1. The US Preventive Services Task Force: Potential Impact on Medicare Coverage Ned Calonge, MD, MPH Chair, USPSTF

2. Introduction l Discuss meaning of USPSTF recommendations and potential impact under MIPPA and health care reform l Discuss impact of evidence-based recommendations on health care systems and health l Discuss coverage decision making and implementation of evidence–based practices

3. Categories of preventive services based on evidence of health benefit 1. Services that have sufficient evidence that delivery will improve health (mortality and/or morbidity) if provided to individuals in a population 2. Services that have sufficient evidence that they provide no overall health benefit, or do more harm than good 3. Services that may hold promise for improving health, but sufficient evidence does not exist to determine overall benefit

4. Positive net benefit (benefits exceed harms) l Small net benefit: benefits and harms are closely matched; the number of individuals who benefit is very small or very close to the number who are harmed l Moderate net benefit: a significant number of individuals will benefit compared to those harmed l Substantial net benefit: many more individuals can be expected to benefit compared to those harmed

5. USPSTF purpose and process l From systematic review and synthesis of existing research, create evidence-based recommendations for use by primary care clinicians that will improve the health of their patient populations l Use a set of key questions within an analytic framework and explicit criteria to judge the strength and quality of existing research and determine a level of certainty that use of a service will translate to an acceptable magnitude of net health benefit

6. Magnitude/certainty of net benefit and letter grades SubstantialModerateSmallZero/Negative Certainty of Net Benefit Magnitude of Net Benefit (Benefit Minus Harms) High ABCD Moderate BBCD LowI — Insufficient Evidence A & B: recommend use C: recommend against routine use D: recommend against use I: no recommendation; insufficient evidence

7. Meaning of A and B recommendations l Magnitude of net benefit is at least moderate l The certainty that the service will provide this magnitude of net benefit, based on the strength and quality of evidence, is at least moderate l Primary care clinicians should provide these services, and doing so will translate to improved health in their patient populations

8. Meaning of a C recommendation l There is at least moderate certainty of a small net benefit; benefits and harms are closely matched l Clinicians should not routinely provide these services, but take into consideration individual patient factors in decision making l Implementation of these services will have little impact on the health of the population

9. Meaning of a D recommendation l There is at least moderate certainty that the service provides no net health benefit, or does more harm than good l Use of these services should be discouraged l The evidence for screening for conditions of very low prevalence often is sufficient to conclude that the assessment of the magnitude of net benefit is likely to include zero net benefit or net harm

10. Meaning of an I statement l An I letter grade represents a conclusion, not a recommendation l An I represents a call for research: »It does not mean the intervention is not effective »It means there is no evidence of effectiveness, not that there is evidence of no effectiveness l Common reasons for an I: »Lack of evidence on clinical outcomes »Poor quality of existing studies »Good quality studies with conflicting results l There is a possibility of clinically important benefit

11. What to do when faced with an I l Consider factors in four domains: »Potential preventable burden of disease »Potential harm »Costs (monetary and opportunity) »Current practice l Support high quality research of the service

12. Evidence-based health policy l Coverage and resource utilization should be aligned with health benefit l Decisions about health benefit should be based on evidence l Priority should be given to providing services with proven, significant benefit discouraging use of services with no benefit, and not supporting use of services with unknown benefit

13. MIPPA and the USPSTF l Additional services may be authorized if »The Secretary determines them to be reasonable and necessary for the prevention or early detection of an illness or disability and »They are recommended with a grade of A or B by the USPSTF

14. MIPPA and the USPSTF l Services with unknown or small net benefit in terms of population health will not be covered l Aligns priorities for resource use with proven impact on health outcomes in prevention l Provides impetus for research on potentially beneficial services l Increases the visibility of the USPSTF

15. USPSTF in health care reform l House bill addresses USPSTF: »Increases size of and resources for the USPSTF »Makes USPSTF a FACA committee »Provides coverage for services with A and B recommendation grades »Similar provisions for the CDC’s Task Force on Community Preventive Services

16. USPSTF and costs l Providing services with an A or B recommendation will translate to improvement in health of a population l The USPSTF does not consider costs in the recommendation process l Coverage for A and B recommendations will improve health, but not necessarily at a lower overall cost