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Health Maintenance Organizations ("HMO’s) typically use third party expert based standards to help determine appropriateness of care. The purpose of this includes: measuring and comparing providers recommendations for specific situations; physician profiling by comparing physician’s performance against peer group, utilization review and utilization management.

A tool commonly used by many HMO’s to help determine appropriate standards of care are the Health Care Management Guidelines ("HMG’s") created by Milliman & Robertson, Inc. ("M&R"). These Guidelines are intended to establish a course of treatment for a specific individual only in conjunction with the application of professional medical judgment which considers the circumstances involved. Proper application of these HMG’s for evaluation of the utilization levels of a provider or insurer of medical benefits requires consideration of all additional factors which might affect desired or actual utilization and treatment patterns.

For example, M&R’s Ambulatory Care Guidelines gives protocols that can be considered a syllabus for training in certain specialties for primary care physicians such as in the following areas: allergy, cardiology, dermatology, endocrinology, gastroenterology, general surgery, gynecology, hematology, neurology, ophthalmology, orthopedics, otolaryngology, psychiatry, pulmonary, rheumatology, urology/nephrology, and vascular surgery.

In cardiology, the M&R "Primary Care Management Guidelines" states:

"CARDIOLOGY

Primary care physician should:

1. Evaluate chest pain, murmurs and palpitations, and recognize significant heart disease by history, examination, electrocardiogram, echocardiogram and stress testing including stress electrocardiogram, echocardiogram or nuclear scan.

2. Evaluate and treat coronary risk factors including smoking, hyperlipidemia, diabetes and hypertension.

3. Treat hypertension, congestive heart failure, stable angina and non life-threatening arrhythmias.

4. Treat angina medically with nitrates, beta-blockers, calcium channel blockers and other medication as appropriate. Evaluate non-invasively those who may need catheterization.

5. Determine whether syncope is cardiac, i.e. valvular or arrhythmic, by history, examination, electrocardiogram, ambulatory monitoring and echocardiogram.

6. Diagnose and hospitalize patients with acute myocardial infarctions. Manage their inpatient course, discharge and follow-up care. Obtain consultation for candidates for thrombolysis, stress testing, catheterization, angioplasty, or surgery and for patients with life-threatening arrhythmias, or hemodynamic complications requiring invasive monitoring.

7. Consult for:

a) unstable angina post-MI,

b) post-subendocardial MI with or without angina,

c) angina despite maximal medical therapy with maximally tolerated doses of nitrates, beta-blockers and calcium channel blockers,

d) intractable heart failure and arrhythmias,

e) pericardial effusion,

f) congenital or valvular disease. Consult only for diagnosis, non-invasive studies and to define appropriate follow-up."

M&R also gives an "Allocation of Physician Services and Per Capita Monthly Services Cost (PCMSC)"^E. This type of calculation helps payors such as insurance companies determine an appropriate amount to pay for health care services. For example:

This chart shows that out of a typical client population of 1000 people, it is expected that 103 will have cardiovascular treatments, 54.8 of which will be due to primary services and 48.2 non-primary services. The per capita monthly service cost can be calculated by taking the annual utilization per 1000 rate divide by twelve months and multiply by the average charge per service cost and then divide by the number of patients. The calculation would be as follows:

(48.2 ÷ 12) x 203.66

1000

The utilization costs are divided into the whole population and calculated on a monthly basis. Accordingly, in this example, the per capita monthly cost for cardiovascular services rendered as non-primary services is $0.82.

There are various ways in which Managed Care Organizations ("MCO’s") encourage providers to follow health care practice guidelines. MCO’s might incorporate the guidelines into the written agreement with providers. Providers might want to make sure they understand what their options are if they disagree with the guidelines or if the guidelines are changed. Utilization Review ("UR") is a tool commonly used by MCO’s to review medical services rendered to determine if they are appropriate and necessary. MCO’s may use utilization review before, during or after services are rendered. Commonly, utilization review departments utilize three forms of review. The review of services before they are rendered is called prospective review. An example of this is requiring physicians to notify the MCO twenty-four hours prior to admitting a patient into a hospital for elective procedures. The review of services at the same time as they are being rendered is called concurrent review. An example of this is requiring providers to notify a MCO to receive authorization for extended length of stay for situations in which providers request a longer admittance of a patient in the hospital than originally authorized by the MCO’s original length of stay authorization. The review of services after they have been rendered is called retrospective review. In retrospective review situations, MCO’s typically audit patient’s charts and medical records to confirm services were rendered and were necessary and appropriate.

Utilization Management may include quality assurance in which MCO’s implement various techniques to ensure and maintain quality of care for their enrollees. Quality Assurance might include peer review of services by providers, looking at grievances filed against providers, credentialing of providers such as confirming providers are appropriately licensed. For example, if the provider is a physician, making sure he/she is board eligible or board certified and if the provider is a hospital, making sure the hospital is appropriately accredited such as by the Joint Commission of Health Care Organizations "("JCAHO").

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