Cover Story

Hospital-stay guidelines: Just plain weird

Milliman USA's advisories on hospital stays are coming under intense attack. How insurers use them may be as problematic as their scientific validity.

By Robert Lowes
Midwest Editor

Back in the heyday of HMOs, health care actuary David Axene gave speeches saying that up to 60 percent of hospital care could be avoided. Either patients could be treated elsewhere, like at home, or they didn't need any care at all.

Someday, predicted Axene, perhaps the only patients that hospitals could count on would be those requiring intensive care or cardiac care.

"All others are at risk," he said.

Axene's old company, Seattle-based Milliman USA, has been leading this movement to empty out America's hospitals. An actuarial firm, Milliman publishes proprietary health care guidelines that it licenses to insurers covering close to 100 million Americans. These guidelines are best known for specifying how many days a patient with a particular illness should spend in the hospital. To insurers, the guidelines represent a powerful cost-control tool. Many doctors, however, see them as a flimsy excuse to discharge patients prematurely.

Let's say you admit a patient in cardiogenic shock to the ICU. He's diagnosed with congestive heart failure. In a best-case scenario, Milliman says, you should be able to discharge him that day or the next. Keep him in four or five days longer, as most doctors do, and you might get a phone call from a health plan's case manager asking, "Why is Mr. Jones still in the hospital?"

Such guidelines, frequently derided as unrealistic, have helped foment the backlash against managed care. In 1996, for example, the protest over Milliman's guideline of 24 hours in the hospital for mothers and newborns following normal vaginal delivery helped spur Congress to mandate a minimum two-day stay.