He noted that the average cost of the behavioral management program was $5,700, compared with the cost of heart surgery, which ranges from $57,000 to $67,000. "By avoiding one procedure, it pays for 10 members to complete the program."
The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.
The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. "The foundation for change is happening at 12 months."
Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those "reported or implied" cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.
In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.
"This is a spectacular example of personalized health care," said William F. Owen Jr., M.D., a professor of medicine at Duke University, Durham, N.C. "I believe this works in a certain patient segment that's cared for by very passionate providers, but I'm uncomfortable about extrapolating it."
Now that the advisory committee has made its recommendation, CMS must decide whether to take up the issue of a national coverage determination, and what scope that potential coverage might have. An agency spokesman said there is no timetable for making the decision.