Health for life

Guideline experts at work

Max Levin of the Health Diplomat Blog isnt sure about the DMCBs suggestion that guideline interpretation for health care coverage decisions (including preventive care)be decentralized.  While pushing responsibility down to the local health plans and provider organizations would certainly defang the powerful special interests, Max points out that without a nationally recognized guideline "Good Housekeeping" seal of approval, charlatans and hucksters will be able to foist their pseudo-clinical recommendations on an unsophisticated and unsuspecting public.

Max has a point, but the DMCB isnt changing its mind:

1. When one big national guideline gets it wrong, the damage involving thousands of patients can be considerable. Examples include years of supporting preventive estrogen for post-menopausal women and aggressive blood glucose control among persons with diabetes.

2. While advocates and lobbyists are just as able to swindle unsuspecting managed care and ACO leaders, theyd need to do so among hundreds of provider organizations.  When power is concentrated in Washington DC, all they have to do is convince one Congressman.

3. In the DMCBs experience, health insurers and ACOs are not only highly expert, but more skeptical when it comes to interpreting clinical trial data and deciding the fit in coverage decisions. For an example of their first-do-no-harm conservatism, recall how managed care used to cover bone marrow transplants for breast cancer.

4. Last but not least, even Atul Gawande pointed out how "local" health care is.  Its up to communities to create working systems out of the complex fragments of health care that best fits the local population.

The Feds should assure guidelines are incorporated in coverage decision-making.  They can accomplish that through the regulatory process, periodic audits and during the appeals process.  Otherwise, says the DMCB, they should stay out of the way.

Here comes the camel nose!

Kudos to JAMA for tackling what the Disease Management Care Blog has been saying for years: now that the Washington DCs camel nose is under the tent, there is no way health insurance coverage - and the care it pays for - isnt going to become politicized.

Thats the bigger issue in this just-published article by Steven Wolf and Doug Campos-Outcalt. Theyre focusing on the political pressure that is being brought to bear on US Preventive Services Task Force (USPSTF). As readers may recall, the Affordable Care Act requires health insurers to fully cover screening services that are deemed effective by the USPSTF. Drs. Wolf and Campos-Outcalt point out that politics rudely intruded on the USPSTFs determination that the evidence supporting mammography for women under age 50 years was lacking. The resulting firestorm not only prompted Congress to not only waive the USPHSTF recommendation, but led some of its members to question the Task Forces integrity.

As academics writing in peer-reviewed journals are wont to do, the authors suggest that this can be remedied by another layer of bureaucracy. They want a new "firewall" committee to be inserted between the "pure" evidence-based USPHSTF and the "political" fisticuffs of the public square.  Itd be the job of this a new entity to insulate USPHSTF by reconciling the proof and the politics prior to the upload of the final recommendations to the mandarins that are running CMS.

"Another committee?" asks the dismayed DMCB. While that would end the Obamacare fiction that health orm was ever going to be truly "based on science," the real Achilles heel of the JAMA proposal is that it literally doubles the opportunity for political meddling. The smartest political operatives will see this as a target-rich environment and naturally seek to influence all of the committees with any jurisdiction over the medical-industrial complex of laboratory medicine, radiological imaging and medical devices.

The DMCB has bad news for its colleagues who thought that they could have the Washington DC "cake" of enlightened government involvement along with the "icing" of scientific independence. Uncle Sams been given a clinical inch and now hell take a political mile to influence clinical guidelines and define standards of care with a one-size-fits-all mentality sprinkled with a healthy dose of cronyism.  Surprise!

The DMCB has an alternative solution: CMS should tread very caully when it comes to insurance design.  Congress needs to reengineer the preventive health part of the ACA. Instead of building new infrastructure to make up for the emerging failures of the old infrastructure, Washington should be pushing benefit design down, not up, to the local level. It can partner with commercial health insurers to assure that the USPSTF recommendations are considered, but with local committee assessments of market demand, provider opinion and community input to determine whats best for its covered population. It should do this while simultaneously promoting the use of shared decision making to help every patient ponder for themselves when testing is in their best interest.
 
Let a thousand flowers bloom.

Image from Wikipedia