Expert Opinion and the US Preventive Services Task Force

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. 

Comments

[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.

No?

[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]

Bill
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.

Brad

[Bill Gardner]

Brad,
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. :)

Brad

[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]

Daniel,,
I think we agree.
cheers
BIll

[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").

http://hcrenewal.blogspot.com/

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):

http://replacetheruc.org/