I was taking a peer review call from a pediatrician. For those of you who don’t know, a request for “peer review” means a physician-to-physician conversation about something that was denied by an insurance company.
In this case, I had denied payment to a hospital (as a medical director for an insurer) for a readmission of a newborn child for phototherapy. The discharge bilirubin was outside the generally accepted guidelines for routine normal discharge (both in the criteria the insurer was using, as well as the American Academy of Pediatrics guidelines).
The pediatrician said she didn’t understand why I had denied the admission. I explained that the care was not denied, but it did not qualify for payment for a separate admission, as the criteria dictated the child should have stayed and been watched, and treated if needed, rather than discharged and readmitted the next day (thus prompting a request for payment for a new hospitalization) when the bilirubin got too high.
When I asked if there was a reason she did not follow the guidelines, she answered, “Well those criteria don’t apply to me.”
As clinicians, we all know what normal is, right? Many define it as a value above the 5th and below the 95th percentile of the range of answers you can get. And if you fall above or below those answers, then you are abnormal.
Yet, we routinely have patients who fall outside the normal range, and statisticians will tell us that happens about one in 20 times. So is that normal?
Guidelines are created for normal populations, and so most try to follow them. But inevitably, some patients fall outside the “guidelines.” How many of your patients fall “outside the guidelines?”
Much of the criticism of guidelines that I hear has to do with the fact that, yes, some patients do need special handling. Because that is true does not make the guidelines faulty, but it does fall on us to explain why.
Yes, that is extra work, but we should document why we’re not doing something the way it usually is done anyway. So, it’s not really any extra work if we document well.
If we are being measured on mammography, and the woman in question has not had one in the appropriate time frame because she had bilateral mastectomies, that is not the fault of the guidelines (unless it fails to account for such cases).
The complex interplay of a guideline, and the physician, and the patient’s preferences are what make medicine more art than science. It is why we will not be able to be replaced by computers with algorithms for every guideline, despite some peoples’ beliefs.
The ability to detect subtle emotion, the hesitancy, the resistance to suggestion, the too eager patient, the liar, are all reasons we will not soon be replaced. The ability to decide when and why a patient doesn’t fall within the guidelines are not machine replaceable (yet)!
So, please, tell me what about guidelines upset you? Are they poorly written? Do they not allow for appropriate exceptions? Do you resent someone else setting expectations of care? Do you think we can be replaced by machines?
