WASHINGTON -- It was the specialists versus the generalists at Wednesday's House hearing on the workings of the U.S. Preventive Services Task Force (USPSTF).
"This is a classic battle that begins in medical school and we're seeing it here again today," (R-Ind.), a member of the House Energy & Commerce Health Subcommittee, said during a hearing examining the work of the task force. The hearing was called in part to discuss a bill sponsored by committee vice-chair (R-Tenn.); would require specialists and sub-specialists to be involved in reviewing the preventive services that the task force examines.
The bill also creates a preventive services advisory board to ensure patient groups, providers, and federal agencies are all involved with USPSTF decisions, and would require the Government Accountability Office to submit a report comparing USPSTF's recommendations with other federal government health guidelines.
Committee members expressed concerns that the Affordable Care Act requires that insurers cover only those preventive services that are given an "A" or "B" grade by the task force. "We have seen from past experiences with PSA [the prostate-specific antigen test] and mammograms, that the task force recommendations have consequences and can deprive patients of lifesaving services," said (R-Texas). Burgess was referring to USPSTF recommendations against routine PSA screening as well as those against routine mammograms in women ages 40-49.
"I recognize that preventive services can prolong the lives of Americans and save tax dollars, but it's important ... that patients and doctors maintain a place in the decision-making process," he said.
(R-N.Y.) questioned the hearing's first witness, task force chair , of the University of California San Francisco, about the fact that the task force doesn't include the cost of a service in its deliberations. "It is in your charter to take into account cost-effectiveness," he said.
That might be true, Bibbins-Domingo replied, but "it is our policy not to consider costs. The main reason is we want people to focus on effectiveness ... We made our own decision not to consider cost. It is in our charter but we've never done it in 32 years." If the task force didn't operate that way, she added, "People would get worried that we are withholding things or making decisions because of costs."
Bibbins-Domingo said that the task force's website clearly states that cost is not a consideration in the committee's deliberations, but Blackburn took issue with that. "Under the task force's standards for guidelines and development, they don't list that they don't consider cost and don't note that they do not follow their charter," and when you go to the website's search function and enter the word "cost," nothing comes up, she noted.
The committee's other two witnesses -- one a specialist and the other a generalist -- presented dueling views on Blackburn's bill.
"Having a specialty voice for individual recommendations could improve the outreach and review process," said , a urologist at Georgetown University here and a prostate cancer survivor.
He related the case of a patient who recently came in and was having urologic symptoms. After performing some tests, Lynch diagnosed him with metastatic prostate cancer that had spread throughout his body -- "treatable but not curable," he said. The man's primary care physician had been performing screening PSA tests on him, but stopped in 2012 after several years of normal results in conjunction with the task force recommendation against routine prostate cancer screening.
"Because prostate cancer often grows slowly, the task force said, screening finds many tumors that wouldn't [otherwise] harm people ... I and many urologists strongly disagree with the task force assessment; it would be better to 'screen smarter,'" he said.
, president of the American Academy of Family Physicians and a family doctor in Centreville, Ala., said, "Subspecialists already contribute to the task force process and they are consulted every step along the way. While we respect our subspecialist colleagues, their role in treating such conditions is not the same as developing guidelines to screen for and prevent such conditions."
In recent years, he noted "our [members] have been subjected to intense lobbying" from various interest groups regarding screening and other medical issues, and "pressure from these groups would only increase if H.R. 1151 was signed into law."
"I strongly support the current process and believe decisions should be made [regardless of cost]," he concluded. "If it ain't broke, don't fix it. Ladies and gentlemen, the USPSTF is not broken ... Please, do no harm."
None of the subcommittee's Democratic members were present because the Democratic caucus was having leadership elections while the hearing was being held. However, (D-N.J.), the committee's ranking member, submitted an opening statement criticizing Blackburn's bill. "Those changes [in the bill] could drive the task force away from its focus of providing unbiased recommendations to primary care providers and providing recommendations influenced by financial interests and other harmful influences," he said.
"These proposed changes to the task force could ultimately put patients in harm's way and needlessly drive up healthcare costs. I'm also concerned that this discussion draft could potentially disrupt the Affordable Care Act's guarantee of private insurance coverage for preventive services without copayments or coinsurance," Pallone said. "Preventive care is an important component of public health, and the USPSTF is a critical resource to our doctors. The integrity and reliability of the task force recommendation process must be protected against bias and any interests that do not put the patient at highest priority."