The Institute of Medicine, chartered by the National Academy of Sciences, has defined practice guidelines as systematically developed statements that assist practitioners in making decisions about appropriate health care for specific clinical conditions. For example, guidelines are available on such topics as the length of hospital stay for maternity care, the need for back surgery, and the management of pediatric asthma. Guidelines are intended to help physicians and others by crystallizing the research in medical literature, evaluating the evidence, applying the collective judgment of experts, and making the information available in a usable form. They are more often written as acceptable therapy options than as standardized practices that dictate specific treatments. Unlike standards of care that have few accepted variations in appropriateness, most guidelines are expected to have some variations because improved outcomes are not necessarily linked by definitive scientific evidence. Where there is a lack of scientific evidence, some organizations make recommendations that reflect expert opinion, while others recommend tests or procedures only when convincing scientific evidence of benefit exists. Many public and private organizations have been developing guidelines for decades. About 75 organizations have developed over 2,000 guidelines to date. The federal government supports the development of clinical practice guidelines through AHCPR, the National Institutes of Health (NIH), the Centers for Disease Control and Prevention, and the U.S. Preventive Services Task Force (USPSTF). Private guideline efforts have been undertaken by physician organizations, such as the American Medical Association; medical specialty societies, such as the American College of Cardiology; private research organizations, such as RAND Corporation; and private associations, such as the American Heart Association. Guidelines are also developed commercially by private companies, such as Milliman and Robertson and Value Health Sciences, which market them to health care organizations. Given the multiplicity of sources for guideline development, it is not uncommon for more than one guideline to exist for the same medical condition or for recommendations to vary. For example, at least four organizations have issued a guideline on prostate cancer screening. In addition, guidelines tend to reflect the specialty orientation of the guideline developers. In the case of the prostate screening guideline, for example, the American Urological Association, the American College of Radiology, and the American Cancer Society recommend using a prostate-specific antigen test for all eligible patients aged 50 and older, whereas the USPSTF recommends against the routine use of this test. Recent national surveys indicate that a majority of managed care plans have adopted guidelines and made them available to providers. For example, a 1994 survey sponsored by the Physician Payment Review Commission found that 63 percent of managed care plans reported using formal written practice guidelines. The results also showed that the use of guidelines was least common among less structured managed care plans because of their more limited ability to influence physicians’ practice. Specifically, 76 percent of the responding health maintenance organizations reported using practice guidelines, compared with 28 percent of preferred provider organizations. 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. In selecting aspects of physician practices that could be improved through the use of guidelines, most plans we spoke with identified those services or conditions that are high cost, high medical liability risk, and high incidence for their patient population. They reviewed the provision of such services as hospital inpatient, pharmacy, and ambulatory care—as well as variations in utilization across physicians—to identify such conditions. For example, one plan identified pediatric asthma as a condition for guideline adoption because it is among the most frequent causes of hospital admission and repeat emergency department visits. Human immunodeficiency virus (HIV) infection and high cholesterol are also among the plan’s top 10 topics for guideline selection. Several plans we contacted reported cost savings from implementing guidelines that specify the appropriate use of expensive services. In one case, a plan adopted a guideline for treating stroke patients that recommended physical therapy early in the patient’s hospital stay. This practice resulted in shortened stays as well as improved outcomes. Another plan adopted a guideline on non-insulin-dependent diabetes to help physicians identify when to provide intensive management rather than routine care to patients with this low-cost condition that can lead to high-cost complications. Another plan used a low back pain guideline that generated savings from the selective use of high-cost diagnostic imaging services. Plans have also reported cost savings from implementing guidelines that reduce the incidence of acute conditions and the need for more expensive care. One managed care chain we contacted increased the percentage of Medicare enrollees receiving flu shots from 27 to 55 percent in 1 year. The chain reported a reduction of about 30 percent in hospital admissions for pneumonia, savings of about $700,000, and fewer lives lost. Practice guidelines were also heavily used by plans that were being evaluated by employers buying health care for their workforce. Standardized measures for assessing health plan performance are set forth in the Health Plan Employer Data and Information Set (HEDIS), which many employers and other payers view as a report card. Purchasers can use HEDIS to compare plans across several preventive services measures, including childhood immunizations, cholesterol screening, breast cancer screening, cervical cancer screening, prenatal care in the first trimester, diabetic retinal examination, and ambulatory follow-up after hospitalization for depression. Of the 19 plans we contacted, 14 collected performance data using HEDIS measures. The adoption of practice guidelines may help plans improve their performance on HEDIS measures. For example, through the use of pediatric and adult preventive care guidelines, one plan claimed that it raised to 95 percent the number of its physicians meeting appropriate childhood immunization schedules and to 75 percent the number of its physicians meeting mammography screening goals. The plans also reported reducing the percent of breast cancers identified at advanced stages from 30 to 10 percent. In addition, plans’ adoption of guidelines is encouraged indirectly through health plan accrediting organizations. Although plans are generally not required to be accredited, many seek a review to satisfy purchasers’ demands and enhance their marketability. The National Committee on Quality Assurance’s (NCQA) accreditation standards require that plans have guidelines for the use of preventive health services. The Joint Commission on Accreditation of Healthcare Organizations also has standards that encourage the use of practice guidelines, but not specific guidelines. States are also influencing plans’ guideline use. For individuals covered under workers’ compensation, for example, Florida specifies guidance on the use of diagnostic imaging to treat low back pain. As states increasingly require plans to meet certain treatment standards, plans are likely to adopt guidelines that will help them comply with these requirements. Few of the plans we visited had the resources to devote to developing an original guideline, since such an effort can be time consuming and expensive. They preferred instead to customize guidelines that had already been published to ensure local physician involvement and acceptance of the guidelines and to accommodate their individual plan objectives. In general, health plans customized guidelines by modifying their scope or recommendations or emphasizing one of several therapy options presented. Because adapted guidelines differ from original guidelines to varying degrees, some experts in the guideline development community caution that certain modifications, when made to accommodate local self-interests at the expense of patients, may compromise the integrity of the guideline. Some of the plans we visited also expressed a need for more medical technology assessments and outcomes data; however, they lack the resources to assume these activities. They suggested that the federal government enhance its role in these areas. Among the most important reasons for not adopting published guidelines strictly as written is the need for local physician involvement and acceptance. Plan managers we interviewed noted that published guidelines usually lack the input of their local physician community. They recognized that some plan physicians are reluctant to put aside their own practice patterns in favor of those recommended by outside sources, particularly when guidelines are based more on expert opinion than on conclusive scientific evidence. Physicians have confidence in guidelines that they or their peers take part in developing or that are developed by their professional organization. Therefore, guidelines adopted by a consensus of local physicians are more likely to be accepted. In one plan manager’s view, without the physicians’ participation in approving the final product, physicians would not be likely to follow the guideline. In citing the need for physician acceptance of guidelines, one plan manager put it this way: “The practice of medicine is parochial.” Similarly, one large plan’s medical policy specialist told us that published guidelines need to be modified because they are often not consistent with local standards of care—that they are not “in synch” with how plan physicians are practicing. This position was corroborated by the American Medical Association’s Director of Practice Parameters, who said “a guideline can be developed at the national level, but it has to be localized . . .. t comes down to local areas developing the recommendations that suit them.” Plans selected practice guidelines from a variety of sources, including federal agencies and medical specialty societies, such as the American College of Physicians. Among the health plans we contacted, few had documentation on the methods they used to adapt guidelines. However, some described their approach as typically including some combination of physician consensus and a review of outcomes of clinical studies. When there was controversy or lack of strong clinical evidence, plans reported making greater use of local physician opinion and often performed independent literature reviews to provide additional information. This was particularly likely with a guideline on a rapidly changing treatment method, such as treatment for heart attacks, since clinical developments may overtake the publication of existing guidelines. Plans have a number of other reasons for customizing clinical practice guidelines. These issues include cost considerations, resource constraints, demographic characteristics of enrolled population, simplicity of guideline presentation, and the need to update information contained in published guidelines. Plans we visited noted that clinical practice guidelines often fail to provide needed information on what is cost-effective care.