Guest post: be wary of legislation to have the foxes guard the health care hen house.

The following is a guest post from Dr. Richard Hoffman, MD, MPH, one of our 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.


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Brad F

July 2, 2012 at 7:12 pm

While I suspect the bill has some buried poison pills, assuming it was passed, can you provide some illustration as to why it will lead to doomsday scenarios.

I get your points, but you dont demonstrate what is in HR 5998 specifically, that arouses your fear.


Richard Hoffman

July 5, 2012 at 11:21 am

Specialty organizations have heavily criticized the Task Force’s recommendations for mammography and PSA testing, partly because none of their ilk was included on the panel. While seeking input from specialists and other key stakeholders is important, H.R. 5998 was crafted with the AUA to reflect urologists’ concerns about “ill-informed” ratings that ignored lower-quality evidence and expert opinion ( Perhaps I’m being overly paranoid, but I feel that the forcing the Task Force to include specialists on the panel—and on an oversight board–could potentially undermine its independence and credibility. As a primary care physician, I ‘d be very skeptical if such a reconstituted Task Force issued revised recommendations that would support the financial interests of specialty organizations.

Spring Texan

July 9, 2012 at 9:33 am

I agree with Dr. Hoffman that this is a very bad bill, and I’ve written my congressman and urge others to do likewise.

Laura Newman

July 9, 2012 at 9:41 am

I will be discussing these issues today on Alaska Public Radio’s Line One with a urologist for more than an hour. You can tune in here ( at 6 pm EST. I’ve been covering prostate cancer issues for longer than any other health issue. Dr. Hoffman raises some interesting points. But my take-home message from the spine surgeon story is that the Agency for Health Care Policy and Research made a swift change to its name to keep its important work alive: it removed the word “policy” from its name, signaling it would not be hard line. That worked and the work supported by the Agency has flowered, putting plenty of medicine on a more scientific base. I see change towards science, but it won’t come easy. I think there is a heck of a lot more discussion about downsides of prostate cancer screening, less willingness to give it without informed consent, and I am hoping for progress. Some PCPs close to USPSTF tell me that there are some damn good specialists who could contribute to the process. Just thinking out loud here: an opening may not be tantamount to “supporting the financial interests of specialty organizations.”

Maggie Mahar

July 9, 2012 at 1:57 pm

Gary– I’m posting the first couple of paragraphs of this piece on, with a link so that readers can read the rest here.

This is, indeed, a blatant example of conflict of interest, and an assault
on evidence-based medicine.

Anthony Miller

July 10, 2012 at 5:13 am

As a cancer epidemiologist, who has written extensively on these issues, and who was a co-author of the report of the US PLCO randomized screening trial that found no benefit from PSA screening in reducing mortality from prostate cancer, I found the report of the US Preventive Services Task Force on this issue balanced and fair. This is because the Task Force was reviewing evidence, and those skilled at evaluating evidence can be depended upon to give dispassionate advice. I suspect that simply adding urologists to the panel would not make any difference if they were clearly independent, but I doubt if such people can be found. Without ensuring the absence of conflicts of interest on such panels would simply result in a document of little value, falling under the advocacy heading.

sidney Goldfarb MD

July 12, 2012 at 9:20 am

I am a self serving Urologist.
The task force could have had a high level academic urologist on it for guidance on other than EVIDENCE BASED MEDICINE. Since screening began in the US in 1990, with PSA, the overall death rate from Prostate Ca is down 36-42%. This is based on population data. Prostate ca is the number 2 cause of death from cancer in men in the uS. The task force editorializes the no one dies from prostate ca and that it is slow growing. A 40-60 year old man with even a small amout of ca found by having a high psa , or a nodule is different from a 90 year old. Acc to recent studies, the pathology worsens as we get older , rather than the opposite.
Sidney Goldfarb MD \
Princeton nj