Mandates on clinical practice could threaten patient care
Mandates on clinical practice could threaten patient care
Case managers worry new laws will tie the hands of caregivers
Federal and state legislation designed to curb perceived abuses among managed care plans could drastically affect the way you provide health care and send the cost of care soaring, experts say.
Indeed, the Dallas-based National Center for Policy Analysis estimates that the more than 1,100 state mandates currently on the books already have driven premiums for small businesses up by 15% to 30%. Bills now under consideration would prohibit time limits on lengths of stay for patients with certain conditions, give patients direct access to medical specialists, and mandate that health plans pay for certain experimental treatments and emergency services. (For a breakdown of state initiatives, see chart on p. 59.)
"These are all efforts to legislate the clinical practice standards or manage the medical policies of health plans," says Susan Laudicina, director of research at the Washington, DC-based Blue Cross and Blue Shield Association. "I think [these mandates] present a lot of dangers, both with regard to safety and cost considerations."
Some case managers believe many of the new laws will hamper their clinical effectiveness, says John Borg, RN, MS, vice president of clinical services at Winchester (VA) Medical Center.
"Any time you take away from the caregiver the clinical decision of length of stay, or where certain procedures should be done or who should do a certain procedure, then you have greatly influenced in a negative sense the relationship between the caregivers and the hospital," says Borg. Such relationships are essential for appropriate clinical outcomes, he adds. Administrators at Winchester have found that good clinical outcomes, with decisions made at the place of service, lead to decreases in cost almost 98% of the time, in any case.
Some legislators are also ill at ease with the notion of legislating clinical practice, says Donald White, spokesman for the American Association of Health Plans in Washington, DC. "Historically, this has not been in the purview of state legislators or the federal government, for that matter," he says. He adds that while the United States has a long history of state-mandated health benefits, the current bills represent "a new phenomenon. What’s new is that legislatures are starting to look at clinical delivery system issues and the proper way to provide health care. And I think there is a very broad recognition that this is not the best approach to the problem."
Preliminary data indicate that hospital stays for maternity already have increased in the 28 states that have passed length-of-stay laws, White adds.
In February, the Baltimore-based Health Care Financing Administration (HCFA), responding to a comment made in President Clinton’s State of the Union address, decided that managed care plans contracting with Medicare could not require patients being treated for breast cancer to undergo outpatient surgery or to leave the hospital within 48 hours after a mastectomy. The ruling is significant because Medicare paid for more than 84,000 mastectomies last year, about a third of all mastectomies performed, according to HCFA.
HCFA issued its decision largely as a result of "heightened political sensitivity" about length-of-stay guidelines, says Jeffrey Kang, MD, HCFA’s chief medical officer in the office of managed care. Kang adds that although the agency had received anecdotal reports about hospitals discharging women prematurely, such reports were not well-substantiated.
Legislating the wrong outcomes
"We have, however, seen some of the patients’ guidelines that are out there. And if they were imposed systematically, from our viewpoint, it would be a problem," says Kang. "Plans will argue that these are just guidelines and that they expect doctors to make exceptions. But the reality is, we don’t know if that’s happening."
White is less concerned with HCFA’s decision regarding mastectomies than with similar legislation awaiting approval in state legislatures. "It’s a payer saying, This is the kind of health care we expect to get for our money,’" says White. "We’re used to that. In a lot of ways, it’s what quality assurance is all about. It’s very different from having a state legislature or the Congress pass legislation dictating how health care services should be provided."
For his part, Kang is also not convinced that legislators should be in the business of making medical decisions for health care providers. "Medicine is not static, while legislation tends to be static," says Kang. "So you get into these funny situations where you’re legislating things that actually ought not happen in the long run. Then, how do you change the legislation?"
Some health care consumer groups, however, such as the Washington, DC-based Families USA, applaud the legislation as a necessary first step in protecting patients from the potentially damaging cost-cutting initiatives of managed care plans. "For example, if you have a good utilization management system where it doesn’t take forever to get a referral, or a good grievance system that’s responsive to enrollee needs, then that’s going to make a big difference in improving the health care system," says Gerri Dallek, director of health policies at Families USA. "We need laws that basically say we’ve got to have some flexibility here; we can’t make decisions based on some cookbook somebody’s sold us."
Laudicina worries that such laws would have the opposite effect, tying the hands of caregivers and limiting their flexibility when dealing with individual patients. "You get a situation where legislators are saying, Well, you should stay in the hospital this long for that condition, or if you had this diagnosis, then we’re going to decide what treatment’s appropriate.’ If you arbitrarily say that everyone has to stay in the hospital for a certain length of time, you certainly do drive up costs. And more importantly, you interfere with medical judgement."
Although Families USA supports initiatives to prohibit time limits on length of stay for mastectomy, Dallek concedes that "body-part-by-body-part legislation doesn’t make a lot of sense. It does make sense to do some legislation that will address this issue in a much more all-encompassing way, so that you don’t end up with these problems in the first place, and that’s what we’re pushing."
Surgery is not like delivering a pizza’
Unfortunately, much of the length of stay legislation being considered is specific to the point of being "nonsensical," claims Laudicina. White offers the example of a bill under consideration in the Maryland legislature that would require a hospital stay for any patient who has a catheter. Laudicina points to a bill in Missouri that would mandate that health plans provide coverage for a minimum of 24 hours of inpatient care following any surgical procedure that takes more than three hours to complete.
"Think about this. If you don’t get it done by a certain arbitrary deadline, then this is automatically what has to happen. Well, surgery is not like delivering a pizza," says Laudicina. "Good care and medical judgement have nothing to do with whether or not a surgical procedure takes three or more hours to complete. Some of these measures and bills are getting bizarre."
Borg worries that new legislation will place case managers in the position of arbitrating legal issues rather than guiding patients through the continuum of care. "What happens is that you’re going to add steps and you’re going to get off course, because the case manager will be interpreting managed care contracts instead of helping the patient negotiate and access the right care at the right place at the right time and at the right cost," says Borg. "We’re not lawyers. We’re trying to do health care. And to be a contract interpreter is going to put extra burdens on and, many times, delay a patient’s access to care."
Laudicina also sees negative consequences for case managers from "direct access" legislation that would allow patients in managed care plans to self-refer to various specialists, including OB/GYNs, dermatologists, and oncologists. Such laws, she claims, would weaken the ability of case managers to coordinate patient care. (For a sample of direct access legislation, see chart above.) "Case managers would have no way of knowing if duplicate tests are taken, or if uncoordinated, unnecessary care has been given," says Laudicina. "We can’t manage the care if we don’t know who the patient sees, how often, and if the doctors are not speaking to each other."
Ultimately, hospitals and health plans achieve quality assurance through good practice patterns established by top physicians and health care teams that follow tested protocols, says Laudicina. "We’ve been able to reduce length of stay for good reasons," she adds. "Women don’t stay in the hospital seven or eight days for a normal delivery anymore. It’s not because there’s an evil plot; it’s because people are able to provide what’s needed in a shorter period of time."
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