The following is a guest post from Dr. Richard Hoffman, MD, MPH, one of our HealthNewsReview.org reviewers.
We live in interesting times. Last week, the Supreme Court largely upheld the Affordable Care Act.* Two weeks ago, legislation (H.R. 5998) was introduced that threatens the autonomy of the U.S. Preventive Services Task Force.
The legislation proposes to mandate a more transparent process for guideline development, a greater role for specialists and advocacy groups, and eliminating the Department of Health and Human Services’ secretarial discretion to withhold Medicare funding for interventions that lack convincing evidence for benefit. The legislation, which comes on the heels of the Task Force’s controversial D rating against prostate cancer screening, is strongly supported by several prominent urological associations. Unfortunately, Congressional efforts on behalf of groups with financial conflicts of interest are not unprecedented. In 1994, the North American Spine Society (NASS) was offended by an Agency for Health Care Policy and Research (AHCPR) report recommending against early spinal fusion surgery for back pain (based on data suggesting increased harms and no benefits). NASS successfully lobbied Congress to essentially defund the Agency. In 1997, an NIH panel of experts concluded that data did not support a universal recommendation that all women in their 40s undergo mammography. Congressional pressure led the then-director of the National Cancer Institute to convene another expert panel—which conveniently offered a politically expedient–if not evidence-based—recommendation for routine screening.
These news items are linked because health care reform will succeed only if it improves quality of care and controls health care costs. When conflicted professional organizations challenge recommendations against providing unnecessary and potentially harmful care, they subvert both quality and cost initiatives. The American Urological Association (AUA) professes concerns about the Task Force, though had no qualms about recommending routine prostate screening for all men in the early 1990s—when the only available evidence was that PSA testing found more cancers (while generating a substantial number of urological procedures). Merely finding more cancers, in the absence of evidence that screening leads to increased survival, hardly meets the definition of a patient-centered health outcome. For many years, the Task Force, an independent panel of experts in prevention and evidence-based medicine, emphasized that available evidence was insufficient to support any recommendations for or against screening. The Task Force did not issue its D rating until survival results from randomized trials were published. While many have challenged this recommendation, the Task Force process, despite claims to the contrary, has been quite transparent and accountable. Moreover, the concern about linking ratings with Medicare coverage seems specious. The PSA test costs less than $50 and many health care insurers publically and fervently promised to continue reimbursing screening mammograms for younger women following the Task Force’s C rating. Medicare will certainly pay for the lucrative urological procedures generated by abnormal PSA tests.
The AUA has called for more meaningful input on guideline recommendations from specialists and stakeholders. However, the inherent potential conflict in this approach is why so many self-serving—and often conflicting–guidelines have been promulgated to health care providers and the public. This is also why primary care clinicians—who actually implement most preventive interventions—value recommendations from a Task Force whose membership excludes anyone with substantial conflicts of interest.
Recently, the Institute of Medicine issued a report on creating “clinical practice guidelines we can trust”—emphasizing the need for a transparent process that manages conflict of interest; assembles a diverse, multidisciplinary guideline development group comprised of methodological and content experts and affected populations; appropriately synthesizes evidence; and explicitly rates the strength of recommendations. In response, the American Cancer Society promised to follow these standards in developing their own guidelines. Meanwhile, the Task Force already follows most of these tenets, with the exception of including specialists as members. However, the Task Force does seek external review and comments from specialists. We should be wary of any legislated efforts to invite the foxes to guard the hen house.
* Publisher’s Note: The American Urological Association states that it is concerned that key aspects of the Affordable Care Act “will ultimately hurt this nation’s ability to provide widespread care for its citizens” and states that “it is a disservice to millions to provide healthcare without also providing a strong infrastructure through which care can be provided.” The American Medical Association and the American College of Physicians spoke out in support of the Supreme Court decision.