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Opinion
VIEWPOINT
Evidence-Based Clinical Prevention in the Era
of the Patient Protection and Affordable Care Act
The Role of the US Preventive Services Task Force
Albert L.Siu.MD,
MSPH
Department o f
Geriatrics and Palliative
Medicine, Icahn School
o f Medicine at M ount
Sinai, New York,
New York.
Kirsten
Bibbins-Domingo,
PhD. MD
Department o f
Medicine and
Department o f
Epidemiology and
Biostatistics, University
o f California,
San Francisco.
David Grossman, MD,
For more than 3 decades, the US Preventive Services
tive se rvice -o n e o f th e several considerations in cover­
Task Force (USPSTF) has made recommendations regard­
age. The task force understands th a t, in addition to the
ing clinical preventive servicesforasymptomaticadultsand
scie n tific evidence, insurance coverage decisions in ­
children in primary care, based on a rigorous analysis o f the
volve o ther im portant considerations, including prefer­
best available evidence. Members o f the task force are ex­
ences o f patients, clinicians, consumers, comm unities,
perts selected from fields involved in preventive services
special populations, purchasers, and others.5 The re­
for a broad range o f health conditions encountered in pri­
sulting A and B recom m endations are linked to cover­
mary care. A broader array o f experts including disease
age in the ACA and form the basis fo r th e decisions o f
specialists provided detailed peer reviews o f task force
others about how to implement coverage consistent with
evidence summaries and d ra ft recommendations. The
the task force grade and the ACA (Table). The passage
USPSTF has an interest in improving the health o f the pub­
o f th e ACA has not influenced th e m ethods or evidence
lic and helping ensure access to preventive care.
thresholds the task force uses to assign an A, B, or any
In the last decade, th e task force has increased e f­
forts to enhance transparency, communications, and en­
letter grade, nor does the task force consider coverage
implications when m aking recommendations.
gagement w ith stakeholders, external scientists, and the
Conversely, fo r services graded o ther than A or B,
public. The USPSTF approach aligns w ith th e recom ­
the ACA does not p rohibit full or partial insurance cov­
m endations o f th e Institute o f Medicine on using evi­
erage. The law states that “nothing in this subsection shall
MPH
dence from high-quality systematic reviews and m ain­
be construed to p ro h ib it a plan or issuer from providing
Group Health
Cooperative, Seattle,
Washington.
taining strict conflict o f interest standards.1
coverage fo r services in a d d itio n to th o se re c o m ­
Corresponding
The recom m endations o f th e task force include a
mended by U nited States Preventive Services Task Force
specific le tte r grade depending on th e magnitude and
o r to deny coverage fo r services th a t are n o t recom ­
certainty o f net benefit (Table). In 2010, the Patient Pro­
mended by the Task Force.” Thus, payers can offer full
tection and Affordable Care Act (ACA) created a link be­
or partial coverage fo r preventive services graded other
tw een USPSTF recom m endations and various cover­
than A or B. Patients and their clinicians may choose pre­
age requirem ents. The ACA specifies th a t commercial
ve n tive services th e y deem appropriate, even those
and individual or fam ily plans must, at a m inim um , p ro ­
w ith o u t A and B grades.
vide coverage and not impose cost sharing fo r any evi­
Some have m isinterpreted task force grades o f C
dence-based preventive services th a t receive a grade o f
o r I as reco m m en d a tio n s against screening o r even
A or B from the USPSTF. Medicare and Medicaid are ex­
agai nst coverage. This is n o t th e in te n t o f th e task force.
cluded from this provision o f the ACA. Some advocacy
A C grade is still a positive recom m endation th a t recog­
groups and others have frequently m isinterpreted the
nizes small net benefit, and th e task force recommends
ACA linkage as licensing the task force to explicitly rec­
that clinicians offer C-rated services to patients after con-
om m end fo r or against coverage.
sideringthe presence o f patient risk factors, patient pref­
The task force maintains th a t th e science on effec­
erences, local disease prevalence, and availability o f ser­
tiveness o f preventive services should help to inform cov­
vices. Considering such factors is especially im portant
erage decisions. It also maintains th a t th e linkage be­
w hen th e re is h e te ro g e n e ity o f risk fo r p a tie n ts a f­
tween USPSTF recommendations and the ACA coverage
fected by a C recom m endation and when the assess­
m andate sets a m inim um standard fo r coverage o f pre­
m ent o f net benefit depends substantially on patient risk,
v e n tiv e se rvice s. T he scie n ce on e ffe c tiv e n e s s –
values, and preferences. Similarly, an I grade, a declara­
although fo u n d a tio n a l-is only one factor th a t needs to
tio n o f insufficient evidence, is not a recom m endation
be considered in developing coverage policy,
against coverage but rather a call fo r more research.
Flaving insurance and a breadth o f coverage affects
For some non-Aand non-B recommendations, cov­
patients’ use o f preventive services.2’4 Lawmakers pro­
ering th e service may be m edically reasonable. H ow ­
vided a mechanism fo r prioritizing services for enhanced
ever, the task force cannot and has never started by pre­
coverage by linking recommendations from the taskforce
determ ining w hether a service should be covered and
and from others (Advisory Committee on Immunization
th e n m an ipulating th e science to reach a grade th a t
M ount Sinai Medical
Practices, Bright Futures pediatrics recommendations, and
w ould link to coverage. Payers currently have the la ti­
Center, One Gustave L.
Levy Place, PO Box
Health Resources and Services Adm inistration women’s
tude to cover such services using well-established p ro ­
Author: Albert L.
Siu, MD, MSPH,
1070, New York, NY
10029 (albert.siu
@mssm.edu).
jama.com
preventive services guidelines) to coverage.
In this context, the task force interprets its role as
focusing on evaluatingthe science supportinga preven­
cedures to assess coverage policy. Lawmakers also have
th e pow er to require coverage o f selected non-A and
non-B graded services.
JAMA
November 17,2015
Volume 314, Number 19
2021
Opinion V iew point
Table. USPSTF R eco m m e n da tio n Grades, Suggestions fo r Practice, and R elative Roles o f th e USPSTF, Law m akers, and Insurers
in D e te rm in in g Coverage
USPSTF Role in Estimating Certainty of Net Benefit and Assigning a Grade
Grade
Definition
Suggestions for Practice
A
Recommends (high certainty of
substantial net benefit)
Offer or provide
B
Recommends (high certainty that net
benefit is moderate or moderate
certainty that net benefit is moderate
to substantial)
Offer or provide
C
Recommends selectively offering or
providing to individual patients based
on professional judgment and patient
preferences (at least moderate
certainty of small net benefit)
Offer or provide for selected
patients depending on individual
circumstances
D
Recommends against the service
(moderate or high certainty of
no net benefit or that harms
outweigh benefits)
Discourage the use of this service
Concludes that current evidence is
insufficient to assess balance of
benefits and harms of the service;
evidence is lacking, of poor quality, or
conflicting, and balance of benefits
and harms cannot be determined
Read clinical considerations
section of USPSTF
Recommendation Statement; if
clinicians offer these services,
patients should understand the
uncertainty about balance of
benefits and harms
1
ACA Linkage
Role of Insurers
ACA mandates coverage with
no cost sharing
Establish coverage policy
consistent w ith USPSTF grade
and ACAb
ACA does not deny coverage
and does not prohibit a plan
Abbreviations: ACA, Affordable Care Act; USPSTF, US Preventive Services
Task Force.
a Breast cancer screening for women in their 4 0s currently has a separate
Determine coverage policy
based on effectiveness, consumer
demand, community norms,
and other considerations’3
b Coverage policy might include specifying the actual service and target
population, which clinicians can provide the service, and where, when, and
^ow ° ^ en they can provide it.
mandate fo r coverage w ith no cost sharing.
Screening mammography in wom en in th e ir 4 0 s provides a case
In essence, the ACA leaves discretion to payers regarding cov­
in point. The USPSTF found th a t screening m am m ography is ben­
erage fo r non-A and non-B graded services-as was th e case fo r all
eficial fo r wom en between the ages o f 4 0 and 49 years. The incre­
preventive services before the ACA. The law adds a “shortcut” to first-
mental benefit o f starting before age 5 0 years is small, and the false-
dollar coverage fo r A and B graded services only, leaving discretion
positives and unnecessary biopsies were significant. A wom an who
to payers fo r other services. The net result is th a t im plem entation
understands the harms b u t values any chance o f reducing her risk
o f the task force recommendations, as well as recommendations by
o f dying o f breast cancer, no m atter how small, should be able to
o ther designated organizations, should lead to expanded access to
make an inform ed decision to begin screening before age 5 0 years.
highly effective, evidence-based preventive services.
The taskforce supports that individual decision, but understands that
The USPSTF supports im proved access to effective preventive
in the absence o f coverage, fewer women will make that choice. How­
services. Although the ACA has provided an o p p o rtu n ity to link evi­
ever, the USPSTF cannot reinterpret the science and exaggerate the
dence to coverage for the most highly recommended services, these
net be n efit sim ply to ensure coverage. Payers, however, have the
A and B recommended services are a floor, rather than a ceiling, on
option o f providing coverage (as many do). Lawmakers have the op ­
coverage o f preventive services. The USPSTF is com m itted to using
tio n o f requiring coverage fo r m am m ography (as th e y have done in
the best science to identify the m ost effective preventive services
the past).
to im prove the health o f th e public.
ARTICLE INFORMATION
Published Online: September 30,2015.
doi:10.1001/jama.2015.13154.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure o f Potential Conflicts o f Interest and
none were reported.
o f Georgia: Francisco Garcia, MD, MPH: Pima
County Health Department: Matthew W.
Practice Guidelines We Can Trust. Washington, DC:
Gillman, MD, SM: Harvard University: Jessica
Herzstein, MD, MPH: Independent Consultant in
2. Lurie N, Manning WG, Peterson C, Goldberg GA,
Phelps CA. Lillard L. Preventive care: do we practice
Occupational, Environmental, and Preventive
what we preach? Am J Public Health. 1987:77(7):
801-804.
Health: Alex R. Kemper, MD, MS: Duke University:
Alex H. Krist, MD, MPH: Virginia Commonwealth
Additional Information—Collaborators: Members
o f the United States Preventive Services Task Force
University: Ann E. Kurth. PhD, RN, MSN, MPH:
New York University: Douglas K. Owens, MD. MS:
Stanford University: William R. Phillips, MD, MPH:
include: Albert L. Siu, MD, MSPH (Chair): Icahn
School o f Medicine at Mount Sinai: Kirsten
Bibbins-Domingo, PhD, MD (Vice Chair):
University o f Washington: Maureen G. Phipps, MD,
MPH: Brown University: Michael P. Pignone, MD,
MPH: University o f North Carolina.
University o f California, San Francisco: David
Grossman, MD, MPH (Vice Chair): Group Health
REFERENCES
National Academies Press; 2011.
3. Solanki G, Schauffler HH, Miller LS. The direct
and indirect effects o f cost-sharing on the use of
preventive services. Health Serv Res. 2000 :3 4 (6):
1331-1350.
4. Goodwin SM. Anderson GF. Effect o f
cost-sharing reductions on preventive service use
among Medicare fee-for-service beneficiaries.
Medicare Medicaid Res Rev. 2012:2(1). pii:002.01.a03.
doi: 10.5600/mmrr.002.01.a03.
Research Institute: Michael LeFevre, MD MSPH
(Immediate Past Chair): University o f Missouri:
1.
Linda C. Baumann, PhD, RN, APRN: University o f
Wisconsin: Karina W. Davidson, PhD. MASc:
(US) Committee on Standards fo r Developing
the Gaps. Washington, DC: National Academies Press;
Trustworthy Clinical Practice Guidelines: Clinical
2011.
Graham R, Mancher M, Miller Wolman D,
Greenfield S, Steinberg E, eds. Institute o f Medicine
5. Clinical Preventive Services fo r Women. Closing
Columbia University: Mark Ebell, MD, MS: University
2022
JAMA
November 17.2015
Volume 314, Number 19
jama.com
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