Editor’s Desk

Has the ACA Put the USPSTF in Over Its Head?

Peter Wehrwein

Experts are beginning to question the large role that U.S. Preventive Services Task Force (USPSTF) recommendations are playing in determining insurance coverage of preventive health services.

And the questions aren’t coming from aggrieved parties or from people looking to score political points.

In an article in yesterday’s New England Journal of Medicine, David Merritt Johns and Ronald Bayer of Columbia’s Mailman School of Public Health say they interviewed 30 current and former USPSTF leaders, members, and liaisons, and that, privately, the leaders “concede” that it might be beneficial to create a separate entity to make coverage decisions.

Last month, three former USPSTF chairs—Virginia Moyer, Michael LeFevre, and Ned Calonge—wrote an opinion piece in the Annals of Internal Medicine that covered some of the same ground.

Moyer and her colleagues teed off on Mylan (there's a lot of that going on these days) and its efforts have the EpiPen classified as a preventive service while noting that we really shouldn’t be surprised to see the USPSTF getting dragged into the political and lobbying fray. The connection between USPSTF decisions and insurance coverage “encourages those with a significant financial interest to attempt to influence the direction and decisions of the Task Force,” they wrote. It might be time, said the former USPSTF chairs, to consider severing the link between USPSTF decisions and coverage decisions if that is the only way to protect the integrity of the task force and the process it uses.

The USPSTF has never been completely divorced from coverage decisions. As Johns and Bayer point out, the reason it was created more than 30 years ago was to weigh the evidence for preventive services at time when insurers were reluctant to pay for them.

What would be the point if the USPSTF was ignored and didn’t have some effect on payers and what they decide to cover?

Still, the guiding notion has been independence. The USPSTF would plow through the studies in a systematic, scientifically rigorous way and rate the strength of the evidence. Others would decide what to do their findings.

Despite the recent hubbub, the USPSTF still operates this way. But its decisions have taken on more significance than take-it-or-leave-it recommendations. The 2008 MIPPA legislation gave the HHS secretary the authority to extend Medicare coverage to preventive services so long as the USPSTF gave them an A or B rating.

Two years later, the ACA took things quite a ways further with the provision that says group and individual health plans must cover—without a copayment—preventive services with an A or B rating. Making coverage automatic if the services got an A or B rating  “shocked” members of USPSTF, according to Johns and Bayer. The members were worried about “the task force’s ability to maintain its stringent evidence standards in the face of this new authority.” (This might be filed under, "Be careful what you wish for.").

Here’s more from Johns and Bayer:

The USPSTF now finds itself required to make complex decisions that appear to demand inputs beyond evidence. “The very thing that the task force wanted to get away from, which is to get involved in the whole cost discussion…it’s now right in the middle of it,” observed one former member.

So far, the discussion has been more about pointing out the problems caused by USPSTF entanglement with coverage decisions than mapping out clear alternatives.

The National Business Group on Health has offered a couple ideas. A separate coverage committee could be created that would be modeled Medicare Evidence Development and Coverage Advisory Committee and other committees that advise HHS and CMS. The business group also suggested that HHS could elaborate upon USPSTF recommendations with guidance for private insurers in the same way it elaborates on USPSTF recommendations with National Coverage Determinations when Medicare coverage is expanded to include a service recommended by the task force.