[ST-26] Statement on the Use of Proprietary Guidelines by
Managed Care Organizations
[by the American College of Surgeons]
The Board of Governors of the American College of Surgeons
is concerned about the use of "guidelines" by managed
care or other health care organizations in determining hospitalized
patients' lengths of stay and the appropriateness of other medical
services for patient care. The concept of guidelines and their
patterns of usage have been thoroughly evaluated and discussed
by the Board of Governors Committees on Ambulatory Surgical Care
and Surgical Practice in Hospitals. As a result, this position
paper is presented to assist practicing physicians and surgeons
in understanding practice guidelines and in managing patient
care in a responsible manner. It is also intended to educate
the agencies that formulate and utilize guidelines that affect
patient care. It is necessary that third-party payers understand
the proper course a physician or surgeon must take in order to
adhere to professional ethics and to the principles of the American
College of Surgeons.
General concepts about guidelines
Guidelines are an expected part of medical practice in today's
society. However, guidelines cannot be blindly accepted or considered
inviolate. If that were to be the case, they would cease to be
guidelines and would become "standards" or even "mandates."
Guidelines and their application must be directed primarily toward
the well-being of the patient. The term "cost-effectiveness"
should refer to efficiency with regard to time, safety, and utilization
of resources for patient care, and should NOT be used as a means
to maximize profit or for any other purpose that does not have
the patient as the primary concern.
Guidelines must be based on appropriate data and research.
They should reflect outcomes, and should be constantly monitored,
evaluated, and updated. Outdated decisions have the potential
of adversely effecting patient care and obstructing medical advances.
The purpose of guidelines is exactly that of being "guides."
They therefore must be formulated so that they serve an educational
purpose for the physician and other health care providers in
the interest of high-quality patient care. Punitive or disciplinary
emphasis is counterproductive.
Guidelines can in no way encompass every diagnosis or treatment
of all disease states, nor can they include the variations that
occur in the complexity of the human response to disease processes,
which includes co-morbid conditions. Where clear discrepancies
of opinion exist, the licensed physician as the caretaker of
the patient must be responsible for guiding the individual patient's
course leading to diagnosis and treatment.
Guidelines should be formulated such that they cannot automatically
be used as a basis for disciplinary action or litigation if the
physician or surgeon determines that strict adherence to their
provisions is not in the patient's best interest. The guidelines
should be flexible to permit variations for patient condition
and circumstances and should provide options for these variations,
including severity of illness and co-morbid conditions. The guidelines
should be formulated to consider the totality of an episode of
care. For example, discharge criteria must take into account
the supportive resources that are available to the patient, such
as convalescent care, home care, hospice care, family availability,
and so on.
Ideally, guidelines should be formulated "locally"
so that consideration can be given to physicians' and other health
care providers' knowledge about standards of care, as well as
to the availability of local resources and community needs. Since
the formulation of guidelines is an expensive process in terms
of time and expertise, guidelines that have been developed regionally
or nationally can be utilized after careful modification or adaptation
to the local hospital, community, or medical society level. Guidelines
that serve to restrict care for reasons other than the patient's
well-being are not acceptable.
Physicians' role
Physicians as the primary health care providers should be
involved in and responsible for the approval and implementation,
review, and modification of all guidelines that affect medical
care. It is incumbent on medical leadership and the individual
practitioner to be diligent in the responsible evaluation and
subsequent implementation of guidelines. Undesirable or unproved
guidelines or portions thereof must be rejected and the objections
appropriately documented.
Guidelines that are formulated and maintained through this
rigorous process should be followed in good faith. Exceptional
circumstances and variations in patient condition or circumstances
should be anticipated and documented. Patterns of exceptions
should lead to refinement of the guidelines.
Governmental role
Guidelines for specific disease processes developed by governmental
agencies or mandated by legislation are inappropriate. These
guidelines are subject to the same arbitrary decisions that interfere
with the physician's primary responsibility for patient care.
They often are unable to assess individual patient care needs,
and thus cannot set appropriate standards for diagnostic and
therapeutic procedures and lengths of stay.
Appropriate changes in legislatively mandated guidelines are
difficult to achieve. Once promulgated, regulated care cannot
easily be updated and made current in a timely fashion.
An appropriate role for government would be to: (1) reaffirm
the physician's responsibility for patient care; (2) ensure patient
access to health care; (3) provide for patient choice and individual
responsibility; and (4) protect against abuses of the health
care system by providers, insurers, and litigators.
The American College of Surgeons believes in the right of
the patient to choose a physician and the right of the physician
to freely direct the care of the patient. Guidelines can be used
to assist the physician, surgeon, and other health care providers
toward achieving this goal, but they should not impede the process
or deviate from this purpose. The American College of Surgeons
is committed to protecting the patient's well-being and the physician's
role in providing efficient, appropriate, and comprehensive health
care.
Statements
menu
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Reprinted from Bulletin of the American College
of Surgeons
Vol.83, No. 03, March 1998
