How will ObamaCare affect prostate cancer screening?

When President Obama turned 50 last year, he made an “informed patient request” for a PSA (prostate specific antigen) test. This is the blood test routinely used to screen men over 50 for possible prostate cancer. The President received his PSA test. But under ObamaCare, you may not be able to.

Now that ObamaCare has been upheld by the Supreme Court, all of its major provisions will be in force, not just the controversial “individual mandate.” This includes government medical practice guidelines that will affect millions of Americans.

ObamaCare empowers the government U.S. Preventive Services Task Force (USPSTF) to determine which preventive health services are medically appropriate. This is the same agency that aroused enormous controversy in 2009 when it proposed restricting screening mammograms to women over age 50 (and only every 2 years), despite the proven benefits of annual mammograms beginning at age 40. (Under pressure, Secretary of Health Sebelius later backpedalled from those guidelines, declaring them non-binding.)

This year, the USPSTF aroused similar controversy by giving a “D” grade (“not recommended”) to routine PSA prostate cancer screening.

Prostate cancer is the most common cancer affecting American men and the second leading cause of cancer deaths. Thousands of American men have benefited from early detection and treatment of prostate cancer made possible by PSA testing.

However, there are legitimate scientific debates regarding PSA screening. PSA testing, like all screening tests, is not 100% accurate. Some patients who initially test positive will undergo further biopsy or surgery that show it was a false alarm. Others who test positive will have slow-growing cancers that do not require treatment — i.e., they will die from unrelated conditions before their prostate cancers pose a threat. Some patients who test positive will suffer unavoidable complications from subsequent “downstream” biopsies or surgeries that in retrospect weren’t necessary. PSA testing can thus cause some patients more harm than good.

For these reasons, the American Cancer Society does not issue a hard-and-fast rule about PSA screening. Instead, they recommend that men over 50 make an “informed decision” following a discussion with their doctor on the “uncertainties, risks, and potential benefits of prostate cancer screening.”

Medicine cannot be reduced to cookbook procedures. A 50-year old African-American man whose father and brother both died of prostate cancer might legitimately prefer PSA screening, whereas a 50-year old Caucasian man without risk factors might legitimately choose to skip it. Patients should decide based on their overall health, family history, and the benefits of detecting a treatable cancer vs. the risks of unnecessary downstream procedures. The physician’s job is to honestly advise the patient of his best medical interests. This is the heart of the doctor-patient relationship.

However, the USPSTF guidelines will undermine this doctor-patient relationship because of their enhanced role under ObamaCare.

ObamaCare links insurance coverage of preventive medical services to their USPSTF rating. Medicare must cover all “A” or “B” services, such as cholesterol testing or colonoscopies. For now, Medicare still covers PSA screening despite the USPSTF “D” rating. But under ObamaCare, Medicare payment decisions will become increasingly controlled by the new Independent Payment Advisory Board, explicitly created to reduce Medicare spending. Given Medicare’s skyrocketing costs, it’s only a matter of time before the government stops paying for services that its own scientific panel has given a “D” rating.

Similarly, private health insurance companies must cover for “free” all USPSTF “A” or “B” rated services, while abiding by government price controls. To reduce costs, many private insurers will likely drop coverage for “C” and “D” rated services. Hence under ObamaCare, the USPSTF guidelines will likely become the de facto standards for both government and private health insurance coverage.

But suppose a patient wishes to pay for PSA testing with his own money, rather than through insurance? Even then, ObamaCare will make that more difficult.

ObamaCare includes various financial carrots and sticks to pressure doctors into joining large “Accountable Care Organizations” (ACOs). These ACOs will use mandatory electronic medical records to track how closely physicians adhere to government practice guidelines. Doctors who obey government practice guidelines will be rewarded. Those who order more tests or procedures than the government deems necessary will be penalized.

ACO physicians may thus be reluctant to recommend PSA screening even when the patient is willing to pay for it himself. Patients who test positive will require further downstream procedures such as prostate ultrasounds, MRI scans, or biopsies, which may count against the doctor’s ACO practice statistics. USPSTF guidelines could slowly erode many doctors’ willingness to offer their best honest advice to their patients. If your doctor recommends against a PSA test, can you be sure he’s offering his best medical opinion, without being biased by the bonus he’ll receive for reducing the number of procedures performed by the ACO?

Urologists — who regularly treat patients with prostate cancer — are overwhelmingly opposed to the USPSTF guidelines. Dr. Ian Thompson, a urologist at the University of Texas, notes that the USPSTF guidelines will prevent his patients from making properly informed decisions about their own health. Instead, they amount to a bureaucrat telling patients, “Follow my priorities instead of your own.”

When President Obama had his routine physical last year, he enjoyed the freedom to consult with his doctors, weigh the pros and cons of PSA testing, and decide for himself what was in his best medical interest. But under ObamaCare, the President will not allow you that same freedom. Instead, the federal government will decide for you.

Is that fair? Is President Obama’s prostate gland more important than yours?

Paul Hsieh is a radiologist and co-founder of Freedom and Individual Rights in Medicine.  This article originally appeared in Forbes.

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  • http://www.facebook.com/profile.php?id=1536833852 Rick Lundgren

    The scientist who discovered the original PSA, Richard Ablin, PhD, from the University of Arizona College of Medicine in Tucson, said that he was “elated” with the USPSTF recommendation. Dr. Ablin has long argued that the PSA test should not be used for routine screening of healthy men because it is not specific for prostate cancer. He also famously described the testing as a “public health disaster.” The American Cancer Society’s chief medical officer, Dr. Otis Brawley, said he agreed with the Task Force recommendations. The previous rating USPSTF was an “I”? Hardly suggestive of a vote of confidence before. However, DRE’s are not recommened by the USPSTF yet that is still covered by Medicare. I feel the same will occur with PSA screening.

  • http://www.facebook.com/profile.php?id=826734007 David Hanson

    Of course. the urologists want to continue PSA testing (when used as general population screening) even it is more harmful on average than helpful. They are looking out for their own self interest. Obamacare is not good but if they can eliminate harmful testing like PSA and mammograms, it will do a little good. The medical industry has “educated” the public to almost completely misunderstand cancer. Combine that with the mathematical and statistical dumbness of the people and we have the current political mess about population screening.

  • Killroy71

    Interesting….next, will we have urologists writing in support of mammograms, despite the evidence?
    All doctors at least pay lip service to evidence, except when it affects their own practice. I suspect that a person’s actual risk factors would be considered when determining whether screenings are medically necessary, factors over and above hitting a certain birthday.

  • http://www.facebook.com/PaulHsiehMD Paul Hsieh

    So if the USPSTF recommendations should be hard-and-fast rules and PSA screening is medically inappropriate for the population at large, then President Obama’s physicians committed an egregious error in allowing him to receive a PSA test.

    On the other hand, if it was appropriate to allow the President some latitude to decide this for himself (in consultation with his physicians), then *all* Americans should enjoy the same latitude.

  • southerndoc1

    “ObamaCare empowers the government U.S. Preventive Services Task Force (USPSTF) to

  • Ronald Yap

    Nice post, Paul.
    The PSA screening controversy is nuanced and not one that is easily solved by a singular blanket statement against screening altogether.
    The USPSTF guidelines were created without involvement of specialists such as radiation oncologists, oncologists, or urologists. This has reached the attention of the AMA who recently passed a resolution advising the USPSTF to take into account specialists when making future recommendations.
    Ron Yap, MD – http://prostatepals.blogspot.com

    • http://twitter.com/zindoc Keith Marton

      While the USPSTF is made up of people who specialize in health services research, epidemiology and clinical decision making, it does not include clinical specialists from the affected decision areas. However, that does NOT mean that these specialties were/are not involved. In fact, the USPSTF asks for input from many sources, including specialty societies before it reaches it conclusions.
      So let’s dispense with the myth that these guidelines were “created without involvement of specialists…” They were definitely involved. , What WAS left out from the guideline development was this: conflict of interest.
      Furthermore, these guidlines and their implementation reflect a truly American process. All available and credible evidence is weighed to create a guideline. It’s then disseminated to be used in any number of ways, the most common being “use it however you want’. If a payer chooses to not pay for it, then an individual–if they choose– can stiil pay for it himself. That is, the test has not been outlawed, It’s still very much out there, but now there’s more evidence to support the contention of “let the buyer beware” . A thoughtful doc might offer the following advice to a patient” “If you’re terrified of prostate cancer and want to do anything to avoid it, then you might want to undergo a PSA. If you don’t liked being poked and prodded by physicians, then you might want to forego the test.”

      By the way, the evidence about the failings of the PSA have been out there for years. I’m a 67 year old physician. When i turned 50, I explicitly told my doctor that i did NOT want a PSA ( don’t like being poked and prodded unnecessarily ), and have repeated those instructions every year since without regret. Having looked at other evidence, I have faithfully undergone colon cancer screening and have hounded–successfully–my wife to have regular mammograms.

  • http://www.facebook.com/people/Hilary-Gerber/600851082 Hilary Gerber

    The USPSTF recommendations are written by top clinical researchers in their fields based on evidence, not by bureaucrats. Politicizing evidence based care is what keeps patients from making informed decisions, not evidence based recommendations.

  • http://twitter.com/WindyCityMed Michael Mank

    Everyone seems to want greater quality and decreased costs; however, when some tests or measures are taken off the table, a lot of people get into an uproar over it. My comment is not necessarily aimed at the PSA test, but you can’t have your cake and eat it too. The triangle of access, quality, and costs is a delicate balance- when you increase one aspect, you may lose in another area. To have a “task force” of educated professionals in the respective fields looking out for the quality of care for patients, the costs they incur, and their access to such procedures, one of the corners of the triangle may just have to give. And if the health care industry, gov’t, and/or medical professionals feel they may have made the wrong suggestion, then it’s back to the drawing board. However, I welcome these endeavors.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      The problem is in the definition of the term “quality”. Guidelines look at quality averaged over populations. People tend to look at quality in their own backyard. The two are not always synonymous.

      If the USPSTF would just issue guidelines that are adopted as standard of care, which means physicians are not exposed to malpractice suits if they adhere to the guidelines, but payers would still honor doctors’ orders even if they go against the guidelines, costs will go down and both types of “quality” will probably increase, along with preserving patients’ freedom of choice and doctors’ freedom to practice good medicine.
      Brute force and blunt instruments are seldom effective when a “delicate balance” is involved.

      • http://twitter.com/WindyCityMed Michael Mank

        If you are equating “quality in their own backyard” with patient satisfaction, I invite you to read a JAMA article on how patient-centered care and patient satisfaction are different (http://jama.jamanetwork.com/article.aspx?articleid=1216487#.T_75F2cDvVA.twitter). Unfortunately, many patients may feel that quality is higher when they are happy with the decisions made.

        Furthermore, specifically for the PSA test, a NEJM article suggested that $5.2 million would be spent on screening and the interventions that follow to prevent one prostate cancer death. http://www.nejm.org/doi/full/10.1056/NEJMp1112191

        Ideally, doctors are supposed to do what is best for their patients. I think many men will still choose to opt in for the PSA even if they are presented with evidence that suggests otherwise. Unfortunately, this may be due to the culture of aggressive medicine that has developed. When some procedures are advised against, some may think their freedoms are being stripped, and they may develop a “Don’t tread on me” attitude.

  • http://twitter.com/sbstrum Stephen B. Strum

    As a medical oncologist subspecializing in PC (prostate cancer) starting in 1983, 4 years prior to FDA approval of the PSA test, and continuing my private practice until Jan of 2012, I can say with certainty the following:
    1. The PSA is the most valuable biologic marker for the most common malignancy of men.
    2. Understanding the PSA and PSA derivatives allows for intelligent risk assessment re the Dx of PC and the ability to monitor men already diagnosed with PC.
    3. Utilizing the CONTEXT of the patient, a Dx of PC should, in the hands of a competent healthcare practitioner (HCP) lead to the proper selection of treatment. In other words, a Dx of PC does not equate with invasive therapies. The biologic milieu, and extent of disease coupled with patient context and patient wishes are key elements of the equation relating to what is eventually done.
    4. A Dx of PC that does not lead to invasive treatment of PC, but instead to an AOS (active objectified surveillance) approach, should also understand that a PC diagnosis is a red flag indicating something is awry in the homeostasis of health. In a way, this is a unified field concept of health i.e., when you find a serious illness like PC, look for related issues that are subclinical but ones that could quickly eventuate to morbidity or mortality e.g., bone loss, CVD (cardiovascular disease), neurodegenerative disease (NDD), vitamin D deficiency, LDL oxidative damage, excessive inflammation as per omega-6 fatty acids to omega-3 fatty acids ratios.

    In essence, the PSA test in the hands of an astute HCP can be of huge significance to the health of an individual, and in the end, should result in billions of dollars saved re healthcare costs. Like everything else in which humankind is involved, distinction between the message and the messenger always muddies clarity of thought.
    Stephen B. Strum, MD, FACP
    Board Certified: Internal Medicine, Medical Oncology
    Member: ASCO, ASTRO; former member of AUA

    Member: International Strategic Cancer Alliance (ISCA)
    538 Granite Street
    Ashland, OR 97520
    T: 541-482-5884
    E: stephen@sbstrum.com

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