The United States Preventive Services Task Force was created in 1984 to make evidence-based recommendations about clinical services, like screening, that make up essential elements of preventive care.  It's comprised of expert volunteers in fields of primary care and preventive medicine, including pediatrics, family medicine, and internal medicine, as well as OB/GYN, nursing, and behavioral health.  I talk about it all the time.  It's also the topic of this week's Healthcare Triage.

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In recent years, the USPTF has been the subject of increasing controversy, likely because it shifted from encouraging expensive and expansive screening to discouraging its overuse.  As with many things in medicine, it's  much more popular to do stuff than to tell people no.  Although the task force itself lacks specific representation from specific stakeholders, specialist physicians, and the public at large, it engages with them at multiple levels when conducting reviews.  It maintains comprehensive standards to monitor and manage financial conflicts of interest so that its reviews can remain as impartial and unbiased as possible.

Each recommendation is issued a specific letter grade.  An A means that the task force recommends that all clinicians offer or provide a service because there's a high certainty of a substantial net benefit.  A B also means that all clinicians should offer or provide a service, but that there's only a high certainty of a moderate net benefit or a moderate certainty that the net benefit is moderate to substantial.  A C level recommendation, on the other hand, says that a service should not be universally offered.  Instead, it should be left to the individual patient and clinician to decide whether the net benefit is worth the cost and potential harms.  A D recommendation argues that a service should not be used, because there's at least a moderate certainty of no net benefits, or that harms outweigh benefits.

The Affordable Care Act, in an effort to encourage the use of evidence-based beneficial preventive services mandates that all recommendations with an A or B rating be covered by insurance with no out-of-pocket payments.  In other words, they have to be completely free, regardless of the type or level of insurance coverage people have.  This doesn't mean, however, that recommendations with a C or D won't be covered by insurance.  They almost always are.  They just might be subject to deductibles, copays, or coinsurance.  It's up to the insurance provider to decide.

The final grade, that of I, argues that insufficient evidence exists to assess completely the harms and benefits.  It's a call for more research, as was done recently for autism screening, and we did an episode on that.  As I've discussed in the past, screening mammography for women age 50-74 years earned a B recommendation, as there is moderate net benefit to its biennial use in this age group.  Before the age of 50, however, a C recommendation indicates that women and their doctors should make individual decisions to screen.  

The D given to screening for prostate cancer with a PSA test argues that the use of the test likely does more harm than good.  The test forces review concluded that PSA screening did not result in a decrease in mortality when used broadly, and that the extra treatment screening induced had caused significant problems including the occasional death.  This type of recommendation has consequences.  The use of PSA screening in men has fallen.  A recent study published in JAMA showed that in 2010, before the USPSTF D announcement, about 35% of men between 50 and 74 were screened vs. just over 30% in 2013.  

Another study in the same journal examined the incidence of prostate cancer and the stage of cancer being diagnosed before and after the latest recommendations.  In 2008, about 541 cases of prostate cancer were diagnosed per 100,000 men.  In 2012, however, that number had dropped to 416.  From just 2011 to 2012, the researchers estimated that more than 33,000 fewer cases of prostate cancer had been diagnosed nationwide.  Is that good or bad?  It's hard to say.  Certainly some of those non-diagnoses will never cause problems and not lead to death, but some might.  In an accompanying editorial, Dr. David (?~4:07), chairman of urology at Vanderbilt University Medical Center argued that better strategies might be needed.  Perhaps we could screen less often, or target those at highest risk.  We might even raise the PSA threshold of suspicion, so that fewer non-threatening cases of cancer are acted upon.

The recommendations on mammograms, while less restrictive, have caused even more controversy.  However, they really haven't gone into effect.  In 2009, when the USPSTF issued the C rating for women younger than 50 years of age, many people got upset.  Amendments to the Affordable Care Act specifically mandated that the ACA would consider the 2002 report's B rating and not the 2009 report's C rating when making coverage decisions.  In other words, the ACA specifically ignored the 2009 recommendations and it'll continue to do so until the next set of recommendations come out.  That's happening now and once again, it's leading to controversy.  Bills have been submitted in both the House and the Senate to continue to override the USPSTF.  Another bill would radically change how the task force works and functions.

It's hard not to read all of this as an attack on the USPSTF itself.  Some argue that the task force is taking away medical procedures that would save lifes.  That's just not the case.  The ACA always intended that recommendations from the USPSTF, along with other bodies like the advisory committee on immunization practices, bright futures, and the committee on women's clinical preventive services be a floor, not a ceiling.  They were just supposed to identify those services which were so beneficial that they should be free of charge to anyone.

When they don't give an A or B, all they're doing is leaving it to payers to decide whether services should be free.  That's how insurance works for almost all other medical services.  There's no reason to blame the USPSTF for that state of affairs.  Further, if lawmakers don't like what payers are doing, they can overrule them with legislation, just like they did for screening mammograms.  That may make many people uncomfortable, including me.  After all, it's hard to argue that politicians always have the necessary expertise to understand the risks and benefits of complex medical procedures and tests.  Unfortunately, payers are obviously conflicted in determining what to cover and how much to make people pay.  Many Americans aren't happy leaving such decisions in their hands, either.

If we expect individuals to negotiate for packages designed just for them with respect to when screening is covered, we'll be back to the individually rated broken insurance system that we had before the ACA went into effect.  If we don't want to leave things up to the lawmakers or insurance companies, one of the few options left is to identify non-conflicted experts and let them make recommendations.  As we've seen from recent events, Americans aren't always satisfied with that either.  Someone has to decide.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation.  Your support makes this show bigger and better.  We'd especially like to thank our research associate Joe Sevits, give a special shout-out to Jonathon Dunn, and thank our surgeon admiral, Sam.  Thanks Joe and Jon.  Thanks, Sam.  More information can be found at patreon.com/healthcaretriage.  

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