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Daniel S. Goldberg

Without really disagreeing with anything you say, I would argue that the fact that the USPSTF is comprised largely of expert generalists is a strength rather than a weakness, given the virtual consensus that a health care nonsystem dominated by specialists and specialty care is generally not likely to maximize health outcomes nor do so with particular efficiency (insofar as these outcomes are products at all of the delivery of health care services).

Thus, while I concur there is merit to Gottlieb's concerns, as you have pointed out with aplomb on this blog, one of the last things the U.S. nonsystem needs WRT health care is another expert panel dominated by specialists. We've had one of those for a long time -- the RUC -- and there is a significant amount of evidence that this has not generally been a salutary development from either absolute population health, distributional concerns, or efficiency.


Bill Gardner

Thanks, Daniel. I agree that there is a need for more generalists in US health care. I also think that specialists in a given field (Gottlieb's expert) may have a greater risk of confirmation bias in their evaluation of evidence. However, there are clearly important roles for both on the USPSTF. The key thing, though, is not generalist versus specialist training, but commitment to the principles of evidence-based medicine.

This shows how little I know, but what is the RUC?

Paul Kelleher

I don't good reason to keep specialists off the USPSTF, as one or two (or more) voices among others. Presumably the deliberative nature of the body would compel these specialists to engage with the scientific evidence rather than rely on conventional wisdom or "expert opinion" in the sense Bill discusses.

What's interesting is that Gottlieb doesn't (or at least doesn't seem to) call for more specialists on the USPSTF, but rather calls for the USPSTF to be be "in sync" with other agency's on the relevant issues.

Bill Gardner

I noticed that too. Not sure why he feels that way.

Brad F

Additional comments. First, on payers having to provide coverage for A and B grade evidence; second, an unforeseen positive exeternality for MCOs:

If the USPTF did not exist--which is what Scott advocates (a world without this body), "A or B evidence" would be strong enough to stand on its own via forces of academic community and professional societies--MCO's would cover anyway. Can you imaging an insurer not paying for treatment validated in a high quality RCT? He has been critical of handling of Avastin payment coverage. Surely, if it extended lives, who would scream the loudest if insurer "x" refused to pay? That would not happen in a USPTF world.

Additionally, he does not discuss those services that get a C or D. Thats cloud cover for payer denial, and a benefit to the commercial world (read quarterly earnings). They can blame uncle sam for "us not paying."

Convenient of him to leave those factoids out.


Bill Gardner

Thanks for the information. I couldn't tell whether Scott actually thought there should be a USPSTF or not.

What are your views on all this?

Brad F

He is of the free market vintage, and most of his WSJ pieces are critical of FDA and other regulatory oversight. He would opt to "leave it to the markets."

Perhaps it is overly critical to state he would vaporize the USPTF, but its safe to assume the agency he envisions, as opposed to the one we do, are vastly different. The word "defang" comes to mind. :)


Daniel S. Goldberg

Just to clarify: I did not suggest that specialists should be excluded from the USPSTF, but rather that the fact that the latter is generally composed of expert generalists rather than specialists is a strength rather than a weakness.

Supplementing these generalists with specialists is perfectly reasonable, so long as the expert body does not by hook or by crook transform into a body of specialists, which would be a terrible occurrence, IMO.

Bill Gardner

I think we agree.

Daniel S. Goldberg

Goodness, Bill, I completely ignored your question:

The RUC is the shorthand abbreviation for the Relative Value Scale Update Committee. I am partial to Roy Poses's excellent blog posts on the subject, which are at Health Care Renewal (just search for "RUC" or "RVSUC").


There's a website devoted to undermining the impact of the RUC, although that's an advocacy initiative (one I unabashedly support, I should say):


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