USPSTF Session Brings Lively Comments on Link Between Ratings, Coverage

The US Preventive Services Task Force (USPSTF) never asked for its ratings to be tied to health coverage decisions under the Affordable Care (ACA), said Maureen G. Phipps, MD, MPH, a former member and current consultant for the task force, as she referenced the 2010 requirement that health plans cover screenings with at least a B rating, which means the service is recommended.

While the idea to link coverage for preventive screenings with evidence-based standards may have seemed like a good idea, exchanges between Phipps and USPSTF member Melissa Simon, MD, MPH, and their fellow obstetricians at the 2018 Clinical and Scientific meeting of the American College of Obstetricians and Gynecologists (ACOG) in Austin, Texas, suggest the move has had some unintended consequences.

The linkage has brought new attention to an agency that had enjoyed a low profile since its founding in the Reagan administration. In recent years, however, USPSTF drew fire from the American Cancer Society over shifting recommendations on mammograms and a highly controversial “D” grade—not recommended—for the PSA test for prostate cancer.

“We do not include cost in our deliberations,” Phipps said, near the end of Sunday’s presentation on USPSTF decision making, where she outlined the rigorous process the task force follows. This includes weighing all available evidence, soliciting public comment, and balancing the potential benefit of screening with the risk of harms. “The potential of harms is taken very seriously,” she explained.

The final result is a letter grade: A means there is a high level of evidence the screening or test offers a benefit, B offers a moderate benefit but is still recommended; C offers limited benefit, but may be recommended for specific subgroups of patients, and D is not recommended. An “I rating” means the evidence is insufficient.

Clinicians pushed back at Phipps’ statement about not considering cost, which came as Simon walked attendees through several key items of concern to OB/GYNs, notably a change in the recommendation for breast cancer screening, which raised the age for starting routine mammograms from 40 to 50. Women ages 40-49 are now advised to make decisions in consultation with their doctor, based on individual risk and circumstances, for a rating of C. In this case, the potential for harms from false positives for younger women was central to the updated recommendation.

But in the real world, clinicians said they must treat women who they feel need mammograms and now can’t get them covered. One female clinician said it was nice for USPSTF to have such a “lofty” process, but “other organizations are using the guidelines in a way to save money for corporations, not to increase access for patient care.”

Phipps noted that while the overall letter grade is based on evidence for the general asymptomatic population, USPSTF does discuss clinical considerations for subgroups. The Health Resources Services Administration, or HRSA, has more recently supported screening for women in their 40s. “That’s where shared decision-making comes in,” she said.

ACOG members said patients often never get past the headlines, and sometimes payers don’t either. One muttered that it can be easier to get a health plan to pay for Viagra than a mammogram for a woman in her 40s.

Simon said it’s essential to keep adding to the evidence base, and she strongly encouraged obstetricians to take an active role part in the public comment process. Her review of key USPSTF recommendations included:

• An “I rating” for pelvic screening of asymptomatic nonpregnant adult women does not apply to screening for specific disorders for which the USPSTF already recommends screening, including cervical cancer with a Pap smear, gonorrhea, and chlamydia. An in-room survey found that 84% of the clinicians had not changed their practice and were still doing exams.
• A draft recommendation for cervical cancer screening is highly controversial. It would give an A rating for screening women ages 21 to 65, but a D rating for women younger than 21 as well as those older than 65 who have had adequate prior screening.
• There was a high level of awareness about a recommendation in place since 2014 for giving low-dose aspirin to women at risk of pre-eclampsia, which has a B rating.