Government Created Medical Practice Guidelines: The Opening of Pandora's Box
Case Citation
Long v. Great West Life & Annuity Ins. Co., 957 P.2d 823 (Wyo. 1998)
Background
The fact-specific holding “Summary judgment was improper in an insured's claim against its insurer for the denial of treatment through a utilization review process because neither Wyoming law nor the insurance contract provided an administrative remedy requiring exhaustion.”
Article Publication Date
1996
Volume
10
Issue
2
Citing Quote
In past decades, health care costs rose dramatically and, by the 1980's, the third party payor system of private insurers had introduced patients and physicians to the managed care notion of cost containment in the form of concurrent and prospective utilization review systems. These systems have fundamentally shifted the way that health care is funded, organized and administered by involving a third party in cost-conscious medical decision-making. Typically, the provider of utilization review services reviews the treating physician's prescribed course of care and treatment plans, requires pre-admission certification for hospital stays, and monitors a hospital stay to determine its continuing appropriateness. Usually, the provider, who may or may not be a doctor, relies upon established clinical guidelines for a "statistical person" and does not have first-hand knowledge of the particular patient. n2 n2 Clinical practice guidelines are defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical conditions. Medical practice guidelines must be distinguished from guidelines for utilization review which serve only a cost containment purpose. William R. Trail and Brad A. Allen, Government Created Medical Practice Guidelines: The Opening of Pandora's Box, 10 J.L. & HEALTH 231, 234-36 (1996); Andrew L. Hyams, et al., Medical Practice Guidelines in Malpractice Litigation: An Early Retrospective, 21 J. HEALTH POL., POL'Y & L. 289, 304 (1996) (citing Grogan, C.M., et al., How Will We Use Clinical Guidelines? The Experience of Medicare Carriers, 19 J. HEALTH POL., POL'Y & L. 7, 26 (1994)).