HMO PRACTICE GUIDELINES: USA Today Addresses Impact

Today's USA Today editorial page takes a look at the role of HMO practice guidelines, which dictate "everything from how long a patient should be hospitalized after bypass surgery to the precise symptoms a woman must have before undergoing a hysterectomy." In the "Our View" column, the paper charges that the guidelines which drive most HMO coverage decisions "aren't grounded in science but are cookbook recipes" designed to minimize HMO expenditures. To bolster its claims, the paper cites several recent studies:

The National Cancer Institute found in June that women receiving outpatient mastectomies were more likely to incur complications and rehospitalization.
The Journal of the American Medical Association published a study last year indicating that infants "discharged within a day of birth face increased risk of developing jaundice, dehydration and dangerous infections."
Researchers at the University of Michigan and Rand released a study in June suggesting that while "most HMOs strictly limit when hysterectomies are allowed ... [they] found little agreement among scientists to justify ironclad practice guidelines for the procedure."

The paper concedes that while the idea of practice guidelines "is enticing" and serves to eliminate wasteful procedures, they "don't work as promised unless they're supported by solid medical research." Further, the paper emphasizes that guidelines governing a particular procedure often conflict among several HMOs, but the secrecy of the guidelines prevents doctors and patients from analyzing the science which supports them. In conclusion, the paper calls for HMOs to make their guidelines open for review, voicing support for the national online guideline clearinghouse being developed by the American Medical Association, the American Association of Health Plans and the federal government, but notes that "the Web site won't list the majority of guidelines used by HMOs as cover for denying appropriate medical care" (12/7).

Weighing In
Dr. James Schibanoff, director of clinical guidelines research at Milliman & Robertson Inc. counters in the "Another View" column that practice guidelines ensure that patients receive high quality and cost-effective health care. He calls guidelines "a set of optimal clinical practice benchmarks for treating common conditions for patients," noting that the "guidelines apply to most patients but not every patient in every situation." He notes that physicians and nurses collaborate to develop the guidelines, which "are based on the actual practices of physicians throughout the United States." Schibanoff insists that while the guidelines are "designed to assist health care providers and others in supplying efficient, quality health care ... they are not based on financial objectives." Indeed, he argues that the guidelines should serve as a tool in "considering the unique characteristics of each patient and should not be used as a basis for denying payment for treatment received." He concludes that guidelines have the potential to both improve care and measure the delivery of care (12/7).

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