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Setting the Standards

December 3, 2012

One of the many interesting aspects of the totally NewSpeak-Named Affordable Care Act of 2010 is that is sets the United Stated Preventive Service Task Force as the entity that establishes Standard of Care that all insurers are required to provide coverage (without patient co-pay).  You can bet that if insurer’s are required to pay for it, that physicians will be required to abide by these recommendations or risk professional and economic censure.  The implementation of EMR’s simplifies the ability for DHHS and AHRQ to data-mine and identify outlying practitioners for what I assume will be the new industry to supersede CME:  MPRC – Medical Provider Re-education Camps.

The USPST was established in 1984 to advise primary care providers how to implement preventive care practices.  Ironic, isn’t it, or is it, that this government task force established under Ronald Reagan has become the DHHS and AHRQ weapon to wield against independent health care practice in the USA?

The Task Force in comprised of “volunteers” who represent the vanguard of progressive preventive health interests in government, higher education and industry.  Their initial forays into recommendations have evolved into a complex industry of making recommendations for further funding of research that not surprisingly encompasses the research that they and their close colleagues themselves make their bread and butter performing.

Some of their recommendations have been quite controversial, but relatively reasonable from my perspective.  But look at the areas they are now recommending be researched so they can be added to preventive health practices that all providers will soon find themselves required to perform and document in the EMR:

High-Priority Evidence Gaps for Behavioral Interventions

Below are three areas from the fields of behavioral intervention and health promotion that the USPSTF has prioritized as having critical evidence gaps that may be addressed through research and that if filled are likely to result in important new recommendations:

  1. Moderate- to Low-Intensity Counseling for Obesity
    The importance of obesity as a health problem in the United States is increasingly apparent. According to recent data, when obesity is defined as a body mass index of 30 kg/m2 or more, 30 percent of American men and women are obese. Being obese is associated with health problems such as an increased risk of coronary heart disease, type 2 diabetes, various types of cancer, gallstones, and disability. In addition, obesity is associated with increased risk of premature death and decreased quality of life. In 2003, the USPSTF concluded that the available evidence supported recommending high-intensity interventions for obese adults and that the evidence was insufficient to make a recommendation about the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. In 2010, the USPSTF recommended screening and intensive counseling for obese children ages 6 years and older. The Task Force is currently completing an update of its 2003 recommendation for adults. Future research is needed in many areas concerning screening and counseling for obesity in children and adults. Continued development and testing of counseling and behavioral interventions with better and longer followup are needed, especially to understand the potential contribution of moderate- and low- intensity counseling. Additional research should also examine the long-term outcomes and effects of interventions delivered to overweight children and adults.
  2. Interventions to Prevent Child Abuse and Neglect
    Approximately 1 million abused children are identified in the United States each year. Despite the dedication and hard work of people in many sectors, no one has discovered an effective role for the primary care system and primary care professionals in preventing child abuse and neglect. The Task Force recognizes that the solution to this issue will include many other efforts and hopes that needed research to find effective interventions initiated in primary care will be conducted. Early research suggests that clinician referrals to home visitation by nurses during pregnancy and early childhood may reduce child abuse and neglect in selected populations, but additional research is needed. Future research must examine both the potential benefits and the potential unintended harms of interventions aimed at preventing child abuse and neglect.
  3. Screening for Illicit Drug Use
    Illicit drug use and abuse is a serious problem in the United States and ranks among the 10 leading preventable risk factors for years of healthy life lost to death and disability in developed countries. In 2008, the Task Force found that there was insufficient evidence to make a recommendation about screening for illicit drug use in primary care practices. Studies are needed to determine whether interventions found effective for treatment-seeking individuals with symptoms of drug misuse are equally effective when applied to asymptomatic individuals identified through screening. In addition, observational studies are needed to establish more clearly the effects of treatment on long-term health outcomes, including morbidity and mortality.

And these are areas the Task Force is highly interested in at the end of their 2012 report to Congress:

  1. How do primary care professionals incorporate new evidence to change their practice?
  2. What are the most effective strategies to assist primary care professionals in the translation of evidence-based clinical preventive services into practice?
  3. How can primary care professionals share evidence with their patients to empower patients and families to make health care decisions about prevention?
  4. How can health information technology, including electronic health records and personal health records, be utilized to increase the number of Americans receiving recommended clinical preventive services?
  5. How can the USPSTF continue to improve its work to better meet the needs of primary care professionals and their patients

To start at the bottom and work your way up, note that they are particularly interested in how best to get “primary care professionals” (who used to be doctors but now include all sorts of licensed and unlicensed individuals) to change their ways to their point of view.  Don’t let #5 fool you.  It comes right after #4.

Screening for illicit drug use.  It certainly is a serious issue.  It is also quite expensive and time consuming just to ask the questions, not to mention perform body secretion testing.  But since the government will now be studying this intensively, you can bet they’ll be requiring a lot of primary care professionals to be documenting in their EMRs not only if patients have been screened for illicit drug use, but just what the drugs used, amounts and frequencies as well.  All that information will be indelibly entered into each patient’s EMR.  Does that bother ANYONE?

Interventions to Prevent Child Abuse and Neglect.  Again, a serious issue we can all agree seems important to study.  Note, however, that up to now even the Task Force agrees there has been no identified benefit of primary care efforts in PREVENTION of abuse.  So they hope that engaging the PCP’s to identify folks to send nurses out to their homes to investigate might be a good thing.  Unfortunately to me, this sounds all to likely to be adopted as one new form of SWATing.  Not right away, mind you, but if you look at what is happening in the UK now, you can see what happens with this kind of interventionism.

Moderate to Low-Intensity Counseling for Obesity.  They want to look into the potential benefits of PCP counseling regarding weight issues.  Of course, that means we’ll have to not only record the weight in every chart, which is already done, but use diagnosis codes delineating the patient’s BMI in their chart, so we can track them better.  More goodies, that like e-mail, are forever in the wonderful world of electronic records.

My real concern is that up until relatively recently doctors were expected to rely on their training, experience and interaction with colleagues to determine just what they did and did not do when providing health care to their patients.  In the past ten years, that has changed.  Now its about to get a WHOLE LOT WORSE.  What has been a decentralized imposition of standard of preventive care practices by insurance formularies, State-generated directives and Federal directives through Medicare, Medicaid, the VA, Public Health Service, Indian Health Service and military health services will now be standardized through the DHHS’s USPST.

But don’t worry.  Big Brother only has your best interests at heart.  Just remember your best interests are what’s best for the corrupt and insolvent Federal US government bureaucracy.

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