Commercial Insured Care Guideline Perspectives

J Clin Pathways. 2024;10(1):26-27.

Many organizations in health care delivery develop, imple­ment, and train staff on care guidelines set by their pro­viders, who deliver direct patient care. However, organizations that fund or manage a commercial plan may seek out consultant groups to further develop and support their care guidelines, re­sulting in different end goals that affect patient care. This col­umn uses two examples of such groups and their guidelines and offers perspectives on patient care impacts.

MCG (Milliman Care Guidelines, MCG Health) and InterQual (Change Healthcare, Optum) are two market leaders among managed care administrative or consultative groups that spe­cialize in managing commercial insured populations. Both vendors cover known and emerging covered conditions that would typically be included in a commercial insurance cover­age policy.

InterQual, part of Change Healthcare at Optum, strives to support the safest, most efficient care decisions by using objec­tive, specific criteria for both medical and behavioral health across all levels of care, as well as ambulatory care planning. InterQual criteria are produced using a rigorous development process based on the principles of evidence-based medicine. Historically their strength was centered in institutional care that now has expanded into the community setting. They are uti­lized by most hospitals and many payers (plans, managed care).

InterQual uses evidence-based criteria to validate the clini­cal integrity of their research for their practice guidelines. Us­ing panels of practicing clinical peers in all major disciplines of practice, they have evolved over decades to enhance decision support. For example, they’ve added cloud-based solutions and artificial intelligence assistance based on the original idea of quality care by validated evidence and peer review.^1,2 InterQual markets to providers and payers.

MCG Health, part of the Hearst Health network, is an industry leader in technology-enabled, evidence-based guid­ance. In early 2023, MCG released its 27th edition of the MCG Care Guidelines. The 2023 updates include expanded content for specialty medications, guidelines, and benchmarking data specific to COVID-19 diagnoses.

MCG Care Guidelines are recognized as a common clinical language between payers and providers and are now used by many US health plans and hospitals. Historically, their strength has been at the provider interface and community-based treat­ment. For the 27th edition, MCG reported a total of 47 635 unique citations in the evidence base, with 5928 of these citations being new to that edition.³ MCG markets to care providers and payers.

Both examples deliver easy-to-use software solutions and enable health care organizations (provider or payer) to docu­ment care decisions; efficiently develop more comprehensive, consistent, and coordinated care plans or coverage policies; identify gaps in care toward improved quality of population health; and enhance operational efficiency (provider or payer).

For the key stakeholders engaged in health care services or insurance, the use of care guidelines offers various advantages or benefits. The following gives some insight on how such care guidelines can be beneficial by stakeholder.

Payers can gain transparency into how care is provided to their members and which medical provider practices deliver the highest (and safest) quality care for a member of the plan. Pay­ers may be an administrative services organization (ASO) for the plan risk of self-insured groups, or they can also be the in­surer of the plan (fully insured) along with its own ASO.

Providers (hospitals, health systems, practice groups, or solo practitioners) can use vendor-supplied guidelines to align clinical decisions with an evidence-based common language used by most payers and hospitals to reduce denial rates. The use of such guidelines can also support risk-based contracts and improvements in delivering patient care for members of a plan.

States can improve their plan member health outcomes, drive administrative efficiencies, and deliver cost savings opportuni­ties with these solutions. These vendor services can be applied to a state self-insured benefit plan (active or retirees) or govern­ment-administered programs (entitlements like Medicaid).

Patients or plan members can be equipped with evidence-based information on clinical care options to have a more meaningful conversation with their direct care team. Such information assists in personalized care programs regarding what is right for an individual patient in consultation with their provider.

In addition, provider or payer users can improve their clinical and administrative workflows by accessing vendor care guidelines directly from the electronic health record or a man­agement workflow via integrations of information technology platforms. Such efficiencies can speed up approvals along with assessing performance in delivering optimal patient care.

From an employer perspective, efficient and effective plan administration—from plan design through patient care ser­vice providers delivering optimal outcomes—is an impor­tant goal. For self-insured plans, compliance with a fiduciary responsibility requirement under federal law is necessary to ensure their plan is beneficial to the member. That benefit compliance includes clinical and financial performance param­eters. As a result, care guidelines that can assist the plan sponsor in achieving that benefit are important. How the care guide­lines are used in various assessment efforts, however, can be controversial depending on the stakeholder.

Patients may feel restricted in their ability to obtain what they believe to be the optimal therapy. This was seen in the ear­ly days of HIV care when evidence-based data was limited and care costs were under scrutiny. Such a scenario was seen again during the pandemic and now with treatments for rare diseases.

Providers can also feel restricted in what they can prescribe or administer as a patient therapy. Timing for approvals has continued to be as important as the selection of a therapy itself. Delays in starting treatment can be problematic in achieving optimal patient outcomes. Not achieving optimal outcomes can result in negative consequences for the provider and their organizational entity due to shared risk or value-based con­tracts in use today.

ASOs rely on care guidelines to assist in determin­ing plan coverage while staying current with the latest evi­dence and therapies, which can be overwhelming with the increasingly faster rate of approvals by the US Food and Drug Administration. Determining appropriate use within existing plan benefits (access) based on evidence remains a standard across all types of administrative organizations. Sitting between care providers and plan members places ASOs (third-party administrators, pharmaceutical benefit manag­ers) in an unenviable position given their role is to act on behalf of the plan sponsor—especially when it comes to self-insured plans.

Overall, the goal of ensuring timely and appropriate care to the right patient at the right time remains a standard ap­plied across all stakeholders involved in health care. De­pending on the stakeholder perspective and responsibili­ties within the care ecosystem, any single stakeholder could be misaligned to the patient care goal; this misalignment could be caused by legal or regulatory issues, contractual requirements or limitations, and dependency on economic considerations, particularly in commercial insured plans.

The promise and applied use of high-quality care guidelines can be beneficial to all stakeholders, but guideline implemen­tation remains an area of conflict. As a result, misalignment continues that contributes to workflow inefficiencies and in­creased costs of care and plan premium fees—all of which lim­its the effectiveness of delivering optimal patient care through commercial insured plans for their members.

Reader questions, feedback, and suggestions are always wel­come and can be directed to JCPEditors@hmpglobal.com.

Affiliation: Principal, Institute for Integrated Healthcare, Board Chair of the Employer-Provider Interface Council, Greenville, SC^.

Disclosure: F.R.V. reported serving as an advisory board member for the Journal of Clinical Pathways.