Health reform vaults the USPSTF into prominence

The most visible impact of Affordable Care Act is surely the expansion of health insurance coverage to 30 million uninsured Americans, but a lesser known provision in the overhaul will have far-reaching implications as well.

The provision catapults the US Preventive Services Task Force (USPSTF) from an obscure agency that produced unenforceable guidelines about screening and preventive services into one whose recommendations directly impact reimbursement.

According to the terms of the new provision, insurers will be required to pay in full for services receiving an A or B recommendation from the Task Force, such as the ones it released last month which call for broadened screening for osteoporosis. Decisions like this increase access to osteoporosis screening services and create myriad new business opportunities as well.

The flip-side of course, is that insurers may not have to pay at all for services not recommended by the Task Force.

As a result, the Task Force’s new best friends include lobbyists and disease advocates who want their priorities – things like screening for Alzheimer’s disease, HIV and diabetes for example – to get covered.

For example, the HIV Medicine Association recently lobbied the USPSTF to broaden its HIV screening recommendations. In doing so, the Association called attention to an appalling statistic, which is that 20% of people who are infected HIV don’t know it. It argued that this knowledge gap can be closed if insurers covered the costs of routine HIV testing, and that will happen only if the Task Force broadens its current recommendations from those “in certain risk groups” to those “in the general population.”

Similarly, the American Diabetes Association is advocating that insurers should cover diabetes screening tests for a broader population than current Task Force recommendations suggest. Current USPSTF recommendations are that such screening should be done only for people with high blood pressure.

The private sector has also been involved in the lobbying effort. For example General Electric, which produces mammography screening tools, has recently lobbied the Task Force.

The risk of exposing the Task Force to lobbying interests like these is that it could undermine the Task Force’s tradition of neutrality and scholarly dedication to science. “If you want to be evidence-based, lobbying just doesn’t fit,” Ned Calonge, the panel’s chairman told Kaiser HealthNews.

The 16-member volunteer USPSTF began work in 1984. Over the years, it has examined issues ranging from colonoscopy screening to fluoride treatment. It consists of primary care physicians and public health officials but not medical specialists, because of concerns about conflicts of interest.

The Task Force, by the way, is the same one that caused a stir just before the last Presidential election by releasing recommendations that women should begin receiving screening mammography at the age of 50 rather than 40, as called for in its earlier recommendation on the matter.

In changing its position, the USPSTF relied on evidence that mammogram screening resulted in too many false positives and trivial benefits for women in their 40s. Unfortunately, the announcement reinforced fringe-Right fears that candidate Obama’s health reform plans included rationing health care and “death panels for Granny.”

Ironically, it was an amendment to the Affordable Care Act—the same bill that bestowed new powers upon the USPSTF—that required insurers to cover the costs of mammograms for women in their 40s. The mammography backlash also prompted the Task Force to begin accepting public comments before finalizing its recommendations.

The Task Force won’t cower in the face of criticism, Calonge insisted. But nor will it be “immune” to input that might add a beneficial perspective. That’s what we call business as usual in the US health care system.

Glenn Laffel is Sr. VP, Clinical Affairs at Practice Fusion.

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  • Thomas Reid MD PhD FACP

    The USPSTF is deadly to clinical medicine – one only needs to refer to the disaster with the screening mammogram recommendations which were base on money, i.e. fiscal rationing. In my oncology practice, I’ve seen many women under 50 who would have not been diagnosed early had it not been for a screening mammogram! Another USPSTF failure was the non-support of virtual colonoscopy for colon cancer screening; arguing that the extra cost to work-up incidental findings. So what? The incidence of incidental findings is low. If there is something potentially curable and it is found incidentally, I’m sure a patient would want to know. The USPSTF and the proposed Center for Comparative Effectiveness are anathema to American Medicine and must be de-funded.

    • DrB

      Dr Reid,

      Great points. Why stop there? I think we should all haev a full body CT once every 6 months or so. Don’t want to miss anything…
      Full disclosure: I own 4 CT and MRI centers, but I promise I am not biased…

    • L.

      Some of us actually understand the subtleties of the recent USPSTF mammography guidelines. I was always high risk – and according to the guidelines (yes, the new ones) I would have discussed this risk with my physician and together we would have determined that I should be tested even earlier than age 40. Which I did and I was.

      Understanding risk factors and the individual are the key to understanding the guidelines.

      The money aspect has to do with the backlash from the breast centers, surgeons and radiologists who stand to lose half their revenue if the guidelines are followed. (But, don’t worry – their PR blitz was quite successful). It’s really quite surprising how supposed scientific minds choose to ignore the science when it effects their earning potential.

      • HJ

        “In my oncology practice, I’ve seen many women under 50 who would have not been diagnosed early had it not been for a screening mammogram!”

        You have no idea whether an early diagnosis saved these women’s lives. You also have no idea how many women were disfigured and irradiated, whose lives were shortened unnecessarily by your treatment.

        • Thomas Reid Md PhD FACP

          Dear HJ,
          Early diagnosis of breast cancer does save lives. If undiagnosed, an early stage breast cancer (e.g. Stage I or II) will progress over time to Stage IV, which is incurable for certain. No question, there is room for improvement in the treatment of more aggressive types of early stage breast cancer (e.g. T1c triple negative)
          We have the option today of sentinel lymph node biopsy and lumpectomy, significantly reducing any disfigurement/morbidity. Radiation therapy continues to improve with lower doses being tested and used.
          Essentially gone are the days when an individual would die from a treatment complication such as neutropenia with sepsis. Moreover, we do not recommend therapy for individuals with poor performance status (e.g. the patient with a performance status of 3 and metastatic breast cancer). So, no, we do not shorten lives with treatment.

          • Thomas Reid Md PhD FACP

            Addendum – I wanted add the following:
            The TailoRx trial, using a 21 gene array, for women with estrogen/progesterone receptor positive early stage breast cancer just completed accrual about 2 weeks ago, The goal is to personalize cancer care so that a women is neither under- nor over- treated in the adjuvant setting.

          • HJ

            “If undiagnosed, an early stage breast cancer (e.g. Stage I or II) will progress over time to Stage IV”

            The statistics I have seen doesn’t support this statement. For every 2000 women who are screened, 1 life is saved while 10 are over-treated.

            “So, no, we do not shorten lives with treatment.”

            So there are studies that women unnecessarily treated for breast cancer live as long as those that didn’t undergo radiation and chemotherapy?

            “The goal is to personalize cancer care so that a women is neither under- nor over- treated in the adjuvant setting.”

            Until that happens, the USPSTF is spot on.

      • Thomas Reid Md PhD FACP

        Dear L,
        Unfortunately, not all risk factors for breast cancer are known.

        As a practicing medical oncologist, I do not benefit financially from ordering mammograms. I recommend what I consider best for my patients.

        • HJ

          “As a practicing medical oncologist, I do not benefit financially from ordering mammograms.”

          You do financial benefit from overtreatment.

  • Wellescent Health Blog

    Like all organizations at this level, the USPSTF will likely face considerable political pressures and will need to balance these against strong science. As governments change, their mandate will also be spun about on occasion as research meets current ideologies. With their ties to the purse strings, they will have considerable power and numerous parties offering unsolicited opinions on how best to wield that power. The key to its success will be to have strong ongoing leadership that can best serve the public in the prevailing winds of the time.

  • Marc Gorayeb, MD

    Virtually all of this mischief derives from the requirement that the screening services be ‘free’ to the public, and paid for by insurance companies. Why are insurance companies involved in this? If the govt deems it advisable to screen all citizens for a given disease, then it should do so directly.
    The purpose of insurance is for an individual to manage his or her perceived risk according to his or her personal need. If a person decides that he or she can forego certain coverage such as screening or preventive care tests, infertility treatments, or other lifestyle-based health services, then he or she should have the option of paying a lower insurance premium, and should not be penalized if the insurance company covers such services for other insureds. The Obamacare mandates are plainly designed to undermine market-driven private health insurance and individual choice.

  • Juliet K. Mavromatis, MD

    Don’t get me wrong, I think the USPSTF is a very important agency that offers useful guidelines…..but did you hear, they recently found insufficient evidence to support going to doctors….

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