Managed care companies are forced to back down
In a first-of-its-kind action, the Washington, DC-based American Association of Health Plans (AAHP), the nation’s trade group for the managed care industry, in November officially opposed insurance guidelines that require outpatient mastectomies. This was the first time the AAHP board has taken a position on how clinical guidelines for a particular medical condition should be applied by health plans. But will it be the last?
According to the AAHP, all 1,000 members of the association which includes nearly all of the nation’s HMOs pledged to abide by the recommendation against requiring mastectomies to be performed as outpatient procedures.
"The decision should be made by the physician in consultation with the patient," says AAHP’s spokesman Don White in an interview with QI/TQM. "What we’re saying is that an HMO should not require outpatient mastectomies."
White acknowledged that the association’s unusual step was prompted by intense press attention and the threat of federal legislation prohibiting the procedure on an outpatient basis. On the same day as AAHP’s announcement, Rep. Rosa DeLauro (D-CT) said she would introduce legislation this month to require a 48-hour hospital stay for any mastectomy patient who wants one.
Florida treasurer and insurance commissioner Bill Nelson has proposed similar legislation in Florida. "The time a woman remains in the hospital following traumatic breast surgery should be determined by medical experts not by insurance conglomerates," he says.
The brouhaha over mastectomies stems from health plans’ use of guidelines crafted by Milliman & Robertson, a Seattle-based, for-profit actuarial firm that markets guidelines to thousands of insurers and health plans.
"Milliman & Robertson has never said in our guidelines that these patients should not be admitted. We simply defined the most optimal and efficient care we have seen," explains Richard Liliedahl, MD, health care management consultant with Milliman & Robertson. "This guideline is developed to show that with a patient who has optimal recovery after the procedure and has the adequate infrastructure including home nursing, access to a physician’s office, adequate post-op counseling, and good teaching about drains could conceivably go home from the hospital [within 24 hours]. That does not mean all patients can go home from the hospital [in this time frame]."
The guideline’s authoring physicians based their recommendation on their own clinical experience and a minimal amount of evidence in the literature, Liliedahl says. "Our guidelines are written by physicians in active private and academic practice, and they describe the way they are currently practicing medicine," he says. "[Mastectomies] were actually being provided in many parts of the country in this way, and we simply defined what was being done. . . . It’s somewhat a false premise that because you’re in the hospital you’ll get better care."
Liliedahl says Milliman & Robertson is in agreement with the AAHP’s decision. The company has two sets of guidelines: inpatient and outpatient. The outpatient guidelines include patient education and a home care assessment.
According to data from HCIA, a Baltimore research firm, about 7.6% of mastectomies performed on Medicare patients in 1995 were outpatient procedures, up from 1.6% in 1991.
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