Clinical Guidelines:
New Approach Simplifies Process

After careful review of the process Humana uses to develop and disseminate clinical practice guidelines for common conditions and diseases, like congestive heart failure and diabetes, Humana’s quality improvement team has decided to refrain from issuing internally developed guidelines. Instead, Humana is moving toward nationally recognized guidelines and reducing the total number of guidelines available to physicians.

The new approach — reflective of Humana's continuing efforts to implement more member/patient-centered initiatives and increase e-enablement — is also intended to reduce Humana's involvement in the physician-patient relationship where treatment plans are concerned, said Darlene Holzbach, R.N., director of corporate quality improvement. "We're moving away from being directive with health care providers and also trying to reduce the administrative burden on both physicians and Humana in disseminating this information," she said.

In the past, Humana issued 16 sets of clinical guidelines for a wide range of conditions and preventive health recommendations. In most cases, the guidelines modeled those issued by nationally recognized entities and were modified by Humana medical directors after regional offices provided input from their medical directors and physician advisory committees. In many cases, the differences between the national guidelines and Humana's were minimal. But the process of adapting and disseminating the guidelines and issuing updates was labor intensive, and in the view of some physicians, it was overwhelming to offices that had to work with differing sets of guidelines from other plans and insurers.

Under the new program, Humana is reducing the number of guidelines it disseminates, to include primarily those required by regulatory and accrediting bodies (see list below). In addition, the guidelines Humana recommends will be readily accessible through links on the providers' section of the Web site, www.humana.com. "That means that as organizations, such as the American Diabetes Association and American College of Cardiology, update their guidelines, physicians will have immediate access to the new recommendations," Holzbach said. "These organizations have issued their guidelines after careful research and collaboration with experts in the field; so, we are confident that they are well accepted by the physician community at large."

Holzbach noted that clinical guidelines, regardless of their issuer, are merely recommendations, and they are not intended as a substitute for a physician's judgment. "As always, physicians who decide to depart from guidelines to better meet the needs of their individual patients are encouraged to do so," she said. In addition, some services suggested in the guidelines may not be covered benefits for certain members, so members should verify their benefit information.
Following are links to the Web sites containing the guidelines that replace the internally developed guidelines previously available on Humana.com:

Asthma Care
www.nhlbi.nih.gov/guidelines/asthma/index.htm

Childhood Immunizations
www.cispimmunize.org/pro/2002_main.html

Diabetes Care
http://care.diabetesjournals.org/cgi/content/full/25/suppl_1/s33

Heart Failure
www.acc.org/clinical/guidelines/failure/hf_index.htm

Preventive Care
www.ahcpr.gov/clinic/ppiphand.htm

Pediatric Preventive Care
www.aap.org/policy/re9939.html