Milliman & Robertson guidelines under fire again
Lawsuit claims guidelines have no medical basis
A longstanding subject of controversy, Milliman & Robertson’s (M&R) health care management guidelines are once again being called into question as two Texas pediatricians file suit against the firm, contending that the guidelines "have no basis in sound medical practice."
The suit, filed by Thomas Cleary, MD, head of pediatric infectious disease at the University of Texas-Houston Medical School, and William Riley, MD, vice president of medical education at Driscoll Children’s Hospital in Corpus Christi, alleges that M&R offered to give the pediatrics department at University of Texas-Houston $100,000 in exchange for an endorsement of its pediatric guidelines.
Phone calls to Cleary’s office were referred to his attorney, who did not return them. M&R, for their part, issued a brief statement: "Milliman & Robertson’s health care management guidelines are widely used in the industry. The guidelines are painstakingly researched and checked. Milliman & Robertson has full confidence in its guidelines and stands behind them 100%."
The two physicians may be the first to directly question the guidelines’ credibility in court. Certainly, they are not the first to maintain that the guidelines are confusing or overly restrictive.
"We don’t have a pediatrics department, so I can’t speak to how realistic [those] guidelines are," says Karen Lighthall, director of case management at South Fulton Medical Center in Atlanta. "What I am finding, however, is that the insurance companies, themselves, don’t know how to use the guidelines — and they will even admit as much."
Lighthall cites a recent case involving a patient who was admitted with congestive heart failure. Among other symptoms, the patient was experiencing nausea and vomiting. "Rather than using the cardiac guidelines, the insurance company instead chose to use M&R’s guidelines for nausea and vomiting, and they denied the case," she says.
Much of the problem stems from M&R’s stringent guidelines, she says. "What makes them especially difficult to use is the fact that they’re set up so [differently]. They don’t include as many medical or surgical situations as, for example, Interqual does, so it’s not like we have the option of being able to go back and look them up. As a result, we end up making probably two to three times as many calls back to an insurance company that uses M&R as we do [one that uses Interqual], and that’s just a waste of manpower." Consequently, more and more companies are making the decision to use Interqual exclusively, according to Lighthall.
What about medically complex cases?
At Rush Presbyterian St. Luke’s Medical Center in Chicago, the M&R guidelines are used only as an educational tool. "We show them to the in-house staff, but we don’t use them specifically," says Debra Levin, RN, CCM, clinical resource coordinator, registered nurse, and certified case manager. "Since we are a teaching school, we have a lot of comorbidities, and M&R makes it clear that their guidelines are designed for uncomplicated patients,"
Nonetheless, having access to the guidelines "lets me know what the other payers are using, and that is very helpful," she says. Also helpful from a teaching standpoint, adds Levin, is that unlike Interqual, which the hospital uses and which is set up to focus on specific parts of the body system, "M&R’s guidelines force you to look at the entire body system."
She says it’s not so much that the guidelines are unclear as that they are restrictive in their coverage. "The literature, I think, is very clear. In the last analysis, it is the responsibility of the physicians to use their judgement. However, having been on pathways with attending physicians, there does appear to be a general feeling that the system really doesn’t address the medically complex cases. If you have a patient who has had a whipple and has multiple drains, IV antibiotics and hyperalimentation, you know that Interqual will pick that up, and they will meet the criteria."
Hinsdale (IL) Hospital has used Interqual’s severity of illness/intensity of service criteria for at least 15 years. "We’ve never felt a need to switch," says Diane Oostendorp, RN, utilization nurse and quality management coordinator.
Oostendorp agrees that the guidelines are "very specific. They certainly appear to focus much more on outpatient management. It’s been our experience that, if someone is looking at M&R, their criteria regarding a patient being in an acute care setting is going to be much more strict," she says.
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