SUMMARY:

The U.S. Preventive Services Task Force (USPSTF) is an independent group that is composed of national experts in prevention and evidence-based medicine. The group makes recommendations that have significant impact on practice guidelines as well as reimbursement. Other governmental organizations such as the AHRQ are responsible for the scientific, technical, administrative, and dissemination support following release of the recommendations

Focus of the USPSTF

• Key focus areas of the USPSTF include those related to clinical preventive services
  • Screening tests
  • Counseling services
  • Preventive medications

Background of the USPSTF

• Created in 1984
• Members appointed by the Director of AHRQ with guidance from the Chair of the Task Force
• Experts’ background
  • Prevention and evidence-based medicine
  • 16 volunteer members
  • Practice areas: Preventive medicine and primary care, including
    • Internal medicine | Family medicine | Pediatrics | Behavioral health | Obstetrics/gynecology | Nursing
• Goal of USPSTF is to provide evidence-based recommendations to improve national health focused specifically on clinical preventative services
  • Screenings,
  • Counseling services
  • Preventive medications

The USPSTF Grade System

The USPSTF Grade Definitions After July 2012

• Grade A
  • The USPSTF recommends the service | There is high certainty that the net benefit is substantial
  • Offer or provide this service
• Grade B
  • The USPSTF recommends the service | There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial
  • Offer or provide this service
• Grade C
  • The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences | There is at least moderate certainty that the net benefit is small
  • Offer or provide this service for selected patients depending on individual circumstances
• Grade D
  • The USPSTF recommends against the service | There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits
  • Discourage the use of this service
• Grade I
  • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service | Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined
  • Read the clinical considerations section of USPSTF Recommendation Statement | If the service is offered, patients should understand the uncertainty about the balance of benefits and harms

USPSTF Recommendation Grade and Impact on Reimbursement

The Affordable Care Act (ACA) Addresses Preventative Care Reimbursement that is Strongly Based on Key professional Recommendations Including USPSTF

• Private health insurance plans: Must provide coverage of certain specified preventive services without cost sharing (there is no out-of-pocket payments)
  • USPSTF “A” or “B” recommendations
  • ACIP recommended immunizations
  • HRSA recommendations for children and adolescents based on Health Resources and Services Administration’s (HRSA’s) Bright Futures Project
  • HRSA recommendations from the Women’s Preventive Services Guidelines, including all FDA-approved contraceptives, sterilization procedures, and patient education and counseling for women with reproductive capacity, as prescribed by a health care provider

Note: Above applies to ‘Non-Grandfathered Plans’ | Any plans established before 2010 would be considered “Grandfathered” and requirements regarding coverage without cost sharing may not apply | Some states may require coverage without cost sharing for older plans

• Medicare: Under the ACA, USPSTF services with a Grade “A” or “B” must be covered without cost sharing if the Secretary determines they are
  •  Reasonable and necessary for the prevention or early detection of an illness or disability
  • Appropriate for individuals entitled to benefits under part A or enrolled under part B preventive care recommendations
• Medicaid expansion plans
  • Describes the extension plan for those with annual incomes ≤133% of the federal poverty level ($16,611 for an individual or $34,247 for a family of 4 in 2019)
  • Required to cover the full range of preventive services included in the essential health benefits (EHB) final rule
  • No cost sharing for all services outlined in the private health insurance plans
• Traditional Medicaid plans
  • States who elect to cover all USPSTF Grade “A” or “B” recommended preventive services, as well as ACIP recommended vaccines and their administration, without cost-sharing shall receive a one percentage point increase in the federal medical assistance percentage (FMAP) for those services

Use of Evidence

• An evidence review will accompany the final recommendations

Incorporating Evolving Evidence – Example Colorectal Cancer Screening 2021

• Colorectal Cancer Screening Age
  • In 2016, the USPSTF recommended screening for colorectal cancer starting at age 50 years and continuing until age 75 years (A recommendation)
  • Based on the newer evidence, the 2021 recommendation still recommends 50 to 75 years (A recommendation), but now also includes screening starting at age 45 years (B recommendation)
• Prioritizing screening options
  • Despite various requests to tier various screening approaches, the USPSTF included multiple options

Because no direct evidence compares different screening tests, and because local resources or patient factors may influence feasibility of different screening strategies, the USPSTF is unable to determine which tests are unequivocally “better” or “worse”

KEY POINTS:

Does Non-USPSTF Clinician Opinion Impact the Recommendations?

• USPSTF does provide opportunity for public comment at the various stages of recommendation development
  • Draft research plans
  • Draft evidence reviews
  • Draft recommendation statements
• Draft recommendations have been changed based on external input

Professional Societies

• Professional societies will help educate and organize members to advocate regarding a certain USPSTF recommendation
  • Practicing physicians in a particular area bring experience regarding evidence and/or local resources related to implementation, adoption and follow-up
• Example
  • Breast Cancer Screening: The American College of Radiology (ACR) submitted comments regarding the Draft Research Plan for Breast Cancer Screening that incorporated feedback, research papers and request for increased transparency

Individual Professional Comments

• The published USPSTF recommendations include a section “Response to Public Comment”
  • Details changes between draft and final recommendations
• Example: Cervical Cancer Screening Recommendations (2018)
  • Concerns regarding the draft (2017)
    • Co-testing was not included for women (30 to 65 years), rather only two options | Cytology every 3 years or Primary hrHPV every 5 years
    • Implementation issues, including lack of access to approved FDA primary tests
    • Modeling study unclear
  • Concerns were addressed in the final version
    • Women (30 to 65 years) can choose between 3 options: Cytology alone | Co-Testing | Primary hrHPV
    • Modeling study clarified and additional language included in the recommendations to acknowledge

… the importance of several different factors that affect overall screening effectiveness, including the primary screening test, screening ages, screening interval, test characteristics, and follow-up protocols, including triage of screen-positive women

How to Keep Up with Public Comment Opportunities

• Comment windows are time-limited but there are ways to find out about
  • New recommendations that impact practice and reimbursement
  • Draft Document Releases
  • How to comment on draft documents and have your voice be heard

The USPSTF Releases Information via Email and/or Social Media

LEARN MORE – PRIMARY SOURCES:

About U.S. Preventive Services Task Force

Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement | Cancer Screening, Prevention, Control | JAMA | JAMA Network

USPSTF Grade Definitions

CDC: Preventive Service Coverage

USPSTF: Opportunity for Public Comment

ACR statement on final USPSTF breast cancer screening recommendations

Draft Recommendation Statement: Cervical Cancer: Screening | United States Preventive Services Taskforce (2017)

Related ObG Topics:

Professional Guidelines: Colorectal Cancer Screening

Mammography Guidelines for Average-Risk Women

Primary Care Screening: USPSTF Recommendations for Your Patient

USPSTF Guidelines for Primary Care Clinicians: BRCA-Related Cancer Risk Assessment

USPSTF Recommendations: Screening for Osteoporosis to Prevent Fractures

Professional Recommendations for Use of Pharmacologic Interventions to Reduce Breast Cancer Risk

The Final USPSTF Recommendations on Pancreatic Cancer Screening

ACOG & USPSTF Guidance: Still a Role for the Annual Pelvic Exam?

USPSTF Guidance on Screening for Lung Cancer

USPSTF Releases Final Recommendation On Ovarian Cancer Screening

USPSTF Recommends Universal Screening for Hepatitis C

Aspirin Treatment for Women at Risk for Preeclampsia – ACOG, SMFM and USPSTF Recommendations

USPSTF Update: Screening for Abdominal Aortic Aneurysm

USPSTF Releases Guidance on Screening for Thyroid Cancer

CDC Guidelines on Antiretroviral Preexposure Prophylaxis to Prevent HIV in Those at Risk

Screening for Perinatal Depression