Prostate Cancer Screening: Can the Government Get It Right?

Senior Man ThinkingProstate Specific Antigen (PSA) tests are back in the news, as they are one entry point for the government to start micromanaging how it pays doctors in Medicare. To set the stage:

  • Currently, Medicare pays for an annual PSA test for men 50 and older as “preventive care.”
  • However, Obamacare does not consider an annual PSA test for men 50 and over as “preventive care.”
  • The U.S. Preventive Services Task Force’s current guidelines (updated in 2012), recommend against PSA tests.
  • PSA testing has declined significantly since the 2012 guidelines were updated.
  • The American Cancer Society favors PSA tests for men over 50, and as early as 40 for men with more than one first-degree relative diagnosed with prostate cancer.

You can be forgiven for being confused. The issue, put most bluntly, is that 70 percent of prostate cancer deaths occur after age 70. Much medical opinion claims that testing men at 50 leads to false positive diagnoses, causing mean to undergo treatment that is unnecessary, expensive, and has a high risk of serious side effects (including incontinence and impotence). Many of these men will die of other causes long before prostate cancer gets them, and it can always be diagnosed later if necessary.

This is not an issue to be taken lightly. The U.S. Preventive Services Task Force has re-opened the question, inviting input on a research plan that should lead to more risk-based guidelines. Further, Medicare has commissioned a consulting firm to develop quality measures (to be collected via electronic health records) that will have an impact on physicians’ pay: Those who order too many PSA tests will have their Medicare payments cut. (You can thank bipartisan super-majorities in the current Congress for this. They granted Medicare this power via the extremely flawed so-called “doc fix” passed last spring.)

There is a better way than giving the government the power to decide the value of PSA tests. Let’s accept that some physicians believe PSA tests are overused, but others disagree based on a different understanding of the evidence. Let’s accept that medical directors at some insurers believe PSA tests for 50-year olds are appropriate and some believe they are not.

Why not just allow individuals to choose doctors and insurers based on their own preferences? Researchers could conduct observational studies on the results. And we would get a lot closer to the truth than by giving the government the power to decide the question.

Comments (31)

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  1. Michael Gorback says:

    Mammogram guidelines deja vu.

    Nobody can “get it right” because it involves making value judgements. How many cancers are we willing to miss in order to offset the complications that result from false positives?

    Should we continue to check PSA and focus on reducing the morbidity and mortality of the procedures generated by false positives or work on a more specific test? What if the more specific test is less sensitive? How much money do you want to spend on whichever research venue you pick? Where will the money come from?

    This is just one test for one illness. It’s very well studied yet there’s no consensus. Now extrapolate that to the 65,000+ conditions listed in ICD-10. Someone has a lot of research to do.

    But on Government World bad answers are better than no answers at all. Combine that with no accountability, add a dash of lobbying from laboratories, and cook until completely beyond recognition.

    “Why not just allow individuals to choose doctors and insurers based on their own preferences?”

    Do you mean be able to pick doctors and insurers who agree with your own philosophy on PSA testing?

  2. Beverly Gossage says:

    Before Obamacare, most carriers that offered “free” physicals included a PSA. Thanks for pointing out that this is not included in the ACA benefits that fall under preventative services. I honestly never noticed.

    I agree that this discussion should be between the doctor and patient.

  3. Ron Greiner says:

    Lets think for a second. Insurance is to pay for an unforeseen claim or expense. Government types decided that physicals should be paid for by health insurance.

    Maybe we should get Life Insurance to pay for those PSAs so that it may prolong when the death benefit is paid, if that makes any sense which it doesn’t.

    John is right, just let people and insurance companies develop the products and if somebody wants to pay extra to have annual physicals covered they can. Remember though, insurance companies always charge enough to cover future claims, administration and to make a profit. The cheapest way to have annual physicals is not by paying extra to include it in your health insurance. It’s simple math.

    • Michael Gorback says:

      The insurer’s [cost + administration + profit margin might still be less than a non-contracted price]. If the contracted price plus insurance overhead is $100 but the noncontract price is $120 you’re better off with the coverage.

      I’m still unclear as to exactly what it entails to say “Why not just allow individuals to choose doctors and insurers based on their own preferences?”

      As a standalone statement it sounds fine. In the context of a discussion of PSA does that mean pick the doctors who share your belief about PSA testing? Does it mean pick a plan that covers it?

      Suppose the options don’t align? Perhaps the insurer offers PSA coverage but the doctor you want isn’t in network. What if you want PSA coverage but not annual physicals but nobody offers that combo? Sort of like which political party do you choose if you’re pro-choice but oppose same sex marriage.

      • I could not go into detail. In our reform, insurance contracts are long term (not annual) through reinsurance (health status insurance). So, if PSA tests really are preventive care and reduce long-term costs for the insured pool, premiums will be lower for plans that cover them.

        If PSA test cause more harm than benefit, premiums will be higher for plans covering PSA tests.

        • Michael Gorback says:

          If you want a PSA test but face higher premiums for a policy that covers it the logical thing to do is buy the cheaper policy that doesn’t cover testing and then pay cash for the blood test.

          • However, the premium increase for the policy that covers the test might be less than the out-of-pocket cost of the test, if the plan believes it will reduce long-term costs. (I am pretending we are in a reformed health system where plans are incentivized to account for lifetime costs, not just annual costs.)

  4. Michael Gorback says:

    Edit: the “]” should after the word “margin”.

    • Ron Greiner says:

      Micheal, HSA Bank is the largest HSA account holder in America after they took over JP Morgan’s HSAs. A good buddy of mine is a VP there. HSA Bank is good for those who want to spend their HSA funds or an employer who has to keep track of 250 employees’ HSA deposits.

      I met the President Kirk in 1998 at the 1st and only annual MSA agents meeting in Chicago. I met Greg Scanlen there and when he spoke Greg said, “The best thing is called HRAs,” Kirk and I just looked at each other and I got up and left. Back then they were called MSA Bank.

      Billy the CEO of New Directions might be better for you with HSA investments.

      https://newdirectionira.com/home

  5. Ron Greiner says:

    Michael, if you choose an HMO that pays for PSA coverage and then use a doc that is Out-Of-Network then you paid for the test but you still won’t have a covered expense.

    If you are pro-choice but oppose same sex marriage you should vote Republican. I hope that helps.

    • Michael Gorback says:

      When did the GOP turn pro-choice?

      • Ron Greiner says:

        Micheal, I thought your question was which political party should you choose?

        • Michael Gorback says:

          “which political party do you choose if you’re pro-choice but oppose same sex marriage?”

          IOW, you have two parties each offering something you want and something you oppose.

  6. Donna Kinney says:

    You got (part of the) problem right with regard to Medicare fee penalties based on bogus “quality” measures, but you got the cause wrong. That “value-based” payment system was created by the Affordable Care Act”. It’s true that MACRA, which was passed this year to do away with the doc-fix problem, changed it a little. But the stupid incentives which punish physicians if their patients use too many Medicare services or don’t always follow doctor’s recommendations were created by the Affordable Care Act. And those Medicare “value-based” policies are VERY BAD for patients!!

  7. Perry says:

    Government needs to stay out of healthcare and the space between physician and patient, period.

  8. Pjohnson says:

    PSA testing points out just how removed medical care and coverage is from the market. I can order this test on my own WITHOUT a Dr. for 35 bucks from Econolab (48 if I want more detail). The guidelines I’ve heard are test at 50, then 60 and never again if all the labs are normal. So is this what we’ve come to? Someone else needs to shell out 35 bucks per DECADE or people lose their mind and rant here an on FB?

    And no, I’m not defending indefensible Obamacare. Just shedding some much needed perspective. This all rings reminiscent of the “war on women” when Sandra Fluke ranted she needed someone else to pay 100 bucks year so she could sleep around. All while attending Georgetown Law School at 40K a year. Somehow she could swing the tuition but not The Pill.

    • Scott says:

      It’s an annual test! I think what you are referring to is a colonoscopy. A PSA test is a simple blood test.

  9. Scott says:

    Before my annual physical my doctor had ordered blood work that included a PSA test. The results came back and my PSA numbers had more than doubled in one year. My doctor ordered a second test and the results were the same. I was sent to an urologist who then performed a biopsy. The biopsy came back that I had a very agressive form of cancer and that I should have it removed as soon as possible, for sure before 6 months. I had to wait 6 weeks after my biopsy for the prostate to heal and on week 8 I had a radical prostectomy performed using the daVinci Robotic method. I am alive today because my doctor performed not only the first test but also the second test to verify the results of the PSA. So take this out of preventive care would be a travesty. This test is included in all blood work ordered by your doctor. So what are they saying, don’t do any blood work because of cost?

    • Michael Gorback says:

      The question is how many people like you we save vs how many we kill or maim due to false positives leading to unnecessary treatments that result in harm.

      All tests have a sensitivity (how well it can find disease) and a specificity (how many false-positives there are).

      PSA testing using a cutoff of 4.0 detects 21% of cancers overall and 51% of high grade cancers.

      If you drop the cutoff to 3.0 you detect more cancer – 32% and 68% – but your false-positives increase from 9% to 15%.

      The men with false-positives then undergo biopsies and other investigations or treatments and incur complications that they would have otherwise avoided.

      The question then is whether PSA testing just swaps one set of morbidity and mortality for a different set and what are the consequences – both for the patients and the cost of care.

      For example, suppose the number of lives saved by a positive PSA is the same as the number of people killed by false-positives. Should we do the test?

      • RCharles says:

        A positive PSA normally leads to either a second PSA test or a bioposy. The bioposy is the real determinate of cancer. It is unlikely that deaths due to negative bioposy testing will ever reach the deaths due to PSA tests not done.

        My high PSA in 2005 led to a negative bioposy. A book on prostate cancer recommended additional bioposies until something was found; an oncologist friend discussed with other professionals and said to wait and watch. Ten years later I have prostate cancer and it was found two years LATER THAN NECESSARY because my primary care doctor dropped the PSA test in 2011/2012, probably to improve his income under new government rules.

  10. Barry Carol says:

    Michael —

    What percentage of the prostate cancer cases are the aggressive type that will kill relatively quickly if not treated as opposed to the less aggressive type that grows so slowly that the patient is more likely to ultimately die of something else before the prostate cancer causes harm? Also, how high can the Gleason score be and still safely take a watchful waiting approach? Thanks.

    • Michael Gorback says:

      Barry,

      This is a very hot topic right now and beyond my pay grade. Can you watch and wait in someone with a positive PSA without a palpable mass? I think there will have to be a lot more work done on that. Personally, if I had a positive PSA I’d wait a while and repeat it, because PSA can go up after several things such as sex or riding a bicycle, or having sex while riding a bicycle.

      After a certain age you’re more likely to die WITH prostate cancer than OF prostate cancer and PSA definitely makes no sense.

  11. Scott says:

    Micheal and Barry,

    First Micheal, how can a false positive kill or mame someone? You get your PSA test done and if warranted based on the increase from the previous year your physician should schedule you an appointment for a prostate biopsy. This is a relatively harmless test, not to say it doesn’t hurt, they take 12 samples. From there you obtain your Gleason Scores if you have cancer within the prostate. A Gleason Score of 3+3=6 is a score your Urologist will take a wait and see attitude. If he/she starts seeing 4+3=7 or 3+4=7 in multiple samples they know they have an aggressive cancer. So, I am lost, how or what is a false positive and how would a false positive kill or mame someone?
    Being a survivor of an aggressive prostate cancer, one that was only found because my doctor does an annual PSA test along with all the other blood work for my annual physical, I am in favor of continuing this PSA testing as part of the care given. If my doctor had not caught this cancer through the doubling of my PSA numbers I wouldn’t be writing this today.

  12. Michael Gorback says:

    Scott,

    A needle biopsy is definitely not a “harmless test”. The most frequent complication of a needle biopsy other than bleeding is infection, and in today’s antibiotic-resistant environment that can be devastating. Complications of the infection that have been reported include meningitis and septic shock.

    Approximately 3% of men undergoing biopsy in the Global Prevalence Study of Infections in Urology required hospitalization after biopsy.

    Despite the use of antibiotic prophylaxis, the incidence of infection has been increasing.

    If you PSA test 1,000 men aged 55-69 every 4 years, you will save one life. OTOH, you will cause many more men to undergo the pain, cost, and possible complications of a biopsy.

    • Scott says:

      Michael, where on earth are you getting your information? First when you have a biopsy, needle or whatever you want to call it, all I know is it takes an approximately 1 inch core sample in 12 locations. Before and after the biopsy you are placed on a very strong antibiotic. Of the 6 men that I have spoken too about the biopsy and eventual surgery, NOT ONE, had any complications after the biopsy. I have a close friend that had complications after his radical prostectomy but after a short stay in hospital her was fine.
      Here’s another fact that no one has thrown out there, before the biopsy the digital probe of the prostate is not the simple “poke”. The digital exam is quite extensive, the urologist circles the prostate and can feel if the cancer has spread to the outside of the prostate.
      Micheal, like I have been saying, if I had not had a doctor who ordered the PSA test, saw it had doubled in a year, ordered the test again to verify and then to the urologist. And as I have indicated my cancer was a very aggressive cancer and some of the core samples taken from the biopsy were 90% filled with cancer.
      I think you are making a mountain out of a mole hill. I would rather error on side of safety, and in this case my life!!

      • Michael Gorback says:

        I get my information from peer-reviewed medical journals. You can do the same with an internet search and see the numbers for yourself.

        I’m glad that they found your cancer and that you survived, but there were others who didn’t have cancer, had PSA screening that was false-positive, and had serious complications, including death.

        That’s what the debate is about: How many men without cancer will we kill or injure due to PSA screening to produce one survivor like yourself?

  13. Ron Greiner says:

    That’s right Micheal. Here at the NCPA we know that the tax-free HSA gives you FREEDOM. Of course the larger your HSA balance is the more FREEDOM that you have.

    On the other hand smart people don’t spend their HSA funds that are growing tax free because they have the FREEDOM to let those funds continue to grow and take their withdrawal at any point in the future.

    I have a friend named Billy that can help you turn high premiums and taxes into GOLD with your tax-free HSA. Or, you may invest into real estate with your tax-free HSA. Anything you can do with an old taxed IRA you can do with a tax-free HSA including mutual funds with no minimum balance at HSA Bank.

    Here is 2 minutes of Billy explaining GOLD and SILVER in your tax-free HSA.

    https://www.youtube.com/watch?v=u_-x6XnDCGc

  14. Michael Gorback says:

    Thanks Ron. I already have a precious metals IRA with storage in 3 different countries. I may wear a tin foil hat but it’s a gold-plated tin foil hat.

    How does HSA Bank differ from other banks – whether bricks or Internet? I looked up the parent company on bankrate.com and was concerned with some of the stats.

  15. What you really want is to print out entries from this blog and NCPA’s health policy research publications, seal them in plastic, and put them in a vault.

    Then, when the EMP hits and the Internet goes down, you will have a portfolio of content that will rise dramatically in value.

    Not sure if it can be sheltered in an IRA, though.