In the fight over Obamacare, one of the hottest points of
contention has been the Independent Payment Advisory Board (IPAB),
an unelected body with powers so broad that it has been called a
“super-legislature”
by some, and a potential “death panel” by others. Major policies
set by the IPAB will have the force of law unless they are
explicitly blocked by Congress. The usual order, of course, is
that Congress is supposed to make the laws and bureaucrats are
supposed to follow them.
Another nasty ingredient in the alphabet soup of Obamacare
is the United States Preventive Services Task Force (USPSTF). This
is “an independent group of national experts in prevention and
evidence-based medicine.” Formerly a sleepy quasi-governmental body
charged with making recommendations about public health screening,
under Obamacare the USPSTF will determine whether your doctor will
be able to diagnose you with diseases.
The USPSTF first made headlines in 2009 when it encouraged women
under the age of 50 to forgo mammogram screening for breast cancer.
Only after an outcry from women’s and cancer advocacy groups did
Health and Human Services Secretary Kathleen Sebelius beat a hasty
retreat, distancing her department from the USPSTF
recommendations.
More recently, the USPSTF advised against use of the
prostate specific antigen (PSA) test. The routine screening of all
men over the age of 50 via PSA testing was originally thought to
have revolutionized the detection and treatment of prostate cancer.
Prior to the development of this test, prostate cancer was almost
always detected after it had already spread—too late to do
anything other than manage the pain and complications it
causes. The medical community understandably embraced PSA
testing, which allowed the disease to be detected in its early
stages.
An unqualified success story?
Hardly. PSA testing detected far more cases of prostate
cancer than had been seen before. Many men suddenly being diagnosed
with (and treated for) prostate cancer would, prior to PSA testing,
have died of other causes, blissfully unaware that they had cancer.
The question, though, has been this: Who benefits from early
treatment, and who is better off left alone? Early on, there was no
way of knowing, so to be on the safe side, nearly all cases were
treated—which meant that some men suffered complications from
treatments that they didn’t need. About that, the USPSTF isn’t
wrong.
Money also entered the picture. A
damning article in the Wall Street
Journal in 2010 revealed that some large urology groups
were setting up lucrative radiation treatment centers to which they
referred nearly all their patients. All this at a time when
responsible urologists were developing and following
observation
protocols to monitor the severity of the disease, only
stepping in to treat in those cases that showed signs of starting
to advance.
What does all of this have to do with the USPSTF? A
blanket declaration that primary care providers shouldn’t screen
for a particular disease tells patients that they are really better
off not knowing whether they have it or not. If you do happen to be
the unlucky bloke whose lethal cancer could have been prevented by
early detection, well, that’s tough luck.
You’re probably wondering whether, under Obamacare,
the USPSTF’s recommendations are binding. The answer is yes
and no. Medicare and other insurers are required to provide
treatments or services given an “A” or “B” grade without cost to
the patient. The law is silent when it comes to services with
grades of “C” or “D,” which explains why Kathleen Sebelius got away
with backpedaling on the USPSTF’s mammography guidelines in
2009, saying that they were “just recommendations.” For the moment,
Medicare still pays for an annual PSA screening.
But technocrats of the future might well offer a radically
different interpretation of the law’s silence. For instance, as
“pay for performance” measures are introduced, there may be
negative ramifications for doctors who frequently order tests
assigned a “C” or “D” grade.
The USPSTF includes the requisite disclaimers, including
the caveat that doctors should exercise judgment and discuss the
pros and cons of various tests with their patients. This seems
reasonable, but the reality is that few non-specialists have either
the knowledge or the time for such discussions. As Obamacare takes
effect and physicians come under increasing scrutinty for their
adherence to official protocols (set, of course, by panels like the
USPSTF), even this level of individual judgment may drop by the
wayside.
About individual judgment: When President Obama had his
physical last year, he made an “informed
patient request.” Guess what it was? Yes, indeed…he was
screened for prostate cancer with a PSA test, in spite of the fact
that the USPSTF’s recently published (and well-publicized) draft
recommendation statement recommended against it. The President’s
physicians were fully aware of this recommendation, which is why
the weasel words of “informed patient request” were used. You see,
a busy president had done his homework and decided on his own to
request a PSA test. He apparently went through with it even after
his own government agencies advised him that the test was
worthless. Right.
Legislation was introduced last year to reform this task
force. The USPSTF Transparency and Accountability Act would have
brought some balance to the panel. Among other things, the act
would have required knowledgeable specialists to be present on the
task force. At present, the USPSTF is making decisions without any
input either from specialists who work with these diseases on a
daily basis or from patient advocacy groups. The act would would
have also made the process by which task force members are
appointed more transparent. (Currently they are chosen by an agency
head who is in turn appointed by the HHS Secretary.) But most
importantly, the bill would have prevented Medicare from denying
coverage for medical tests based on the USPSTF’s opinions.
Unfortunately, with Democrats still in control of both the White
House and the Senate, the chances a bill like this will see the
light of day are slim.
The take-home point is not about prostate cancer or PSA
testing. We should certainly hope that medical science will
continue to refine the answers to questions about exactly who needs
a given test or a given treatment. We should hope that better tests
and less invasive treatments will be developed. In a few decades we
will look back on current medical practices and shake our heads,
just as medical professionals now look back with disbelief at
things that were done routinely in the 1960s.
The point isn’t even about the questionable medical
judgment of the USPSTF. Rather, it is that we are only beginning to
discover the implications of Obamacare, under which unelected
boards like the IPAB and the USPSTF will have the unprecedented
power to dictate what were once doctor-patient decisions.
Nancy Pelosi famously said that we would just have to pass the
Obamacare bill in order to find out what was in it. About that, she
wasn’t lying.
Image: Creative Commons
