By Christopher Weaver
Thursday, July 15, 2010; A17
For years, an obscure federal task force sifted through medical literature on colonoscopies, prostate-cancer screening and fluoride treatments, ferreting out the best evidence for doctors to use in caring for their patients. But now its recommendations have financial implications, raising the stakes for patients, doctors and others in the health-care industry.
Under the new health-care overhaul law, health insurers will be required to pay fully for services that get an A or B recommendation from the U.S. Preventive Services Task Force, a volunteer group made up of primary care and public health experts.
That's good news for patients, who will no longer face cost sharing for these services, but it puts the group in the cross hairs of lobbyists and disease advocates eager to see their top priorities -- routine screening for Alzheimer's disease, diabetes or HIV, for example -- become covered services.
"It's a wide-open door for lobbying," says Robert Laszewski, a health insurance industry consultant.
On Wednesday, first lady Michelle Obama; Jill Biden, the wife of Vice President Biden; and Health and Human Services Secretary Kathleen Sebelius discussed the importance of preventive care at a news conference to unveil regulations for implementing the provisions, which include coverage of immunizations and additional services for women and children.
"Too many Americans don't get the preventive care they need to stay healthy and keep health-care costs down for all of us," Sebelius said. "Our challenge is to remove the barriers."
The preventive-services task force will guide that effort. Founded in 1984, it has 16 members -- many of whom are doctors. The group meets three times a year and is staffed by officials at the Agency for Healthcare Research and Quality.
Under the new law, the task force could become a political lightning rod. If it doesn't recommend a service, insurers might not pay for it, and advocates might argue the decision is a barrier to care. If the panel does back a service, it might increase patients' access, as well as create new business opportunities.
The requirement applies only to plans created after Sept. 23. The Obama administration estimates that 31 million people in new employer plans, and 10 million people in new individual plans, will benefit next year. By 2013 the number of people in employer plans who will benefit is projected to reach 78 million, for a total of 88 million. Health department officials expect the provision will boost insurance premiums by about 1.5 percent.
The increased interest of advocates may conflict with the task force's tradition of scholarly dedication to the science of randomized medical trials.
"If you want to be evidence-based, lobbying just doesn't fit," said Ned Calonge, the panel's chairman and the chief medical officer for the Colorado Department of Public Health and Environment. "My charge to members would be to stay true to the methods and the evidence."
But sticking to the science hasn't always been popular. The task force set off a firestorm in November 2009 when, seemingly oblivious to the politically charged health-care debate, it recommended that women begin getting routine mammograms at 50, rather than at 40.
Critics pounced on the proposal, saying the government would engage in health-care rationing. Breast cancer activists also protested. The result: Sen. Barbara A. Mikulski (D-Md.) inserted an amendment in the health-care law to explicitly cover regular mammograms for women between 40 and 50.
Groups including the American Diabetes Association and General Electric, which manufactures equipment for mammography, also lobbied Congress on task force issues. The diabetes group won a requirement that the task force include in its reviews of evidence the guidelines drafted by specialty groups -- language intended to help preserve diabetes coverage.
In response to the backlash over the mammography recommendation and other calls for transparency, the task force recently adopted a new policy of accepting public comment before finalizing its recommendations.
Calonge said the task force was "willing to take on such challenges as increased scrutiny may bring forward." He said that while the panel wouldn't change its recommendations just because of criticism, it also would not be "immune" to input that might add perspective." But, he added, "the science needs to come first."
In addition to the task force, other scientific bodies and government groups will also help determine the services that must be covered. For instance, plans must also cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices, as well as screening practices for children that have been developed by the Health Resources and Services Administration in conjunction the American Academy of Pediatrics. Health plans will also be required to cover additional preventative care for women recommended under new guidelines that the Department of Health and Human Services is expected to issue by August 2011.
Several disease groups are going directly to HHS to make their cases.
The diabetes association, for instance, is arguing to the department that the current task force guidelines, which call for screening for diabetes only when a patient has elevated blood pressure, could become a barrier to care and that insurers should be required to provide broader coverage.
Lobbyist Tekisha Everette called the guideline "a shark in the water" and said her group has pressed Sebelius to include a broader diabetes screening requirement in regulations.
The HIV Medicine Association is making a similar argument. A two-page memo it delivered to the staff of the preventive services task force explains that one reason 20 percent of people with HIV don't know they are infected is that testing isn't reimbursed by most insurers.
Calonge said his panel's recommendation would only be used to set minimum coverage requirements and that insurers are free to cover additional services. The panel revisits its recommendations every five years.
Many commercial insurers already cover preventive services without cost sharing, often based on the task force's advice, according to Robert Zirkelbach, a spokesman for America's Health Insurance Plans, a trade group based in Washington. "There's broad recognition that prevention is essential," he said.
Weaver is a reporter for KHN (www.kaiserhealthnews.org), an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan health-care policy organization that is not affiliated with Kaiser Permanente. Washington Post staff writer N.C. Aizenman contributed to this report.