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.
