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23–813 2017

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 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

CHRIS COLLINS, New York 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

DORIS O. MATSUI, California 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(III) 

C O N T E N T S 

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 

(1) 

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 evidencebased 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 

2 

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 prosVerDate Nov 24 2008 13:59 Sep 08, 2017 Jkt 037690 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 114\114-176 CHRIS
3 

tate-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. 

4 

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 

5 

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 

6 

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:] 

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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. 

24 

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. 

25 

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. 

26 

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. 

27 

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 

28 

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 

29 

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 

30 

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 AfricanAmerican 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. 

31 

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. 

32 

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 

33 

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. 

34 

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 

35 

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. 

36 

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 indepth 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 paVerDate Nov 24 2008 13:59 Sep 08, 2017 Jkt 037690 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 114\114-176 CHRIS
37 

tients 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. 

46 

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:] 

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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. 

54 

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—— 

55 

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 

56 

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 

57 

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. 

58 

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 

59 

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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