length of stay quandary, The

Controversy and class action suits have brought a medical guideline to the forefront of the battle over health care dollars-length of stay. Hospital stays have long been an element factored into the managed care payment system, but the national furors over 24-hour childbirth stays and outpatient mastectomies have made the health care consumer aware of the statistics used to deny or grant payment in certain situations, writes Helen Lippman in Business & Health.

Length of stay guidelines are mainly determined by one major player: Milliman & Robertson, a Seattle-based actuarial firm. Although competing firms provide guidelines on patient care and length of stay, M&R is the dominant player. Medical directors and executives of managed care plans decide whether to buy a set of guidelines from a provider such as M&Rand choose exactly how to use those guidelines.

Pat Wang, senior vice president for finance and managed care at the Greater New York Hospital Association, says plenty of room for variation exists. Just about everyone is using M&R guidelines," she claims, "but the way they are applied is influenced by the culture and philosophy of the plan." Some plans are rigid in sticking to the guidelines, but others reach out to physicians for input and are more flexible. Very different results can therefore occur; two different patients on the same floor with the same diagnosis can have completely different length of stay coverage depending on their insurance plans.

These guidelines are often criticized for being actuarial rather than clinical. And, in fact, M&R does preface each volume of statistics with the note that the guidelines "should not be used as the sole basis for denying authorization for treatment ... or as the sole basis for denying payment for treatment received." Interestingly, no organization suggests that the guidelines be eliminated or length of stay no longer be recorded, but rather that the data be seen merely as one piece of the payment pie.

What will calm the waters of this argument, state many experts, is an increased focus on best practices, elimination of treatment variation, and revised protocols-quality improvement measures that invariably affect patient length of stay and ease managed care plan payment tensions.