American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Statement on the Use of Proprietary Guidelines by Managed Care Organizations

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 Outdated decisions have the potential of adversely effecting patient care and obstructing medical advances.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.

Reprinted from Bulletin of the American College of Surgeons
Vol.83, No. 03, March 1998