Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage

The comparisons presented in the paper by Lesser et al. represent 2 snapshots, with different angles and perspectives, as a body of evidence on preventive services is translated into recommendations and ultimately health policy. It aims to contrast an advisory body, the US Preventive Services Task Force Recommendations (USPSTF), and Medicare coverage in a large government program focused on paying for health care. The differences noted by the authors can be attributed to different focus for prevention (disease or service), timing issues, and equity. How important are they? Reducing or eliminating the important differences can contribute to public health in the large Medicare population.

Over its 25 years of evidence evaluation, the USPSTF has advanced its methodology and promoted prevention through its laser focus on what works. Recently, society through its political and health care leadership has recognized the strength and utility of USPSTF recommendations by broadly endorsing, though the Affordable Care Act in 2010, its recommended services for coverage in all basic insurance benefits, and by eliminating cost sharing in the payment for such preventive services.

Until 2009, Congress added preventive services piecemeal to Medicare. Subsequently, the authority given to the Centers for Medicare and Medicaid Services (CMS) to add Medicare preventive services through national coverage decisions (NCDs) permits the more timely translation of USPSTF recommendations to Medicare policy through an evidence-based transparent public process. The NCD process is focused on items and services, while the Task Force takes the perspective of prevention of a specific disease. The first 2 NCDs under this new authority provided expanded coverage of HIV screening and tobacco cessation counseling for Medicare beneficiaries. While the authors have concluded that Medicare should focus more on preventive coordination, such a focus is needed by many stakeholders: patients, clinicians, specialty societies and the USPSTF. The busy clinician still needs to set priorities and even if a set of services are recommended, covered and paid for, there is no assurance that they will be done in sufficient magnitude to accomplish population-level improvements in health. The Medicare tools for coordination are relatively new and need to be continuously improved.

Finally, the authors examined a number of non-recommended services, rated ‘D’ by USPSTF, and assert that Medicare should not cover these services. Some of these services were covered by statute. Although, as the authors note, ACA permits rescinding earlier coverage, this path has not yet been pursued by CMS. The potential inequity of developing gender- or age-specific coverage policies to follow USPSTF recommendations militates against dealing with recommendations to stop screening through coverage policy rather than physician practice. Further, if a small high- risk subgroup exists within a non-recommended population (e.g. a woman with a family history of abdominal aortic aneurysm [AAA]), non-coverage may create additional problems without benefit. Finally, the CMS focus on service simplifies payment, and avoids the question of purpose (is a pelvic examination is looking for cervical or ovarian cancer, or both?).

Differences attributable to timing are inevitable. The UPSTF has recognized the need to periodically re-evaluate the evidence base for its recommendations, and a full re-review could take 2 years. Similarly CMS has sometimes reconsidered specific NCDs based upon development of new evidence; the NCD takes 9-12 months. CMS and USPSTF may need to enhance their communication to better streamline the process and ensure a close working relationship. Enhanced communication could speed the adoption of preventive services and improve population health.

Competing interests:   None declared