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Medicare Payment Advisory Commission Commissioner Seeks to Reduce Often Unnecessary Care

By Kerry Young, CQ Roll Call

April 8, 2016 -- Medicare payment adviser William J. Hall said he sees firsthand the challenges of trying to reduce the federal health program's spending on low-value services, or treatments and procedures that researchers say provide little benefit and often carry some risk.

One example is prostate-antigen testing for men older than 75 who show no symptoms or strong risk for the urological cancer.

"If I take 100 patients that I have counseled on any of these topics here, PSA testing, X-rays for low back pain, et cetera, 99 of 100 would have one response after my pitch," said Hall, a University of Rochester geriatrician and Medicare Payment Advisory Commission (MedPAC) panelist, at a Thursday MedPAC meeting. "They say 'Does Medicare pay for it?' and that just erases the last 10 minutes of my life."

A  MedPAC analysis suggests that 23 to 38 percent of people enrolled in Medicare may have received at least one low-value service in 2013, with an estimated cost of $2.6 billion to $7.1 billion, according to a Thursday presentation from commission analyst Ariel Winter. In some cases, these procedures can trigger a cascade of follow-on procedures and services, MedPAC staff said. 

MedPAC members and staff discussed ways to reduce the widespread use of low-value services, which Medicare coverage often inadvertently encourages. The panel did not vote on any recommendations, however.

The commission's interest in low-value services builds on a growing trend to identify common practices that may offer little benefit. CMS officials, for example, have suggested looking to the kind of recommendations by the Choosing Wisely campaign as they write the rules needed to carry out an overhaul of Medicare's payment for doctors. Recommendations from the campaign suggest that men older than 75 rarely need a PSA test unless they are at higher risk for prostate cancer, such as having a family history of the disease.

The American Urological Association in 2013 said that routine PSA screening is not recommended in men over age 70 or any man with a life expectancy of less than 10 to 15 years. Prostate cancer is often a slow-growing disease, with tumors in many cases unlikely to threaten men's lives. Prostate cancer treatment can save lives, but also may result in harms such as incontinence and impotence.

Still, Medicare covers annual PSA tests for men age 50 and older without charge. "You pay nothing for a yearly PSA blood test," Medicare says on a web page that explains the program's benefits in simple terms.

The Medicare site does link to more detailed advice on prostate cancer screening from the Centers for Disease Control and Prevention (CDC) and the American Cancer Society.

The CDC follows the recommendations of the U.S. Preventive Services Task Force, which seek to reduce widespread routine PSA screening. The CDC notes that other organizations may differ. Its website links to the American Cancer Society and the American Urological Association.

"There is no question that screening can help find many prostate cancers early, but there are still questions about whether the benefits of screening outweigh the risks for most men," the American Cancer Society said. "There are clearly both pros and cons to the prostate cancer screening tests in use today."

Growing awareness of the risks of the PSA makes it easier to have candid conversations with patients, Hall told CQ HealthBeat in an interview.

But it's difficult to get the time needed to counsel people about why they may not need other services, such as an X-ray for back pain, and to explain how this could lead to unneeded follow-on treatment, Hall said.

"The evidence suggests that it really doesn't make much difference and it could lead to some harm, because everybody has an abnormal back x-ray after a certain age," Hall said. He sees a common response when patients learn that Medicare covers a procedure or test: "Well, what's the problem then?'" 

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