AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 817
(I-00)
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Introduced by:
Georgia Delegation
Subject:
Appropriate Use of HCFA Medicare Quality Indicators
Referred to:
Reference Committee H
(Eugenia Marcus, MD, Chair)
Whereas, The Health Care Financing Administration recently published state and national
profiles of 24 “process-of-care” clinical performance measures of 6 medical conditions (acute
myocardial infarction, breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke) to
measure the quality of medical care provided to Medicare patients; and
Whereas, The HCFA Medicare Quality Indicators are based on practice guidelines that were
translated into process measures; and
Whereas, Practice guidelines are designed to offer physicians a generally accepted treatment
recommendation based on current research findings for an average patient only; which must be
considered in light of the patient’s medical condition and history, possible contraindications,
patient preference, available resources, etc.; and
Whereas, The National Guideline Clearinghouse, sponsored by the Agency for Healthcare
Research and Quality, in partnership with the American Medical Association and the American
Association of Health Plans, finds in their National Guideline Clearinghouse Disclaimer, that
guidelines are not fixed protocols that must be followed, but are intended for health care
professionals and providers to consider; that while they identify and describe generally
recommended courses of intervention, they are not presented as a substitute for the advice of a
physician or other knowledgeable health care professional or provider; and that individual
patients may require different treatments from those specified in a given guideline; and
Whereas, The measure of quality of a patient’s medical care is made up of many factors, i.e.,
the total hospital system of care, the training and education of the health providers, state of the
art equipment, laboratory schedules, staffing, patient compliance, outcome measures, etc.,
which are often not in the control of an individual physician or medical staff; and
Whereas, As a result of the HCFA study, some hospital and/or other state health data reporting
systems are planning to use the Medicare Quality Indicators to routinely report and develop
cumulative data on the status of hospital and medical staff performance to determine, so called,
“best performers”; therefore be it
RESOLVED, That our American Medical Association reject the notion that the Health Care
Financing Administration Medicare Quality Indicators, developed as they are as guidelines for
an average patient’s disease state, can be used as a requirement of medical treatment or as a
summative judgment of a physician’s clinical care; and be it further
Resolution: 817 (I-00)
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RESOLVED, That our American Medical Association reject the use of cumulative information
derived from the application of these “Guidelines” as a quality indicator of a physician’s or
medical staff’s clinical medical care; and be it further
RESOLVED, That our American Medical Association recognize that cumulative data gathered
from the use of HCFA Medicare Quality “Guidelines” are inadequate as measures to determine
hospital performance and rankings of “best performing” hospitals in a state; and be it further
RESOLVED, That our American Medical Association reject the use of these “Guidelines” by
federal, state, hospital, or other entities, as measures of medical errors by physicians or hospital
medical staffs, and reported as such.
Fiscal Note: No Significant Fiscal Impact
Received: 11/3/00
RELEVANT AMA POLICY
H-320.949 Clinical Practice Guidelines and Clinical Quality Improvement Activities
Our AMA adopts the following principles for the development and application of utilization management
guidelines: (1) The criteria or guidelines used for utilization management shall be based upon sound
clinical evidence and consider, among other factors, the safety and effectiveness of diagnosis or
treatment, and must be age appropriate. (2) These utilization management guidelines and the criteria for
their application shall be developed with the participation of practicing physicians. (3) Appropriate data,
clinical evidence, and review criteria shall be available on request. (4) When used by health plans or
health care organizations, such criteria must allow variation and take into account individual patient
differences and the resources available in the particular health care system or setting to provide
recommended care. The guidelines should also include a statement of their limitations and restrictions.
(5) Patients and physicians shall be able to appeal decisions based on the application of utilization
management guidelines. (6) The competence of non-physician reviewers and the availability of samespecialty peer review must be delineated and assured. (7) Maintaining the best interests of the patient
uppermost, the final decision to discharge a patient, or any other patient management decision, remains
the prerogative of the physician. (BOT Rep. 6, A-99; Reaffirmed: Res. 820, A-00)
H-185.977 Milliman and Robertson Guidelines
Our AMA will use its influence to stop the inappropriate application of the Milliman and Robertson
Guidelines to clinical situations; and will offer its support amicus in any appropriate court action which
centers upon adherence to the Milliman and Robertson Guidelines. (Res. 710, A-94; Reaffirmed: Sub.
Res. 709, I-97; Reaffirmed: Res. 820, A-00)
H-410.970 Use of Practice Parameters
Our AMA: (1) urges organizations that have developed practice parameters to recognize that practice
parameters are educational tools, not mechanisms to determine reimbursement or credentialing, to assist
physicians in clinical decision making and are not replacements for clinical decision making. Physicians
must retain autonomy to vary from practice parameters without retribution in order to provide the quality of
care that meets the individual needs of their patients; (2) encourages physicians to be cost conscious and
to exercise discretion, consistent with good medical care, when implementing practice parameters; and
(3) encourages physician organizations developing practice parameters to include appropriate
explanatory disclaimers to ensure that practice parameters are used in a manner that is consistent with
AMA policy. (Consolidated by CMS Rep. 8, I-96; Reaffirmation I-98; Reaffirmed: Res. 820, A-00)
See also: H-410.998 Development of Practice Parameters