Scott Gottlieb is a physicisian and policy analyst writing for the American Enterprise Institute. He has written a thoughtful critical review of the functions that the USPSTF is likely to serve under the Affordable Care Act, and considers how it should be structured given those functions. His briefing completely avoids the defamatory rhetoric of Steve Forbes and Newt Gingrich. More importantly, it raises important issues about the USPSTF that merit extensive public discussion.
I want to look at just one point here: What role should "expert opinion" play in the recommendations of the USPSTF? Gottlieb writes,
The sixteen advisors appointed to serve on the USPSTF are mostly primary care physicians, generally experts in preventive and public health. However, as clinical generalists, they rarely have deep expertise in the discrete medical disciplines in which they are asked to pass judgment, such as oncology or infectious diseases.
To fix this, Gottlieb argues that
Congress also should make sure that recommendations issued by the USPSTF are in sync with sister public health agencies that have far more expertise in the domains in which they operate. These include the CDC,the National Institutes of Health, and the FDA. The USPSTF lacks the capacity of these other agencies, and as such, its analysis should not supersede their expert opinions.
I agree that it would be good to include more specialists on the USPSTF. In part, this is because I think that the panel should be expanded, so that it can speed up its reviews.
But there are several problems here. First, we want to be very careful what role expert opinion should play the USPSTF evaluations. "Expert opinion" is a term of art in the world of evidence-based medicine. It means, roughly, "what experts think be done in the absence of sufficient empirical data." It is too simple to say that medical progress is the replacement of expert opinion by evidence-guided clinical judgment, but that is a good first approximation. The USPSTF's role has been to follow procedures derived from evidence-medicine, to give an objective scoring of the evidence. It's important that the USPSTF continue to require data supporting the value of preventive services, rather than just expert opinion. Gottlieb may well agree with me about this, but I want to stress it because of unusual meaning of "expert opinion" in this game.
Second, we want to maintain the USPSTF's independence from institutions such as the FDA and the NIH. We want this for the same reason that we want judges to be independent, accountants to be independent, and the FDA itself to be independent -- it is essential if we want the evaluation to be objective.
Finally, an adequately resourced USPSTF would be able to evaluate whether treatments work without the need to rely on expertise from the NIH. A certain level of expertise is required to read and critically evaluate the research on a given treatment or service. Beyond that, however, you do not necessarily need to how treatment X is supposed to work to determine whether treatment X actually does work.