Saturday, November 21, 2009

Physicians and patients will both pay more attention to the USPSTF after medical care is "reformed"

Very newsworthy in recent days has been the publication of the latest recommendations from the USPSTF regarding mammograms. Surprising to many and shocking to some were the changes from earlier recommendations and the degree to which they differ from the widely disseminated and adhered to recommendations of the American Cancer Society.

Seemingly to allay some of the shock and likely backlash from those who fear and/or write about the "r" word (rationing) in regard to health care , HHS Secretary Sebelius told the country not to worry about their recommendations regarding women less than fifty and over seventy-five .She reassured everyone that- no these are not binding to Medicare or to any insurance company and for everyone to go along just as they had before and be sure to check with their physician about proper advice in that regard.

DrRich of The Covert Rationing Blog dug through goodness knows how many pages of HR 3962 and pulled out some very interesting, and to some of us, very alarming provisions. Go here to read what he found.
HR 3962 provisions, if they survive, will elevate the USPSTF to something much more than an advisory body and morph them in to an entity named TFCPS (Task Force on Clinical Preventive Services) and when they make an "A" or a "B" level recommendation that will become part of the essential package that will be required to be included the coverage of "qualified health plans".

But there is even more. Not just incorporating future recommendation of the TFCPS aka USPSTF the HHS Secretary will go back and use their previous recommendations as policy. Here is a quote from the bill as reported by DrRich;

All recommendations of the Preventive Services Task Force and the Task Force on Community Preventive Services, as in existence on the day before the date of the enactment of this Act, shall be considered to be recommendations of the Task Force on Clinical Preventive Services and the Task Force on Community Preventive Services, respectively, established under sections 3131 and 3132 of the Public Health Service Act, as added by subsection (a).” (Section 3171, page 1319).

Since all their current recommendation may become policy not only should the breast cancer/mammograms interest groups be very interested, so should others and they read through their 2009 set of recommendations here.

The American college of Radiology alertly recognized what clout the USPSTF is likely to have and recommend that the USPSTF change its stance (fat chance of that) and/or for whatever deliberative body there will be to be more "inclusive".

In regard to the more narrow issue of what lead the USPSTF folks to reach their conclusion, this analysis by Dr. John Goodman is worthy considering. Apparently the issue of false positives and the necessary and costly followup weighed fairly heavy in their calculus. ( Aside, warning biased anecdote to follow -- in the years when I recommended PSA screening, over a five year period 12 cancers were detected and another 6 patients were evaluated and no cancer was found.Interesting the false positive group all expressed relief that they did not have cancer a view that I have also observed in other patients who had a scare based on a lab test.) From what I have observed the false positive issue is larger in the eyes of those who write guidelines and they speak of anxiety but really are concerned over aggregate cost that accrues when false positives are further evaluated.

Dr. Mark J Perry, an economist from the University of Michigan, makes insightful comments here regarding this issue.In the world of HSA (Health Saving Accounts ),which are under assault in the senate health care bill, the pronouncements of the USPSTF would not be determinative and the individual patient could confer with her individual physician to decide when and if you get mammograms and the secretary of HHS would not be in charge.

1 comment:

Michael Kirsch, M.D. said...

This was shameful conduct from Sebelius. This was a golden chance to demonstrate how comparative effectiveness research is supposed to work. Instead, she put the USPSTF revised guidelines into the wood chipper. This was gutless and feeds our pessimism and skepticism. Who will make the tough decisions we need? See http://bit.ly/656CwP