Too Late?
Dr. Thomas Cleary, head of pediatric infectious diseases at the UT-Houston Medical School and Dr. William Riley, now vice president of medical education at Driscoll Children's Hospital in Corpus Christi are suing the publisher and Dr. Robert Yetman, a UT-Houston associate pediatrics professor who received $40,000 from Milliman & Robertson to organize writing the book. After the doctors complained that their names were not authorized to be used in the list of contributors, Milliman & Robertson sent letters to those who had already purchased the guidelines listing four doctors who did not wish to have their names listed in the publication and enclosed a corrected list of contributors to be inserted into the books. But Clearly and Riley maintain that because their names had become "so intertwined with the promotion, publication and existence" of the guidelines, the correction was not enough and pushed for a recall of the guidelines, public apologies and an agreement to no longer publish recommended hospital stays for children. Milliman & Robertson declined to settle, thus sparking the trial set for January.
Too Legit to Quit?
Cleary said, "I want Milliman & Robertson to get out of the business of writing pediatric guidelines because they can't do it in a credible way. My main purpose in the lawsuit is to make all this public so people get outraged at what's going on." Lawsuits pending against Humana in Miami and Prudential in New York also contend that those companies denied care based on the Milliman & Robertson guidelines. Although Cleary and Riley maintain they did not directly contribute to the guidelines, Yetman argues that they did in fact make contributions. But Cleary said, "It was supposed to look like an activity the whole department was working on in some sort of collaborative way. I think for pediatric-care guidelines, they thought they needed to get a medical school." However, Yetman argues that for Milliman & Robertson, it made no difference "one way or the other," if the school participated, adding that the university was the only entity that benefited from the partnership because it would be associated "with a good publication that is well thought-out, that is pro-children, that gives power back to the physician in an era of managed care."
A Bad Book?
Although regarded "as the industry leader in selling cost-cutting guidelines," Milliman & Robertson maintains that the guidelines "should never be used to deny treatment," but only as "reference points for discussions with doctors." The guidelines are for uncomplicated cases and represent the "'best practice' in medicine by combining quality care and efficiency." According to a statement, "Milliman & Robertson's health care management guidelines are tools that are widely used in the health care industry. They have been painstakingly assembled and checked. Milliman & Robertson has full confidence in the integrity of its guidelines and stands behind them 100%." But Cleary maintains, "Physicians who are forced to follow these guidelines are forced to commit malpractice," adding that "there is at least one risky recommendation on each page of the 400-page" pediatrics guidelines. Cleary added, "There are no data or clinical studies that show the recommendations are safe. Zero. None. Nothing. The guidelines don't reflect reality." Promotional material from Milliman & Robertson acknowledges that the guidelines "are not all based on controlled scientific studies." Writing in the October 1998 edition of the Annals of Surgery, Dr. Robert Rutledge of Durham, N.C., noted the need for standardization of treatment and length of hospital stays, but said that using large database studies and involving the American Medical Association would be more accurate (Nissimov, 3/3).