LEGAL BARRIERS TO INSURERS' USE OF PRACTICE GUIDELINES

该项目将系统地分析所有相关的法院判决， 为了预测哪些因素会影响接受或拒绝 医疗实践指南，以确定公共或私人保险 覆盖 我们对早期法院判决的初步分析表明， 法院有时但不经常发现医疗技术评估 当被病人或医生质疑时， 保险人支付与评估相反的程序。 的 法院对保险公司依赖 技术评估，但他们也提出了技术， 增加保险公司的决定被发现的可能性 可以接受的 考虑到AHCPR的大量投资， 医师学院和其他发展医疗实践的机构 因此，必须了解法院的保留意见， 制定建设性建议，以增加指导方针的可能性 验收 该项目有四个具体目标： 对联邦和 州法院决定确定影响法院的因素， 接受或拒绝实践指南，以确定公共或 私人保险。 与以下各方分享关注事项清单和建议的修改 政府代表（AHCPR，HCFA），供应商（AMA，ACP，AHA， GHAA）、保险公司（HIAA、BCBSA）、消费者（AARP、CDF）和学术界， 他们的评论和评论。 宣传影响司法态度的因素 指导小组、PORT、政策制定者、医生、律师、法官和 通过出版物和演示文稿与其他感兴趣的各方进行交流。 将研究结果存入数据库， 将允许随后的调查、更新和检验结论。

This project will systematically analyze all relevant court decisions in order to predict which factors will influence the acceptance or rejection of medical practice guidelines to determine public or private insurance coverage. Our preliminary analysis of older court decisions suggests that the courts have sometimes but not often found medical technology assessment to be persuasive when been challenged by a patient or physician who wants the insurer to pay for a procedure that is contrary to the assessment. The courts have raised a number of specific objections to insurers' reliance on technology assessments, but they have also suggested techniques that would increase the likelihood that the insurers' decisions will be found acceptable. Given the considerable investment of AHCPR, the American College of physicians, and others in developing medical practice guidelines, it is important to understand the courts' reservations and to develop constructive suggestions to increase the likelihood of guideline acceptance. This project has four specific objectives: To conduct a comprehensive and systematic content analysis of federal and state court decisions to identify the factors that influence courts' acceptance or rejection of practice guidelines to determine public or private insurance coverage. To share the list of concerns and recommended modifications with representatives of government (AHCPR, HCFA), providers (AMA, ACP, AHA, GHAA), insurers (HIAA, BCBSA), consumers (AARP, CDF), and academics for their review and comment. To disseminate the information about factors that affect judicial attitude to guidelines panels, PORTs, policymakers, physicians, lawyers, judges and other interested parties through publications and presentations. To make the findings available to other investigators in a database that will allow subsequent investigation, updating, and testing of conclusions.