It’s Nice That the USPSTF Isn’t NICE … For Now
Christine Harbin recently wrote an interesting post about the new mammography guidelines issued by the U.S. Preventive Services Task Force. This is a hot topic in the public health field at the moment, and we have talked about it in a number of my graduate classes. I agree with Chrissy’s ultimate reasoning: When something is paid for with tax dollars, the taxpayers should be getting the best bang for their buck. However, I disagree with the USPSTF’s new recommendations, because they did not use sound reasoning in formulating them. Their recommendations have potentially negative ramifications for future coverage when one considers them in light of the pending federal health care legislation.
The USPSTF based its guidelines on the results of a poorly conducted study. Some of the data is predicated on decades old studies, which were conducted when mammography was very different than it is today. The American Cancer Society looked at the all the data and additional studies, and came to the opposite conclusion. Out of all breast cancer deaths, 17 percent occurred in women who were diagnosed from ages 40 to 49, and deaths of similar women would substantially increase if women were not screened until their 50s.
Additionally, the USPSTF study did not take into account more recent studies or changes in health technology, like digital mammography, which is more effective for finding tumors in dense breast tissue — something more common in women aged 40 to 50, the very group that USPSTF recommended against receiving annual mammography. The group’s recommendation may have made sense a few decades ago, when some of the studies originally came out, but it does not make sense in light of today’s constantly improving technology.
Potential anxiety over false positives and overtreatment supposedly justify the USPSTF’s recommendation. Yes, overtreatment might be a problem, but most women (if they are going to get a mammogram) are trying to detect a potentially deadly disease. Personally, I would prefer to get a false positive than to miss a fatal true positive. When I turn 40, I want to be able to get a mammogram. I want to have the choice either to select an insurance company that covers it, or to be able to pay for the test out of pocket.
This may not be an option very soon. At the end of her post, Chrissy wrote:
Paranthetically, I want to point out that the guidelines issued by the U.S. Preventive Services Task Force are normative and non-binding. The panel isn’t banning anything. A person can get a mammogram or a PSA test at any age if she or he has both the desire and the ability to pay for them, either via insurance or out of pocket.
This is true — but not entirely true. The recently proposed federal health reform legislation specified that insurance companies and Medicare will cover what USPSTF recommends. Even now, certain insurance companies and Medicare base their compensation decisions in part on the USPSTF guidelines. This is a real problem. It is illegal to accept Medicare money outside of the Medicare system (if a doctor takes any Medicare patients), so it could conceivably become illegal for non-recommended breast exams. This may not have been USPSTF’s intention, but unintended consequences always need to be considered.
The USPSTF’s recommendtion is a great preview of what it would be like if the National Health Institute of Clinical Excellence (NICE) or a governmental group were making health decisions for the United States. The USPSTF’s study was poorly conducted — but it will still have repercussions for insurance coverage if it or any government entity chooses what constitutes a proper private insurance plan.
I completely agree with Chrissy that when taxpayer funds are involved, cost-effectiveness needs to be considered. But, when health is involved, most individuals would like to make the decision — and pay for it themselves — than to let a government organization like USPSTF base life-and-death decisions on questionable science.
I don’t think your interpretation of the legislation is correct.
It says, “private insurers, Medicare and Medicaid would only be required to cover services receiving a specific grade from the U.S. Preventative Services Task Force.” This does not mean that private insurers cannot go beyond what is required.
I am confused by your argument. Didn’t you earlier suggest that the government should limit its requirements and let the market and individuals decide how much coverage they consume?
Comment by Andrew Hanson — December 6, 2009 @ 3:30 p.m.
Andrew,
I wasn’t making an argument in that line. I was only making the point that the recommendations DO have ramifications, especially for Medicare/Medicaid, which have specific rules for what participants can do outside of it.
Comment by Caitlin Hartsell — December 6, 2009 @ 11:38 p.m.
Also, I pointed out the implications of the USPSTF being the decider of what “needs to be included” as an issue overall. They were wrong here, and recommended against something. But what if they are wrong in the other direction, and recommend things that the public does not need? Then we have the issue of every health insurance package coming with things people don’t need, and not including things people need. That is hardly a market situation, and it will be extremely expensive for people to find the appropriate equilibrium.
We do not know whether the insurance mandates in the new bill will be like Canada (where you cannot go above it) or the UK (where you can purchase another tier of private insurance.) Our governmental insurance is currently like Canada, but if our private insurance becomes more like the UK, than the mammography wouldn’t be as big of an issue. (But as I said before)
Comment by Caitlin Hartsell — December 7, 2009 @ 8:26 a.m.
Caitlin,
Your position is still a bit unclear to me. It seems like you’re trying to come at this beast from two incompatible angles.
First, you’re giving a free-market-equilibrium analysis about health care. “If the government mandates X minimum of coverage, it will effectively be a price floor that will result in a supply shortage of health care that will increase costs and lower the quality of care.” Note that this argument doesn’t work in the current context. If the government reduces or restricts its mandated minimum (i.e., its recommendation), equilibrium will be unaffected.
Second, you’re arguing that government should increase its mandated minimum because–well, the ACS thinks people of ages 40 to 50 should get mammograms. I’m not clear on how you’re reconciling these two positions.
Perhaps it’s this: “the recommendations DO have ramifications, especially for Medicare/Medicaid, which have specific rules for what participants can do outside of it.” I’m not aware of any rule that does not allow participants to purchase insurance that covers mammograms. In either case, individuals can seek supplemental insurance or pay out of pocket.
Comment by Andrew Hanson — December 7, 2009 @ 8:58 p.m.
Perhaps I was not clear: the thesis of this post is that it is a bad idea to let a government entity (like USPSTF) make decisions about what should or should not be included in health insurance/care, because they are very inept at it (case in point: bad mammography recommendation). They (questionably) recommended against mammograms; this lowers the mandate in this one instance. But when this is the group making health insurance decisions, who is to say they won’t keep making bad recommendations, but in the other direction? (I don’t have any of their data off hand on other recommendations.)
They WILL be the decider when the bill is passed. There is no “rule that does not allow participants to purchase insurance that covers mammograms” but there is a rule that patients cannot use their own money outside of Medicare. Medicare currently follows the USPSTF recommendations, and will after the bill is passed.
This is more of an illustration of what can and will happen if the bill passes and the USPSTF decides what a “proper” insurance package covers: it will have things people don’t want and won’t include things that people need.
Comment by Caitlin Hartsell — December 8, 2009 @ 12:49 p.m.