Why preventive care guidelines shouldn’t be tied to insurance coverage

Recommendations from the U.S. Preventive Services Task Force (USPSTF) shouldn’t be tied to insurance coverage, according to the physicians who helped craft those guidelines.

In a commentary in the Annals of Internal Medicine, three former chairs of the task force—Virginia Moyer, MD, MPH, Michael LeFevre, MD, MSPH, and Ned Calonge, MD, MPH—said the controversy over dramatic price increases of EpiPens since it was acquired by Mylan show the potential to corrupt the task force’s mission to evaluate preventive services like vaccines and screenings.

Under the Affordable Care Act (ACA), insurers have to cover preventive services with no copays if the service is given an A or B rating by the USPSTF. According to the authors, Mylan has used its considerable lobbying power (its CEO, Heather Bresch, is the daughter of U.S. Sen. Joe Manchin, D-West Virginia) to have EpiPens listed as a preventive service.

“To legitimize this goal, the company has written an article, found a willing physician to attach his name to it and published it in a medical journal,” Moyer, LeFevre and Calonge wrote. “The physician, listed as the sole author of the article, did not write it; as stated in the publication, it was drafted and revised by a paid consultant, ‘based on input from the author.’ The sole—and openly acknowledged—purpose of calling the EpiPen a preventive service would be to trigger first-dollar insurance coverage for the device.”

The strategy had first been reported by the New York Times in September.

If the EpiPen was classified as a preventive service, patients wouldn’t have to pay for it, but insurers would—which the authors called a “blatant attempt to twist the notion of prevention” in order to “deflect legitimate concerns about the dramatic and as of now indefensible increase in the cost of the device.”

This kind of manipulation led the authors to question the ACA provision, while arguing it has been beneficial for patients to have increased access to preventive care. Their fear is if more companies try to influence the process and use the preventive service mandate to their advantage, the resulting increase in deductibles and copays may discourage other important care.

“Parity in coverage of preventive and nonpreventive services should be expected, but preventive services cannot be assumed to be of greater value than other services,” Moyer, LeFevre and Calonge wrote. “The linkage also encourages those with a significant financial interest to attempt to influence the direction and decisions of the Task Force. We doubt that Mylan will succeed with these current efforts, but it attempts to violate the integrity of the process and thus distracts from the mission.”

The authors conclude the USPSTF guidelines may need to “inform, but not determine coverage.” Such a change would requiring amending the ACA.