HMO SUITS: Study on M&R Guide Accuracy Could Fuel Fire
A study examining the discrepancy between care guidelines widely used by insurers and actual lengths of stay recommended by physicians is set for release today, and is expected to add fodder to lawsuits alleging insurers unfairly deny payment for needed care, the Wall Street Journal reports. The study, conducted by the for-profit research company HCIA-Sachs, reviews the guidebooks developed by Milliman & Robertson Inc., used by many insurers to determine "how much care they ought to reimburse in various medical situations." M&R guidelines -- also used by doctors and hospitals as "cookbooks" to "make certain they are practicing medicine in an efficient manner" -- provide a "day-by-day checklist that hospitals can use to accelerate the treatment of almost any serious illness." The HCIA study, which investigated more than 3.5 million pediatric cases in 1998 in hospitals across the nation, reportedly reveals a "wide gap" between M&R's "goal lengths of stay" and actual average lengths of stay. For example, while M&R recommends three days of hospital stay for pediatric bacterial meningitis, the actual average length of stay is 8.5 days.
Efficiency or Rigidity?
An M&R spokesperson defended the company, saying that it tells clients the "goal length is merely the 'optimal' situation for an uncomplicated case and definitely should not be considered the average outcome." The company also says that the guidelines are not based on financial objectives but are intended to "support the efficient delivery of quality care." However, Marc Edwards, senior vice president of medical affairs at New Brunswick, N.J.- based St. Peter's University Hospital, said that insurers "apply the guidelines rigidly" and that health plans frequently deny payment of portions of hospital bills based on the guidelines, disregarding patients' unique conditions. But Charles Cutler, chief medical officer of the American Association of Health Plans, countered, "I don't believe the health plans are using them as rigidly as some describe."
Study Could Bolster Suits
In November, a Florida federal judge is expected to determine whether to approve class-action status for a collection of cases that claim insurers' "failure to disclose their use of M&R's guidelines deliberately misleads patients about the amount of care" covered by their health plans. Last week, the Connecticut attorney general also filed suit against four major health insurers, alleging they "forced members to accept less effective care in a quest for profits." Dozens of states have already passed laws that require insurers to cover more than some of M&R's "bare minimums," such as 24-hour maternity stays and outpatient mastectomies for breast cancer patients. Stephen Neuwirth, an attorney with Boies, Schiller & Flexner, which brought one of the cases in Florida, said the HCIA study "reflects what we think the [insurance] companies have known for a long time: that Milliman & Robertson's guidelines are a way to reduce the amount of care provided and therefore to save money. We believe that our case will show that they marketed these guidelines for that purpose, and the health plans bought them for that purpose" (Martinez, 9/14).