Insurers: Decisions on coverage for PSA screening will take time

November 23, 2011

The U.S. Preventive Services Task Force (USPTF) announced it was no longer recommending the PSA test to screen healthy men for prostate cancer, but experts say the impact this recommendation could have on health insurance coverage and treatment decisions remains unclear. While insurers are likely to take their time issuing formal coverage decisions, the AUA and other urology organizations have been quick to respond to the recommendation.

The U.S. Preventive Services Task Force (USPTF) announced it was no longer recommending the PSA test to screen healthy men for prostate cancer, but experts say the impact this recommendation could have on health insurance coverage and treatment decisions remains unclear. While insurers are likely to take their time issuing formal coverage decisions, the AUA and other urology organizations have been quick to respond to the recommendation.

F. Randy Vogenberg, PhD, RPh, of the Institute for Integrated Healthcare, which provides benefits consulting to self-insured employers, said the decision whether to cover the blood test in a benefit plan will be a risk-versus-reward equation for health insurers. The benefit of early detection could be an incentive for insurers that want to avoid or limit more invasive and costly procedures downstream that may be necessary in more advanced disease states.

"From a commercial insurer perspective, they are really into health and wellness and preventive care-this kind of flies in the face of that," he said.

The USPSTF found that scientific evidence does not support the claim that early detection of prostate cancer prolongs lives. In addition, it says the test could lead to over-diagnosis and overtreatment of non-lethal forms of prostatic tumors.

Dr. Vogenberg believes health plans will be careful when making coverage decisions because they will not want to deter men from getting beneficial prostate screenings and tests. For example, national insurer Aetna has not yet decided how it will interpret the task force guidelines. James Cross, MD, head of medical policy and operations at Aetna, stated in written comments that the recommendations "have merit" and are being reviewed by the company.

Susan Pisano, of America’s Health Insurance Plans, a national association for health insurers, says the PSA guidelines are meant to change the physician-patient conversation in the decision-making process.

"What we expect to see is when individual clinicians and patients have those discussions-not that everyone will come to the same conclusions-but that when presented with the information about significant risks, that fewer patients will opt to have the test," she said. "And when it’s the right thing for the patient, there will be coverage."

She says the emphasis in reaction to the new guidelines has been misplaced.

"The real value is the information being provided to patients to let them make their decisions," Pisano said. "There is likely to be a change in clinical practice because physicians will be giving a different presentation than they gave before. You would expect that fewer patients, given the information on significant risk, will opt to have the test."

Several physician groups have strongly opposed the USPSTF recommendation. Rather than discourage men from being tested for prostate cancer, the USPSTF should instead focus on how to better educate key audiences about targeted screening, risk, and the role of active surveillance in the management of the disease, the AUA said in comments submitted to the task force.

In its Nov. 8 letter sent to Task Force Chair Virginia Moyer, MD, the AUA urged the USPSTF to reconsider its draft recommendations, pointing out that it is not the PSA test itself, but rather what is done with the information, that has created much of the controversy regarding over-diagnosis and overtreatment of prostate cancer.

"Telling men not to get tested for prostate cancer will move us backward, not forward," said AUA President Sushil S. Lacy, MD. "Instead, our approach should involve screening a more focused, healthy population, with a contemporary discussion of all therapeutic options, including active surveillance by knowledgeable providers and integrating better molecular markers and imaging into the decision pathways.

"To say that only men with symptoms of prostate cancer should be tested will potentially result in a return to a time when men presented with high-grade, metastatic disease for which there were few treatment options," Dr. Lacy said. "Issuing a 'Grade D' recommendation for prostate cancer testing sets a course that may, in fact, do more harm than good."

One recent survey of urologists, conducted by U.S. News Media Group, found that 95% of those surveyed disagreed with the task force recommendation. In an online survey conducted by Urology Times, 77% of respondents said they were concerned that their male patients will be less likely to undergo screening for prostate cancer following the new recommendation.

According to the Institute for Integrated Healthcare’s Dr. Vogenberg, the opinions of physicians will likely play a role in any PSA coverage decisions.

"The last thing you want as a problem-as a health plan or a self insured-is a problem with your physician network," he said.

Given that the test is not overused or expensive, Dr. Vogenberg believes health plan sponsors and employers who design worker coverage will take their time before making coverage decisions.

"Unless the volumes really go up dramatically, it’s not going to shift premium costs, so there’s really not a lot of compelling reasons to jump all over this," he said.

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