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ARTICLE
HMO Guidelines or
New Mandates?
by Twila Brase, R.N.
President, CCHC
The "managed" in managed care has taken a new turn, as
Minnesota's five major managed care organizations recently agreed
to jointly develop comprehensive treatment guidelines for patient
care.
Although the project, to be led by the Institute for Clinical
Systems Improvement (ICSI), has the blessing of the state's most
prominent HMOs, several concerns dampen the expectation of
improved health care quality and lower health care costs.
To begin with, the health care guidelines are clearly intended
to standardize the practice of medicine. While standardization and
automation are perfectly suited to the making of widgets, they may
not serve the goals of quality patient care. Each individual's
complex and unique combination of physical characteristics, mental
capacity, and emotional energy are unlikely to be sufficiently
addressed through standardized treatment guidelines.
Micromanagement of health care workers is another potential
problem. Depending on the diagnosis, ICSI's treatment guidelines
for doctors will contain flow charts, reference guides,
measurement criteria, and specific questions to be addressed at
various points of the assessment. Receptionists and emergency
personnel are also given diagrams and algorithms to follow, with
instructions that sometimes refer to
separate but related guidelines. One envisions health care
workers at every juncture trying to locate the right guideline,
follow the charts, ask the questions, and document their
performance.
Aside from any problems with the content of these guidelines,
their sheer volume could prove daunting. With at least 12,000
known medical diagnoses and the guidelines averaging 50 pages
each, at least 600,000 pages could eventually be written to guide
the practice of medicine in Minnesota. And this figure does not
include the guidelines aimed at assessing symptoms prior to
diagnosis. It is quite possible that
some hospitals and non-specialty clinics may require a small
library to house the entire set of treatment instructions.
The guidelines are also troublesome because they divert a
large amount of time away from patient care. Health plans,
clinics, and hospitals must commit doctors and nurses--their most
valuable health care resources--to the development process,
thereby taking time and energy away from patients.
Even worse, doctors are expected to revise and update the
guidelines every 12 to 18 months. With doctors and nurses already
pressed for time, and patients waiting longer to see them, ICSI
may be tempted to limit the use of medical professionals in
developing the guidelines.
The Power of the List
Above all else, though, the greatest concern with the
comprehensive guidelines lies in their origins.
Funded by HMOs, written with input from health plan managers,
and suggesting that treatment decisions be regularly monitored
through medical record reviews, the guidelines may be nothing more
than a cleverly marketed management tool designed to cut costs by
influencing physician treatment decisions. Given the history of
HMO relationships with health care professionals, there is an
uneasy possibility that what starts out as a simple guideline may
quickly look and feel like a mandate.
As physicians know all too well, HMOs already have the power
to de-list doctors and other health care professionals from their
provider networks. With little or no explanation, a health plan
can eliminate a physician's access to entire populations of
patients, severely limiting his or her ability to practice.
With implementation of HMO-funded health care guidelines, one
reason for de-listing could include documented non-compliance with
suggested treatment protocols--whether or not the doctor's
decisions were beneficial to individual patients.
Health care guidelines are not new. The American Medical
Association has posted 2,000 guidelines on the Internet. What is
new is the coordinated funding of guideline development and
implementation by Minnesota's competing HMOs.
Whether the guidelines prove useful, increase bureaucratic
micromanagement, increase patient satisfaction, limit care, or
increase the level of provider frustration with HMOs remains to be
seen.
Minnesotans have much to gain if health care quality is the
primary objective of this budding endeavor. However, if the goal
is cost-containment by limiting access to health care services,
the public's discontent with managed care will not be assuaged.
The key to cost-containment is consumer control over health
care dollars. Personal financial incentives, such as medical
savings accounts and federal health care tax deductions, will
drive health care costs down by encouraging individual
cost-consciousness. Although HMOs want their enrollees to believe
treatment guidelines will provide safer and better medical care,
patients should be cautious about embracing an initiative that may
use words on a page to limit health care services.
Written for the Heartland Institute's
Intellectual
Ammunition, May/June 2001.
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Citizens' Council on Health Care
1954 University Avenue West, Suite 8, St. Paul, MN 55104
Phone: 651.646.8935 / Fax: 651.646.0100, e-mail
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