I hope you had a chance to read an article published online in the Journal of the American Medical Association (JAMA) on April 18. Authors Steven Woolf and Doug Campos-Outcalt very clearly explain the growing concern associated with a provision in the Affordable Care Act (ACA) that mandates first-dollar coverage for any preventive service that receives an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF). It’s a concern that I and many others share. If you’re not familiar with the term, first-dollar coverage means that patients have no copayments and no out-of-pocket expenses for services that qualify for first-dollar coverage. The ACA specifies that payers must provide first-dollar coverage for all preventive services for which the USPSTF has determined there is compelling scientific evidence that the benefits outweigh the risks.
Why am I concerned? Certainly I agree that evidence must form the foundation for the services we provide to patients. After all, I’ve dedicated my business to the delivery of high-quality healthcare and improved outcomes through the integration of evidence into decision making and policy development. But other factors come into play, as well, and they should be used to inform coverage policy. Basing coverage policies on the recommendations of one group is hardly ideal.
A big problem with the ACA as currently written is that by linking the USPSTF’s recommendations with policy, it risks the organization’s objectivity and autonomy. Since its creation during the Reagan administration, the role of the USPSTF has been solely to review and grade the scientific evidence to determine whether certain screening and preventive services resulted in a net benefit to patients. It was not charged with developing coverage policy then, nor should it be now.
Once the payment issue enters the equation, the potential for bias explodes. The authors of the JAMA article explain the external pressures to which the ACA exposes the USPSTF, so I won’t repeat their argument here other than to say they are right on the mark. Any entity that has a vested interest in the USPSTF’s recommendations soon will be beating down the door trying to exert influence. Unfortunately, most of these organizations have an inherent conflict of interest. Manufacturers could push for the inclusion in the recommendations of products they sell. Likewise, professional specialty societies and patient-advocacy organizations that have a strategic plan for expanding awareness and coverage for a particular disease and/or intervention might decide to lobby legislators who could potentially influence the USPSTF’s recommendations. I’m not implying here that the USPSTF won’t continue to be objective, but let’s face it. Objectivity often becomes compromised under political pressure.
So what’s the solution? We need to maintain the integrity of the USPSTF and enable it to focus on providing the public with unbiased information about efficacy and safety. In my opinion, the best solution is to allow the USPSTF to do its work as it has done in the past without any political pressure and create a different body that focuses strictly on policy development. That group would review the USPSTF’s recommendations as well as those of other organizations before developing policy. At the same time, we need to devise ways to educate the public about evidence analysis and better communicate the rationale for the USPSTF’s recommendations. I think we can all agree that we haven’t done a very good job of explaining to the public why certain tests should or should not be performed at all or for certain populations. Just look at the confusion surrounding the recent recommendations for routine prostate-specific antigen (PSA) testing. As the full implementation of the ACA continues, and providers focus more on shared decision making with their patients, we’ll want consumers to be as fully informed as possible.
It’s time to do all we can to prevent the USPSTF from being compromised. Contact your legislators and ask that they amend the ACA to remove the provision linking coverage policy with the USPSTF’s recommendations.