Are you thrilled and excited about the U.S. Preventive Services Task Force’s (USPSTF) proposed rating upgrade from “D” to “C” for PSA testing for prostate cancer in men aged 55-69? Dancing in the street, expressing your jubilation, celebrating victory? Or are you bemoaning the inadequacy of a too-meager upgrade? Maybe you’re in the “couldn’t care less what they say” group? Regardless, the USPSTF does seem to garner a ton of attention, and with their every announcement they ignite impassioned and fierce debate.
In the midst of the current round of prostate screening controversy, I instead became curious about the origin, structure, and mission of the USPSTF—generally referred to as the “Task Force,” maybe to avoid confusing it with the other USPS. Specifically, I wanted the name of a real person who would be the rightful recipient of any credit or blame associated with starting the USPSTF ball rolling in the first place.
Starting from a position of relative ignorance on the topic, this turned out to be a more daunting challenge than I anticipated, and I only partially succeeded in satisfying my curiosity. Before embarking on this journey, I reminded myself that curiosity kills cats, but it didn’t help. Curiosity also often sends the likes of me down the proverbial rabbit hole, and that’s where I’m headed now with you, my willing accomplice.
USPSTF
Our deep dive into the USPSTF abyss begins on the “About” page of the Task Force’s website. The first paragraph summarizes their makeup, mission, and method:
Created in 1984, the U.S. Preventive Services Task Force is an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. All recommendations are published on the Task Force’s Web site and/or in a peer-reviewed journal.
In my initial searches, nearly every result began in a similar manner, with a cavalier and dismissive, “created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent …” blah blah blah. Sounds like divine creation. POOF! There’s a task force! But who are they?
There are sixteen members, including the Chairperson and two Vice-Chairpersons. This currently includes nine men and seven women, all sporting very warm, natural smiles. Seven wear glasses, some are youngish, some are older, one is bald, another white-haired, and one bears a striking resemblance to Matt Lauer. I will leave the examination of their backgrounds and qualifications to you, as that is not my purpose here.
Are Task Force members paid? They only receive reimbursement for travel expenses. The Federal Register (Vol. 78, No. 75) states that members do not receive any compensation beyond support for travel to in person meetings. Such meetings occur three times each year, for two days. The many additional hours of work between those in-person meetings are without compensation.
How did the Task Force members become such? Are they elected? Hired? Appointed? It turns out that they can be nominated by literally anyone, but are appointed by the head of another government entity, the Agency for Healthcare Research and Quality (AHRQ). The Chair of the Task Force might sit at the head of the table when USPSTF meets, but the Director of AHRQ arguably has more power and influence.
AHRQ
Who or what, then, is the AHRQ? They state their mission as follows:
The Agency for Healthcare Research and Quality’s (AHRQ) mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.
AHRQ’s connection to USPSTF began in 1995 when the Public Health and Human Services Act (Title IX, 42 U.S. Code § 299b–4) required it to provide administrative, research, technical, and communication support to the Task Force. Well, that’s pretty much everything except the medical recommendations. Clearly, the AHRQ is intimately involved with the USPSTF. The day-to-day operations, development of evidence reports, promotion of recommendations … all AHRQ.
I found it particularly interesting that the AHRQ also “supports” the Task Force by funding Evidence-based Practice Centers (EPCs), which are academic or research organizations. The EPCs work with the Task Force to develop research plans and conduct the evidence reviews used by the Task Force to determine its recommendations. More AHRQ influence and involvement, along with some external organizations.
To whom does the AHRQ answer? As implied by its mission statement, it is an agency within yet another government entity, the Department of Health and Human Services (HHS). Pour yourself a large cup of coffee and have a look at the HHS organizational chart. You’ll find AHRQ listed as one of its Operating Divisions.
HHS
AHRQ answers to HHS, but who exactly is that? Their website describes them as the nation’s principal agency for protecting the health of all Americans and providing essential human services. Here is their official mission statement:
It is the mission of the U.S. Department of Health & Human Services (HHS) to enhance and protect the health and well-being of all Americans. We fulfill that mission by providing for effective health and human services and fostering advances in medicine, public health, and social services.
HHS has been around since 1980. When the Department of Education Organization Act was passed in 1979, the Department of Health, Education, and Welfare (HEW) was split, creating a separate Department of Education. What remained became the Department of Health and Human Services (HHS) on May 4, 1980. HHS is headed by the Secretary of HHS, one of fifteen cabinet level positions in the federal bureaucracy, appointed by the US President and confirmed by the US Senate.
So there we have it. POTUS picks someone to lead HHS, and … out pops the Task Force at the other end. We start at the top with the US President, and then follow the path to the Senate, to HHS, to AHRQ, and to USPSTF. Along the way we encounter many people and entities, all working in harmony to make sure you and I are healthy. All from the government, and all here to help us.
I feel better already.
The birth of the Task Force
We have now arrived at what appears to be the USPSTF’s birthday. The New England Journal of Medicine takes us all the way back to the inception of the USPSTF, explaining it as follows:
The USPSTF was first established in 1984, at a time when health care purchasers were reluctant to reimburse clinicians for preventive care. To overcome this resistance, U.S. Deputy Assistant Secretary for Health J. Michael McGinnis convened a panel of experts in primary care and public health to analyze the literature and build an “airtight case” for effective preventive services. Though supported by the Office of Disease Prevention and Health Promotion, the USPSTF was configured as a nonfederal body to insulate it from political and commercial pressures. Its findings were framed as advice to clinicians, not the government, and it was encouraged not to consider costs.
If you’re looking for original intent, I suppose the above quote sums it up as well as possible. If you’re looking for a warm body to praise or vilify, you can read about the aforementioned J. Michael McGinnis to see if he fits your bill. To help you decide, read his own words in his statement to the US Senate on the Disease Prevention and Health Promotion Act of 1978, six years before the Task Force was born.
The National Academy of Medicine (NAM) seems to like Dr. McGinnis, as indicated by his recent appointment. On the other side, you’ll find a stunning and entertaining example (if not entirely literate) of vilification on the Smokers’ Rights Blog. They devoted an entire page to him, and it’s brutal. I’ve done no fact checking of their information, so do your own or take what they say with at least a few grains of salt (or puffs of smoke).
USPSTF 1984 and beyond
The Task Force left the starting gate in 1984. Broadly speaking, section 1.3 of the USPSTF Procedure Manual (84 fascinating pages) concisely tells us what the Task Force has done since then. I suggest you download the manual into your Kindle to help you pass the time (or fall asleep) on your next long flight.
… the Force can now be with you always, via an app …
it was 1989 when they offered their first publication, the “Guide to Clinical Preventive Services.” In 1996 they published the second edition of the same. Beginning in 1998, they began releasing recommendations incrementally in addition to occasional larger publications. The 2014 Guide to Clinical Preventive Services can be found here, and their up-to-the-minute updates and recommendations are on their website. To date, there are 98 published recommendations you can search, sort, and read here.
And if that’s not enough, the Force can now be with you always, via an app. That’s right, you can review what your friendly Task Force has to say anywhere, anytime, from the convenience of that handy computer in your pocket. It’s actually a nice little free app from AHRQ called ePSS (Electronic Preventive Services Selector). Your tax dollars at work. Get it for Android here, and for iPhone here. Other formats for ePSS are listed here.
Nobody can accuse them of being behind the times.
The slippery slope
In light of the original intent, it’s worth wondering whether the Task Force has maintained being a nonfederal body, insulated from political and commercial pressures. Well, let’s see now. POTUS, the Senate, HHS, AHRQ, EPCs … that’s a lot of government. Sure, Task Force recommendations are not subject to approval by other agencies, but isn’t it naïve to think they’re not paying attention? The chain of power behind the USPSTF is long and winding. To believe there is no influence along that chain of command is naïve.
The Task Force members can no longer pretend to be independent advisers making benign recommendations. They are official policy makers …
The USPSTF has undeniably become an ingrained part of the federal bureaucracy. And now (since 2010) the transformation is complete. The Task Force members can no longer pretend to be independent advisers making benign recommendations. They are official policy makers, thanks to the Patient Protection and Affordable Care Act (PPACA, a.k.a., Obamacare). That controversial legislation changed the very nature of the USPSTF, taking it a full 180-degrees away from its original intent.
What began as an ostensibly independent, insulated, non-federal body making recommendations, now determines the behavior of Medicare. Although the Task Force’s pronouncements are still called recommendations, they are policy. They determine (among other things) what Medicare reimburses.
This transformation is described and discussed in the New England Journal of Medicine in the November 9, 2016 article called The Paradox of Authority — Transformation of the USPSTF under the Affordable Care Act. I suggest you read it.
People, not groups
It’s easy to depersonalize all this massive governmental, bureaucratic structure. It’s common for individuals to become hidden behind the groups of which they are members. I find it helpful to remind myself it’s not the Senate, the HHS, the AHRQ, the USPSTF, etc. who have increasing power over my healthcare—it is numerous individual people with varying viewpoints. Senators are people. The Secretary of HHS is a person. The Director of AHRQ is a person. The Chair and members of the USPSTF are people. As a voter, I have some influence over a few of them, but mostly it’s out of my hands.
What began as a benign seed of a seemingly noble idea has grown out of control.
What began as a benign seed of a seemingly noble idea has grown out of control. The USPSTF and its associated entities have become a kudzu-like entanglement, endlessly growing, wrapping around my life, hampering my ability to make decisions that affect my health. Unraveling it and breaking free will be a daunting challenge. If that’s not your wish, rest easy—and may the Force be with you.
Next month I am due for a PSA test. My doctor and I agree about that.
Seems so simple.
I’ve included many links in this post. If you didn’t click them on your first read, I encourage you to start again and click some. They document and add to what I’ve said here, which is only the tip of the iceberg.
History is not my strong suit, and for me, tackling the Task Force was no easy task. If you find something to correct or add, send me an email—thanks!
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