A pillar of last year’s health care reform law was the notion that providing better medical care that is proven to work will improve the country’s health and cost the medical system less money. It’s a principle that was echoed in an anticipated Institute of Medicine report, also released Friday, that gave Health and Human Services Department regulators advice about how to decide what benefits should be considered “essential” and required of all insurance products offered on public exchanges in 2014.
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That report homed in on two main themes: make the coverage affordable enough that people can buy it, and cover medical interventions that are “evidence-based.” Those guidelines sound like common sense, but crafting medical practice around what’s evidence-based, especially with emotionally charged diseases like cancer, can be difficult.
When the task force downgraded its rating of mammograms two years ago, saying women between 40 and 50 need not get the test every year, controversy abounded, resulting in legislation guaranteeing that all new health insurance plans offer annual mammograms to women in the affected age group. (Low income women without insurance already had access to free screenings subsidized by the federal government.) Congress has already passed a law guaranteeing that Medicare pay for annual PSA tests for all men. That’s despite a longstanding recommendation that the test has no value for men over 75.
The mammogram recommendation was released in the midst of the debate about the larger health care reform law, and critics of the law seized upon the new guideline as an example of how government regulation of health care could lead to the denial of lifesaving interventions. That analysis misunderstood the nature of the recommendation—that it was advisory, that it recommended leaving choices with women and their doctors, and that, as with prostate cancer, the task force found that the evidence of harms from screening outweighed any improved rates of survival.
But that firestorm apparently chastened the task force. According to the New York Times, the group had been ready to release the prostate cancer guideline shortly after the mammography one, but had held back twice out of fear of a backlash. A physician on the support staff of the panel, Kenneth Lin, resigned from the task force in protest after the second such delay, in 2010. “Politics trumped science,” he wrote in a blog post explaining the decision.
It will take time to see what the fallout is from the PSA guideline change. Though men with prostate cancer have recently begun organizing into groups like ZERO to raise money for research and encourage early detection, prostate cancer still lacks the grassroots organization of breast cancer advocates, who were able to protest the mammography decision so loudly.
The message on the PSA test is also more clearly negative. While the task force found that the risks of mammography outweighed the benefits, it still acknowledged a small survival improvement in screened women under 50—and it has been long established that older women do survive longer if they get mammograms.
But it is highly unlikely that any insurance company will stop paying for the test any time soon, whether insurance regulators require it or not. Responsibility for change, and any cost savings that result, will come from patients and doctors who decide to forgo testing.