In wake of mammography guidelines, U.S. health task force faces new scrutiny
Sunday, December 20, 2009
The once-obscure federal panel that triggered a firestorm with its new mammography guidelines would get far greater authority under the health-care reform proposals pending in Congress, sparking more debate about its power and independence.
Critics of the U.S. Preventive Services Task Force say that the panel would become a stealth tool for government bureaucrats bent on rationing health care. Supporters worry that little-noticed provisions to overhaul the group would jeopardize its long-valued objectivity.
"One of the great things about the task force is it's never had a dog in the fight," said Kevin Patrick, editor in chief of the American Journal of Preventive Medicine. "The task force has been one of the crown jewels of evidence-based neutrality. It's like the Switzerland of thought on evidence-based medicine. I worry about it being politicized."
Since its creation in 1984, the task force has been the federal government's primary source of recommendations for doctors and patients on how to try to prevent health problems. Although its guidelines have long been considered authoritative and have been used to determine some Medicare coverage, the group's conclusions have been primarily advisory.
But under the health-reform legislation in the Senate and House, the panel's ratings would serve as the basis for determining which preventive services the government would require insurance plans to cover at little or no cost to patients. Tests and other preventive care that get an "A" or "B" rating would have to be covered by plans participating in a new insurance exchange, and eventually all plans would have to include services receiving those rankings.
That provision was largely overlooked during the health-care debate until last month, when the panel recommended that most women wait until age 50 to start routine mammography, then get the exam every two years instead of annually. The panel concluded that for most women, the false alarms, anxiety, unnecessary treatment and other harms of more-frequent mammography outweighed the benefits. The task force gave a "C" rating to routine mammograms for women in their 40s, which has been the recommendation.
The new guidelines were welcomed by many advocates for breast cancer patients, women's health experts, doctors' groups and independent researchers. But the recommendations were met by intense criticism from the American Cancer Society, the American College of Radiology and other groups, as well as many individual doctors, patients and members of Congress. Critics said the benefits of mammograms had been demonstrated.
The guidelines also stoked fears about federally imposed rationing of health-care services. The Obama administration quickly distanced itself from the recommendations, and the Senate approved an amendment to the legislation guaranteeing that mammograms and other women's health services would be covered.
But critics argued that under the legislation, the panel's recommendations could still limit coverage of other services.
"We're starting down a path, in my opinion, of socialization of medicine in this country," Rep. Joe L. Barton (R-Tex.) said during a daylong grilling of task force members at a congressional hearing on the new mammography guidelines. "We don't want rationing of health care in America. We don't want to intervene between the doctor-patient relationship."
Democrats dispute the charge that the panel's ratings could ration care. "There have been many false charges about the role of the U.S. Preventive Services Task Force recommendations, with some individuals claiming that they would establish a 'ceiling' of covered benefits and dictate what a person can and cannot receive," said Rep. Henry A. Waxman (D-Calif.). "Nothing can be further from the truth."
The task force's recommendations would only help determine a minimum set of services required to be covered, Waxman said. Insurance plans would be free to cover additional services, and the Health and Human Services secretary and a separate Health Benefits Advisory Committee could require more expansive coverage, he said.
But some question whether the panel's recommendations would become the default standard for coverage for most insurance plans.
"The task force's recommendations would become a benchmark -- and we're concerned it could become the only benchmark," said Stephen Finan, senior director of policy for the American Cancer Society's Cancer Action Network.
Proposals for change
In response, the Cancer Society, the American Heart Association and others are supporting language in the House bill that would fundamentally change the task force. The bill would expand the membership from 16 to 30 and would require a broader array of expertise, including specialists in women's health, geriatrics and health disparities.
The task force would also be designated as an official federal advisory panel, which would make its activities subject to federal laws requiring they be more public. The legislation would also create a "stakeholders board" that the panel would be required to consult; the board would include representatives from the public, disease advocacy groups and the insurance industry.
"Science and the public both benefit from increased transparency, and conducting business behind closed doors only adds to the perception that special interests will have an undue influence," Waxman said. "That is why I believe that the proceedings of the task force should be open to the public whenever possible."
While satisfying the Cancer Society and other groups, the proposed changes are doing little to assuage the fears of the most intense critics in Congress. At the same time, they are raising alarm among many supporters of the panel. Enlarging the task force would make it unwieldy, and the other changes could make the group more prone to outside pressure, they say.
"I think it's important to keep the science separate from the policy judgments," said Russell Harris, a professor of medicine at the University of North Carolina at Chapel Hill who served on the task force from 2002 to 2007.
"The science is what the task force is dealing with -- not policymaking. It's saying: 'This is what the science shows.' I think that process could be disturbed if people were to bring their emotional views to the task force."
But others, including some current task force members, acknowledged that if the panel assumes more authority, steps to make it appear more accountable are probably necessary.
"The introduction of politics into the process is a real danger. We need to make sure the task force's evaluations remain free from advocacy, politics and economics," said Ned Calonge, the task force's chairman. "It all depends on how it's implemented. What we need to do is find is the right balance between independence and transparency."