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.