When James Schibanoff was heading Sharp Memorial Hospital in San Diego in the early 1990s, he rarely looked beyond his own medical staff for advice on patient care and running the hospital.
CHARLIE NEUMAN / Union-Tribune
Dr. James Schibanoff edits the Milliman guidelines, the best-practices guide for treating patients who have a specific ailment or injury.
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But another San Diego doctor who had worked at a rival medical center was developing a radically different approach, using data collected from dozens of hospitals to create a standard set of benchmarks for treating patients.
How long should a person stay in the hospital after heart surgery? Statistics collected by Dr. Dick Doyle of Scripps Mercy Hospital offered a recommendation based on the experiences of hundreds of other patients cared for by numerous doctors at many hospitals.
“This fantastic resource was right under my nose, and I never accessed it,” Schibanoff recalled recently.
Schibanoff's conversion came in 1996 when Doyle recruited him to become the new editor of the guide to best practices, which had become known as the Milliman Care Guidelines.
“When I finally sat down with Dick and he showed me the elegance and simplicity of what he had done, it was one of those moments of epiphany,” Schibanoff said.
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James Schibanoff
Age: 63
Home: San Diego
Job: Editor-in-chief of Milliman Care Guidelines, which creates and publishes standard sets of benchmarks for treating hospital patients
Education: Medical degree from the University of Southern California School of Medicine, 1969; resident at the University of California San Diego School of Medicine, 1970-72
Work experience: President of San Diego Pulmonary and Critical Care Medical Group, 1975-1993; medical director of Sharp Memorial Hospital, 1976-1988, and Sharp Cabrillo Hospital, 1982-88; Sharp HealthCare medical affairs coordinator, 1988-1993; chief executive of Sharp Memorial and Sharp Cabrillo, and senior vice president of Sharp HealthCare, 1993-96
Personal: Married to Nancy, with four daughters and one son, 16 to 36
Hobbies: History, architecture and collecting early American furniture
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It has taken the rest of the health-care industry a decade to catch up.
Schibanoff, 63, now finds himself at the forefront of the so-called evidence-based medicine movement, a major shift in the way health-care providers deliver their services.
The Milliman guidelines are written recommendations of how to treat patients who have a specific ailment or injury. They're based on analyses of data collected from U.S. hospitals and are marketed as the current “best practices” in medicine.
Hospitals, insurance companies and individual doctors pay fees to access the Milliman guidelines through the Internet, on CD or in print. The benchmarks are one tool in deciding how to treat a patient.
Milliman guidelines are used by nine of the 11 largest health insurance companies as well as by several hundred hospitals including Sharp Memorial, Schibanoff's former employer.
“More than 100 million Americans potentially could be influenced by Milliman guidelines,” Schibanoff said.
An increasing number of doctors, hospital operators and insurers believe that medical procedures can, and should, be validated by mining the vast amount of patient data available in giant hospital and insurance company computer systems.
That view challenges the traditional notion of a doctor dispensing treatment largely based on his or her own experience with other patients and on reading the latest published research.
Huge volume of research
The problem is with the human mind, Schibanoff said. “There is so much stuff out there. The amount of research done in the world of health care is so enormous that no individual physician can be expected to stay up to date,” he said.
In a sign of growing acceptance of the evidence-based medicine approach, Schibanoff last month was named one of the 50 most influential physician executives by Modern Physician magazine. The San Diego internist ranked 35th among a list that included chief executives and leaders of major insurance companies, hospitals and medical schools.
Schibanoff deserved the recognition, said Christopher Ohman, president and chief executive of the California Association of Health Plans.
Editing the Milliman guidelines “is a very influential position. It is a role of ensuring that the processes used to come to decisions about guidelines (are) sound and credible,” Ohman said.
Schibanoff didn't set off to become a power force in the health-care industry.
His decision to become a physician was most strongly influenced by a childhood family medical crisis, he said. “My father had life-threatening appendicitis when I was in the second grade. The doctor who saved him was a family hero,” he recalled.
The New Jersey native and grandson of a Russian immigrant chicken farmer became a state champion hurdler in high school before becoming a pre-med student at Princeton University. He attended medical school at the University of Southern California and completed his residency in 1972 at UCSD Medical Center.
Schibanoff spent the first part of his career as an intensive care doctor at several Sharp hospitals in San Diego County before becoming chief executive of Sharp Memorial and senior vice president of the entire health-care system.
Standing 6 feet, 2 inches, Schibanoff still has the long frame of a hurdler, but he long ago traded the track for an indoor stationary bicycle. He still speaks with the soft tones and gentle words of a practicing physician well-versed in the methods of a good bedside manner.
From his office in La Jolla, he oversees a staff of 20 – including other doctors – that writes and updates five Milliman publications containing specific standards for treating more than 1,000 conditions. The guidelines offer advice on everything from how long patients should stay in a hospital to what type of therapy they should require.
About 1,000 clients subscribe to the publications through licensing agreements that cost from a little as a few hundred dollars to as much as $1 million a year depending on the size of the organization, Schibanoff said.
Milliman competes with several other commercial medical guidelines producers as well as with medical societies, such as the American Academy of Pediatrics, that distribute their own care recommendations at no charge.
“If not the most widely referenced, (Milliman is) one of the leading sources of clinical guidelines,” Ohman said.
The benchmarks can play a critical role in efforts by hospitals and insurers to provide up-to-date treatments and to control costs, the insurance industry advocate said.
If an insurer declines to pay for a procedure that proves to be prudent, the company likely could face a lengthy appeal by the patient, Ohman explained. On the other end of the spectrum, liberal approval of care could result in unnecessary treatments.
“Either way, it will be costly,” Ohman said. Evidence-based guidelines can help avoid those financial pitfalls, he said.
A radical approach
When Schibanoff took over the Milliman editing job a decade ago, using statistical experience to help make clinical judgments was seen by some health-care professionals as a radical and, perhaps, even dangerous approach to medical care.
Soon the guidelines were facing mounting criticism from some of Schibanoff's peers in the medical and academic worlds, as well as from several class-action suits that accused insurance companies and hospitals of relying too heavily on the benchmarks when administering care.
The controversy peaked in the late 1990s when Milliman's recommendation that mastectomy patients spend two days in the hospital after surgery generated a flurry of national publicity that coincided with an emerging debate in Washington over the rise of managed health care.
“It became a huge issue,” Schibanoff recalled recently. “It was included in President Clinton's State of the Union address. I was shocked that this became a huge issue around the country.”
The mastectomy recommendation had been part of the guidelines since the late 1980s. Doyle had discovered that most mastectomy patients in San Diego left the hospital after a couple of days – often at their request – to complete recovery at home surrounded by their families. The practice had been validated by at least five articles from academic medical journals, Schibanoff said.
Still, as the Milliman guidelines became more widely used outside of southern California the mastectomy recommendation became a lightning rod for critics of the health insurance industry, particularly in areas where breast surgery was treated as a major operation.
“I rapidly realized that the practice in California was very different than in the rest of the country,” Schibanoff said.
The turmoil prompted a major change in the guidelines.
“In the early years, it was not our practice to describe all the medical literature that showed that you could do this procedure safely,” Schibanoff said. “What this pointed out to us was that we needed to be rigorous in displaying the sources of each recommendation.
“When we started to do that, then the controversy really started to die down,” he said.
In more recent years, with the Milliman guidelines receiving wider acceptance, Schibanoff has had more time to devote to his greatest passions: history, architecture and collecting early American furniture.
He has developed a particularly deep level of knowledge on British history and Southern Californian architecture, said Dr. John Carson of La Jolla, who recruited Schibanoff to join the Zamorano Club, an exclusive Los Angeles-based group of writers and historians.
“Delightful companion”
“He is a delightful companion,” Carson said of Schibanoff. “Whatever he digs into, he digs into it in depth and becomes an expert on it.”
Schibanoff's wife and five children, ranging in age from 16 to 36, have become accustomed to family vacations organized around important builders or design periods.
His most recent pilgrimage took Schibanoff, his wife, Nancy, and their youngest daughter on a three-week, 3,000-mile tour of northern Italy in search of villas designed by renowned Renaissance architect Andrea Palladio, whose classically inspired work later influenced the Georgian movement in England and colonial construction in America.
“We used to kid him about vacations being like a forced march, but we all actually enjoy them,” Nancy Schibanoff said.
Her husband's love for history and design “comes from deep within him,” she said.
The epic trips have bonded the family more closely, and they have served as an extended classroom for the couple's children, the wife said. “Our 16-year-old daughter could probably teach an art history class.”
James Schibanoff's passions took a more serious turn in 2001 when the owner of a historic home in the doctor's Del Mar neighborhood announced plans to tear down the 1911 structure. Schibanoff and his wife launched a campaign to save the Canfield-Wright Mansion, also known as the Pink Lady for its exterior shade. The effort eventually persuaded the owner to sell the home to San Diego developer Bill Davidson, who is restoring the structure.
Last year Schibanoff joined the board of Save Our Heritage Organisation, the region's leading historic preservation group.
“He has always had an appreciation for the best things in life, and much of that is (historically) related,” said SOHO executive director Bruce Coons, who has known Schibanoff since the mid-1980s when the doctor maintained a personal library outfitted with early American furniture in a late-19th century row of brick townhouses in National City's Heritage Row.
Schibanoff has helped SOHO increase its contact with the business community, Coons said. The doctor acted as a go-between during last year's debate over the Salk Institute's plans to expand toward a canyon that serves as a wildlife habitat.
“He was able to put us together with the right people,” Coons said.
Without taking a position in the fight, Schibanoff said, he encouraged his friends at the institute to talk more directly with people who oppose the expansion.
City officials haven't decided whether to approve the plans.
Like in his work with Milliman, Schibanoff's growing role as a preservationist often puts him in the middle of controversy.
“I spent 18 years in intensive care units,” he said. “I thrive on challenges.”
Keith Darce: (619) 293-1020; keith.darce@uniontrib.com
