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.