When insurance and managed care companies develop internal reimbursement policies, they have to obtain reliable information about particular procedures and therapies. One of the two primary companies that provide guidelines for the industry is Milliman USA (formerly Milliman and Robertson).
On November 1, 2002, Milliman will release updated guidelines for chiropractic. Its interest in updating the chiropractic guidelines was sparked by the American Chiropractic Association (ACA), which contacted Milliman with concerns that the previous guidelines needed to be reviewed.
While the guidelines are not available for review at press time, we interviewed David Zieve,MD, the editor of the Milliman Care Guidelines.
Dynamic Chiropractic: Dr. Zieve, what are the Milliman Care Guidelines?
Dr. Zieve: Milliman Care Guidelines is a division of Milliman USA. The first guidelines were published by the division in 1989. We have six evidence-based guidelines publications that bring the best in practice to point of care.
(Editor's note: Those guideline publications are Inpatient and Surgical Care; Primary and Pharmaceutical Care; Pediatric Care; Return-to-Work Planning; Case Management: Home Care; Case Management: Recovery Facility Care; and Workers Compensation. Milliman also has a new publication for patient education. Milliman will release Ambulatory Care, the updated version of Primary and Pharmaceutical Care, Nov. 1, 2002, which includes a set of chiropractic guidelines.)
There is a primary editor responsible for putting each publication together. Some of the books have an associate editor to aid in research. The basic research process is to sort through randomized, controlled trials first, followed by meta-analyses and then systematic reviews, a variety of review articles and nonrandomized trials. They also use textbooks. Once a guideline is written or updated, it's sent to an outside expert reviewer. We have dozens of outside reviewers selected from around the country. Our selection criteria combine academic knowledge and practice skills. The reviewers return the material to us with their comments. We quite often speak with the reviewers to exchange ideas and to discuss their suggestions and comments. They may suggest studies or articles that should be included or considered? We also discuss content and phrasing. A certain recommendation in the literature may sound nice, but does it fit into everyday practice?
We take the reviewers' suggestions and their real life practice input, and integrate those into the guidelines. The guidelines are quite often read by someone else in-house, and are always read by our editor-in-chief. Our editor-in-chief makes sure that the guidelines in Ambulatory Care, for instance, don't conflict with the same or similar topic in the inpatient surgical book. We have a peer-review process in the Milliman organization to keep track of the guideline development process. That's a quick summation of the process.
DC: We understand that the guidelines are available on subscription to insurance companies and managed care organizations.
DZ: Our customers primarily include managed care and/or payer-type organizations, hospitals, large medical groups, integrated medical groups/IPAs, and home care agencies or recovery facilities. We have contracts with the Department of Defense health-care facilities, and other medical groups within the federal health care system. The military health care system uses some of our guidelines, both hospitals and large physician portions of it. Those are probably our main customers. We have a variety of single users, sometimes down to individual providers or small provider groups. They may be seeking the clinical knowledge, or sometimes want to know what some of the managed care organizations are basing their decisions on.
DC: Is your organization the major provider of these guidelines?
DZ: We're one of the two major providers of these types of guidelines, at least as guidelines that are purchased by managed care organizations. There are other smaller guideline providers, although some have recently gone out of business. We're a major player, if not the major player, in different segments of the market.
DC: We're told you're going to be releasing new guidelines for chiropractic on November 1, 2002.
DZ: We're coming out with the eighth edition of our four biggest products on November 1. Within the Ambulatory Care publication is a set of chiropractic guidelines.
DC: And those will be different than the guidelines that you've had in the past?
DZ: They're certainly different. I mean, we're always updating. There are some added diagnoses.
DC: John Triano,DC,PhD, of the Texas Back Institute was your outside consultant on the chiropractic guidelines?
DZ: Yes, we used Dr. Triano as our outside expert reviewer for the chiropractic guidelines.
DC: Can you tell us anything about the review process with Dr. Triano? We understand you're subscription-based, but what can you share?
DZ: We've had input from chiropractic physicians in the past into some of the guidelines. Dr. Triano is an eminent doctor in his field. He worked on the government's low back pain guidelines in 1994. (Editor's note: Dr. Zieve refers to Acute Low Back Problems in Adults, clinical practice guideline of the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services.) He works in a large multidisci-plinary environment, he's still seeing patients and he's done lots of research and published many papers. I think the attractive part of working with him is his eminence in the field, and his skill and knowledge. He brought academic and practical input to the guidelines. These are good, solid guidelines.
DC: Let's say a doctor of chiropractic would like to find out what's in those guidelines.
DZ: We obviously can't release content ahead of the publication date. A doctor can, of course, purchase the Ambulatory Care volume, but most practicing doctors are not going to want to spend the money to purchase an entire volume that contains a relatively small chiropractic guidelines section, relative to the full volume. The more common and easier way for them to get it is through a managed care company. Part of our contract with all of these organizations with the large payers and people who buy our guidelines is they are able to (and in fact we encourage them) to be able and willing to distribute guidelines to providers. So, that is a way to get them (after November 1).
DC: Based on the new guidelines, do you anticipate any changes in how some of those MCOs deal with chiropractors?
DZ: That's hard to say. Managed care is evolving away from the rigid "Let's pick a number and manage by it" mentality that doesn't really care what's going on with the patient or the provider, to looking at the broader issues and more patient-centric issues. One of the ways our guidelines have improved over time, including the chiropractic guidelines, is the way we present evidence. We've always generally been evidence-based, but I think we've become much more explicit over the last several volumes in demonstrating that evidence. For instance, you'll now find explanatory footnotes that describe what's behind different decisions and recommendations. Doctors and health organizations will appreciate more information than just the two or three bulleted recommendations.
DC: How important have the research studies been in the development of your guidelines?
DZ: I think they're very important, but I don't think they're the only things. My search in the medical and chiropractic literature over the last seven or eight years reveals a lot more systematic reviews and randomized, controlled trials. Still, except for a few small areas in health care, there are not a lot of randomized controlled trials (RCTs). To do a good RCT, you have to control the variables - that helps give you an answer you can stand behind. But you have to look at that and say, "How much does this situation that we're studying, given that we've had to control the environment to meet the scientific parameters, reflect what's going on in the real world?" It's important to use the RCT data, but try to apply it to the real world. We must remember that although we're using scientific data in the production of a guideline, a guideline is a recommendation of best practice; it isn't going to fit every situation. There still has to be the care of patients in everyday practice, and that input has to go into the development and usage of guidelines.
DC: Is there anything else you'd like to add?
DZ: I know there are a lot of issues and reactions by all kinds of providers to how guidelines are used or misused. We've gone to a fair amount of effort to educate organizations and providers on how to correctly apply the guidelines. We have a national user's forum; we have training sessions often based around real-life scenarios on how to use the different guidelines, and when they apply and when they don't. We also have a website with a lot of information (www.mnr.com). In short, we've done all we can to make sure that the guidelines are used with the best care of the patient in mind.
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