Controlling Costs and Improving Performance Are Leading Influences in Guideline Adoption

Health plans we reviewed had three strong motives for adopting guidelines: pressure to moderate expenditures, to show a high performance level across key quality indicators when compared with other plans, and to comply with accreditation and regulatory requirements. These plans view practice guidelines as tools to achieve these ends by promoting greater uniformity within their own physician networks and by helping physicians increase their efficiency, improve clinical decision-making, and eliminate inappropriate procedures. Therefore, guidelines adopted by a consensus of local physicians are more likely to be accepted. Customization Also Driven by Local Organizational Constraints

Plans have a number of other reasons for customizing clinical practice guidelines. Cost-Effectiveness Concerns

Plans we visited noted that clinical practice guidelines often fail to provide needed information on what is cost-effective care. In its 1992 report, the Institute of Medicine recommended that a clinical practice guideline include information on both the health and cost implications of alternative treatment strategies. Format may also be an issue with practice guidelines developed by health plans. Finally, some changes could be considered substantial. Plan managers also told us that their needs for medical technology assessments and outcomes data remain unmet. Instead, they should publish and update summaries and evaluations of evidence on medical conditions and services so that plans could use this information to develop and update their own guideline recommendations. Other plans proposed that the federal government increase funding to develop useful practice guideline tools, such as methods to incorporate cost assessments and patient preferences into practice guidelines.
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed how managed health plans make use of existing clinical practice guidelines.

What GAO Found

GAO found that: (1) clinical practice guidelines promote greater uniformity within physician networks, encourage improved efficiency and clinical decision-making, and eliminate unnecessary care; (2) several health plans have adopted clinical practice guidelines to control costs, improve performance on standardized measures, receive accreditation, and comply with regulatory requirements; (3) due to time and fiscal constraints, many health plans customize published clinical guidelines rather than generate original guidelines; (4) physicians are more likely to use a clinical practice guideline if it is developed by local health providers; (5) managed health plans customize existing clinical practice guidelines to suit alternative treatments, available resources, population needs, and format and currency concerns; (6) while health plans modify existing clinical practice guidelines to varying degrees, extensive changes could jeopardize the guidelines' effectiveness; and (7) some health plans would prefer that the federal government publish and update evidence on medical conditions and services, develop useful practice guideline tools, and perform outcomes research and medical technology assessments that would help them to develop, modify, and update their guidelines.