They've done it again. Some of the health professionals who are supposed to give us advice on what preventive care we should get have changed their advice, and told older men they no longer need to get regular PSA tests to screen for prostate cancer. This follows similar
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Wharton School health economist and LDI Senior Fellow Mark Pauly characterizes the recent U.S. Preventive Services Task Force PSA announcement as "a masterpiece of double negatives and doubletalk."
switches for breast cancer screening for younger women, and testing for infection by the human papilloma virus. And as usual, other physicians and health advocacy organizations have begged to differ with the conclusion, "fearing" that foregoing screening may do patients more harm than good.
Technically, the draft "recommendation" that comes from the United States Preventive Services Task Force (USPSTF) does not say that we ought not to get these measures; they only "decline to recommend that physicians offer these tests routinely." Instead, as a patient you are (if you are so motivated ) advised to talk over with your doctor about these procedures -- although, beyond the tiny fraction of people at high risk who will be told to get the test, the likelihood of getting conclusive advice in that talk is unclear. Patients will be told that there are pros and cons, and new studies with somewhat differing results, so ultimately it will be up to them to decide what chances they are willing to take.
Worried about insurance coverage That doctors cannot agree is upsetting enough to consumers. But the real problem is the fear, on the part of consumers, that if they decide they do still want one of these tests, insurers will use these developments as excuses not to cover them when they had formerly done so. As an insurance economist I cannot referee the argument among health professionals, but I can offer some advice on whether you should be worried about your insurance.
The surest thing we can say is that, if the USPSTF had recommended positively (technically a grade "A" or "B" recommendation) for routine PSA testing, that would have mattered for insurance. This is because a provision of the health reform law essentially requires insurance to cover in full services recommended (at a high enough grade) by this federal advisory body. Had that happened, if your plan already covered PSAs it would probably be reassuring that it would now have to continue to cover, but if it did not, you might or might not be pleased to know that it would now be forced to do so. Of course, if you thought you were going to get the test anyway you would be happy -- but if you were not going to get it
(either because you were an older man who decided against it or because you are not a man), you might not be happy that your insurer is now forced to give its other beneficiaries reimbursement for the test. This is because insurers never give anybody anything: if they have to pay for this test for thousands of their insureds, whereas they formerly did not, they will raise their premiums. Not a lot, because the test is relatively cheap (at about $30) and used by a minority of members -- but with private health insurance premiums taking a big jump this year and with other required preventive care coverages being added, all these small things could add up to something material.
Evidence-based? But the USPSTF declined to recommend, so now what? If you are on traditional Medicare, no worries: it will pay anyway, and you as beneficiary are at worst paying only a tiny fraction of the cost of your Part B coverage. You will still get the test for free. But for private insurance, an unbiased observer (which surely does not exist for these gender-specific screening tests) might think that, if doctors cannot even agree on whether some medical procedure does more good than harm, maybe it is not so important that it be covered by insurance. Indeed, in other contexts insurers are being urged to implement "evidence based coverage," paying for what it is known to work and not for what is not known to work. These tests would seem to be poster children for the latter case.
So what will happen? The best guide to prediction here is the observation that private insurers do not really have scientific principles on the basis of which they decide what to cover. Instead, they choose what to cover based on what those who buy the insurance and pay the premiums want them to cover. Take the PSA test. Right now, many older men (myself included) will probably react to their physicians' ambiguous advice by playing it safe and getting the test. We can always wait until later to make the more fateful decision of whether or not to have a biopsy if the test results are at the high end or jump up from the last time. It is the painful biopsy that starts the cascade of events that begins with gut-wrenching worry and may end with surgery with serious sexual and quality of life side effects for cancers that would never have been lethal (unless you live to 130). This means that insurers that cover will keep covering, unless their customers tell them to stop. Coverage should be especially persistent for men who work in higher wage jobs, because any reductions in premiums would be offset by higher taxes on money wages.
Provoking change What might provoke change is if insurance buyers ask for it. Individual workers might want to keep premium growth or growth in deductibles down, and so ask insurers the dangerous question of whether anything can be done. There is a major disconnect here; although workers ultimately need to be pleased by and pay for their job-based health insurance, some employers think it is their profits that are at risk, and that makes them upset. But assuming the cool heads prevail, it really will be up to workers -- who unfortunately have no clear way to make their preferences for coverage versus higher premiums or lower raises known.
No single screening test is going to make a big enough difference to matter. What could happen in the future, however, is that insurers may consider designing plans that bundle all of these evidence based non-recommended services into a plan that does not cover them, with seriously lower premiums, or better coverage for things that do work. Perhaps the "No Nonsense" insurance plan could garner enough of a following among consumers that it would be able to make it. Regrettably, the workers who attach the most value to saving money are likely to be those with relatively lower wages, who are being dumped out of insurance markets even now and who have only minor tax breaks to help cushion insurance premiums. Still, it may be better to take this route than to keep covering what is not known to work or, even worse, turn such decisions over to more political advisory bodies on "essential benefits," all of whose professional members (including urologists who are still heavily pro-test) will want to make sure that what they do or what creates demand for what they do is included.
The health care and the health insurance climate is in the midst of enormous but unpredictable changes. It may be some consolation to say that most older men and younger women should confine their worrying to the hard tradeoffs between conflicting test-related health risks whose values are not known with any precision, and not be obsessed with demanding insurance coverage one way or another. It still pays to watch your back (or watch your boss), but it is most important to take care of yourself.
