Few issues are more central to the ongoing debate about health care in the United States than concerns about cost and quality of medical care. The recent development and implementation of medical management guidelines that include recommendations for diagnostic and therapeutic interventions, hospital length of stay, intensity of service, home care, and access to specialists have often focused this debate on the potential trade-off between cost reductions and quality of care. The American Academy of Pediatrics recognizes that cost and quality are integrally related and that it is possible to reduce costs while maintaining and improving quality. The purpose of this statement is to help pediatricians and other health care providers interpret, evaluate, and improve medical management guidelines.
Because of the rapid rise in health care costs, many employers, state Medicaid programs, and other purchasers of health care have turned to managed care organizations (MCOs) to control costs and provide care. Increasingly, MCOs are using medical management guidelines to make coverage determinations about medical interventions, length of hospital stay, intensity of service, home care, and access to specialists. Many of these guidelines are not well-supported by medical evidence and have not been developed with a pediatric focus. They may be derived from actuarial or utilization data and based on best-case scenarios for resource use and length of stay. Often, the methodology and data behind guideline recommendations are proprietary and not available to clinicians and the public. Concerns exist not only about the development of these guidelines but also about their application. The implementation of medical management guidelines that do not address the unique health care needs of children may adversely impact the health and well-being of pediatric patients, especially children with special health care needs. Too often, these guidelines are interpreted and applied by medical staff with insufficient pediatric experience and knowledge of available local pediatric resources to ensure that needed care is provided.
Members of the American Academy of Pediatrics (AAP) may be asked to play a role in the review, improvement, and potential endorsement of medical management guidelines. The purpose of this policy statement is to describe the necessary attributes of medical management guidelines and important principles of medical management guidelines to provide guidance to AAP members in these activities. The principles are intended to provide a comprehensive set of tenets by which guideline development and implementation process should be assessed. Attributes are defined as the inherent characteristics of the process that should be used to develop the guidelines and the clinical content of the guidelines. These attributes have been adapted from the American Medical Association/Specialty Society Practice Parameters Partnership.1
PRINCIPLES AND ATTRIBUTES FOR THE DEVELOPMENT AND IMPLEMENTATION OF PEDIATRIC MEDICAL MANAGEMENT GUIDELINES
The pediatric medical management guideline attributes are inherent characteristics of the process that should be used to evaluate the development process and clinical content of the guidelines.
Pediatricians (primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists), other primary care physicians, the family, and the patient must retain the responsibility for patient management decisions.
Pediatric medical management guidelines should be developed to maintain or improve quality of care and secondarily provide for more efficient use of resources.
Pediatric medical management guidelines should be based on sound clinical evidence, when available, and on professional consensus.
Guideline methodology and the supporting clinical evidence used to develop medical management guidelines should be apparent and readily available to the pediatrician on request.
Pediatricians should participate in the development of pediatric medical management guidelines and criteria for their application.
Pediatric medical management guidelines must be child-centered and age-appropriate.
Pediatric medical management guidelines, when used by MCOs or health care systems, must allow for practice variation and must recognize individual patient differences.
Patients and physicians must be able to appeal decisions that are based on the application of pediatric medical management guidelines. The appeals process must be clear and readily available to parents, patients, and clinicians. Timely access to appeals personnel must be available and clearly delineated.
The competence of nonphysician reviewers and the availability of pediatric peer review and pediatric subspecialty review must be delineated and assured.
Appendix A provides a development and implementation checklist for the evaluation of pediatric medical management guidelines that reflects the principles listed above. It can be used as a tool to assess the implementation of medical management guidelines by a health plan or MCO.
Pediatric medical management guidelines are systematically developed statements to assist clinicians and patients in making decisions about appropriate health care for specific clinical circumstances and are based on current professional knowledge. The methodology used to develop the pediatric medical management guidelines is clearly stated.
Pediatric medical management guidelines should assist the clinician and the patient in making appropriate health care choices for specific clinical circumstances. Pediatric medical management guidelines should provide data (clinical, scientific, and economic) needed to make medical decisions. The form and format are adaptable to various practice environments, are age-appropriate, and recognize that different practice locations have different local resources. The guidelines recognize the importance of the patient’s social environment.
Pediatric medical management guidelines are based on current professional knowledge and are reviewed and revised at regular intervals.
Pediatric medical management guidelines should be developed with input from clinicians with appropriate and relevant expertise and experience and with input from professional organizations, consumers, and advocacy groups affected by the guidelines. Clinicians from a variety of geographic areas and types of practices (private, group, hospital based, military, etc) should be involved.
Pediatric medical management guidelines are widely disseminated. There is a plan for wide distribution of the guidelines to practicing physicians, which should include sources where the guidelines are available, costs for physician acquisition of the guidelines, and mechanisms for the distribution of the guidelines.
Companies and organizations developing medical management guidelines are accountable for educating purchasers and users of their guidelines in appropriate application of the guidelines. They should take an active role in educating users and purchasers of their guidelines about the appropriate implementation of the guidelines and seek feedback from customers and consumers about the applicability, safety, and effectiveness of the guidelines.
THE ROLE OF THE AAP IN MEDICAL MANAGEMENT GUIDELINES
There is an increasing demand for medical management guidelines in the current managed care environment.2 These guidelines have affected and will continue to affect children’s health care. The responsibility of the AAP in the development and dissemination of medical management guidelines that affect the care of children is to provide its members with the knowledge necessary to evaluate and/or improve these guidelines. The role of the AAP in the evaluation and improvement of medical management guidelines will include:
Working with its members to ensure that these guidelines focus on improvement of the health and well-being of infants, children, adolescents, and young adults;
Providing the knowledge needed to allow members to critique the clinical validity and soundness of the methodology used to develop the guidelines;
Educating AAP members in the valid application and implementation of guidelines;
Sharing concerns and recommendations about medical management guidelines reviewed by the AAP with members;
Promoting widespread dissemination of high-quality pediatric medical management guidelines; and
Helping to train pediatricians in the process of development, review, implementation, and outcomes evaluation of medical management guidelines.
THE ROLE OF PEDIATRICIANS
Pediatricians should be fully informed about medical management guidelines, including how they are developed and the science used to support them. The AAP encourages pediatricians to evaluate the clinical validity and implementation of medical management guidelines (see Appendices A and B).
Pediatricians should know their legal rights with regard to medical management guidelines and the MCO appeal process. They are also encouraged to become actively involved in helping health plans or MCOs develop, implement, evaluate, and revise guidelines. Pediatricians are encouraged to evaluate the impact of the medical management guidelines on pediatric health outcomes.
THE ROLE OF MCOs
The AAP and its members should work closely with MCOs to develop medical management guidelines based on the attributes presented in this statement and to ensure the effective implementation of medical management guidelines according to the principles outlined in this statement. The current implementation of some medical management guidelines raises serious concerns about the following:
How to address the ethnic and cultural diversity of children in the United States;
How to train MCO clinicians in the proper use of medical management guidelines;
How to effectively disseminate guidelines to clinicians;
How to ensure flexibility or adaptability of guidelines to local practice conditions and resource availability;
How to ensure that patient welfare is the primary concern and reducing costs is considered only after ensuring patient welfare; and
How to work with MCOs to assess the impact of the guidelines on pediatric health outcomes and using this information to revise and update their recommendations.
To help address these concerns, MCOs should:
Involve pediatricians with the appropriate knowledge and experience in the development, review, and revision of the guidelines;
Involve pediatricians in the literature and evidence reviews;
Implement a system to achieve group consensus;
Clearly delineate the methodology used to develop the guidelines;
Clearly delineate the medical evidence used to develop the guidelines;
Define the competence level of nonphysician reviewers and clearly delineate the availability of pediatric peer review or subspecialty peer review;
Widely disseminate the guidelines to appropriate parties;
Design a process for the effective and appropriate use of the guidelines;
Clearly delineate an appeals process for patients, families, physicians, and institutions using the guidelines; and
Educate guideline users (patients, families, advocates, physicians, MCOs, and health care systems and facilities) and those affected by the guidelines (patients and clinicians) as to their use.
Medical management guidelines are a reality in the current health care environment. Therefore, the AAP and pediatricians should continue to take an active role in their development and critique. To ensure that medical management guidelines are implemented in a way that will not compromise the quality of care delivered to children of all ages, pediatricians should continue to review medical management guidelines using principles and attributes outlined in this policy statement and become knowledgeable about medical management guidelines, including what they are; how, by whom, and why they are developed; and the pediatrician’s roles in helping to develop, review, and implement guidelines and evaluate their impact on pediatric health outcomes.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Task Force On Medical Management Guidelines, 1999–2000
David A. Bergman, MD, Coordinator
Robert M. Arensman, MD
Richard D. Baltz, MD
Edward O. Cox, MD
David Ray Hardy, MD
E. Susan Hodgson, MD
Alan Kohrt, MD
Robert Sebring, PhD
- American Academy of Pediatrics