[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]







       EXAMINING THE UNITED STATES PREVENTIVE SERVICES TASK FORCE

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           NOVEMBER 30, 2016

                               __________

                           Serial No. 114-176






[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]










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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman
JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Chairman Emeritus                    Ranking Member
JOHN SHIMKUS, Illinois               BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania        ANNA G. ESHOO, California
GREG WALDEN, Oregon                  ELIOT L. ENGEL, New York
TIM MURPHY, Pennsylvania             GENE GREEN, Texas
MICHAEL C. BURGESS, Texas            DIANA DeGETTE, Colorado
MARSHA BLACKBURN, Tennessee          LOIS CAPPS, California
  Vice Chairman                      MICHAEL F. DOYLE, Pennsylvania
STEVE SCALISE, Louisiana             JANICE D. SCHAKOWSKY, Illinois
ROBERT E. LATTA, Ohio                G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington   DORIS O. MATSUI, California
GREGG HARPER, Mississippi            KATHY CASTOR, Florida
LEONARD LANCE, New Jersey            JOHN P. SARBANES, Maryland
BRETT GUTHRIE, Kentucky              JERRY McNERNEY, California
PETE OLSON, Texas                    PETER WELCH, Vermont
DAVID B. McKINLEY, West Virginia     BEN RAY LUJAN, New Mexico
MIKE POMPEO, Kansas                  PAUL TONKO, New York
ADAM KINZINGER, Illinois             JOHN A. YARMUTH, Kentucky
H. MORGAN GRIFFITH, Virginia         YVETTE D. CLARKE, New York
GUS M. BILIRAKIS, Florida            DAVID LOEBSACK, Iowa
BILL JOHNSON, Ohio                   KURT SCHRADER, Oregon
BILLY LONG, Missouri                 JOSEPH P. KENNEDY, III, 
RENEE L. ELLMERS, North Carolina         Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota

                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
JOHN SHIMKUS, Illinois               ELIOT L. ENGEL, New York
TIM MURPHY, Pennsylvania             LOIS CAPPS, California
MICHAEL C. BURGESS, Texas            JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
LEONARD LANCE, New Jersey            JOHN P. SARBANES, Maryland
H. MORGAN GRIFFITH, Virginia         DORIS O. MATSUI, California
GUS M. BILIRAKIS, Florida            BEN RAY LUJAN, New Mexico
BILLY LONG, Missouri                 KURT SCHRADER, Oregon
RENEE L. ELLMERS, North Carolina     JOSEPH P. KENNEDY, III, 
LARRY BUCSHON, Indiana                   Massachusetts
SUSAN W. BROOKS, Indiana             TONY CARDENAS, California
CHRIS COLLINS, New York              FRANK PALLONE, Jr., New Jersey (ex 
JOE BARTON, Texas                        officio)
FRED UPTON, Michigan (ex officio)
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                             C O N T E N T S

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                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     2
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................     4

                               Witnesses

Kirsten Bibbins-Domingo, M.D., Professor of Medicine and of 
  Epidemiology and Biostatistics, University of California, San 
  Francisco, Chairperson, U.S. Preventive Services Task Force....     5
    Prepared statement...........................................     7
John H. Lynch, M.D., Chairman And Professor, Department of 
  Urology, Georgetown University.................................    36
    Prepared statement...........................................    38
John Meigs, Jr., M.D., President, American Academy of Family 
  Physicians.....................................................    45
    Prepared statement...........................................    47

 
       EXAMINING THE UNITED STATES PREVENTIVE SERVICES TASK FORCE

                              ----------                              


                      WEDNESDAY, NOVEMBER 30, 2016

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 11:02 a.m., in 
room 2322, Rayburn House Office Building, Hon. Joseph R. Pitts 
(chairman of the subcommittee) presiding.
    Present: Representatives Guthrie, Shimkus, Murphy, Burgess, 
Blackburn, Lance, Bilirakis, Long, Bucshon, Brooks, Collins, 
and Pitts.
    Staff Present: Rebecca Card, Assistant Press Secretary; Jay 
Gulshen, Legislative Clerk, Health; Dan Schneider, Press 
Secretary; Adrianna Simonelli, Professional Staff Member, 
Health; Heidi Stirrup, Health Policy Coordinator; Dylan 
Vorbach, Deputy Press Secretary; Waverly Gordon, Minority 
Professional Staff Member; Samantha Satchell, Minority Policy 
Analyst; and Arielle Woronoff, Minority Health Counsel.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. The subcommittee will come to order. I might 
note that the Democratic members of the subcommittee are still 
at their caucus leadership elections. They will come as soon as 
they finish that.
    The chairman will recognize himself for an opening 
statement.
    Today's hearing will be taking a close look at the United 
States Preventive Services Task Force created in 1984 as an 
independent volunteer panel of 16 national experts in 
prevention, primary care, and evidence-based medicine and 
tasked with making recommendations about clinical preventive 
services which could work to improve the health of all 
Americans.
    The Affordable Care Act required the Task Force to issue 
annual reports to Congress, to include information on gaps in 
the evidence-based research related to clinical preventive 
services, and recommend areas that need further examination 
through targeted research. The Affordable Care Act also tied 
some of the Task Force recommendations directly to 
reimbursement requirements for private insurance.
    Recommendations do not consider cost-effectiveness and are 
based solely upon evidence of medical benefit to the patient, 
no matter how expensive it is. The Task Force independently 
evaluates the medical evidence on clinical preventive services 
to inform healthcare professionals, healthcare systems, and the 
American people to make careful decisions about their health 
and health care. It is believed that by identifying evidence 
gaps and highlighting them as priority areas for research will 
inspire public and private researchers to collaborate, target 
their efforts to generate new knowledge, and address important 
health priorities.
    However, experience has shown that a number of the Task 
Force recommendations have the effect of limiting access to 
preventive care. For example, one recommendation was against 
screening for prostate cancer in healthy men with a prostate-
specific antigen blood test. Another recommendation was against 
routine annual mammogram screenings for women age 40 to 49. 
Such recommendations contradict clinical guidelines based on 
medical literature and experts in the field. The concerns are 
that these recommendations could undermine new models of care 
delivery.
    Our colleague, vice chair of the full committee, 
Representative Marsha Blackburn, has a legislative discussion 
draft entitled, ``USPSTF Transparency and Accountability Act of 
2016,'' which would require specialists and subspecialists to 
be involved in reviewing the preventive services examined by 
the Task Force. The legislation would allow a wide range of 
patient groups, providers, and Federal agencies to be involved 
in the important review process of preventive services. 
Furthermore, any evidence reports and recommendations would be 
available for public comment. Transparency is further enhanced 
by establishing a preventive services stakeholders board to 
provide feedback on Task Force activities.
    We have before our committee today some of the very 
stakeholders who can answer our questions surrounding the 
proposed legislation. So I look forward to hearing more about 
the work conducted by the Task Force, how it might be improved 
with passage of this legislation, and recognize----
    Anyone seeking time? Dr. Burgess.

               Prepared statement of Hon. Joseph R. Pitts

    Today's hearing will be taking a close look at the United 
States Preventive Services Task Force, created in 1984 as an 
independent, volunteer panel of 16 national experts in 
prevention, primary care, and evidence-based medicine and 
tasked with making recommendations about clinical preventive 
services which could work to improve the health of all 
Americans.
    The Affordable Care Act required the Task Force to issue 
annual reports to Congress to include information on gaps in 
the evidence-based research related to clinical preventive 
services and recommend areas that need further examination 
through targeted research. The Affordable Care Act also tied 
some of the Task Force recommendations directly to 
reimbursement requirements for private insurance. 
Recommendations do not consider cost-effectiveness, and are 
based solely upon evidence of medical benefit to the patient, 
no matter how expensive it is.
    The Task Force independently evaluates the medical evidence 
on clinical preventive services to inform health care 
professionals, health care systems, and the American people to 
make careful decisions about their health and health care. It 
is believed that by identifying evidence gaps and highlighting 
them as priority areas for research will inspire public and 
private researchers to collaborate and target their efforts to 
generate new knowledge and address important health priorities.
    However, experience has shown that a number of the Task 
Force recommendations have the effect of limiting access to 
preventive care. For example, one recommendation was against 
screening for prostate cancer in healthy men with a prostate-
specific antigen blood test. Another recommendation was against 
routine annual mammogram screenings for women ages 40-49.
    Such recommendations contradict clinical guidelines based 
on medical literature and experts in the field. The concerns 
are that these recommendations could undermine new models of 
care delivery.
    Our colleague, Vice Chairman of the full Committee, Rep. 
Marsha Blackburn, has a legislative discussion draft, entitled 
``USPSTF Transparency and Accountability Act of 2016'' which 
would require specialists and subspecialists to be involved in 
reviewing the preventive services examined by the task force. 
The legislation would allow a wide range of patient groups, 
providers and federal agencies to be involved in the important 
review process of preventive services.
    Furthermore, any evidence reports and recommendations would 
be available for public comment. Transparency is further 
enhanced by establishing a preventive services stakeholders 
board to provide feedback on Task Force activities.
    We have before our committee today some of the very 
stakeholders who can answer our questions surrounding the 
proposed legislation.
    I look forward to hearing more about the work conducted by 
the Task Force and how it might be improved with passage of 
this legislation.

    Mr. Burgess. Thank you, Mr. Chairman.
    So people familiar with this subcommittee know I never come 
without my copy of the Affordable Care Act, and this morning we 
are concerned about section 2713, which by Federal statute 
linked preventive service coverage requirements to the 
recommendations of the federally appointed United States 
Preventive Services Task Force.
    Interestingly, this entity is not subject to the Federal 
Advisory Committee Act or the Administrative Procedures Act, 
providing the public with little opportunity for accountability 
and transparency and no review and comment period. So we have 
seen from past experiences with the prostate-specific antigen, 
the PSA test for prostate cancer, from mammograms for breast 
cancer, the Task Force recommendations have consequences and 
can deprive patients of lifesaving services.
    Last year, the GOP Doctors Caucus wrote a letter to CMS 
urging them to withdraw the ``nonrecommended PSA-based 
screening'' quality measure that was based on Task Force 
recommendations. CMS did withdraw the draft measure, but this 
situation clearly demonstrates the danger of the broad 
discretion that the USPSTF represents to patients.
    Legislation, as Chairman Pitts pointed out, does provide 
accountability and transparency for the public. It provides 
opportunities for stakeholders to give their input. I 
understand the value of identifying preventive services. I 
recognize that they can prolong the lives of Americans. I 
recognize they can save taxpayer dollars. However, it is 
important that a process is in place to ensure providers and 
patients that they are involved in the development of 
recommendations that carry so much weight and that patients and 
their doctor retain a share of the decision-making process.
    Thank you, Mr. Chairman. I will yield back the balance of 
the time.
    Mr. Pitts. The chair thanks the gentleman, and now 
recognize the vice chair of the full committee, Mrs. Blackburn, 
5 minutes for opening statement.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Chairman.
    And I am so appreciative that we are moving forward on this 
legislation today. And I wish Mr. Rush were already in the 
room. I just want to commend him and his staff for the work 
that they have done on this issue. And Mr. Rush had a birthday 
last week and he thought having this hearing was a pretty good 
birthday present for him, because he does want us to move 
forward on this.
    And our legislation will address some of the concerns that 
have been articulated, the growing concern over a number of the 
USPSTF recommendations, and the attempt to control cost by 
limiting patient access to preventative care. And I appreciate 
that the subcommittee is taking the time to drill down on the 
issue and that our witnesses are working with us on this.
    We want to make certain that the advice and the guidance 
that is there is appropriate. And Mr. Burgess said it well, 
that patients and doctors are going to have their say in this 
process. Congress must not allow Federal agencies to be making 
the individual health choices on behalf of providers. Health 
decisions in the country must remain between doctors and 
patients.
    Currently, there is no congressional appointment process or 
oversight mechanism within the USPSTF. Further, I am concerned 
that the Task Force members do not always meet with relevant 
stakeholders during the review process and often there is no 
public dialogue with medical specialists who have years of 
expertise on the matters that are under review.
    Over the years, we have learned that this insular decision-
making process at times directly conflicts with the informed 
views of expert physicians. The USPSTF turned its back on over 
20 million women by finalizing erroneous guidelines that would 
limit access to mammograms for women between the ages of 40 and 
50. Their recommendations have impacted PSA tests and skin 
cancer checks. Their reach is broad and can impact each and 
every one of us at any time.
    Therefore, it is timely that this committee examine the 
Task Force to ensure transparency and accountability and make 
certain those are embedded in the process. Scientific evidence 
should motivate decisions but also support informed decision-
making between physicians and patients. It is important that we 
reform the flawed system and ensure informed patient-centered 
choices are provided.
    Congress does have the oversight responsibility, and 
today's hearing will help us to better understand the 
implications of recommendations and their impact on access to 
health care.
    Mr. Chairman, I have got six statements for the record, to 
submit for the record. These are all in support of the bill. 
They are from the Men's Health Network, Solis Mammography, the 
National Business Group on Health, the Urology Policy Forum, 
and the HR Policy Association. And, with that, I yield back my 
time.
    Mr. Pitts. The chair thanks the gentlelady.
    Is anyone else seeking time? If not, I will add to the UC 
request a letter from the National Association of Pediatric 
Nurse Practitioners, a statement from ZERO--The End of Prostate 
Cancer. And the Democratic members have asked me to enter into 
the record a number of documents, including Ranking Member 
Green and Pallone's opening statements, letters to the 
committee from a number of parties with statements regarding 
the Preventive Services Task Force.
    Without objection, so ordered.
    [The information was unavailable at the time of printing.]
    Mr. Pitts. All right. As usual, the written opening 
statements will be made a part of the record.
    We will now go to our first panel. We have two panels 
today.
    The first panel--thank you very much for coming today--is 
Kirsten Bibbins-Domingo, Ph.D., M.D., M.A.S., chairwoman of the 
USPSTF, the Task Force. So welcome. Your written opening 
statement will be made a part of the record. You will be 
recognized for 5 minutes for your summary. The chair recognizes 
the gentlelady.

   STATEMENT OF KIRSTEN BIBBINS-DOMINGO, M.D., PROFESSOR OF 
 MEDICINE AND OF EPIDEMIOLOGY AND BIOSTATISTICS, UNIVERSITY OF 
    CALIFORNIA, SAN FRANCISCO, CHAIRPERSON, U.S. PREVENTIVE 
                      SERVICES TASK FORCE

    Dr. Bibbins-Domingo. Thank you very much, Chairman Pitts 
and members of the House Energy and Commerce Health 
Subcommittee. I am grateful for the opportunity to talk with 
you today about the U.S. Preventive Services Task Force.
    I am the chair of the Task Force, and I am professor of 
medicine and epidemiology at the University of California, San 
Francisco. I am also a general internist, and I provide primary 
care to a diverse population of adult patients at our public 
hospital in San Francisco, Zuckerberg San Francisco General. I 
have been in practice for more than 15 years.
    Primary care providers specialize in preventing disease 
before it starts. Let me tell you a bit about a patient I saw 
in clinic several weeks ago. Ruth is a lovely, active 63-year-
old woman. During our visit, she asked me what many of my 
patients do. What can I do to make sure I live a long and 
healthy life to lower my chance of getting sick in the future?
    I take my answers to these questions very seriously. I want 
to be clear that the things that Ruth and I decide together 
have some chance of preventing disease and prolonging or 
improving her life. I also want to make sure I can give Ruth a 
complete understanding of the side effects of the tests and 
treatments. I want to be sure that she is more likely to 
benefit from my recommendations than to be harmed. She has put 
her trust in me, and I want to know that my advice and our 
shared decisionmaking will help her keep healthy for many years 
to come.
    This is what we do in primary care. We make recommendations 
for people without signs or symptoms of disease about services 
aimed at preventing future disease and prolonging healthy life. 
And because of this important responsibility, it is crucial 
that we know what the science says.
    I want to help Ruth prevent breast cancer and cervical 
cancer and colorectal cancer. I also want to minimize her 
chance of developing a heart attack or stroke, to help prevent 
her from falling, and to identify any underlying depression. 
For Ruth, and for the many patients like her, we look to the 
Task Force for guidelines to tell us about the range of 
preventive services that might be applicable and whether they 
are likely to be beneficial.
    As background, the Task Force was established in 1984 under 
the Reagan administration. We are an independent nonpartisan 
expert panel that works to improve the health of all Americans 
by making evidence-based recommendations about clinical 
preventive services, such as screenings, counseling, and 
preventive medications. All Task Force members are experts in 
evaluating the scientific evidence.
    We value the input of subspecialists. We have explicit 
procedures for working with subspecialists and for getting 
their feedback at every stage in our recommendation process. 
For example, we are now working to update our recommendation on 
prostate cancer screening, and we have engaged 15 subspecialty 
experts with expertise in prostate cancer, including 
urologists. We have found that engaging subspecialists on 
specific recommendations where they have expertise to offer is 
the most effective and efficient approach to our work.
    I want to be clear that decisions about insurance coverage 
are not in our domain. These are the domains of insurers, 
regulators, the State, and the Federal Government. We do 
maintain that regardless of how health care is financed, 
knowing what the science tells us is critical. This was true 
when we were created over 30 years ago and it remains true 
today.
    One of the joys of primary care is being able to develop a 
relationship with our patients over time. I look forward to 
continuing to get to know Ruth even better and to working in 
partnership with her, armed with the science, to make decisions 
that can help keep her healthy. As Ruth ages, we will face 
different decisions and we will perhaps make different choices. 
I know that I can look to the Task Force to help guide our 
conversations.
    It is the trust in the Task Force's high-quality, unbiased 
recommendations that gives us confidence as primary care 
providers to answer Ruth and the many, many patients like her 
with assurance when they ask, what can I do to live a long and 
healthy life and reduce my chance of getting sick in the 
future?
    Thank you for inviting me to testify today. I look forward 
to our discussion.
    [The prepared statement of Dr. Bibbins-Domingo follows:]
    
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    
    
      
    Mr. Pitts. The chair thanks the gentlelady.
    We will now begin questioning. I will recognize myself 5 
minutes for that purpose.
    Dr. Bibbins-Domingo, in your testimony you mentioned the 
extensive process that the Task Force undertakes to produce 
your recommendations. Would you please elaborate a little bit 
more, explain the structure of your recommendations?
    Dr. Bibbins-Domingo. Sure. We have an explicit process for 
and procedures that guide the way we do our work. We have an 
open nomination process. We publish in the Federal Register and 
solicit nominations from the public. When we take on a topic, 
we post our draft research plan for public comment, and we 
solicit specific comments from specialty groups and from other 
groups that might be concerned about specific populations. We 
then incorporate all of that feedback into our fi research 
plan. That guides how we review the evidence.
    When we get the evidence together, our evidence report that 
is conducted by the evidence-based research centers, as well as 
our draft recommendation statement, are posted for public 
comment. We take the public comment process extremely seriously 
and we take the process of getting comments from specific 
experts in the field very seriously.
    We review all of those comments, and then our response to 
those comments and how we have changed our recommendation goes 
into the final recommendation, which is then issued. We do 
about 12 recommendations a year.
    Mr. Pitts. OK. Would you please explain the review process 
of the comments that you receive through the recommendation 
process?
    Dr. Bibbins-Domingo. Sure. So we have a Web site. Anyone 
can comment on the Web site. We read every single comment. And 
the way we address the comments, we summarize at the end of our 
document. We highlight all of the themes that come up in the 
comments. And then we also not only list the themes in the 
comments, but explicitly how we have addressed those themes, so 
that someone can see from beginning to end what we are doing in 
response to the comments.
    Mr. Pitts. How do you incorporate feedback that you have 
received through the comment process? Do individuals who submit 
comments receive a response directly?
    Dr. Bibbins-Domingo. Individuals don't receive a response 
directly, but all of the comments are read, and we take 
seriously responding to the major themes that are contained in 
the comments. And that is why we publish them in our final 
recommendation, so that you could trace our response to that 
particular theme.
    The range of responses might be sometimes people are 
bringing attention to specific studies, other times people are 
asking us to clarify sections of our document. It is critical 
to us that we found all of the evidence and that we communicate 
clearly. And so that is how we use our comments primarily to 
make sure we have not missed anything in the evidence and that 
our statement is as clear as it can possibly be to as many 
people who are interested in our recommendations.
    Mr. Pitts. Now that the Affordable Care Act ties your 
recommendations directly to insurance reimbursements, do you 
feel that the Agency for Healthcare Research and Quality still 
meets the needs of the Task Force?
    Dr. Bibbins-Domingo. The Agency for Healthcare Research and 
Quality has done an outstanding job. We have really expanded 
our efforts, in the time I have been on the Task Force, to 
increase our transparency, to increase our availability to the 
public. We have a Web site with over 10,000 hits a month. We 
have an app. We have many products to communicate. And the 
logistical support for all of that comes from the Agency for 
Healthcare Research and Quality.
    Mr. Pitts. Do you believe that there should be a 
clearinghouse within HHS to modify the recommendations, if 
needed?
    Dr. Bibbins-Domingo. I am not commenting on the specific 
legislation. We believe that the independence of our Task Force 
and having an independent body to evaluate science is 
essential. What others do after they receive our reports, I 
think, pertains to the other decisions that happen after that. 
The decisions about coverage, the decisions about other things 
that one might do with the recommendations, that should happen 
after our process. The science is what is foundational to our 
work, and that is what it has been since the beginning and what 
we continue to do.
    Mr. Pitts. The chair thanks the gentlelady. My time is 
expired.
    The chair recognizes the gentleman from Illinois, Mr. 
Shimkus, 5 minutes for questions.
    Mr. Shimkus. Thank you, Mr. Chairman.
    I am going to kind of go off script because I am curious 
on--I have got a couple questions just for you, Doctor. And I 
appreciate you coming here and I appreciate your service.
    So you are an internist, right?
    Dr. Bibbins-Domingo. Yes.
    Mr. Shimkus. And you work for a public hospital. Tell me 
about the hospital.
    Dr. Bibbins-Domingo. I work for the University of 
California, San Francisco. So we have many different sites. We 
have a VA, we have a community site, we have a public hospital 
site.
    Mr. Shimkus. So the public hospital, you named it. What 
was----
    Dr. Bibbins-Domingo. Zuckerberg San Francisco General.
    Mr. Shimkus. Is that financed through San Francisco 
government taxes partly? I mean, the funding and compensation 
for health care is a big deal in this country, and so I am 
always curious when there are publicly funded hospitals, safety 
net hospitals, they come probably through property taxes or 
sales taxes from different entities. I know you may not know 
this, but----
    Dr. Bibbins-Domingo. We actually do in part, but we also--
about half of our patients are publicly insured patients 
through Medi-Cal or Medicare, so that is about our 
distribution. And then, of course, we are part of the city 
government. I am paid by the University of California, San 
Francisco. We are also a public institution, but that is who 
pays my salary. And so I get money from the University of 
California, San Francisco. The city contracts with me to 
provide care there.
    Mr. Shimkus. And then the other question is, the public 
hospital, there has always been a challenge of directing 
patients to, in essence, more urgent care type operations 
versus emergency operations. And that is in-house, so it 
doesn't matter if it is a private or not-for-profit.
    Does that hospital, especially that public hospital, do 
they make some effort to try to do that? M-Cal has a lot of 
that--if someone is sick, the emergency room, they have to be 
seen, whether it is something really life-threatening.
    So that has been a challenge in health care cost, because 
it is a higher cost venue to go get the the fishhook cut out of 
your hand in an emergency room versus going to an urgent care 
facility.
    Dr. Bibbins-Domingo. Yes. I would say, it is interesting. 
Our hospital is the city and county trauma center, but we also 
provide primary care. And so my patients I have seen in clinic 
I have seen for over 10 years, for most of them. And I would 
say, because all of us are professors at the University of 
California, San Francisco, we are committed to delivering 
evidence-based primary care, and so we are a combination of 
both of those things in our system.
    Mr. Shimkus. But you don't know how the hospital may try to 
direct people from the emergency room care to an urgent care 
setting? You don't know how----
    Dr. Bibbins-Domingo. I don't know actually how.
    Mr. Shimkus. It is a very tactful dance of how, because 
probably some people view that that you can't, by the law, if 
people want to go. But I'm just----
    Dr. Bibbins-Domingo. I would say, since we are the city and 
county's trauma center, most of those patients end up--if other 
hospitals are doing that, they end up at our hospital. And I 
would say that I am not an emergency physician, so I don't know 
how the hospital makes those decisions.
    Mr. Shimkus. Very good. Well, I'm sorry to get off topic, 
but I just was very curious, based upon your testimony. Thanks 
for coming.
    And I yield back, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman, now recognizes 
Dr. Murphy, 5 minutes for questions.
    Mr. Murphy. Thank you.
    Doctor, it is great to have you here today. So I want to 
ask a little bit about the prevention things. And I like the 
legislation that my colleague and friend, Mrs. Blackburn, is 
putting through here. But I want to ask you about expanding 
this.
    So you are talking about prevention and about primary care. 
I want to see how we expand this and how those things fit in 
too. So you are familiar with the concept of primary, 
secondary, and tertiary prevention, right?
    Dr. Bibbins-Domingo. Sure.
    Mr. Murphy. So primary prevention is populationwide, to 
reduce or eliminate risk, et cetera; and secondary prevention 
are those things that may be by genetics or family or lifestyle 
or environment, history, et cetera, where you minimize the risk 
that is already there; and tertiary, the people already have 
symptoms, you are going to manage what is there.
    I am particularly interested in what direction you see us 
going into in looking at this as the integrated care of 
behavioral and physical health models. I am astounded when I 
see the Medicaid data saying that 5 percent of people are 
Medicaid beneficiaries, account for over 50 percent of Medicaid 
costs, and virtually all those have concurrent mental illness 
with other chronic illnesses, for example, people with diabetes 
or heart disease or lung disease. It doubles the risk of 
depression and other psychological disorders and, untreated, it 
doubles their cost.
    And when I have seen studies on whether it is people with 
migraine headaches, they have a migraine, they go to the 
emergency room, they get the mega workup, MRI, CT scan, et 
cetera, or when they have issues too--inflammatory bowel 
disease, cancer, just pick it out, lots of visits to physicians 
and emergency rooms. But when that primary care physician 
manages the case very carefully, so it is not just integrated 
care but coordinated care, and then capitated care in the sense 
that everybody has a stake in this, doing the right thing, how 
that works better.
    So I wonder if you could comment on primary care and what 
we need to do in the areas of medicine and as we look to reform 
the healthcare model for delivery, the role the primary care 
physician has in that and how they can integrate that 
behavioral medicine and physical medicine together for not just 
cost savings but, really, life savings. Can you comment on some 
of those things?
    Dr. Bibbins-Domingo. I think you are commenting on the very 
large role for primary care providers. And I think that that is 
an important role and one that, for those of us who were drawn 
to primary care as a calling, that is why we went to primary 
care, to take care of the whole patient, to think in an 
integrative way about how we can care for them.
    For me and my role in the Task Force, preventive care is a 
big part of that. Trying to prevent disease, primary or 
secondary prevention, which is in the purview of the Task 
Force, is essential to the work that we do, and it is work 
that, really, there is no other specialty in medicine that is 
doing that. Primary care is the front line doing that.
    I think the large role of primary care providers in the way 
we deliver care means that we have to be able to provide the 
tools for primary care providers to be able to do their work 
most effectively. And our role on the Task Force is to give 
them the tools for what the science tells us about prevention 
in a way that they can make sure that they are delivering high-
quality, evidence-based care in the midst of all of the things 
that they are responsible for doing. And that is what we take 
seriously on the Task Force.
    Mr. Murphy. So when you said that primary care--and I know 
we do not have enough primary care providers, and you refer in 
your testimony that is a specialty, along with being a 
generalist. A study I saw recently was where doctors working 
with inflammatory bowel disease, they give examples of people 
who have symptoms. And traditionally, it has been one where, 
you know, a physician can bill on a fee-for-service model and 
just it is a lot of cash. And they say, you know, this person, 
they are always calling my office, I am not going to see them.
    But they actually flip that around, and the primary 
provider says, we are going to see you as often as you need to, 
and you are going to have my direct phone number and you can 
text me or email me at any time. And they really find that they 
keep those people out of emergency rooms and they get more 
directed care.
    So this is something that you are seeing as well and how we 
can put--and some of them even said, hey, the money we save, 
they actually have a psychologist on staff, a psychiatrist on 
call. They can Skype them at any time. And these people's 
healthimprove dramatically. Part of what you are looking at as 
well?
    Dr. Bibbins-Domingo. Yes. So I really can't comment on how 
we finance health care. That is not my area of specialty or the 
focus of the Task Force. I can comment on the fact that we do 
take prevention seriously and we take seriously both mental 
health and physical health, just the things that you are 
talking about.
    We have a recommendation on screening for depression. And I 
think that that was very important, not just the recommendation 
and the evidence base, but that we looked in a variety of 
different populations--pregnant and postpartum women, older 
adults--to make sure that we can address the mental health 
needs, and then that we follow it up to make sure that it is 
not just screening but followup.
    Mr. Murphy. Right. This is what I want to know, that as you 
are looking at your data, are you seeing cost savings that 
come? That when you screen that person with heart disease and 
you recognize they also have depression, when you treat those 
things, does it save money? Are you pulling up that data or no?
    Dr. Bibbins-Domingo. So we aren't. The Task Force doesn't 
consider cost. It is not an area that is our focus. We are 
really focused on effectiveness. And so we are focused 
primarily--but we know that it is important to identify people 
who have underlying depression who may not have those symptoms 
at the surface, because when we do that, treating that is 
effective for improving their health.
    Mr. Murphy. Thank you. Yield back.
    Mr. Pitts. The chair thanks the gentleman, now recognize 
the gentlelady from Tennessee, Mrs. Blackburn, 5 minutes for 
questions.
    Mrs. Blackburn. Thank you, Mr. Chairman.
    And, again, thank you for being here and for working with 
us, because we do want to move forward on this.
    I want to go back into your testimony, because you 
mentioned the subspecialists that you had identified and used 
and that you value their input. So let's talk about process, 
and talk to me about how you identify the subspecialists that 
you use. The three urologists, let's take that as kind of our 
case study. The urologists that you identified for the study on 
prostate cancer, go into how you selected them. What is your 
decision-making process?
    Dr. Bibbins-Domingo. Yes. So I have to say that I don't 
know all of the specifics of the process for identifying them. 
I will say it is important to us that we evaluate a few things. 
One is our process takes a fair amount of commitment to do, so 
it takes a period of time. So commitment to the entire process. 
We vet the conflicts of interest very seriously, and so that is 
an important feature in how we look at this. And we want people 
who are going to be experts in this area. That is probably 
fundamental. We are looking for people who have expertise in 
screening and treating prostate cancer who can help advise us 
for every stage.
    I don't exactly know how. I do know, and I learned in the 
process here, that our chair of urology at the University of 
California, San Francisco is one of the experts that is 
consulting with us. He is an outstanding physician. But I would 
have to defer to--and I hopefully can get the information back 
to you----
    Mrs. Blackburn. Yes, that would be----
    Dr. Bibbins-Domingo [continuing]. On exactly how we choose 
them.
    Mrs. Blackburn. That would be great. If you would submit to 
us what that process is.
    Dr. Bibbins-Domingo. Sure.
    Mrs. Blackburn. How you all go about it. I think it would 
be helpful to us.
    And let me ask you this. Did you seek input from the AUA? 
Did you go to any of these groups and seek their input and say, 
do you have people to recommend? Or did you go to the clinical 
oncology, go to the American Society of Clinical Oncology and 
say, do you have people that you want to recommend to us?
    Dr. Bibbins-Domingo. So, again, I don't want to be off in 
my comments on the very specifics here on prostate cancer. I 
would say we routinely engage with the specialty societies that 
have expertise in the topics. The American Cancer Society I 
know, because we do several cancer topics, is one where we do 
that.
    And so we engage very specifically and deliberately, not 
just to help us identify experts, but also to help give us 
feedback on each of our steps in our process.
    Mrs. Blackburn. OK. And you mentioned you were surprised to 
learn that one of your colleagues was serving on the prostate 
task force. So what is the transparency modeling for making the 
information public of who is serving on these task forces?
    Dr. Bibbins-Domingo. Yes. I guess that is publicly 
available. My surprise just reflects that I have not looked at 
every single expert for every single topic. I was pleasantly 
surprised, and I think it reflects not just that I am 
recommending our friends but, rather, that there is an 
independent process to really find the experts who really have 
expertise in this area and who can devote the time to really 
giving us feedback throughout the process. So it just reflects 
that we do many topics, as I said, and I don't know the list in 
all the topics so----
    Mrs. Blackburn. You mentioned that you all do not consider 
cost.
    Dr. Bibbins-Domingo. That is right.
    Mrs. Blackburn. So are you concerned that the Task Force 
recommendations affect coverage?
    Dr. Bibbins-Domingo. It was the decision of Congress to 
link the Task Force recommendations to coverage. We existed 
before that linkage. And regardless of how health care is 
financed, the science of what works, how do we know what works 
is essential. We think that is essential to how doctors and 
patients make their decisions together. And we know that people 
use that information in these other venues, but our processes 
have not changed. They have been the same before the ACA, they 
have been the same after the linkage was made. And, really, it 
is our process and our evaluation of science that is 
foundational. It is other people's jobs to determine the 
coverage.
    The other thing I would say is that oftentimes Congress has 
expanded the coverage. They have decided what is supposed to be 
covered. That is exactly what we think should happen. That is 
not our domain. And so the example in breast cancer, where we 
said women from 40 to 74 benefit from screening, 40 to 74 we 
have given a grade that there is benefit from regular 
mammography screening, the decision of Congress was to cover 
all of those women. And that is somebody else's decision. In my 
view as a clinician, it is the appropriate decision. And that 
is what we think the process should be. We don't do coverage. 
We do the science, and other people should determine the 
coverage.
    Mrs. Blackburn. Do you think that limiting coverage is 
linked to your decisions that it is used as a measure to 
control cost? Do you think that is inappropriate?
    Dr. Bibbins-Domingo. Again, we don't consider cost. We 
don't do coverage. Our processes are really for evaluating the 
science.
    Mrs. Blackburn. But would you call it inappropriate that 
limited access many times gets linked to your decisions?
    Dr. Bibbins-Domingo. So I would say, as a clinician, I am 
always concerned that patients have access. As a clinician, I 
understand the value of access.
    Mrs. Blackburn. So that would be of concern to you?
    Dr. Bibbins-Domingo. I think that those people who 
determine coverage and access should act to assure that there 
is access for patients who need it. I would like for the 
science to help inform, but the decisions about coverage have 
always been made by other people, and science is only one of 
the pieces that should play into a coverage decision. We think 
it is a piece, an important piece, but it is only one of the 
decisions.
    Mrs. Blackburn. Excellent. I yield back.
    Mr. Pitts. The chair thanks the gentlelady, now recognize 
the gentleman from New Jersey, Mr. Lance, 5 minutes for 
questions.
    Mr. Lance. Thank you very much, Mr. Chairman.
    And good morning to you, Doctor, and thank you for being 
with us.
    In your testimony, you mentioned the 2012 prostate cancer 
screening recommendation. As I understand it, only 4 percent of 
the clinical trial participants were African Americans. And we 
all know that African American men have an extremely high rate 
of prostate cancer. And I would like your views on that and how 
we might improve the process moving forward.
    Dr. Bibbins-Domingo. This is such an important issue, I am 
really happy that you brought this to light. As you say, 
African Americans suffer from prostate cancer at higher rates 
and, unfortunately, they are included in our clinical trials 
and the evidence base at much lower numbers.
    Our process means we have to use the evidence to arrive at 
our recommendations. When we don't have the evidence, we don't 
substitute our judgment and what we might do in clinical 
practice with a particular patient. We can't substitute that. 
What we do do is we make specific language in our 
recommendation statements to highlight important evidence gaps, 
and we hope that this will prompt the scientific community to 
then engage in the process of doing the scientific studies that 
we need to generate the guidelines.
    This is what we did in 2012 with prostate cancer. We 
highlighted the fact that it is really a sad reality that we 
have so few African-American men included in the trials. We 
called for more studies on African Americans and other high-
risk men. That is very important for our evidence base. We also 
gave clinicians some tools. We said, we know that you are going 
to continue screening some people, and if you do that, we think 
you, doctors and patients together, should understand benefits, 
should understand harms, and make informed decisions when 
making the decisions about screening, because we know that 
doctors still need to act without evidence and we try to give 
some guidance for doctors and patients to do that.
    Mr. Lance. Thank you, Doctor. Are there other minority 
groups where the numbers are not as high as they should be, 
based upon percentages in the population?
    Dr. Bibbins-Domingo. In prostate cancer, it sticks out in 
particular. In other recommendations, we have focused on other 
groups. For our diabetes and obesity recommendation, we have 
focused on Asian Americans and Pacific Islanders. For every 
group we have tried to focus on where the evidence gap is 
because, especially if that group is disproportionately 
affected by a disease, we need the evidence in order to figure 
out whether we should be doing something different.
    Mr. Lance. Is there a disproportionate effect regarding 
certain minority groups related to diabetes, for example?
    Dr. Bibbins-Domingo. I think that diabetes occurs at a 
lower body weight in Asian Americans, and I think that is what 
we wanted to highlight there. It is occurring at high rates, 
but it is at a lower body weight, so sometimes physicians may 
not know. That is what it says explicitly in our 
recommendations. It is important for doctors and patients to 
know that a person from an Asian background who might be not 
obese by our current thresholds might still have a risk for 
diabetes.
    Mr. Lance. Thank you. And in another area, how do morbidity 
and mortality rates factor into the current scientific review 
analysis and reporting on public health matters?
    Dr. Bibbins-Domingo. Great. So we look at the rates of 
morbidity and mortality for a condition. That is important 
background information for all of our recommendations. If there 
is a group, a group by age or by race, ethnicity, or by parts 
of the country, or something that is disproportionately 
affected, we highlight that and we try to understand whether we 
need to tailor a recommendation in some way.
    Sometimes we don't have enough information to do that, but 
we provide all of the information about morbidity and mortality 
rates in our recommendation statement, so that the doctor who 
is sitting in their own clinic can make the decision for the 
patient in front of them. We want to give them all the tools, 
and we write much more than just the top line grade so that a 
doctor faced with a patient in front of them can make their own 
decisions.
    Mr. Lance. Thank you very much for your expertise.
    And I yield back half a minute, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman, now recognizes 
the gentleman from Indiana, Dr. Bucshon, 5 minutes for 
questions.
    Mr. Bucshon. Thank you, Mr. Chairman.
    Good to see you and thank you for being here. As you know, 
the house of medicine changes slowly. I was a physician before 
I was in Congress, a surgeon. That said, the level of 
skepticism, I think, that you are probably hearing from the 
committee is based on the fact that the ACA links what you do 
to coverage. And the ACA happens and suddenly recommendations 
are less testing in certain areas. And so that, unfortunately, 
has brought suspicion on your hard work and all the really 
quality work that you do. Because there is interest from 
governments, whether that is the United States or others, as 
well as private payers in what your recommendations are and how 
that may or may not save them money. So that is the lead-in to 
my questions.
    The biggest question I have is, kind of describe how you 
choose studies that you might include because, as you know, in 
medicine there are literally tens of thousands of clinical 
studies that come out from around the world, many of which they 
are paid for by different entities, whether that is government, 
whether that is private, and also some that are non-U.S. 
studies that could call into question whether or not that is 
applicable to the American people.
    So can you kind of describe how you might figure out, for 
example, on just any issue how you pick and choose what studies 
to look at?
    Dr. Bibbins-Domingo. Sure. Thank you. So the evidence-based 
practice centers that are located at universities around the 
country, they conduct the evidence review after we give them 
the research plan that we agree on.
    They are going to comb through all of the evidence, but 
they are going to focus primarily and use the studies that are 
done in the U.S. That is going to be a particular focus. And 
they are going to be particularly concerned about who is 
funding the studies, because we know that the people, the 
entities that fund studies, they can perhaps dictate or lead to 
bias in those studies.
    So a best study for us would be a study that is done in the 
U.S., that is not funded by industry, that would be funded by 
the NIH. That would be probably our highest quality study, and 
then, depending on the study design, would be most likely to 
inform our particular decision. We rate the quality of a study, 
and the quality of the study includes who is funding it and how 
relevant it is to our population.
    Mr. Bucshon. Yes. Thank you for that. Because some of the 
mammogram recommendations came based on some Canadian data, I 
think.
    So I want to give you the opportunity on some of the more 
controversial areas, prostate screening and mammograms, to 
maybe clarify what your recommendations actually said, 
including some details that might help us on the committee get 
a better idea of what they actually said versus what sometimes 
the impression that is created what they have said.
    Dr. Bibbins-Domingo. Great. So thank you for the 
opportunity to do that.
    So for breast cancer, I want to be clear. We recommended 
that there is evidence--we said, there is evidence that 
mammography works for women between the ages of 40 and 74. That 
is what we said. It works--there is a greatly likelihood of 
benefit in older women than younger women, but we did say that 
many women will choose to screen in their forties, because the 
evidence says that it works in the forties, even though the 
likelihood of benefit is smaller. It is often miscommunicated 
that we said women shouldn't get screened in the forties. That 
is absolutely untrue. It is not what we said.
    In prostate cancer, there is a mixed bag of evidence. There 
is evidence of benefits. There is also evidence of important 
harms. We said that on balance, that we didn't think there 
should be routine screening in everyone. We did say, if you are 
going to engage in screening, you should make an informed 
decision and know the benefits and the harms.
    I want to speak to the issue that you raise that, since the 
Affordable Care Act, we have made decisions that appear to take 
away something.
    Mr. Bucshon. I just said the appearance of. I didn't say 
that you had.
    Dr. Bibbins-Domingo. I want to highlight that many things--
because we now have more evidence, we now have more confidence 
to recommend actually more things. We have a recommendation for 
use of statins to prevent heart disease. We have a 
recommendation to screen for lung cancer with CT scans. We have 
recommendations to screen for diabetes and to screen for 
depression. All of those things that we moved from insufficient 
evidence to now a B grade evidence, because scientists have 
done the work, we now have the evidence and we can make that 
recommendation.
    Mr. Bucshon. OK. Thank you very much.
    Dr. Bibbins-Domingo. Not at all.
    Mr. Bucshon. I yield back.
    Mr. Pitts. The chair thanks the gentleman, recognizes the 
vice chair of the committee, Mr. Guthrie, 5 minutes for 
questions.
    Mr. Guthrie. Thanks a lot.
    And just, actually, Dr. Bucshon asked a couple questions I 
was going to ask, but just kind of piggybacking a little, what 
do you say--as you said, the appearance. You know, things 
happen, things change in Washington, D.C., then you start 
hearing recommendations that, as you have described today, is 
not really accurate that you said don't screen, have mammograms 
when you are 40, wait till later. That is the kind of stuff 
that you hear and so you just tie together. That is why these 
hearings are important to flesh this out.
    And so just looking at transparency, I guess, within your 
group. So one of mine was the Task Force--I understand that you 
guys have actually, the Task Force has taken steps over the 
past years to improve transparency. Do you agree that more can 
be done? And then how would you recommend that if the 
information you put out isn't accurate, because it certainly 
was portrayed in the public that way, how would you kind of 
recommend that that information flows better?
    Dr. Bibbins-Domingo. So I would say transparency is core, 
it is a core principle to the work that we do. If people don't 
trust our recommendations, it is not good for us, because we 
want people to use our recommendations. So I would say our 
efforts over time have been to improve what others see and hear 
about us. That is why we have worked to talk with as many 
groups that we can who might have an interest in a particular 
population or a particular disease about what the Task Force 
does. We urge them to read beyond our top-line recommendation 
to understand all of the text that we have written, and to help 
them use the text how they might use it in clinical practice or 
in other settings.
    We have worked on our Web site and other tools for 
dissemination, other tools to make it easier for doctors and 
patients to make the decisions together, because they have 
other tools available to them.
    I think an important feature of our work is that the 
integrity, our conflicts of interest process, and the integrity 
of the Task Force, I think, is essential for allowing many more 
groups to feel that they can come to the Task Force and their 
recommendations and see something they might be able to use. 
And I think it has helped us in our dissemination. But, of 
course, we always want to work to improve.
    Mr. Guthrie. Thank you. And what Dr. Bucshon asked, I was 
going to ask you, is how you determine your research plan, how 
you determine how you are going to move forward. If you are in 
a research plan and you are looking--and say you see something 
that has been brought up that, well, we only have 4 percent 
African American men, we know that there are different effects 
of these kind of studies, that they would be more susceptible 
to prostate cancer; therefore, let's change our plan to--I 
mean, how do you react to those kind of things within the 
research plan? Do you just put an asterisk to say, this doesn't 
really reflect this group of people? I mean, that is pretty 
serious when you screen or don't screen, based on your makeup. 
Yes.
    Dr. Bibbins-Domingo. It is a really great question. I had 
this discussion most recently with an advocacy group for 
African American men with prostate cancer. They gave a summit 
here on Capitol Hill on African American prostate cancer 
disparities, this group, Prostate Health Education Network, 
PHEN. They provided us comments on our research plan. We posted 
the draft. We included a lot of information about African 
American men that we hope to be a focus.
    They provided us comments that made it clear that we should 
include different types of studies. And so based on their 
comments, we actually expanded our research plan directly in 
response to their comments. And I was really happy to see, when 
I went to this particular summit, that they commented that they 
could see the changes in our research plan.
    I will say in the end, when there are no studies, that is 
itself a limitation, because we cannot not make guidelines on 
no evidence.
    Mr. Guthrie. Right.
    Dr. Bibbins-Domingo. So we have to call for more research 
when there is no research. But we always provide language that 
hopefully helps doctors and patients make decisions even in the 
absence. And so the fact that African Americans are 
disproportionately affected, they have higher rates, those are 
the types of things we include in our recommendations so that 
doctors and patients might make that decision, even in the 
absence of evidence saying that the screening is effective.
    Mr. Guthrie. Well, thanks for that. And the discussion 
draft we are looking at today requires collaboration between 
other agencies. And I believe collaboration is key, it must be 
done to connect all health agencies. How often does your group, 
your Task Force work with NIH, DOD, CMS, or the VA?
    Dr. Bibbins-Domingo. Oh, we are really fortunate to have 
very strong partners. And the National Cancer Institute is one 
of our strongest. They come to all of our meetings. They give 
their input on what science might be in progress that they have 
funded. And they take very seriously when we say we are stuck 
here because we don't have enough evidence in this area. That 
helps inform how they might prioritize certain types of 
research within their agency.
    The DOD is present there. I can't remember all of our 
partners, but our partners are present at our meeting, and that 
has been essential to us, both for providing input to us but 
also for helping to disseminate, to get the words out to their 
own communities, and to informing other research.
    Mr. Guthrie. Well, thank you, and I appreciate your 
answers.
    And I yield back.
    Dr. Bibbins-Domingo. Thank you.
    Mr. Pitts. The chair thanks the gentleman, and now 
recognizes the gentleman from New York, Mr. Collins, 5 minutes 
for questions.
    Mr. Collins. Thank you, Mr. Chairman.
    Thank you, Doctor, for coming in. I think you have answered 
a lot of our concerns, but I guess I would just like to 
reiterate on the specialist piece. We do hear from some of our 
urologists and others on the specialty care piece that the Task 
Force is primarily made up of the primary care type physicians, 
but as you have moved into making some recommendations in the 
specialty areas.
    I think you have answered a lot of those concerns here, but 
just to follow on just to make sure that is always top of mind 
that these folks are concerned. They are worried. You can 
understand why.
    Dr. Bibbins-Domingo. Absolutely.
    Mr. Collins. But to follow up on something Representative 
Blackburn asked you about, the cost piece, I think you said you 
don't factor in cost. But if I could just read something to 
you, and I just looked up the current law on the Task Force, 
and it says directly, ``The Task Force is directed to review 
the scientific evidence related to the effectiveness, 
appropriateness and cost-effectiveness of clinical preventive 
services.'' So really, that is in your charter to take into 
account the cost-effectiveness, yet--is there a disconnect here 
where you said you don't take into account cost?
    Dr. Bibbins-Domingo. You are right that it is in our 
charter. We have never in our 32 years considered cost. It is 
explicitly on our Web site. It is our policy not to consider 
cost. And the main reason is we want people to focus on 
effectiveness. We want people to understand what works and not 
to get confused that we might be rationing or trying to 
withhold something or trying to shift in any other way. We made 
our own decision not to consider cost, because we have left it 
to other people to make that determination related to coverage.
    But you are right, it is in our charter, but we have never 
done it in the 32 years we have been in existence.
    Mr. Collins. Shouldn't you change your charter then or ask 
us to--there is always the issue. It is there for a reason and 
you are just ignoring it. I mean, it is not supposed to work 
that way.
    Dr. Bibbins-Domingo. It is a good question. I personally 
think that--and I think that the rationale behind the Task 
Force making the decision not to consider cost is because 
people get worried that we are withholding things or making 
decisions because of cost. We want to start first with what 
works. And by not considering cost, we can focus on what works.
    Mr. Collins. Well, just a recommendation. If that is on 
there, you should perhaps put a disclaimer that says, even 
though we were directed to do this, we have, in our own 
judgment, decided to ignore that and here's our reason. I know 
why you might not want to do that.
    Dr. Bibbins-Domingo. Yes.
    Mr. Collins. It might make people not realize you are doing 
that. But transparency is transparency.
    Dr. Bibbins-Domingo. Yes.
    Mr. Collins. So you have answered the question. Question 
asked, question answered. I would say I think you owe it to put 
something like that up there or change the charter or get us to 
change it. I mean, you realize you are kind of operating in the 
smoke-and-mirror world.
    Dr. Bibbins-Domingo. Actually, Congressman, I believe it is 
on our Web site.
    Mr. Collins. OK.
    Dr. Bibbins-Domingo. I appreciate that we might be able to 
make it more widely aware that that is the case, but I do 
believe it is on our Web site that we don't consider cost.
    Mr. Collins. You have answered the question and I brought 
it up, and thank you for that.
    And with that, Mr. Chairman, I will yield back.
    Mr. Pitts. The chair thanks the gentleman.
    That concludes the questions of the members who are here. 
We will have followup questions. I am sure other members will 
have questions. We will send those to you, ask that you please 
respond.
    Dr. Bibbins-Domingo. OK.
    Mr. Pitts. With that, thank you very much, Doctor.
    And we will call our second panel to the witness stand. And 
there are two members, and I will introduce them in the order 
of their presentations. First, Dr. John Lynch, member of the 
American Urological Association, Chairman, Professor, 
Department of Urology of Georgetown University; and secondly, 
Dr. John Meigs, M.D., F.A.A.F.P., President of the American 
Academy of Family Physicians.
    Thank you very much for coming today. Your written 
statements will be made a part of the record. You will each be 
recognized for 5 minutes to summarize your testimony.
    So I would like to first recognize Dr. Lynch for 5 minutes.

  STATEMENTS OF JOHN H. LYNCH, M.D., CHAIRMAN AND PROFESSOR, 
 DEPARTMENT OF UROLOGY, GEORGETOWN UNIVERSITY; AND JOHN MEIGS, 
  JR., M.D., PRESIDENT, AMERICAN ACADEMY OF FAMILY PHYSICIANS

                STATEMENT OF JOHN H. LYNCH, M.D.

    Dr. Lynch. Chairman Pitts, Ranking Member Green, members of 
the Energy and Commerce Health Subcommittee, and honored 
guests, my name is Dr. John Lynch, and I am testifying today as 
a member of the American Urological Association, and as a 
practicing urologist, prostate cancer researcher, and professor 
and chairman of the Department of Urology at MedStar Georgetown 
University Hospital.
    Mr. Pitts. Just pull it closer to you a little bit. Yes, 
thank you.
    Dr. Lynch. I also appear before you today as a prostate 
cancer survivor, who feared that if the U.S. Preventive Task 
Force recommendations were in existence when I was diagnosed, 
my prostate cancer might have been missed. Early detection 
saved my life, which is why this hearing today is of utmost 
importance.
    The AUA would like to thank the subcommittee for taking an 
in-depth look at H.R. 1151, the USPSTF Transparency and 
Accountability Act. This legislation, spearheaded by 
Representatives Marsha Blackburn and Bobby Rush, would make 
four key reforms to enhance the transparency and accountability 
of the Task Force. First, it would ensure that representation 
of the Task Force is balanced, to include practicing specialty 
care providers. Second, the bill requires an accountable and 
transparent process for comments and considerations related to 
research plans and recommendations. Third, the bill would 
establish an advisory board to ensure regular input from 
interested stakeholders and Federal agencies and payers likely 
to be impacted by Task Force recommendations. Fourth and 
finally, it would require a process to request review of 
previous recommendations when additional peer-reviewed 
scientific evidence is available.
    These reforms are necessary because the Affordable Care Act 
requires coverage without copayment, coinsurance or deductible 
when provided by an in-network provider for certain age-
appropriate preventative health services. Those services 
include Task Force recommendations with grade A or B. This 
change in law shifted the role of the Task Force from a 
scientific advisory body to a body with the authority to 
influence Federal benefit and coverage requirements.
    However, the long-term impacts of these recommendations 
aren't always clear. For many patients, the stakes are high. 
Earlier this year, the Task Force published a final research 
plan to update the PSA screening recommendation. That is a good 
thing and something urologists and many patients have been 
urging for for the past several years. However, since the 
release of the 2012 recommendation, providers face conflicting 
recommendations and patients did not know how to determine what 
was best for their individual needs.
    More accountability and transparency in the Task Force 
process would help identify evidence that should be reviewed 
and identify any potential issues earlier in the process. 
Likewise, it would be helpful for the Task Force to acknowledge 
other recommendations or practice guidelines available in the 
medical and patient community as well as those issued by 
Federal agencies.
    The recommendations clearly have an impact on patient care. 
Last year, the Journal of the American Medical Association 
published two peer-reviewed studies which documented that fewer 
men are being screened for prostate cancer and fewer early-
stage cases are being diagnosed and detected. These studies 
highlight that the cases have not dropped because the disease 
is becoming less common but because there is less effort to 
find it.
    Because prostate cancer often grows slowly, the Task Force 
said, screening finds many tumors that may have never harmed 
the patient, resulting in potential overtreatment for some 
patients.
    As a result, it concluded, testing saves few lives and 
leads too many men into unneeded surgery or radiation, which 
potentially leaves them impotent and incontinent.
    I and many other urologists strongly disagree with the Task 
Force's assessment. Rather than issuing a blanket 
recommendation that ends screening, it would be better to 
screen smarter. These decisions are best made between the 
physician and the patient, taking into consideration their 
individual risk factors and family history.
    The AUA's 2013 guideline emphasizes the importance of 
shared decisionmaking as well as a consideration of risk 
factors. Representation by urology or other medical specialties 
is noticeably absent from the Task Force. By including, in some 
manner, those that treat conditions for which recommendations 
are being made, the Task Force will ensure appropriate 
interpretation of currently available literature and can 
benefit from added expertise and input into the diagnosis and 
treatment of a disease or condition, as well as ensure the 
appropriateness and relevance of recommendations in a clinical 
setting.
    I understand that every specialty provider cannot be 
represented full time on the Task Force, but having a specialty 
voice for individual recommendations can improve the outreach 
and review process. Likewise, an advisory board would allow 
more formal and consistent input and improved engagement of 
interested stakeholders.
    I hope that Congress will enact USPSTF Transparency and 
Accountability Act to improve the process for determining 
preventive care coverage and access for patients. I am happy to 
answer any questions or follow up with any additional 
information.
    Thank you, Mr. Chair.
    [The prepared statement of Dr. Lynch follows:]
    
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    Mr. Pitts. The chair thanks the gentleman.
    Now recognizes Dr. Meigs, 5 minutes for your summary.

               STATEMENT OF JOHN MEIGS, JR., M.D.

    Dr. Meigs. Chairman Pitts, Ranking Member Green, and 
members of the Health Subcommittee, thank you for the 
opportunity----
    Mr. Pitts. Can you poke the button? Yes. That's it.
    Dr. Meigs [continuing]. To testify on behalf of the 
American Academy of Family Physicians and our 125,000 members. 
I am honored to serve as AAFP president, and I proudly 
represent physicians who, like myself, provide essential 
primary care services and rely on the integrity of the U.S. 
Preventive Services Task Force. It is important to note that 
the cornerstone of optimal health depends on a robust primary 
care and preventive health system.
    Decades of studies confirm that States with a higher 
concentration of primary care physicians have better health 
outcomes, including lower rates of all-cause mortality, even 
after controlling for socioeconomic, demographic, and lifestyle 
factors. Research also shows that the benefits of primary care 
are measurable. An increase of one primary care physician for 
10,000 people is associated with an average mortality reduction 
of 5.3 percent. In real terms, in real lives, that represents 
49 fewer deaths per 100,000 of the population per year.
    In addition, high quality primary care is necessary to 
achieve the triple aim of better patient care, improve 
population health at lower cost. Evidence-based Task Force 
recommendations help family physicians frame discussions with 
patients who are at risk for disease, guiding them to make 
informed decisions based upon timely scientific information and 
their personal preferences.
    For example, when the Task Force made its 2009 decision 
about mammography screenings for women aged 40 to 49, my 
patients had questions. We discussed what the recommendations 
meant for them as individuals, considering their health status, 
family history, and personal preferences. My patients came to 
different decisions. Some wanted to screen anyway, others 
declined.
    Currently, four family physicians serve on the Task Force, 
and the AAFP has its own experts who also review the evidence 
and Task Force recommendation statements that we adopt and 
share with our members. Overall, the AAFP has come to rely on 
the Task Force's objective rigorous assessment of scientific 
medical evidence. The AAFP believes the current composition of 
the Task Force is appropriate and should not change. Thus, 
enactment of H.R. 1151, in our opinion, would undermine the 
Task Force.
    First, H.R. 1151 calls for specialty representation on the 
Task Force. Subspecialists already contribute to the Task Force 
process, and their expertise is consulted every step along the 
way, and the final vote is left to those with expertise in 
primary care and evidence-based preventive medicine.
    While we respect our specialty and subspecialty colleagues, 
their role in treating specific conditions and organ systems is 
not the same as developing guidelines to screen for and prevent 
such conditions.
    Second, the legislation would require input from the 
broader healthcare industry. In recent years, Task Force 
members and even our AAFP liaisons have been subjected to 
intense lobbying from professional societies as well as 
pharmaceutical and medical device companies that have 
significant economic interest in its recommendations. I have no 
doubt that pressure from these groups would only increase if 
H.R. 1151 were to be signed into law, and consequently, family 
physicians would be unable to trust that the Task Force's 
recommendations were completely unbiased.
    Third, the legislation would require the Task Force to 
assess how its decisions or grades would impact access to 
health services, devices, Federal programs, or private health 
insurance coverage. The AAFP strongly supports the current 
process and function of the Task Force and believes that its 
recommendations should be independent of cost and access 
considerations.
    In conclusion, I want to call your attention to two key 
principles. The first is an underlying tenet in all of 
medicine: Primum non nocere, first, do no harm.
    The second principle, which is not unique to medicine but 
certainly seems apropos to today's discussion is if it ain't 
broke, don't fix it.
    Ladies and gentlemen, the U.S. Preventive Services Task 
Force is not broken. It does important good work on behalf of 
primary care physicians and our patients. I urge you to 
maintain this valuable source of unbiased evidence-based 
primary care guidance. Please, do no harm.
    Again, I thank you for inviting me to testify, and I would 
be happy to answer any questions you might have for me.
    [The prepared statement of Dr. Meigs follows:]
    
    
  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
  
    
    Mr. Pitts. The chair thanks the gentleman, and we will now 
begin questioning. I recognize myself 5 minutes for that 
purpose.
    Dr. Meigs, in your testimony, you mention the importance of 
the doctor-patient relationship. I agree with that. How do we 
ensure the Task Force recommendations still value this 
relationship with the insurance tie to the Task Force 
recommendations?
    Dr. Meigs. The Task Force recommendations apply to the 
population, and it is a difficult concept to understand when 
you are talking about the population as a whole or an 
individual. It still is important, when I have my patient in my 
exam room, that she and I or he and I discuss the risk and 
benefits, the harms, cost, and concerns about whatever 
treatment may be under discussion.
    So we use the Task Force recommendations as a starting 
point as the basis for a discussion, but that is a 
recommendation based on what is best for the population. That 
does not change the individual decision that I make with my 
patient one-on-one.
    Mr. Pitts. All right. Dr. Lynch, as you know, the Task 
Force was formed in 1984. What do you think the true impact of 
the Task Force has been? Is there a way to measure their 
influence on the health of our Nation within the physician 
communities?
    Dr. Lynch. Well, I can address that specifically to 
prostate cancer, which I am far more familiar with and can tell 
you that there is now evidence in the literature, following the 
2012 recommendations, and I have personal experience with this 
as well, that we are seeing a larger percentage of men with 
metastatic prostate cancer and higher rate and higher stage 
prostate cancer than we did before these recommendations. So I 
would say that that has had a deleterious effect on the health 
of these men.
    Mr. Pitts. As a urologist, would you please speak to the 
specific importance of regular PSA test? Why do you think the 
Task Force did not recommend routine PSA tests in 2012?
    Dr. Lynch. I know the Task Force has excellent intent. They 
base their recommendation on 2012 primarily based on two 
studies. One was called the PLCO study, which is in the United 
States, and the other was the European trial. The PLCO study is 
flawed in that actually a report of the New England Journal of 
Medicine last year described how there were actually a higher 
percentage of men in the arm that was not supposed to be 
screened who actually received screening than the men in the 
screened arm. So there is really no differences in those two 
arms, and one would not expect to show a mortality difference. 
So I don't think the literature was there to really support the 
recommendations.
    Mr. Pitts. So how do you think the Task Force can prevent 
something like this from happening in the future?
    Dr. Lynch. By involving specialists who treat the disease. 
I understand, as I said in my testimony, that not every 
specialist can be present on the Task Force, but I think a 
specialist has a different skill set, and a lot of them are 
experts in evidence-based medicine who would actually add to 
the Task Force. And I certainly think the importance of the 
advisory board comes through with that when you can have 
specialists in open dialogue, just like this is an open 
hearing, you can have an open dialogue between an advisory 
board and the Task Force to try and look at these issues and 
discuss these issues in person.
    Mr. Pitts. How often do you think the Task Force should 
review recommendations they have previously issued?
    Dr. Lynch. I think that depends on the literature, and 
there should be access to be able to do that. I think, for 
example, if they make a recommendation today, and there is 
evidence in the literature next year to support a different 
recommendation, they should be able to review that and change 
that. Waiting 5 years is too long.
    Mr. Pitts. Would you please elaborate on your views of the 
grading system the USPSTF uses for recommendations? Do you 
believe the discussion draft addresses your concerns?
    Dr. Lynch. The grading systems are A, B, C, and D. Right 
now, a patient's coverage is tied to A and B. I think that the 
draft legislation would help to improve that system by giving 
more input, again, to the Task Force and providing more 
evidence from specialists.
    Mr. Pitts. In your testimony you mention the disconnect 
between practicing physicians and the Task Force. Would you 
elaborate on that a little bit?
    Dr. Lynch. I can elaborate. If you look at the makeup of 
the Task Force, for example, there are primary care physicians, 
there are internists, there are geriatricians, there are 
pediatricians, there are obstetrics and gynecology. There is no 
one representing men's issues. Men's health is certainly an 
important issue.
    Urologists--interestingly enough, in this area, there are a 
fair number of my patients who don't have a primary care 
physician and don't have an internist. So even yesterday I had 
to talk about tobacco cessation, talk about weight reduction 
for an obese patient, alcoholism, depression, in addition to 
their prostate cancer. So I think adding an additional person 
to deal with that would also be very beneficial.
    Mr. Pitts. Do you believe the discussion draft before us 
today would solve some of this disconnect?
    Dr. Lynch. Yes, I do.
    Mr. Pitts. Thank you. My time is expired.
    The chair recognizes the vice chair of the full committee, 
Mrs. Blackburn, 5 minutes for questions.
    Mrs. Blackburn. And I will not take all of my 5 minutes. I 
do want to thank you all for being here.
    And, Dr. Lynch, let's go back to your testimony. The AUA 
guidelines differ from the USPSTF guidelines. So I want you 
just to walk us through a patient who comes to you and needs 
that care, and what does the impact and the difference of those 
guidelines have on the care that that patient has access to?
    And I appreciate what you just said about timely review. I 
think that technology, advances in technology, utilization of 
informatics and delivery of health care is something that 
changes so rapidly. We never keep pace with that. Government 
doesn't keep pace with that. So I think the differences in 
these guidelines, how often you all change yours, what you see 
or what hesitancy you see from the Task Force, if you will just 
speak to that and that relevance to the patient.
    Dr. Lynch. Congressman Blackburn, thank you for the 
question. If I can give you a specific example----
    Mrs. Blackburn. I would love it, yes.
    Dr. Lynch [continuing]. Related to a patient. About 8 weeks 
ago, I had a African American gentleman walk into my office in 
his mid-50s with some urologic symptoms. After a day or two of 
testing, I had to sit down with this gentleman and tell him 
that he had metastatic prostate cancer that had spread 
throughout his skeleton, that he was treatable but certainly 
not curable.
    I went back and reviewed his records. He had been 
receiving, at high risk as an African American male, PSA 
testing up through 2012, and then his internist or primary care 
physician stopped getting the PSA. He did not have evidence of 
prostate cancer in 2012. Now he has widely metastatic prostate 
cancer. That was a difficult discussion.
    He asked me why, why didn't he do this, why didn't they get 
this test? It's a very difficult situation to deal with, and 
unfortunately, we are seeing it more and more.
    Mrs. Blackburn. OK. Thank you.
    And with that, Mr. Chairman, I yield back.
    Mr. Pitts. The chair thanks the gentlelady.
    I now recognize the gentleman from Pennsylvania, Dr. 
Murphy, 5 minutes for questions.
    Mr. Murphy. Thank you, Mr. Chairman.
    I don't know if you heard some of the questioning I had for 
the previous presenter, but I want to raise some of those for 
you as well, and then looking at the integrated care model and 
noting how, when we are looking at behavioral and physical 
medicine together and managing them in terms of primary, 
secondary, and tertiary prevention, whether it makes a 
difference in terms of quality of care.
    Obviously, the patient you just mentioned must have been 
dealing with a great deal of psychological issues at that 
moment of describing it, and we know a person can be 
overwhelmed with anxiety, with panic, with depression, 
deterioration of family, other stresses that can come with a 
diagnosis or even a risk of a problem. And I have seen studies 
where people have actually looked at this, having the primary 
care physician work with the specialist and very carefully 
managing the psychological and the physical medicine aspects, 
and they improve compliance or they reduce errors, medication 
compliance, et cetera.
    I am wondering if, in your work, you have also looked at 
those aspects as well and what you have found in looking at 
those parts of prevention and cost savings and better care.
    Dr. Lynch. Well, I think that is key, and I think, again, 
as the urologist delves into a lot more of men's health and 
their urologic issues, a conversation back with their internist 
or primary care physician. Because sometimes they will bring 
things up to me, as the urologist, that they won't necessarily 
bring up to their primary care physician. So the dialogue back 
from the specialist to the primary care is getting--the key to 
getting that patient the care that he needs and wants and that, 
in the long term, is going to reduce costs.
    Mr. Murphy. Do you also then, with that, do screening, or 
do you recommend the primary care physician also do some 
screening for other things like depression, anxiety, and the 
impact that may have upon their illness?
    Dr. Lynch. Absolutely. And we do that as urologists, 
especially in dealing with cancer patients. That is a very 
frequent occurrence, and that is something we have to watch 
very closely for.
    Mr. Murphy. Dr. Meigs, do you do work in this area, too, in 
that same--look into behavioral, physical medicine aspects?
    Dr. Meigs. In primary care and family medicine, we see 
behavioral and psychological problems every day all day long. 
That is an extremely important part of our practice, and there 
is no way for a good primary care physician to divorce mental 
health and behavioral health from physical or other sources of 
health care. We treat people. We don't treat organ systems or 
diseases. We treat the whole person. And if you ignore that 
subset of problems, you have not adequately treated the 
individual.
    So we are especially in tune to looking for the depressed 
patient, the anxious patients, patients with other mental 
health issues that need to be addressed because they most 
definitely have an effect on their physical health.
    Mr. Murphy. In testimony we have heard before this 
committee in other parts of Energy and Commerce, we recognize a 
person who has a severe mental illness, for example, 75 percent 
of the cases have at least one other chronic illness, 50 
percent have at least two, a third have at least three, and 
that also the person with severe mental illness has triple the 
risk for poverty, and the person in poverty has triple the risk 
for severe psychological disorder. The list goes on and on as 
you have these.
    And that we have heard that some practices which actually 
employ people to work in behavioral medicine, social worker, 
psychologist, or have telemedicine with a psychiatrist there, 
they can address those things immediately as opposed to saying, 
here is a card, call this person, and let us know what happens. 
Because when it is just a referral, compliance drops below 50 
percent. When it is in the office, a warm handoff, it is high 
level.
    So in the practice of primary care and family medicine, is 
that something that you are able to do or do you see that, 
look, that is not billable hours right now, and so we can't do 
that but even though there is a need?
    Dr. Meigs. There is a shortage of primary care physicians. 
There is just as much a shortage of mental health workers, 
psychiatrists, and psychologists. I would love to have one in 
my office. I could use them every day.
    I practice in a rural community of 2,700 in central 
Alabama. There are no mental health professionals. That is a 
big area of concern for me and my patients. When I have 
patients whose needs exceed my abilities, trying to find 
someone to see them or somewhere they can get to, then you get 
into the other social determinants of health, they can't afford 
the transportation, they have no one to take them, they have 
all the other issues that become involved when we are trying to 
meet a real critical need for these people.
    Mr. Murphy. So that you know, we are going to have a bill 
before the House in a couple of hours here to vote on, such 
things as providing telemental health consultation for primary 
care, and I hope that is something that we can get into 
nationwide to really help the rural areas. Over half the 
counties in America, as I said before, have no psychologist, 
psychiatrist, social worker to deal with these things, but we 
know it is a pervasive problem throughout the field of medicine 
that is hurting patients.
    We want to hear more from you in the future of how we can 
do this with secondary and tertiary prevention and help reduce 
the problems. Thank you very much.
    I yield back.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentleman from Indiana, Dr. Bucshon, 5 
minutes for questions.
    Mr. Bucshon. First of all, thank you both for being here to 
testify today.
    And, Dr. Meigs, I respectfully disagree that a specialist 
might not have more input. I mean, as both of you know, this is 
a classic house of medicine battle that starts in the first 
year of medical school between--in primary care providers and 
specialists, and it is seen here today again, unfortunately. 
But it is what it is. We all work together. We all know we have 
a specific role in taking care of the patients.
    But in this particular instance, just when we are looking 
at studies and input to try to decide what the appropriate 
screening is, what is the down--what would be the downside of 
having more specialist input, other than, from my--as a 
specialist, other than as a battle between in the house of 
medicine that begins literally in the first year of medical 
school? I mean, what would be the potential downside?
    Dr. Meigs. I certainly would hope that--and I am sure our 
urology colleagues are more than competent to take care of the 
urological diseases, but the U.S. Preventive Services Task 
Force, their job is to look at the evidence and make 
recommendations for primary care on screening for primary 
prevention of diseases.
    It is a different concept. And as we have already 
testified, they bring in the they bring in the consultants, 
they bring in the specialists to evaluate the evidence. But 
these are physicians and others who are specialists in primary 
care, in preventive care, in evaluating evidence, and making 
recommendations on the quality of the evidence as to an 
unbiased recommendation I can use every day in the exam room 
with my patient about what is best for them.
    Mr. Bucshon. Yes. I saw a lot of patients with tertiary 
care disease and heart disease primarily, right, or lung 
cancer. And I have found in my own practice that working 
together with my primary care referring doctors, that that kind 
of collegial discussion about what my treatment options were of 
their patient for this particular thing, whether or not I have 
an area of expertise, which I don't claim to have in primary 
prevention, it just seems to me that there is not really a 
downside to at least having specialists involved in discussing 
what the potential treatment options are and what the potential 
downsides are of changes in screening recommendations. Because 
as Dr. Lynch has pointed out, it does affect specialists if you 
change the screening recommendations for prostate cancer or 
breast cancer or other things.
    To get that, at least followup input maybe later on, like 
we are getting from the 2012 recommendation, say, hey, look 
here is the result, primary--how would primary care physicians 
know that that is the result until their patient comes back to 
them with problems that were recognized at a later state? That 
is all I am saying.
    I just think that the more input you get in healthcare--I 
found that to be true as a heart surgeon. If I had an 
infectious problem, I would call an ID person. I got as many 
minds thinking about a problem as I could get on behalf of the 
patient.
    So I am just trying to get why there is a potential 
downside in having more input on this. As a specialist, I am 
having a hard time seeing that.
    Dr. Meigs. As you well know, a lot of the diseases that you 
treated and that we all treat are preventable.
    Mr. Bucshon. They are, yes.
    Dr. Meigs. For me, it is a success if my patient needs you 
when he is 85 instead of when he is 45 because I treated his 
blood pressure----
    Mr. Bucshon. I agree.
    Dr. Meigs [continuing]. I treated his cholesterol, I got 
him to exercise, I got him to lose weight and eat better, then 
I think that has been a success. You have a much more dramatic 
outcome, but I think the value to the society is just as good 
for what I do in that case.
    Mr. Bucshon. Absolutely. You are getting no disagreement 
from me. In fact, in the last seconds I have, I want to address 
the nationwide shortage of primary care physicians, and we are 
trying to figure out why that is. And we have to address that 
issue in our country.
    Southern Indiana, rural Indiana where I live, we have a 
critical shortage in our rural counties of primary care 
physicians. And to your point, without that success that you 
have for your patients, the patients end up seeing me or Dr. 
Lynch at a later stage.
    So it is critically important. We are adding a medical 
school branch of Indiana University Medical School in 
Evansville, Indiana, more residency programs. And so as a 
Member of Congress, I am doing what I can to get that message 
out, that whatever we can do to increase primary care, we 
should be doing.
    Dr. Meigs. For preventive care and primary care, when I 
send a patient to you, I have got a failure.
    Mr. Bucshon. I understand.
    I yield back.
    Mr. Pitts. The chair thanks the gentleman.
    That concludes questions of members present. As always----
    Mrs. Blackburn. Mr. Chairman----
    Mr. Pitts. Yes.
    Mrs. Blackburn. May I reclaim a moment of my time just to 
make----
    Mr. Pitts. All right. Go ahead.
    Mrs. Blackburn [continuing]. One clarification for the 
record. Going back to what Mr. Collins had said, going to the 
USPSTF Web site, I think we do want to note that under the 
standards for guidelines and development, in that section, they 
absolutely do not list that they don't consider cost or they 
don't note that they do not follow their charter. And when you 
go to a screen shot or you go to your Web page, and this is a 
screen shot of it, and enter the word ``cost,'' nothing comes 
up. So we may want to just consider that as we look at changes 
for the Task Force.
    I yield back.
    Mr. Pitts. The chair thanks the gentlelady for her 
clarification.
    We will have followup questions, other members have 
questions, we will send those to you. We ask that you please 
respond. I remind members that they have 10 business days to 
submit questions for the record. Members should submit their 
questions by the close of business on Wednesday, December 14.
    So thank you very much for coming, for your expertise, for 
sharing in a very important hearing.
    Without objection, this hearing is adjourned.
    [Whereupon, at 12:26 p.m., the subcommittee was adjourned.]

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