PSA Police?
Screening for prostate cancer is controversial for reasons outlined in this article from the Wall Street Journal, but now the controversy is taking a new turn. The government is becoming more aggressive in determining what high-quality care is. In the past, Medicare and private insurers would not pay for certain tests or medications that were unapproved. Now, Medicare will actually penalize doctors for ordering such tests. This goes way beyond educating the public. It interferes with shared decision making by patients and their doctors.
Doctors Could be Penalized for Ordering This Test
Wall Street Journal
November 20, 2015
By Melinda Beck
Medicare officials are considering a measure that would penalize doctors who order routine prostate-cancer screening tests for their patients, as part of a federal effort to define and reward quality in health-care services.The proposal, which hasnât been widely publicized, has prompted a flurry of last-minute comments to the Centers for Medicare and Medicaid Services, including more than 200 in the past two days, virtually all in opposition. The official comment period began Oct. 26 and ends Friday.
The proposal, which hasnât been widely publicized, has prompted a flurry of last-minute comments to the Centers for Medicare and Medicaid Services, including more than 200 in the past two days, virtually all in opposition. The official comment period began Oct. 26 and ends Friday.Many of those commenting said the measure would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.
Many of those commenting said the measure would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.âPSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,â said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. âTo make it a quality measure would say, âYouâre a poor quality doctor if your patients get this test.â â
âPSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,â said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. âTo make it a quality measure would say, âYouâre a poor quality doctor if your patients get this test.â âThe proposed measure is part of continuing federal efforts to develop ways to identify and reward value in health care. The Obama administration has said it plans to tie 50% of Medicare payments to such quality measures by 2018.
The proposed measure is part of continuing federal efforts to develop ways to identify and reward value in health care. The Obama administration has said it plans to tie 50% of Medicare payments to such quality measures by 2018.Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits donât outweigh the harms.
Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits donât outweigh the harms.Studies have shown that screening reduces the risk of death from prostate cancers only minimally, if atStudies have shown that screening reduces the risk of death from prostate cancers only minimally, if at all, because most grow so slowly they effectively are harmless.
Yet many men diagnosed with prostate cancer undergo surgery and radiation, which can have lifelong side effects.
Meanwhile, about 28,000 U.S. men die annually from aggressive prostate cancers, often despite getting regular PSA tests and fast treatment. (This is not substantiated).
Both the rate of PSA testing, and diagnoses of early-stage prostate cancer, have declined significantly in the U.S. in recent years, according to studies published in the Journal of the American Medical Association this week. But whether treating fewer cancers early results in more deaths from late-stage prostate cancer later wonât be known for many years.
A CMS official said that as currently drafted, the proposed measure addresses only ânon-recommended PSA screeningsââthat is, âmen who get PSA screening when, under current clinical guidelines, it is not recommended for them.â She said it wouldnât restrict needed or medically necessary PSA tests.
âPhysicians can still order PSA tests if they feel the test is recommended or if the patient requests it,â she said.
The proposal lists some categories of men who would be excluded from the measure, including those with a history of prostate cancer or enlarged prostate, prior elevated PSA levels, or those taking certain medications for prostate issues. It doesnât mention men at high risk for prostate cancer due to family history or African-American heritage. Some experts say the benefits of screening may outweigh the harms for such patients.
Wanda Flier, president of the American Academy of Family Physicians, which is working with CMS on other quality measures, said it planned to urge the agency to adopt a more flexible measure for PSA screening that would allow for shared decision-making between a patient and physician based on individual circumstances.
âOur goal, as we move to value-based care, is to get to a system that is based on evidence and individual circumstances and not create harm to the patient or undue economic harm to the country,â she said.
Here is the bottom line on prostate cancer screening from the most recent Annals of Internal Medicine:
Clinical Bottom Line: Screening
Screening for prostate cancer and active treatment may prevent some prostate cancer deaths, mostly a decade or more later. However, screening also produces false-negative and false-positive results and over diagnosis. Cancer treatments cause sexual dysfunction in most men and distinct patterns of urinary and bowel symptoms. Therefore, harm is much more likely than benefit. Because men differ in how they weigh these outcomes, a shared decision-making process that reviews benefits and harms is essential to any informed decision to screen. However, providers should recommend against screening for men who have no risk factors and are younger than 50 years, most men older than 69 years, and those with a life expectancy less than 10 years.
