Clinical Care Guidelines

Clinical care guidelines are being promulgated throughout the entire spectrum of medicine, from hospitals to physicians to therapists to O&P professionals. A multinational publishing company purchased the major purveyor of clinical care guidelines, MCG (formerly Milliman Care Guidelines), in November 2012. But, MCG is working both sides of the street, and therein lies the rub. Its website says that it has numerous experts who gather all manner of data and analyze it to provide "eight of the ten major insurance companies" (amongst others) with their guidelines. Using those guidelines, insurers will be able to delay and/or deny claims. On another page of its website, where it is pitching to hospitals, MCG claims that using these guidelines will enable hospitals to better defend against audits. During a recent search of Aetna's website, I came across its own clinical care guidelines for spinal orthoses, lower-limb orthoses, and lower-limb prostheses. Anthem BlueCross BlueShield appears to have made customizations to the clinical care guidelines that it purchased from MCG, perhaps indicating its own misgivings of those guidelines. This leads me to ask: Who is keeping account of the data being gathered and subsequently distributed? Who is the arbiter in a dispute about validity? Does the healthcare universe just accept MCG's word, or is some other party actually ensuring that the analysis of the data is correct? In addition, if the company selling the guidelines to hospitals can gather information that will help hospitals to audit take-backs, are there not conflicting data available with which to contest the validity of these guidelines? When private sector insurance companies set clinical care guidelines, they are essentially telling healthcare practitioners how to do their jobs or, alternatively, forfeit fees, much like the Centers for Medicare & Medicaid Services (CMS) is doing. This is done under the guise of best practices for patient care, but, invariably, their "best practices" are also the least expensive for them and, frequently, the most expensive for patients and providers. The clinical care guidelines that I have come across so far are more restrictive than permissive. When no one is challenging the authors/sellers or the insurance companies that are using the guidelines, they will continue to spread. These guidelines are derived from statistical analyses of peer-reviewed papers chosen for their relevance. I have a problem with this concept in that we are dealing with real people who have real problems and who need our help to solve those problems. There are few qualified and quantified independent analyses of the work that O&P care providers do every day. What little that might exist was done by researchers on the periphery of our profession. Few of the articles that are published about O&P procedures and outcomes enjoy widespread peer review to validate or debunk the author's efforts. From my perspective, we need to acquaint ourselves with these restrictions on the professional interactions that we expect to have with our patients and be prepared to contest those restrictions when appropriate. Alternatively, you can anticipate having customers line up at the front window and tell you which item that the insurance company wants them to have (will pay for). R. James Fenton, CPO/L, is president of Fenton Orthotics & Prosthetics, Miami, and a past president of the Florida Association of Orthotists and Prosthetists (FAOP), and of the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC).

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Certified Prosthetist / Prosthetist-Orthotist (CP/CPO) Gates Prosthetics + Mobility Clinic — Mountain Home, AR

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Clinical Care Guidelines

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Certified Prosthetist / Prosthetist-Orthotist (CP/CPO) Gates Prosthetics + Mobility Clinic — Mountain Home, AR

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