Managed Care

Great Taste or Less Filling? Guidelines Have Their Uses

John Marcille

The rich ferment of ideas, opinions and causes in managed care today — a source of consternation to some, of stimulation to others — is evident throughout this issue.

Senior editor Michael D. Dalzell, in our cover story, grapples with the issue of treatment protocols or guidelines. Gradually, physicians are coming to terms with guidelines, though of course they see them as valuable when they improve the process of care and as harmful when they prescribe procedures that, on average, might be appropriate for the designated population but inappropriate for an individual. Doctors and physician organizations — the AMA in particular — are suspicious of guidelines promulgated by organizations whose goals they perceive to be minimization of cost, rather than maximization of health. And if they don't "buy in" to the concept, health plans will fall short of their cost-effectiveness goals. (Next month: an article on how disease management programs are getting physician buy-in).

For a discussion of a particular guideline, see the column by senior editor Frank Diamond on the Centers for Disease Control's new guidance on sexually transmitted disease.

Another area of ferment is Medicaid managed care, seen a few years ago as a golden opportunity for HMOs to corner one of the few remaining chunks of the market still in fee-for-service hands. Ferment may be too weak a word for what's going on in the sector.

You want more controversy? Doctors often complain that powerful HMOs practically force them to sign contracts that give the plan too much power. The AMA has come up with a model contract for docs to present to plans. Lawyer Mike Folio analyzes it from both the doctors' and the plans' point of view.

Finally, ferment at the top: Senior contributing editor Pat Mullen reports on reform bills in Congress.

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