Originally published in MedPage Today
by Emily P. Walker, MedPage Today Washington Correspondent
The emotional debate over a federal panel’s proposal to end routine mammograms for women in their 40s has reignited controversy over a contentious healthcare reform issue: comparative effectiveness research.
Healthcare reform opponents say the new mammogram guidelines by the U.S. Preventive Services Task Force (USPSTF) make their point: If healthcare reform passes, government entities will have a heavy hand in determining what medical treatments patients receive.
“It’s just kind of a peek under the curtain, if you will, of what we can anticipate with a government-run program,” said Sen. Lisa Murkowski (R-Alaska).
The release of the mammogram guidelines coincides with Congress’ attempt to overhaul the U.S. health system and slow the growth rate of its enormous cost.
One reason the U.S. spends so much on healthcare is that expensive tests and procedures, such as mammograms, have become common practice. So an integral cost-control measure in both the Senate and the House healthcare reform bills is the creation of a federal board to provide guidance about how different medical procedures compare head-to-head.
The idea is to assemble a group of experts to decide what treatments work best — regardless of cost — and issue guidelines that would enlighten patients and save doctors from wading through endless journal articles.
However, opponents argue that the panels’ decisions will be tied to costs — and the board might turn thumbs down on expensive treatments in favor of cheaper options. Even if the board doesn’t consider costs, Republican critics say, insurance companies could use the guidelines to justify denial of coverage for a particular procedure or drug.
On the other side, many academics and health policy experts have long supported comparative effectiveness research as a science-driven mechanism to cut down on unnecessary medical services.
“Most of the noise about this analogy to a future governmental role seems misplaced,” said Ted Marmor, professor of public policy and management at Yale University. “Such evaluations of the risks, costs, and benefits of screening — of mammography or of statins — are what medical science and policy analysis does and should do.”
Richard Hirth, associate professor of health management at the University of Michigan, said the reaction to the guidelines and their connection to reform is predictable, but misplaced.
“The message that has not gotten out is that the new recommendation attempts to balance benefits and harms, not reduce costs,” he said. “In that way, it’s quite parallel to comparative effectiveness, which is also supposed to focus on clinical, not economic value.”
But no one denies that money could be saved if insurers followed the USPSTF recommendations against routine annual mammograms for women in their 40s.
That’s one of the reasons for the emotional backlash from American Cancer Society (ACS), a variety of interest groups who have lobbied hard for research into women’s diseases such as breast cancer, and the lawmakers who listen to those groups. Even the Obama administration joined the chorus of boos.
The recommendation has “caused a great deal of worry and confusion among women” Kathleen Sebelius, Health and Human Services Secretary, said in a statement, adding that USPSTF “won’t determine what services are covered by the federal government.”
The Senate bill would direct Medicare to cover 100% of of preventive services with an “A” or “B” rating from the USPSTF, without specifically excluding other services.
The American Cancer Society, which recommends annual mammography beginning at age 40, expressed concern about about legislation linking the task force’s recommendations to insurance coverage.
“ACS Cancer Action Network is working with lawmakers to ensure that legislation guarantees access to proven preventive services, including mammography for all women aged 40 and over,” the organization said in a release.
“ACS CAN also is advocating that an essential benefits package cover more than what receives a task force grade of ‘A’ or ‘B,’ and that USPSTF recommendations constitute a floor, not a ceiling, for coverage.”
Sen. Mike Enzi (R-Wyo.) said the guidelines should be prompting people to ask questions about excessive government control in healthcare reform bill — which survived a critical procedural vote Saturday night but will face numerous attempts to amend it in the coming weeks and months.
“Congress should not pass a healthcare reform bill that denies you the right to receive the medical procedure or treatment that you and your doctor agree is right for you,” Enzi declared.
Democratic Senate leaders said they had no intention of doing that. In fact, the furor prompted Senate Majority Leader Harry Reid (D-Nev.) to issue a statement Sunday saying the task force “will have absolutely no impact on the bills we in the Senate write, debate, or vote on.”
He said the healthcare bill would actually improve access to preventive treatments, such as mammograms, not deny them.
“There will be nothing in our bill to discourage or prohibit preventive treatments — quite the opposite, in fact, Reid said. “And, as a result, our historic reforms, like mammograms, will save lives.”
Even so, Sen. Dick Durbin (D-Ill.) expressed the discomfort many Democratic supporters of healthcare reform felt — at least with the timing of the USPSTF’s announcement.
On one hand, Durbin told the press that the advisory panel “got it wrong” in the new mammogram guidelines “Just because a panel of doctors came to a conclusion doesn’t mean it’s the right conclusion,” he said.
On the other, he said the comparative effectiveness research in the the Senate bill would be more “experience-based” and would “go to a different level,” that the USPSTF.
A variety of health policy experts said the new cancer guidelines have nothing to do with the current healthcare reform debate, and have been years in the making.
“The timing of the cancer guidelines is extremely unfortunate,” said Robert Field, a professor of Health Management and Policy at Drexel. “They are being used as ammunition in the health reform debate because they play into the scare stories about death panels and rationing.
Gary Lyman, MD, of the Duke Center for Clinical Health Policy Research, agreed.
“These issues should be separate discussions, but unfortunately are being tied together with one another by some in the public and some in Congress for apparent political reasons,” Lyman said.
Field said the cancer guidelines and research into comparative effectiveness signal a shift toward relying on evidence-based care, rather than doing what has always been done.
“Medicine changes,” said Field. “If it didn’t, it would never improve. How do we want our physicians to be guided — by the best scientific evidence reviewed by top experts or by conventional wisdom?”
Field predicted that talk of rationing might work as a short-term scare tactic by healthcare reform opponents, but lacks staying power.
“I do not think this will have a major impact on the debate any more than the scare stories about death panels did,” Field said. “They will cause a lot of commotion, but I expect that larger concerns about providing access to insurance will prevail.”
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