Screening Tests Under the ACA

The Affordable Care Act specifies that all insurers, including Medicare, will pay for cancer screening tests given an A or B rating by the US Public Services Task Force (USPSTF). That almost certainly means that they will not pay for cancer screening not recommended by the USPSTF, and that will come as a surprise to many patients because the USPSTF tends to be more conservative than other organizations in its recommendations.

Some patients will find that screening tests their insurers have been paying for will no longer be covered. No screening test for prostate cancer or melanoma made the cut, so PSAs and skin checks probably will no longer be covered. On the other hand, the USPSTF recently endorsed for the first time annual low-dose CT screening for lung cancer in patients 55-79 years old with a 30-pack-year smoking history who still smoke or only quit within the past 15 years.

The USPSTF recommendations are evidence-based, and the quality of the evidence is graded A-D or labeled as an I statement (I for insufficient evidence, presumably). The recommendation for screening for skin cancer, for example, is that the evidence is insufficient to assess the balance of benefits and harms of a whole-skin examination by a primary care provider or a self-examination by the patient. Annual skin checks by dermatologists, which some insurers cover now, apparently are not even worth considering. Too harmful or too expensive, I wonder?

The USPSTF makes recommendations for non-cancer screening as well, and I assume those will also determine what insurers will pay for. The USPSTF does not recommend screening older adults for vision or hearing impairment. That could be more harmful than beneficial? I fear that the evidence may be insufficient to balance the benefits and harms of a lot of common practices, including a physical examination and walking through the door of a doctor’s office. I am sure we will hear more about all of this, possibly even in future issues of The Medical Letter.

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  1. “Harms” include resources misspent and needed elsewhere in our over-priced, over-utilizing U.S. health care world. The editor might speak more effectively with more time spent studying the USPSTF’s website and publications. Better yet, using his position to have a conversation or two with Task Force physician members about the contrast between their evidence-based rigor and the processes that create other kinds of “guidelines,” like some for breast and prostate cancer screening that have had long and undeserved lives (organizations will remain nameless to protect the…). What he and I could choose and afford as an enhanced screening option is not necessarily good national health policy, and not always even good for us in the end.

  2. Jonathan Wolf says:

    it’s all about the benjamins.

    • The ACA (Affordable Care Act) is in no way perfect. Its developer acknowledges that there is no way the ACA could be perfect on first try. But at least it is a start (assuming one faction of one party in one house of Congress in one branch of government doesn’t close out the ACA before it starts simply because they don’t like the law). The GOAL for all should be to aim to fix the obvious problems with current black-white policy stating no payment for screening not recommended by the USPSTF. There are overscreening and underscreening measures (in my opinion) that need to be corrected. The choice of whether to view the problematic areas cited above by Mark Abramowicz as a glass “half full” or “half empty” is up to us. This IS a problem that potentially CAN be fixed (unlike the problems that will be caused if Congress remains closed because of objections to the ACA).

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