Peter Wehrwein

Editor

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.

 

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.