Practice Guidelines:

Managed Care Plans Customize Guidelines to Meet Local Interests

HEHS-96-95: Published: May 30, 1996. Publicly Released: Jul 1, 1996.

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

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.

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