Commentary by Matt Barry
The recommendations from a federal advisory body recommending against screening healthy men for prostate cancer distill many of the difficult decisions confronting our nation’s health system.
The guidelines pit facts versus feelings, rational decision-making versus the human element, and the sheer variability in how individuals respond to different treatments.
I should know. If those recommendations to scrap the standard prostate cancer test had been in place 18 months ago, the likely result would be my death five to 10 years from now.
As a career health policy professional and as someone who just finished treatment for prostate cancer, the divide for me is very real. According to the new guidelines, I should never have been diagnosed in the first place as a 44-year-old man. It was a prostate-specific antigen test, a PSA test, as part of an annual physical that was the first signal that something may be wrong. While the PSA can’t determine the extent or severity of cancer, in my case it served as a flare in the night sky.
The U.S. Preventive Services Task Force, an advisory body to the federal government, now “recommends against prostate-specific antigen (PSA) screening for prostate cancer.”
Much like recommendations the task force issued in 2009 on the treatment of breast cancer, which significantly narrowed the number of women recommended to receive mammography screening, this guidance is likely to be met with confusion, uncertainty and disparate views on the best path forward.
In the case of breast cancer, the outcry was so loud that Congress intervened and inserted language into President Obama’s health overhaul law to revert to previous policies that encouraged screening more women for breast cancer.
This debate over so-called evidence-based treatment comes at a time when there is increasing political and ideological tension over its role in individual medical decisions, as well as in coverage decisions by health plans and public and private purchasers of health insurance.
Rationality vs. Choice
Proponents argue that it’s the only way to bring greater rationality to a system that we can no longer afford. Opponents argue that we’re restricting the choices of patients, and some go so far as to suggest we’re putting their health and lives in jeopardy.
Examples of these tensions include debate over government-funded cost-effectiveness research through the Patient Centered Outcomes Research Institute and the Independent Payment Advisory Board, both established as part of the Affordable Care Act.
The business implications are significant. The Affordable Care Act included language that mandates health insurance coverage of any preventive health service that is rated as an “A” or a “B” by the task force – the new federal guidelines give PSA screening a “D” recommendation which “discourage the use of this service.” Examples of preventive services rated “A” or “B” includes cervical-cancer screening for women, tobacco-use counseling for men and women, and daily aspirin therapy to prevent heart attacks in men 45 to 79 years old.
It’s too early to know whether the task force’s latest prostate cancer screening recommendation will receive the same treatment as breast cancer did from Congress, or if it will be changed in response to public comments.
If the task force recommendation stands, then insurers won’t be required to cover or pay for PSA tests. That financial burden may then shift to the patient. If the task force is correct in its assessment of the data, then this should translate into fewer unnecessary tests and fewer side effects that require additional treatment, all of which cost money.
If the task force is wrong, and men go untested and then develop prostate cancer, insurers may be saddled with the higher costs of treating men with more advanced stages, if not terminal forms, of prostate cancer, rather than treating it when it is curable and the side effects of treatment less severe.
On the positive side, if the effectiveness of the PSA test is as dubious as the new recommendation suggests, then this decision could spur investments in identifying more effective markers for detecting prostate cancer.
The policy wonk in me is convinced that this increasing focus on evidence-based medicine is necessary. It will drive better decisions, better outcomes and a system of care that pays based on value and the best outcomes. From a federal budget perspective, it’s necessary to bring more rationality to coverage decisions and a system of care for programs such as
Medicare and Medicaid, which account for one out of every five federal dollars spent. It’s necessary because the current system is financially unsustainable.
The prostate cancer patient in me has a different point of view. My PSA results ultimately led to surgery and then pathology findings that found the cancer had spread beyond the prostate. If my doctors followed the letter of the new guidelines, I would never have been screened, wouldn’t have learned the cancer had spread, and in five to 10 years I would likely have been confronted with a much graver prognosis.
This is the dilemma confronting business leaders and politicians. How do they reconcile these seemingly intractable positions? The evidence may say don’t do it, but individual circumstances say otherwise. How do we strike a balance between the societal need to get health spending under control and to make wiser health investments, versus the need to respect individual choice?
We need to get to a point where the best policy is also the best medicine.
Matt Barry is a health analyst for Bloomberg Government focusing on Medicare, Medicaid, public health and prevention issues. Barry has more than 20 years of health policy experience in the executive and legislative branches of the federal government, non-profits, private consulting and public affairs firms. He has worked on payment and access issues under Medicare and Medicaid, tobacco control policy, rural health care, and childhood immunization policy.
(Matt Barry is the health-care analyst team leader for Bloomberg Government. The views expressed are his own.)