by Terry A. Rondberg, D.C.

Early last month, Milliman USA released its updated "Primary and Pharmaceutical Care" guidelines, which included a section on chiropractic. This is the book that numerous insurance companies and HMOs will use to judge your cases and deny your claims.

Chances are, you haven't seen a copy of these guidelines and never will. They're specifically developed for "hospitals, physician groups, HMOs, insurance companies, employers, and other healthcare managers," according to the company. In other words, they're meant for the people whose business is to reduce medical costs, not those who deliver health care.

Milliman is a huge actuarial and management company that helps large firms cut costs and increase profits. How does a group of accountants and business consultants manage to write a set of chiropractic guidelines? That's one of their big secrets.

All their guidelines are written in the dark, so to speak, with the aid of "reviewers" who are supposedly experts in the respective area. According to Harry Lewis, a Miami attorney on the board of the National Coalition of Mental Health Professionals and Consumers, "Milliman and other insurers pay a few physicians and nurses to sign off on criteria they develop in secret. Often the physicians are retired, and don't subject the proposed criteria to rigorous academic or scientific scrutiny... Physician 'approval' under these circumstances is merely window dressing, a way of providing 'medical cover' for rationing criteria."

In the case of chiropractic, the American Chiropractic Association was involved in "discussions" (their word) with Milliman for more than year on these guidelines, and, according to an article in I>ACA Today, recommended John Triano, D.C., Ph.D. as a "reviewer" for the document.

Dr. Triano was involved in the guidelines process for the American Academy of Orthopaedic Surgeons and the North American Spine Society and was also a member of the Mercy Guidelines commission. Considering how soundly that document was rejected by the chiropractic profession, he wouldn't seem to be the best choice for the job of reviewing Milliman's chiropractic guidelines.

Milliman's rationale behind its reviewer selection, however, is another "trade secret." We probably wouldn't know anything at all about how they go about choosing reviewers and authors if it weren't for a lawsuit filed against the company in 1999. In that case, two Texas medical doctors charged the company with libel, defamation, fraud and deceit for listing them among the authors of its pediatrics guidelines.

According to a report in the AMA News, during discovery it was revealed that Milliman paid Robert Yetman, M.D., $40,000 to be "chief author" of the book. It also gave a $100,000 grant to the University of Texas Medical School at Houston, where Yetman worked as a department head. (The company, it turns out, listed all 17 department heads as co-authors, even though they hadn't given their permission and hadn't really been involved in the process.)

Why did Milliman choose Yetman? Because he was a leading expert in the field? Maybe. Or maybe it was because, as a 1998 Wall Street Journal article noted, he was an advocate of shorter hospital stays. That's something Milliman's insurance company and HMO clients would love.

Between you and me, I think the less time spent in hospitals the better. But that's a health consideration on my part, not an economic one. In the case of these guidelines, the dollar reigns supreme.

Don't for a minute think that the chiropractic guidelines will be any different. Although I haven't yet been able to obtain a copy of them (they are sold primarily to HMOs and insurance companies at a very steep price), I feel I'm pretty safe in predicting two things: they'll help insurance companies cut your claims and they'll be quoted by IMEs in court to prove your care wasn't "medically necessary."

Although the Mercy document gave us a sneak preview of what we're in for, chiropractors haven't yet had any experience with Milliman guidelines. Still, we can learn from the medical professions who have been fighting them for years.

For instance, the Milliman (then Milliman & Robertson) guidelines on eye surgery dictated that cataract surgery in older people should be restricted to just one eye. I guess their reasoning was that old people didn't need two good eyes. Blue Cross/Blue Shield in Rhode Island and Mutual of Omaha tried to enforce the restriction until ophthalmologists revolted and both plans dropped the rule.

In 1998, a group of surgeons from the University of North Carolina conducted a year-long study of hospital stays and concluded that the Milliman guidelines were, as Physicians Weekly put it, "too optimistic and possibly dangerous."

The AMA News, in Oct. 2000, stated "Many physicians believe ... that the M&R guidelines threaten quality of care. And the studies are likely to add fuel to a growing backlash against utilization guidelines used by many health plans to speed discharges and cut costs without consideration for patient outcomes."

The guidelines "appear to have been arbitrarily made with little understanding or insight into the disease processes. Physicians forced to follow them may be forced to commit malpractice," said Dr. Thomas Cleary, one of the University of Texas doctors who sued the company for listing him as a co-author of its pediatrics book.

Patients don't like the guidelines either. In New York last year, a class action suit was filed against Prudential Insurance for letting the cost-cutting guidelines dictate medical treatment. In its brief, the Medical Society of the State of New York noted, "Milliman & Robertson itself admits that the guidelines are not based on prevailing medical opinion, but are goals that predict what should happen in the best cases with patients free of any complications. Yet Prudential -- and others -- are mechanically using these guidelines to determine the necessity and appropriateness of medical treatment. This practice endangers public health."

Milliman guidelines were so obviously flawed that at least one member of Congress took a stand against them. In 1999, Rep. Greg Ganske, author of the "Managed Care Reform Act of 1999," sent a letter to his colleagues warning that, "Industry guidelines are frequently done by Milliman and Robertson, a strategy shop for the HMO industry. This is the same firm that championed 'drive through deliveries' and outpatient mastectomies. Many times, these practice guidelines aren't grounded in science but are cookbook recipes derived by actuaries to reduce health care."

Of course, Milliman shields itself from most lawsuits -- although not from criticism -- by always adding a disclaimer that their guidelines are not meant to be used to deny medical care. But few health care providers believe that any more, if they ever did.

If this is the way they write their medical guidelines, what do you think they did with chiropractic guidelines? How often do you think they'll let you see a patient who comes in complaining of headaches? How many adjustments do you think they'll recommend for the correction of subluxations?

These so-called "guidelines" are a complete farce and must be resisted and objected to in the most strenuous manner.

All chiropractic organizations should make clear that they will not tolerate any attempt by the insurance or managed care industry to dictate how chiropractors should best care for their patients. They should put that position in writing so all D.C.s can have a weapon with which to fight against these guidelines (the WCA will soon be issuing such a position paper).

If any organization or individual holds, markets or sponsors "seminars" to teach you how to practice in adherence to the Milliman guidelines, protest vehemently. No chiropractic group should exploit the situation and try to make money on these books.

If you are a member of an HMO, oppose the use of the Milliman guidelines (you shouldn't have any trouble gathering support from medical doctors in the group as well).