Mammography outcry points to trouble for healthcare reform
Some Republicans say the new recommendations are an example of 'rationing' that would take place under Obama's plan to save money by basing treatment on experts' advice.
By Noam N. Levey
http://www.latimes.com/features/health/la-na-health-evidence18-2009nov18,0,3113676.storyNovember 18, 2009
Reporting from Washington
A core tenet of the healthcare overhaul President Obama is pushing through Congress is that medical care can be improved -- and costs contained -- if the country relies more on experts to determine which procedures and treatments work best.
But Monday's mammography report by the U.S. Preventive Services Task Force delivered a swift and stark reminder that few ideas are more explosive in healthcare.
The expert panel -- which recommended that women in their 40s should no longer get annual mammograms to screen for breast cancer -- sparked an outcry from those who say that the federal government is more interested in saving money than in improving women's health, even though the panel did not consider costs in its analysis.
Some Republicans jumped on the report as the kind of government intervention in medical decisions that Obama's healthcare plan would bring.
"This is really the first step toward that business of rationing care based on cost," said Rep. Phil Gingrey (R-Ga.), a physician.
The uproar also provided a likely preview of future battles. A potentially revolutionary improvement in the medical system would almost certainly bring controversy, confusion and uncertainty along with it.
Proposed changes to standard medical procedures, even when supported by scientific evidence, almost always challenge someone's expertise and someone's bottom line. And even the most careful scientific evaluations cannot always provide definitive answers on what works best for all patients.
"Unfortunately, there is no magic way to make these decisions," said Dr. Sean Tunis, a former chief medical officer for Medicare and Medicaid in the George W. Bush administration who works on ways to evaluate medical technology.
The problem, Tunis and others experts say, is that leaving the decisions to the marketplace -- as the U.S. healthcare system has done for decades -- has not produced very good results, even for patients.
Doctors in one hospital may favor one surgical procedure or drug regimen, while those in another favor something else. Individual insurance companies decide to cover some procedures and not others, often varying their policies from patient to patient.
Even state lawmakers have gotten in on the act, passing hundreds of laws requiring that insurance companies provide particular benefits such as prostate cancer screening or, in one case, varicose vein treatment. According to the Council for Affordable Health Insurance, an industry group, there are more than 2,000 insurance mandates nationwide.
The variations and the resulting differences in the way that patients are cared for is one of the main reasons that the American healthcare system is so inefficient, many experts think.
The United States spends a greater share of its gross domestic product on healthcare than any other industrialized country, yet ranks near the bottom in many outcome measures such as unnecessary deaths and infant mortality.
A 2003 study by the Rand Corp. found that adults receive the recommended care for many illnesses only a little more than half of the time. The results were even worse for children.
Obama and his congressional allies have pledged to correct these shortcomings in their health overhaul, in large part by expanding the healthcare system's reliance on independent government institutions to recommend standards of treatment and develop basic levels of medical coverage.
Those institutions will probably look a lot like the U.S. Preventive Services Task Force that evaluated the efficacy of breast cancer screening.
In fact, the Senate Finance Committee's healthcare bill -- the likely foundation of the legislation the Senate is expected to begin debating soon -- relies on the task force's recommendations to outline what preventive benefits Americans should have access to in new insurance exchanges. (The House bill would create a new task force to do the same.)
The existing task force, created 25 years ago, is made up of 16 public health specialists, including academic deans and department heads at major medical centers, including Cedars-Sinai in Los Angeles.
They are charged with reviewing studies and other data on preventive services, such as medical imaging and cancer screening, and evaluating their benefits and potential dangers. They then grade the service based on the strength of the evidence.
"This is the kind of analysis we should be doing," said Dr. David Shih, senior director of medical affairs at the American College of Preventive Medicine.
But the panel helped fuel an uprising among radiologists and the medical imaging industry by concluding last year that there was insufficient evidence to recommend the use of computed tomography, or CT, machines to screen for colon cancer. That decision helped convince Medicare not to cover the procedure as an alternative to colonoscopy.
The panel's warning that routine mammograms for women under 50 heightened the risk of false positives and resulting complications from invasive biopsies was no different.
Radiologists and oncologists accused the U.S. Preventive Services Task Force of acting unethically and risking women's lives. And representatives of the imaging industry and some patient groups said that the Obama administration was pursuing a "federal plot against medical imaging."
The task force did not consider cost in its recommendation. Nor would the task force guidelines automatically lead to limits on coverage.
From a clinical standpoint, the task force members evaluated a classic medical trade-off: whether the risks of screening many healthy people are outweighed by the benefits to a few whose illnesses will be detected early enough to be treated.
But there is a cautionary tale in the uproar for those pushing a healthcare overhaul, said Dr. Mark B. McClellan, a champion of evidence-based medicine who headed the Medicare and Medicaid programs in the Bush administration
"One of the important things in health reform will be to distinguish between guidelines and coverage decisions," he said. "Those are not the same thing."
noam.levey@latimes.com
Kim Geiger in the Washington bureau contributed to this report.
http://www.latimes.com/features/health/la-na-health-evidence18-2009nov18,0,3113676.story
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