Getting Serious about a Bad Medicare Recommendation

zappaFrank Zappa and the Mothers
Were at the best place around

In Memory of Frank Zappa

Prostate Cancer Victim

Yes, we got a site permit. Yes, a construction fence is up, though I have not seen it yet, and by the time I get to our lot it may be buried by snow. But that is all the update on the house you are going to get today. It is soapbox time. For those of you who don't like medical news, cover your eyes or skip to another blog, but this pathologist needs to unload!

The Centers for Medicare & Medicaid Services (CMS) is the federal agency that, you guessed it, runs Medicare. Part of what they do is establish "quality" measures and review bills and electronic medical records to determine how well physicians are following in line with these measures. For the last few years, compliance with these measures has had an effect on how much Medicare pays physicians for patient treatment, and this impact on reimbursement is scheduled to grow over the next few years, with penalties for docs who don't keep on the straight and narrow. So these measure can have an impact on how doctors practice.

Now you all know I look at a lot of prostate biopsies in my practice, and that my dad died of prostate cancer, and that I run every year to raise money for prostate cancer awareness. So prostate cancer is a big deal to me. Most of the prostate cancers that I diagnose are a result of a man having an increased Prostate Specific Antigen (PSA) blood test in their primary doctors office and being referred to a urologist for evaluation and triage with such newer tests as the PHI test or MRI of the prostate. Sometimes the triage leads to a prostate biopsy. Close to half of the men who have a biopsy sent to us wind up having prostate cancer diagnosed. The goal of all this is to detect men with prostate cancers that are high grade, bad actors that  have the ability to spread, cause symptoms, and shorten the patient's life. We want to see those men treated with therapies such as surgery, radiation, hormones or newer immune therapies in an attempt to improve their lifespan and quality of life. We also detect a lot of men with prostate cancers that look less aggressive and might not have such a significant impact. In the past, most of these low aggression tumor patients also received treatment such as radiation or surgery, but now, with better tools that look into the actual genetic (DNA or RNA) makeup of the tumor, and with better understanding of which tumors are likely to spread, many men are placed on "active surveillance." They are monitored closely by their urologist, but unless there is evidence that the tumor has changed and become more aggressive, they avoid treatment and any related side effects.

Still following me? Well, in the last few years, there has been review of long term data, much from outside the USA and all of it is from before genetic markers were available and before "active surveillance" was an established treatment plan. The data suggested that PSA testing is a lousy way to detect prostate cancer and leads to too many men having too much treatment.  Because of these studies, in 2012 the United States Preventive Services Task Force (whew) recommended AGAINST PSA screening. So fewer men have been getting PSA testing, or have been skipping a few years of testing, and guess what? We now see more men with the nasty acting prostate cancers than we did five or ten year ago. It seems to us here in the lab (and to urologists and pathologists around the country) that less PSA screening=worse outcomes.

Now remember those CMS quality measures we were talking about a few paragraphs above? Well, the CMS has just released a new proposed quality measure. You guessed it. They are proposing that NOT doing PSA testing is better quality. So your doc, or your dad's doc, or your husband's doc will get paid more for NOT doing PSA testing on their patients. Yes, I know it is not a perfect test. It is not appropriate in certain age groups. But with logical triage of patients with abnormal PSA results, and then logical treatment or surveillance of men in whom prostate cancer is diagnosed, PSA testing can lead to a strong, positive, impact on the male population. I am a believer. I know that I will keep having my PSA checked--and so should you!

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