US Preventive Services Task Force and the Future of Prostate Cancer Screening

Ross D. Margulies; Jayson Slotnik, JD, MPH

October 2011, Vol 2, No 6 - Health Policy


Ross D. Margulies, JD, MPH (Cand), and Jayson Slotnik, JD, MPHThe decision this month (October 2011) by the US Preventive Services Task Force (USPSTF) to recommend against a prostate-specific antigen (PSA)-based screening for prostate cancer in healthy men1 has caused quite a stir both in and outside of medical circles, reminding many people of the task force’s 2009 recommendation against routine breast cancer screenings for women under age 50 years.

The task force’s “D” rating for the PSA test, which signifies that “there is moderate or high certainty that the service has no benefit or that the harms outweigh the benefits,”1 has no immediate effect on access to or coverage for the PSA screening test. Medicare, the single largest payer of healthcare costs in the country, for example, currently pays for 44% of preventive services receiving a D rating by the task force, including prostate cancer screenings for men aged ≥75 years.2 Moreover, in the Affordable Care Act, Congress overrode the task force’s under-age-50 mammography recommendation, in a legislation that was in a large part in response to the public backlash.3

Nevertheless, it would be shortsighted to assume that the task force’s recommendation carries no weight. What does the new rating ultimately mean for patient access? In this age of fiscal stress, will federal and private payers opt to cut a service that is estimated to cost $3 billion annually?

Preventive services were excluded from Medicare coverage when it was created in 1965, and over the years, Congress has amended the Social Security Act to add individual preventive services. Private payers have historically followed Medicare’s lead in developing their coverage policies, and therefore, any major changes to Medicare coverage of products or services often has an industry-wide impact. In the Balanced Budget Act of 1997, for example, Congress mandated coverage for a number of preventive ser vices, including “prostate screening tests.”4 Private payers were quick to follow suit, if they were not already covering the service.

With the passage of the Medicare Im provements for Patients and Providers Act in 2008, Congress empowered the Department of Health and Human Services to add preventive services to Medicare without congressional action.5 The law permits the Secretary of Health and Human Services to authorize Medicare coverage for services rated A or B by the USPSTF. In enacting the Affordable Care Act in 2010, Congress extended the reach of the task force to private health plans by requiring group health plans to cover items receiving an A or B rating from the task force.

As noted, the task force’s recommendation has no immediate impact on coverage for and access to the PSA test. Ultimately, however, both federal and private payers may eliminate coverage for the test. For example, the Affordable Care Act requires that group health plans cover only services rated A and B by the task force.

With a D rating, plans may very well drop coverage for the screening procedure. Moreover, if Medicare does ultimately eliminate coverage for the PSA test, private payers will likely follow suit.

Critics of such a prediction argue that legislation requires Medicare to pay for the PSA test, and therefore, the task force’s recommendation carries no weight in coverage for the test.6 Nevertheless, it is possible that Congress, facing increasing budgetary pressure, could amend the language to take into account the task force’s finding. Indeed, Congress predicted changes in coverage for prostate cancer screening tests in the statute, granting the Health and Human Services Secretary authority to cover other procedures taking into account “effectiveness” and “costs.”7

What will ultimately happen to the coverage of the PSA test remains to be seen. The draft Recommendation State ment is available for comment from October 11, 2011, until November 8, 2011, at www.uspreventiveservices taskforce.org/draftrec3.htm.

References

  1. Chou R, Croswell JM, Dana T, et al. Screening for Prostate Cancer: A Review of the Evidence for the U.S. Preventive Services Task Force. AHRQ Publication No. 12-05160-EF-3. www.uspreventiveservicestaskforce.org/uspstf12/prostate/pr ostateart.htm. Published October 2011. Accessed October 10, 2011.
  2. Lesser LI, Krist AH, Kamerow DB, Bazemore AW. Comparison between US Preventive Services Task Force recommendations and Medicare coverage. Ann Fam Med. 2011;9: 44-49.
  3. Patient Protection and Affordable Care Act §2713(a)(5), Pub L No. 111-148, 124 Stat 132 (2010). www.gpo.gov/fdsys/pkg/ PLAW-111publ148/pdf/PLAW-111publ148.pdf. Accessed October 10, 2011.
  4. Balanced Budget Act of 1997 §4103, Pub L No. 105-33, 111 Stat 361 (1997). www.gpo.gov/fdsys/pkg/PLAW-105publ33/pdf/ PLAW-105publ33.pdf. Accessed October 10, 2011.
  5. Medicare Improvements for Patients and Providers Act of 2008, Pub L No. 110-275 (2008). www.gpo.gov/fdsys/pkg/ PLAW-110publ275/pdf/PLAW-110 publ275.pdf. Accessed October 10, 2011.
  6. Social Security Act §1861(s)(2)(P). www.ssa.gov/OP_Home/ ssact/title18/1861.htm. Accessed October 10, 2011.
  7. Social Security Act §1861(oo). www.ssa.gov/OP_Home/ ssact/title18/1861.htm. Accessed October 10, 2011