A study released in September 2000 by the Solucient Leadership Institute found that at least one segment of a set of guidelines commonly used by payers to determine healthcare coverage differs significantly from actual hospital practice.
A product of Solucient's 100 Top Hospitals Clinical Research Program, the study compared the pediatric length of stay guidelines developed by the Seattle-based actuarial firm Milliman & Robertson with empirical results from inpatient data. The researchers quantified 45 pediatric conditions using 1998 data from Solucient's projected inpatient database, which contains more than 3.5 million pediatric discharges from short-term, general, nonfederal U.S. hospitals.
As stated in the introduction to the report, Solucient's primary goal was "to determine the proportion of cases to which Milliman & Robertson guidelines can be applied." A secondary objective was to compare actual pediatric lengths of stay from a national sample with M&R recommendations. The study was particularly timely considering that several recent lawsuits have accused health plans of using the M&R guidelines to reduce the amount of care provided in order to save on costs.
Solucient claims that Milliman & Robertson guidelines do not differentiate between complicated and uncomplicated cases. While researchers say that 74% of the patients they studied were classified as uncomplicated, they questioned the applicability of the guidelines to those conditions where the majority of cases are complicated.
What Solucient found was that 67% of all pediatric cases examined had lengths of stay in excess of the relevant M&R goal lengths of stay. The percent by which individual types of uncomplicated cases exceeded the M&R guidelines varied widely by condition, ranging from 9% in epiglottitis to 88% in bacterial meningitis.
Solucient recommends that insurers and managed-care organizations develop condition-specific criteria that differentiate complicated from uncomplicated cases. The pediatric report concludes by saying further study on the effect of shortening length of stay on cases of complications or readmissions would benefit the discussion of quality of care issues.
"This kind of public debate does frequently result in policy changes," says Dave Foster, assistant vice president of research at Solucient.
"It makes it feel like we're doing something worthwhile."