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Mammography Debate Rages After USPSTF Recommendation Changes

(photo by splorp)

(photo by splorp)

It was inevitable that the news of the US Preventive Services Task Force changing their guidelines on mammography would cause a political uproar. In a year where Congress is not trying to do comprehensive health care reform, the findings would be controversial. In this year, especially because of the role of the USPSTF in at least the House health care bill, it’s even more so.

Rep. Frank Pallone Jr. (D-N.J.) announced Tuesday that his House health subcommittee will hold hearings on the mammogram issue next month. Other lawmakers from both parties suggested that the task force had been swayed by insurance companies that stand to save money if fewer screenings are performed.

“We can’t allow the insurance industry to continue to drive health-care decisions,” said Rep. Debbie Wasserman Schultz (D-Fla.), who said earlier this year that she had undergone treatment for breast cancer.

I think that jumps to conclusions just a little. We have no idea if the recommendations will even result in fewer screenings. Adam Sonfield, a health policy expert at the Guttmacher Institute, said to me “I can’t imagine it would result in dropping coverage. It depends on whether doctors will agree with the recommendations, and if they don’t, I can’t imagine that insurance companies would want to upset their doctors and deny coverage to things they find medically necessary.” The early signs are that doctors will continue to recommend the same level of screening.

Despite new recommendations that most women start breast screening at 50 rather than 40, many doctors said Tuesday that they were simply not ready to make such a drastic change.

“It’s kind of hard to suggest that we should stop examining our patients and screening them,” said Dr. Annekathryn Goodman, director of the fellowship program in gynecological oncology at Massachusetts General Hospital. “I would be cautious about changing a practice that seems to work.”

The bigger question is how this change in USPSTF recommendations would affect the health care bills. . . .  Dan Pfeiffer, the White House communications director, took to the White House blog to knock down criticism of the decision and the implications. Pfeiffer correctly explains that the USPSTF recommendations would be used to determine which preventive services would be exempt from cost sharing, not what services would be required for coverage. Pfeiffer says that “Women who are currently getting mammograms under Medicare will continue to be able to get them,” and since women on Medicare are over 50, that’s self-evident, since the recommendations didn’t change for that group of people – also, there would need to be a formal rulemaking process to change those guidelines. In addition, 49 states already mandate breast cancer screenings be covered for women over 40, and there’s no sign of that changing.

As for the cost sharing role for the USPSTF:

We have tremendous respect for the Task Force and the work they have done. They are an independent scientific body that makes recommendations based on scientific evidence; however they do not set official policy for the federal government. Under health reform, their recommendations would be used to identify preventive services that must be provided for little or no cost […]

What do these recommendations mean for the current health reform bills?

While the bills are still being drafted and debated in Congress, health insurance reform legislation generally calls for the Task Force’s recommendations to help determine the types of preventive services that must be provided for little or no cost. The recommendations alone cannot be used to deny treatment.

This tracks with what I’ve been saying about how the USPSTF recommendations are limited to cost sharing and not coverage. What’s unclear, however, is whether only recommended services would be free or at little cost, or whether the HHS Secretary could go beyond that in the implementation phase. “It’s unclear from the legislation,” said Sonfield, the health policy expert. “There are interpretations either way.”

Perhaps the bigger issue is whether the USPSTF has the capacity or the time to make recommendations on every single preventive service, calling into question whether they should be used as a baseline for things like cost sharing. That’s why the Senate bill, which added the opportunity for additional preventive services beyond the USPSTF recommendations to be free, improves upon the House language.

CommunityThe Bullpen

Mammography Debate Rages After USPSTF Recommendation Changes

It was inevitable that the news of the US Preventive Services Task Force changing their guidelines on mammography would cause a political uproar. In a year where Congress is not trying to do comprehensive health care reform, the findings would be controversial. In this year, especially because of the role of the USPSTF in at least the House health care bill, it’s even more so.

Rep. Frank Pallone Jr. (D-N.J.) announced Tuesday that his House health subcommittee will hold hearings on the mammogram issue next month. Other lawmakers from both parties suggested that the task force had been swayed by insurance companies that stand to save money if fewer screenings are performed.

“We can’t allow the insurance industry to continue to drive health-care decisions,” said Rep. Debbie Wasserman Schultz (D-Fla.), who said earlier this year that she had undergone treatment for breast cancer.

I think that jumps to conclusions just a little. We have no idea if the recommendations will even result in fewer screenings. Adam Sonfield, a health policy expert at the Guttmacher Institute, said to me “I can’t imagine it would result in dropping coverage. It depends on whether doctors will agree with the recommendations, and if they don’t, I can’t imagine that insurance companies would want to upset their doctors and deny coverage to things they find medically necessary.” The early signs are that doctors will continue to recommend the same level of screening.

Despite new recommendations that most women start breast screening at 50 rather than 40, many doctors said Tuesday that they were simply not ready to make such a drastic change.

“It’s kind of hard to suggest that we should stop examining our patients and screening them,” said Dr. Annekathryn Goodman, director of the fellowship program in gynecological oncology at Massachusetts General Hospital. “I would be cautious about changing a practice that seems to work.”

The bigger question is how this change in USPSTF recommendations would affect the health care bills. Dan Pfeiffer, the White House communications director, took to the White House blog to knock down criticism of the decision and the implications. Pfeiffer correctly explains that the USPSTF recommendations would be used to determine which preventive services would be exempt from cost sharing, not what services would be required for coverage. Pfeiffer says that “Women who are currently getting mammograms under Medicare will continue to be able to get them,” and since women on Medicare are over 50, that’s self-evident, since the recommendations didn’t change for that group of people – also, there would need to be a formal rulemaking process to change those guidelines. In addition, 49 states already mandate breast cancer screenings be covered for women over 40, and there’s no sign of that changing.

As for the cost sharing role for the USPSTF:

We have tremendous respect for the Task Force and the work they have done. They are an independent scientific body that makes recommendations based on scientific evidence; however they do not set official policy for the federal government. Under health reform, their recommendations would be used to identify preventive services that must be provided for little or no cost […]

What do these recommendations mean for the current health reform bills?

While the bills are still being drafted and debated in Congress, health insurance reform legislation generally calls for the Task Force’s recommendations to help determine the types of preventive services that must be provided for little or no cost. The recommendations alone cannot be used to deny treatment.

This tracks with what I’ve been saying about how the USPSTF recommendations are limited to cost sharing and not coverage. What’s unclear, however, is whether only recommended services would be free or at little cost, or whether the HHS Secretary could go beyond that in the implementation phase. “It’s unclear from the legislation,” said Sonfield, the health policy expert. “There are interpretations either way.”

Perhaps the bigger issue is whether the USPSTF has the capacity or the time to make recommendations on every single preventive service, calling into question whether they should be used as a baseline for things like cost sharing. That’s why the Senate bill, which added the opportunity for additional preventive services beyond the USPSTF recommendations to be free, improves upon the House language.

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David Dayen

David Dayen