Monday, June 9, 2008

A Prayer for the 3rd MCCD Report (Part 3 of 4)

Should prayer for those with chronic illness be covered under Medicare? Such a notion is probably an anathema to many of the level-headed readers of the Disease Management Care Blog. The remainder probably thinks the DMCB is going off on some bender. Yet, many reasonable persons believe in the intercessory ability of humans to either harness or appeal to forces that transcend logic or our five senses. On the surface, a majority of Americans would agree that it’s not that radical a concept, especially since there are some compelling anecdotes.

Leaving aside the obvious religious questions and inevitable legal objections, one way to come up with an answer would be to fashion a Demonstration, prospectively randomizing beneficiaries to control and intervention groups and then assessing the statistical significance of between-group differences in quality, cost and satisfaction. Since believers would argue not all prayer is the same, the Demo would need to test several belief systems involving multiple settings and multiple conditions. Think it silly? There have been several per-reviewed publications assessing the impact of such ‘distance-based interventions.’ All that is lacking is sufficient venture capital.

But seriously, the DMCB is not attempting to equate prayer and population-based approaches to care. However, thinking about the challenges of ‘testing prayer’ is instructive about the limits of scientific inquiry. It is very hard to simultaneously test 1) multiple, 2) interdependent, 3) socially complex and 4) variable interventions like prayer and then rely on unidimensional outcomes (like A1c or PMPM) to gauge success.

The DMCB is not being naive. It understands the similarities between prayer and disease management are a stretch (except maybe for what it will take for DM to be covered by Medicare). There are multi-million dollar disease management companies that want a place at the Medicare trough and the implications of coverage are huge. That being said, the DMCB also wonders if disease management has greater similarity to the health care quilts of community-based institutions, families and religious organizations than the more circumscribed interventions of a drug or an x-ray. Assessing multiple-packaged-interdependent-complex-variable interventions like reassurance, support and encouragement through the narrow aperture of a randomized clinical trial (RCT) just isn’t up to the task of assessing the real values of ‘care coordination.’ It also doesn’t work for other long-accepted approaches like primary care or hospice, neither which has also been evaluated in an RCT. Nor should they be.

By the way, the DMCB doesn’t think Medicare should ‘cover’ prayer, but not for the usual reasons: it’s already freely available.

Unfortunately, the acolytes of care coordination and disease management (and the Medical Home, by the way) have to play with the cards they’ve been statutorily dealt. If the path to explicit inclusion in the Medicare benefit is lined with RCT demos like MCCD and Medicare Health Support, it looks like the population-care industry is going to have a tough time. Medicare beneficiaries will be worse off for it.

What’s the fix?

Fashioning Richer Studies That Ask How, Not What: Don Berwick tells us that we need to do a better job of assessing how interventions work best. The MCCD, for example, tells us that in-person care coordination seems to have greater success than remote approaches. Duh. We already know that, but we sure could do a better job of understand the circumstances It’s doubtful that an RCT will be able to sort that out.

Assess Value, not Savings: Is it possible that in the Medicare FFS Program, care coordination strategies add cost but with comparatively greater gains in value? Suppose we found a version of disease management, inclusive of fees, that cost $50,000 per quality adjusted life year (QALY). That’d be a deal, but it wouldn't be cost saving.

The DMCB is having trouble finding the 3rd report on line. If that keeps up, it'll have to figure out how to post it here. Email if you want a copy.

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