The Wonk Room

Carly Fiorina Exploits Recent Bout With Cancer To Fearmonger About Mammogram Recommendations

California Senatorial candidate Carly Fiorina is exploiting her recent bout with breast cancer to lie about the role of the U.S. Preventive Task Force and fearmonger about the consequences of health care reform. “This Task Force was explicitly asked to focus on costs, not just prevention. As it turned out, costs were a significant factor in this recommendation,” Fiorina says in this week’s Republican address. “Will a bureaucrat determine that my life isn’t worth saving?,” she asks before suggesting that the Senate health care bill would allow the Task Force to ration cancer treatments:

Do we really want government bureaucrats rather than doctors dictating how we treat things like breast cancer?…The health care bill now being debated in the Senate explicitly empowers this very Task Force to influence future coverage and preventive care. Section 4105, for example, authorizes the Secretary of Health and Human Services to deny payment for prevention services the Task Force recommends against. Another section requires every health insurer in America requires to cover Task Force recommended services….While some defend the idea of a government Task Force, my experience with cancer tells me it’s wrong.

Watch it:

The U.S. Preventive Services Task Force is an independent panel of experts first convened by the U.S. Public Health Service during the administration of President Ronald Reagan. The panel “is financed by the Department of Health and Human Services but works at arms length from it, making its decisions without consulting the agency.” Panelists are prohibited from “considering costs when they make guidelines.”

“Our job is to review scientific evidence, politics play no role in our deliberative processes. Costs were never considered in our considerations,” Task Force Chairman Dr. Ned Calonge testified last week before the the House Subcommittee on Health.

The task force issues recommendations that help doctors decide on a course of treatment. Providers can use the recommendations as a starting point to examine a patient’s particular needs, but the task force has no authority over coverage or treatment decisions. “We expect clinicians to do what they’re trained to do in order to address the needs of the individual patient and his or her best interest,” Calonge said in his testimony. For the mammogram decision, which received a Grade of ‘C’ from the Task Force, “we recommend that the patient be informed of the potential benefits and harms and then be supported in making his or her informed choice about being tested.”

The Senate health care uses the recommendations of the Task Force to establish minimum requirements. Section 4105 gives the Secretary of Health and Human Services the authority, “if the Secretary determines appropriate,” to modify existing preventive care guidelines for Medicare and Medicaid only. If the Secretary chooses to modify the existing package of preventative services, the legislation instructs the Secretary to rely on scientific guidelines. The bill specifically contradicts Fiorina’s claim that care or treatment would be rationed in lines 6-9 on page 1190. “Nothing in the amendment made by paragraph (1) shall be construed to affect the coverage of diagnostic or treatment services,” the bill states.

If the Secretary were to adopt the Task Force’s grade ‘C’ mammogram decision — which Sen. David Vitter’s (R-LA) amendment already invalidated — the guideline would advise the doctor that the Task Force “recommends against routinely providing the service.” But, the recommendation stipulates that doctors should “offer or provide this service only if other considerations support the offering or providing the service in an individual patient.” Doctors could use the recommendations as a starting point to examine a patient’s particular needs; they would not replace professional clinical judgment.

On Thursday, the Senate also accepted an amendment from Sen. Barbara Mikulski (D-MD) that prevents private insurers from charging women for mammograms and specifically states that “nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force.’’

Preventive Task Force Chairman Undermines Republican ‘Rationing’ Rhetoric On Mammograms

This afternoon, the House Subcommittee on Health held a hearing about the Preventive Task Force’s ‘C’ – grade guidelines advising primary care physicians against recommending mammograms to women under 40 years of age. While the guidelines were the result of comprehensive scientific review of the benefits of mammogram testing for women under 40 and have no bearing on coverage decisions, Republicans have presented the Task Force as a poster child of health care rationing — a one-size-fits all approach to medicine that places the cost of care ahead of patients’ well being.

Today’s testimony by Task Force Chairman Dr. Ned Calonge highlighted the desperation of the Republican attack. President Bush may have left the White House but Congressional Republicans continue to scare women and wage war against science. Some highlights from today’s hearings:

- “Our job is to review scientific evidence, politics play no role in our deliberative processes. Costs were never considered in our considerations. We voted on these recommendations long before the last Presidential election.”

- “For ‘C’ recommendations we recommend that the patient be informed of the potential benefits and harms and then be supported in making his or her informed choice about being tested. The specific C language that we recommend against routine provision was intended for consideration by primary care clinicians.”

- “We expect clinicians to do what they’re trained to do in order to address the needs of the individual patient and his or her best interest.”

Watch it:

As Rep. John Dingell (D-MI) observed, “From the things I’ve heard said about you on the other side of the aisle about you folks at the agency, I was afraid you’d appear with horns, tail, fangs, and in red suit breathing fire. Demanding that we immediately terminate all health benefits for the the unfortunate, weak, sick, and especially with regard to mammogram and pap smears.”

The Wonk Room Takes On Sen. Barrasso On Mammogram Myth

Yesterday, I appeared on the Senate Doctors Show to ask Sen. John Barrasso (R-WY) about his recent claim that page 1190 of the Senate bill allows the Preventive Task Force “to decide what care is given and not given.” I read from page 1190 of the bill, pointing out that the Task Force does not have the power to mandate coverage.

Barrasso disputed my claim by arguing that the first line of page 1190 would prohibit the government from paying for preventative services that “has not received a grade of A, B, C, or I by such Task 5 Force”:

Watch the exchange (starts at 5:57):

So who’s right? Pages 1189 and 1190 of the Senate health care bill give the Secretary of Health and Human Services the authority, “if the Secretary determines appropriate,” to modify existing preventive care guidelines for Medicare and Medicaid only. If the Secretary chooses to modify the existing package of preventative services, the legislation instructs the Secretary to rely on scientific guidelines (instead of industry lobbyists, for instance). The bill specifically contradicts Barrasso’s claim that care or treatment would be rationed in lines 6-9 on page 1190. “Nothing in the amendment made by paragraph (1) shall be construed to affect the coverage of diagnostic or treatment services,” the bill states:

If the Secretary were to adopt the Task Force’s grade ‘C’ mammogram decision, the guideline would advise the doctor that the Task Force “recommends against routinely providing the service.” The recommendation stipulates that doctors should “offer or provide this service only if other considerations support the offering or providing the service in an individual patient.” In other words, providers like doctors Barrasso or Coburn, can use the recommendations as a starting point to examine a patient’s particular needs.

If the doctor decides that the patient needs the test, it will be paid for by Medicare. If the doctor relies on the recommendation and does not order a treatment, a patient would have to pay for her own mammogram. If that test is positive, lines 6-9 specifically state that cancer treatment would be fully covered. In short, the Task Force has no power to “decide what care is given and not given.”

Sen. John Barrasso: Preventive Services Task Force Would Have Pulled The Plug On My Wife

Yesterday, Rep. Debbie Wasserman Schultz (D-FL), a breast cancer survivor, accused Republicans of politicizing breast cancer. This afternoon, Sen. John Barrasso (R-WY) — a doctor who runs a private orthopedic practice and serves as Chief of Staff of the Wyoming Medical Center — proved her point. Barrasso called Fox News to register his opposition to the Senate health care bill and argue that the new mammogram guidelines would have pulled the plug on his wife:

And we just saw this past week the first step in rationing of health care in the country with this panel that they have, this preventive panel. A government panel that says women between 40 and 50 shouldn’t have mammograms. You know, my wife Bobbi is a breast cancer survivor. She was diagnosed by a mammogram, went for an operation, the cancer had already spread. The mammogram has saved her life, but yet this preventive panel that the bill says, this health care bill says, ‘oh no, they’re the ones who get to decide what preventive measures are paid for or not.’ That panel would have not allowed her to have this care.

Watch it:

Given Barrasso’s medical background and personal experience with breast cancer, his claim is especially irresponsible. It’s also completely inaccurate. The U.S. Preventive Services Task Force is an independent panel of experts first convened by the U.S. Public Health Service during the administration of President Ronald Reagan. The panel “is financed by the Department of Health and Human Services but works at arms length from it, making its decisions without consulting the agency.” Panelists are prohibited from “considering costs when they make guidelines.”

Rather than mandating “what preventive measures are paid for or not,” the task force issues recommendations that help doctors decide on a course of treatment. Providers can use the recommendations as a starting point to examine a patient’s particular needs, but the task force has no authority over coverage or treatment decisions.

Barrasso’s wife Bobbi Brown would have received a mammogram regardless of any recommendation. Wyoming, along with 48 other states, requires insurers to cover mammograms and if the Senate bill were to become law all insurers would be required to pay for the procedure.

Under the bill, health insurance issuers would offer “services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force” without “any cost sharing requirements.” Last week’s guideline was rated ‘C,’ meaning that the panel “recommends against routinely providing the service” but stipulates that doctors should “offer or provide this service only if other considerations support the offering or providing the service in an individual patient.”

Ultimately, the Panel’s recommendations are just guidelines, not mandates. They have no authority to “decide what preventive measures are paid for or not.”

Rep. Debbie Wasserman Schultz: Republicans Have ‘Politicized Breast Cancer’

During an appearance on This Week with George Stephanopoulos, Rep. Debbie Wasserman Schultz (D-FL), a breast cancer survivor, strongly criticized Republicans for suggesting that the new mammogram guidelines released by the Preventive Task Force last week would restrict access to cancer diagnosis. “What’s unfortunate is that, the Republicans and Ms. Blackburn, have for the first time politicized breast cancer,” she said.

In the exchange below, Rep. Marsha Blackburn (R-TN) repeatedly misquoted the House health care bill to suggest that the Task Force’s guidelines would become law:

BLACKBURN: The guidelines that came out this week, by the Preventive Services Task Force, have a direct link to what would be offered if the House and the Senate bills were to go into law…if you go to page 1296 of the House bill, the engrossed copy…They become the law. They become the law. The mandate…. When you look at what’s going to happen with these 118 new bureaucracies on what insurances can be offered, and what’s going to be paid, you know that this is the bureaucrat in the exam room. This is how it’s going to happen. This is the first step.

Watch it:

In reality, the U.S. Preventive Services Task Force is an independent panel of experts in primary care and prevention. The panel offers evidence-based guidelines and issues recommendations on a scale of A to D (and even I) for providers to consider when treating patients. Grades A and B indicate that “there is high certainty that the net benefit is substantial” and suggest that providers “offer or provide this service.” Grade C “recommends against routinely providing the service” but stipulates that doctors should “offer or provide this service only if other considerations support the offering or providing the service in an individual patient.” Generally, all of these guidelines are a single piece of scientific data that could help guide physicians in treating individual patients. They are not binding.

The House and Senate health care bills only include “services recommended with a grade of A or B by the Task Force on Clinical Preventive Services” in standard benefit packages, but even these guidelines could be expanded by the Secretary of Health and Human Services. Last week’s mammogram guideline would not be included in the packages. It received a ‘C’ rating from the Task Force.

Ultimately, as Congresswoman Wasserman-Schultz points out, Republicans are manipulating the Task Force decision to scare women into opposing a health reform package that expands access to screenings. The legislation requires insurance companies to cover mammograms and other cancer screenings at no additional cost, ends unfair insurer price discrimination against women and guarantees that all health insurers provide women with the health care services they need.

The Case For Recommending Mammograms To Women Over 50

Lawmakers and some doctor and patient groups are criticizing the “new guidelines from a government task force that recommends against routine mammograms for women under 50.” The U.S. Preventive Services Task Force advises doctors against routinely providing the service to women under 50, but notes that “there may be considerations that support providing the service in an individual patient.”

For the average female population, mammograms cause more harm than good:

The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman’s lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman’s life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.

The debate underscores the complexity surrounding public health care management and raises new challenges for comparative effectiveness research. More immediately, the new guidelines create a political dilemma: clinical trials suggest that mammograms don’t work very well for younger women with thicker breast tissue. The test yields more false positives, anxiety, and over treatment (that itself can lead to more serious health problems) than saved lives. It also drives up health care costs.

Undoubtedly for some women, the mammogram is a life saver, and lawmakers fear that insurance companies will seize the new guidelines to deny coverage for mammograms for younger women. But the Prevention Services Task force had a choice. It could have issued a recommendation that would have 1) hurt the majority of the under 50 population, 2) helped a small number of women, but 3) added to skyrocketing health care costs. Or it could have issued a recommendation that would have 1) benefited the majority of the under 50 population, 2) didn’t create more waste in the system and 3) harmed a small percentage of women. Only in the world of political rhetoric can one test everyone and improve all health outcomes.

At the end of the day, health care providers need to follow scientific protocols. The system can’t accommodate a situation in which doctors order CAT scans for simple headaches or complicated surgeries for problems that can be solved with a regimen of medication. Policy makers must balance risk and benefit because a free-market approach creates the kind of health care costs that price millions out of the health insurance market. It produces a situation where 46 million Americans are uninsured, 45,000 die every single year because they don’t have health insurance, while the nation spends 16% of it’s GDP on health care and $800 billion/year on health procedures that actually worsen health outcomes.

In a situation with no good answers, scientific research should inform the best answer.