By Dr. Jaan Sidorov

First Posted at Disease Management Care Blog on 5/27/2013

Dr. Jaan Sidorov, host of Disease Management Care Blog

Dr. Jaan Sidorov, host of Disease Management Care Blog

Max Levin of the Health Diplomat Blog isn’t sure about the DMCB’s 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 isn’t changing it’s 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, they’d 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.

Guideline experts at work

3. In the DMCB’s 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 refused to cover bone marrow transplants for breast cancer.

4. Last but not least, even Atul Gawande pointed out how “local” health care is.  It’s 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.