An interesting discovery of USPSTF guidelines and Kaiser Permanente. The nutshell version.
The USPSTF was originally an advisory committee to congress and primary care. But the reins of decision making were passed from congress to the USPSTF to make recommendations that would be covered by Medicare - A & B recommendations were covered and most C, D & I recommendations are not.
Bring in the Affordable Care Act/ Obamacare that said that A & B recommendations must be covered by private healthcare too.
In 2012 the USPSTF made a detrimental knee-jerk reaction: D - do not use PSA testing for screening of prostate cancer. This is when we had national outrage by many urology groups who are the true experts in the disease. They expressed their concerns in the flaws of the studies used by the USPSTF and the fallout of such a reckless decision. The urology groups had made huge progress on who and how to treat after 20 years.
Then in 2018 the USPSTF barely raised the bar to C for 55 - 69 and still a D for age 70+. Their big reveal = shared decision making, family history and high risk ethnicities. In reality, there was nothing new.
But who is the outlier in the mix? Dr. David Grossman with Kaiser Permanente who was part of the reckless 2012 decision when he was with KP/ Group Health and stayed on an extra 12 - 18 months at the USPSTF to lead the 2018 recommendation. The USPSTF has 4 year terms but Grossman was there about 9 years. Grossman stepped down after the USPSTF had finalized the recommendation in early 2018 and the draft was published 4 - 6 months later.
Why is this worth the mention? Because Grossman just shaped their company guidelines by his position at the USPSTF. He saved Kaiser Permanente billions in preventive care measures by his leading the 2018 recommendation by making sure it did not get an A or B recommendation. And if you look at the way Kaiser Permanente runs their prostate cancer care and treatment they provided the Permanente Medical Group the protection of defaulting to the "recommendation of the experts at the USPSTF". They can wait for men to show up with symptoms. They don't have to protect those under 55 who would benefit from early detection, etc.
This is the conflict of interest that we have in our healthcare policy in the US. These policies allow the burden to be absorbed by the patient physically and financially and obviously the emotional toll it takes. We need change to better allow the urologists to make recommendations about the disease as they work with patients daily.
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Cyclingrealtor
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What I do not understand is that the test, even if not covered by insurance, costs $40 out of pocket.
When you read through all of the USPSTF recommendations over the years......it's about the MONEY! The 1996 recommendation said back then the first year screening would run $12B - $28B for 29M men. By 2020 the projected population was estimated to be 44M men. Kaiser Permanente insures about 3.25% of that population and they are a single payer system. If it received an A or B recommendation for preventative care, Kaiser Permanente would be responsible for a multi-billion preventative care program. It also provides legal protection to the Permanente Medical Group as they can ignore, miss and delay care all on "the recommendation of the USPSTF" - which they led the recommendation on.
Thanks CR for diving in the weeds with this, not to take away but to add by saying in my post My decision self heal, I elude to this sorta thing also in my replies . The days of large corporate health care systems is going to end. When the undenieable data and proof that's already gathered finally fully surfaces ( the event) in the eyes and ears of the unsuspecting public, the outrage will be beyond words. Many doctors who went along( concensus ) to get along no longer feel safety by numbers or capital letterheads and are changing there tune hoping history deals with them kindly. Health care crisis will be an understatement when all that transpired in the past few years is revealed . Hint The first rule of medicine should be do no harm, how about if harm was known and intentional cover up sorry I'm just watching a Stephen King movie don't mind me.
Sadly the USPSTF and Kaiser Permanente do NOT give a fair presentation of what intermediate and high-risk disease is regarding prostate cancer. Go to their website and use their "health tools" to determine whether you are at risk of disease. One standout on their description on screening is - risk of infection from a prostate biopsy as a reason to not screen - but even when you look at the USPSTF evidence they represent it as 2/1,000. Everything they claim to protect you from you will be thrown into with a late diagnosis. They spin the data to create their "evidence".
Your proof for your assertions re the 2018 revision? Kaiser offered me the PSA test a number of times, and I doubt anyone who asks for it would be rebuffed. Oh well, we are now in the age of conspiracies. Testing for blood Vitamin D is not SOC either......my very low D discovered only after my DEXA scan showed me to be osteopenic...... Ca was in range.
I suppose I should research the reason that D test is not SOC......osteopenic and facing ADT not a good combination.
Again, 2018 recommendation does NOT say that PSA test should not be offered. BTW, TRUS infection rates I've seen reported usually 2-3%.
Yes, costs are a factor in our medical system....and we still spend more than any other nation !! 17% of GDP....we should spend more???
Read through all of the USPSTF prostate cancer screening guidelines. It's not a conspiracy theory.
If we do not screen we have no opportunity to catch prostate cancer when it is most treatable. It's a numbers game: fewer cells and fewer mutations and less chance of metastasis.
How old were you when offered psa screening by Kaiser? 55 - 69? My neighbors KP pcp tried talking him out of screening last week because he is 70. He is in good health and his father had prostate cancer. KP has a pop-up in their doctor notes that says that they are making recommendations outside of the recommended guidelines - ask your KP doc.
There is NO proof that PSA testing should not be used for prostate cancer screening, but the USPSTF made that choice for the US guidelines on the 2012. There are studies that show that prostate cancer is showing up younger and more aggressive. This is from the American Cancer Society: The number of prostate cancers diagnosed each year declined sharply from 2007 to 2014, coinciding with fewer men being screened because of changes in screening recommendations. Since 2014, however, the incidence rate has increased by 3% per year overall and by about 5% per year for advanced-stage prostate cancer.
The studies show that when prostate cancer is caught, organ confined, the results are far superior to local and distant spread. That is also documented in the USPSTF guidelines.
Men hospitalized for a biopsy complication 2 from 1,000 men in the study - that is taken right off of the 2018 USPSTF guidelines.
The USPSTF guidelines say that men 55 -69 should have shared decision making and that men with family history and of high risk ethnicities should be offered a discussion.
They're so vague that they can't even publish that Black/ African American men are at high risk on the recommendations. And the fact that men with family history and Black men are at higher risk is NOTHING new or of great insight by the USPSTF. This has been WELL documented for several decades.
As far as costs go I really encourage you to read "The Price We Pay" and "UnAccountable" by Dr. Marty Makary - "It's a blind system that we pay into. It's not what it costs, it's what they charge". You will have so much insight into all of his studies and research into the US healthcare system and you will be sick to your stomach.
I was looking at my latest billing from KP for my last Lupron injection and it was something along these lines: Charge $32,000 Insurance Paid $30,200 Patient Responsibility$1,800. Interestingly enough I found a website that had the current wholesale pricing of Lupron Depot 45/ 6 month injection and it was $922. NO CLUE why even putting down $32K is reasonable or logical but they do it for "wow factor" and the perception that my insurance is good? But the truth is that they have a 195% margin is still price-gouging!
And I can get into the charge that my Mom told me about for a two-level cage for a back or neck surgery $490,000 is what was being charged to the patients insurance.
At the end of the day we have a VERY BROKEN FOR PROFIT healthcare system that is being run by Wall Street and private equity groups.
My ER doc friend stepped down from his position because his PIMP (private equity group) was demanding that he squeeze the other ER docs that he was managing to push more patients through the ER faster. His obligation to his heart and profession was to provide good quality care for his patients so he stepped down and back into a full-time ER doc so he can care for patients how he chooses. His coat says "Dr. Smith ABC Hospital" but he's actually a production worker for Vituity because California Emergency Physcians sold out to them, Vituity.
All I can say as a Kaiser patient for decades is "Be your own advocate." That is true with Kaiser or any other health care provider. My care has been outstanding over the years. I agree that PSA testing is a simple, cheap test that should be administered no later than 50 years of age even if you pay out of pocket for it.
You absolutely must be your own advocate but especially at Kaiser. That was my huge mistake…trusting a Kaiser Urologist who blew off my repeatedly elevated PSAs (post-six weeks of antibiotics, around 20) as prostatitis. No exam, no MRI (both of which I specifically asked for)…he said the PSA elevation was likely prostatitis even though my symptoms resolved. Well, it wasn’t prostatitis. It was a high volume Gleason 9 which had already gotten through the capsule and into my seminal vesicles and lymph nodes. I seriously regret not pushing back when I first saw him. I learned my lesson the hard way.
I think one of the reasons he dismissed my concerns was because of how I was only 51 at the time and not in KPs age range for concern (55-69).
Of note, I had gotten my initial PSA outside of Kaiser like Cyclingrealtor.
I’ll never recommend Kaiser to anyone after my experience with the San Diego Urology Department. How my diagnosis was ‘managed’ was just the beginning of many issues with that department. Worst urologic care anywhere.
Anyone who believes any "system" is run to really benefit the patient is a fool. It is a business run to benefit the "shareholders", whomever that may be (actual shareholders, the academic organization, etc). Yes, the individual practitioners in that system mostly act with the patient best interest in mind, but not always. Survival of the fittest (those taking care into their own hands and doing their own research and advocacy) is alive and well in most endeavors.
Sadly our healthcare system has evolved into a BLIND money pit that is bilking and bankrupting Americans left & right. My Mom has worked for the same neurosurgical group for 38 years now. They went from private practice contracted with Sutter Health to Dignity Health and 8 years later they all agree that is the biggest mistake they made in their careers. They are basically just another employee these days!
I am sorry to hear of your experience. I was diagnosed at 50 so can relate to the "Outside of recommendations for testing". I repeat "Be your own advocate" no matter which medical plan you use.
The recent JAMA paper--a metastudy stating that cancer screenings (with the exception of sigmoidoscopies) do NOT extend life, and proposing that those who profit from testing (and downstream treatment) should NOT be the people proposing screening recommendations is causing the expected discussion. F. Perry Wilson (who is a nephrologist, but who seems to have a special interest in the use of statistics in these kinds of studies) discusses some of the salient points here:
That's a very interesting video. Some great points but also lacking some other perspective too.
You can't say that saving lives from cancer death will decrease all-cause mortality by a significant amount. The variables of all-cause mortality are very different from cancer specific mortality.
From the American Cancer Society:
The number of prostate cancers diagnosed each year declined sharply from 2007 to 2014, coinciding with fewer men being screened because of changes in screening recommendations. Since 2014, however, the incidence rate has increased by 3% per year overall and by about 5% per year for advanced-stage prostate cancer.
What do you think the outcome for these men will be?
The problem with most cancer screening is that it's not designed to catch it early. It is to catch it when the system thinks that it is or about to be the MOST prevalent.
Look at prostate cancer. The reality is that starting in men in their 40's about 20% of men have prostate cancer (I read the report on one of the USPSTF studies selected). So the BS that about 1:8 men will be diagnosed with prostate cancer has to do with screening guidelines, it's actually about 1:5 men will have prostate cancer in their 40's.
The BIG debate around psa testing is that it catches most all grades of prostate cancer that produce the antigen. So who do you treat? When do you treat? The challenge is what grade of cancer do those men have?
It's a numbers game. When you catch cancer with 10M cells that's easier to treat than 10B cells. The longer cancer has to develop the more opportunity to mutate, spread and metastasize.
The 1996 USPSTF report included crazy stats: Because local extension beyond the capsule of the prostate rarely produces symptoms, about one to two thirds of patients already have local extracapsular extension or distant metastases at the time of diagnosis. Ten-year survival rates are 75% when the cancer is confined to the prostate, 55% for those with regional extension, and 15% for those with distant metastases. The potential morbidity associated with progression of prostate cancer is also substantial, including urinary tract obstruction, bone pain, and other sequelae of metastatic disease.
It seems like if we pivoted off of the 75% confined timing it's 36% better timing than later. It is a very basic example of early detection produces better results.
Bottom line is that until we do a better job of catching and treating cancer earlier we will never know the results. Healthcare policy is one of the biggest challenges in the way of progress.
I've never heard of a 20% prevalence for PC for men in their 40s. Of course, if you don't look, you ain't gonna find it. Likewise, I've never seen a 10 year CANCER-SPECIFIC survival anywhere near as bad as 75% for localized disease--so perhaps that is all-cause mortality.
Wilson in the video discusses some of the problems with the all-cause mortality figures--does screening actually INCREASE mortality in non-cause-specific causes? In any case, certainly any cause-specific benefit is going to be diluted when all-cause mortality is looked at--particularly in an older cohort.
The knock on earlier detection of course relates to "harms" of screening, and they're real. However, while these harms are non-fatal, so too are there "harms" of later detection (as you point out) other than death--but these are never figured into the cost/benefit analysis, in my experience.
What we really need, of course, is a screening test for cancer more specific than PSA. Thanks for the discussion.
This is the 2015 report that explains the prevalence of asymptomatic disease upon autopsy. It's way more prevalent than what's generally reported. And it also gives a look at the complexities of when and how to treat.
In the interim until we find better markers and diagnostics a positive psa of "X" should be combined with the other blood tests to help determine the aggressiveness of the cancer. (4K score, Decipher, etc).
This just hurts. We were with Kaiser for over 10 years when my husband was diagnosed with metastatic prostate cancer at age 45. He has asked about screening and thought he had done everything right. They had clearly taken a stance against PSA testing well before this went through.
I have a similar story. I had ED issues at 46 (2014), most likely a physiological issue along with lower testosterone, low libido yet in my fittest shape of my life (just rode my bike across the US). The urologist ran a testosterone test and only inquired about "do you have family history of elevated psa?" but never checked the box for psa. He basically told me that I had nothing to worry about because I don't have family history but maybe in my 60's or 70's. ED most likely caused by "psychological issues". Stage-fright at 46? I was on my game by that point in life and in a new relationship! 😉
Then somehow I had a divine tap on the shoulder in 2021 to run a huge blood panel from an online company that included a psa test....... 15.2 and that led so surgery with a G7 (4+3) tertiary 5 at the bladder neck, svi, pni, epe, etc. 8 months after surgery .1 to .4 in 9 weeks and radiation, lupron and abiraterone.
I BELIEVE the first urologist was lazy and this was in the heated debate of the USPSTF to not use psa testing for screening for prostate cancer, but this guy was a urologist and should have known better or at least offered me the choice to test or educated me. Then in 2021 at no efforts of Kaiser since they led the recommendation of no psa screening until 55 and NOT considering psa screening preventative care and not covering psa testing I GOT LUCKY and discovered my elevated psa that would have most likely continued to spread further and would have most likely been dismissed if metastasized onto the pelvis area as I have family history of bad hips and bad backs.
Are people here saying such situations have happened only with Kaiser patients?? Kaiser is easy to target....... but smaller medical clinics not so easy. Should we start asking a LOT of guys in their 40s to have prostates removed....remeber that one factor in previous recommendations has been the very small use of astive surveillance, as opposed to urologists advice for RP. At Kaiser, I feel more confident that I won't be advised to take drugs or undergo any type of procedures just to line the Docs' pockets!!!
My wife has worked at Kaiser for 28 years, and there are pros/cons as with any organization's service....... I know the pros after 28 years, but people seem to have their minds set, so I won't bother to list them here.
This impressed me.....several years ago, Emma suddenly lost contact with reality and entered an imaginary world. Admitted to Kaiser hospital, in 1-2 days after tests, etc, Docs concluded that she was suffering from encephalitis.....almost certainly virus-caused. This was just as Covid was starting to get some press, so that possibility probably wasn't really on their radar.....anyway, her hallucinatory state was not a common Covid symptom I think. During her 10 day hospital stay, for at least 3 days, she had an assigned nurse with her in her room round the clock !!
Ata around Day 5 I believe, I mentioned to an RN that perhaps lack of sleep was slowing her recovery from hallucinations, and I asked if anything could be done to help with her sleep. The RN conveyed my comment to the attending Doc and or neurologist, and very soon after she was given a common anti-psychotic drug......when I returned to visit the next day, she was sleeping soundly and seemed to be making more progress in regaining a normal mental state.......could have been a coincidence, but happy that a Kaiser Doc evidently considered my concern about her sleep and decided to act on it.
BTW, Kaiser does not profit shareholders, as there are none. Yes, they probably have too many overpaid executives.....not sure I have the capability to evaluate that factor.
Any part of our economy that is 17% of GDP is complex, to be sure. Books have been written, but conclusions vary!!
The FOR PROFIT "Permanente Medical Group" does have shareholders. The doctors themselves.
Shareholder track
In order to become a The Permanente Medical Group shareholder, a physician must be board certified in the specialty in which the physician practices and work a minimum of 24 hours per week.
Three retirement plans, including pension and 401(k)As you grow your career with The Permanente Medical Group, you can prepare for your future retirement with plans that work with your goals.
I guess, in one way or another, anyone who works for an income is a shareholder. Are you saying that Kaiser Docs are overcompensated compared to non-Kaiser Docs.......is their total compensation, including their shareholder profits, public info?
Their compensation and benefits is available on their job openings. What's more important to look at is their philosophy and business structure. How does an HMO like Kaiser Permanente make money?
They are "evidence based" medicine, but THEY pick their evidence and apply it to their philosophy and standards.
Their evidence based medicine is EXACTLY what the USPSTF recommends. Why?
They are the not for profit insurance. ✅️
They are the not for profit hospitals. ✅️
They are the FOR profit doctor groups. ❌️ No different than for profit systems.
You are NOT allowed a second opinion outside of KP for almost everything. Why?
They have their own grievance form for the state of California. Why?
They have their own private "arbitration court" that members and the public are not privied to. Why?
They were kicked out of Texas because of their business practices.
When they own the entire system (insurance, hospitals and doctors) they have to be selective of the "evidence" they need to manage and the mandatory services they are required to provide by law.
Who exactly is "they" ? I mentioned pros/cons of almost any system.....you seem to be unaware of any pro for Kaiser's system? As though anything non-Kaiser is better? IMHO, the biggest con with Kaiser is the limitation of Doc choice, except in extenuating circumstances.. ...... as far as I'm aware, there are no insurance company profits, and I know of no proof that Kaiser Docs overall are more highly compenasated than non-Kaiser Docs ..are you critical of the compensation for all other Kaiser employees, and does their total executive compensation greatly exceed that at other insurers of comparable size?
I mentioned the care my wife got at Kaiser for a life-threatening situation.....you said nothing?
My friend Shelly had a late diagnosis of colon cancer. Kaiser only uses a FIT test for testing and they lowered the screening age not with other associations and providers, but not until the USPSTF recommendation was changed almost 3 years later. She was 50 and dead before her 52nd - died 9/27/22.My friend above was in district management at a big school system. And she shared this before she passed: I have a really good friend whose husband was cared for by Kaiser and they removed his cancerous tumor and never even did a pet scan before or after. Years later when they left Kaiser because she retired and the district doesn't offer Kaiser in your retirement she went to Sutter. Sutter was shocked he never had any follow up after the removal of his cancer. They did a standard procedure and found he was loaded with more cancer that would've been preventable if it was monitored. He died very recently as a result.
Another friend had a partial finger amputation. The surgeon broke the sterile environment because he didn't have everything needed for his procedure. The surgeon wouldn't allow the ER doc to unwrap my friends bandage when it hurt so bad. Gangrene.
Another friend had psa of 20 that went to 30 - no dre, no scan, 90% tumor, G9 and mets into lymph nodes - KP stated it was just prostatitis. And one of his friends had a psa of 82 and his KP doc told him he had a couple of years to make a decision about treatment.
I have about 3 - 4 women I know who went through breast cancer at KP and they all said the care was good with a multidisciplinary team. Doc, social worker, MO, plastic surgeon, etc. They always had someone to go to and were happy with their care.
Thank you !!! My friend here is married to a very sharp woman with 20 years at OHSUas RN, and then back to school to become an NP. In addition, my friend's parents were BOTH Docs. After she left regular employment and essentially became self -employed, she decised on Kaiser insurance, and while with Kaiser had breast cancer and satisfied with their care. Some years later, for some reason I can't remeber, they decided to try something like Blue Cross insurance and use OHSU clinics for their healthcare. After several years, they became frustrated with both the claims process with an insurer like Blue Cross, and also dissatisfied with services at the OHSU clinics. Now on Medicare, they went back to Kaiser. again, Kaiser is an easy target for complaints, because the insurance and providers are all under one umbrella. You will not hearas many complaints about XYZ or ABC hospital, because they each serve a much smaller number of patients....ie NOT nationwide as is Kaiser.
As I said, my personal complaint, based on my LIMITED experience at Kaiser, is the limitation of number of covered Docs/medical clinics........ then again, I really have no way of knowing if I would actually find more PCa expertise at any other institution/clinic in the nearby area. Perhaps in Seattle, but 200 mile drive.
What I DO know is the good things about Kaiser that I would lose should I swithch to "traditional" Medicare coverage witha supplement.
I wouldn't take the time, as I cannot fix the system. IMHO, it all comes down to the $$$ we as a country are willing to spend. I support universal insurance, but that will not substantially reduce the $$ spent. In fact, when one reads complaints from average citizens, answering the complaints generally involves spending more, not less. Anyway, maybe we should mostly just be thankful we have what wehave...probably the majority of world's population aren't so lucky?
Well thats why in the US the wealthiest country in the world with the 3rd largest population we spend $10,498 per capita with the average of the other developed countries at $3,902. Overall quality was 6th and fiscally 29th. pgpf.org/blog/2022/01/us-he...
As far as prostate cancer screening goes we need to look at the public healthcare policy.
The 2012 USPSTF guidelines had ZERO overwhelming evidence that we should not use psa testing for prostate cancer screening. That is 100% putting their heads in the sand. And with the latest studies we're paying the price with more advanced disease showing up younger and more aggressive.
The 2018 USPSTF guidelines have absolutely zero new evidence. Family history and black/ African American men are at higher risk is nothing new as is shared decision making.
Age 55 as a starting age? Look at the men here on HU and other social media platforms who are in their late 40's and early 50's with prostate cancer. That decision was made to limit their financial exposure.
Healthcare needs to get better at catching the intermediate and high risk disease earlier. But when we have healthcare policies that try and catch cancer at ages that are in the range of well known prevalence we're not going to get ahead of this disease. Policy gets in the way of progress.
As far as costs, we know why it's so expensive. It's a blind system that is running out of control and that is in the hands of big healthcare and our government.
easy to criticize ...more difficult are detailed imrpvements. Shal we biopsy evryone with PSA >1? after all , some men have PCa with a PSA of 1.8, and we are missing those men!!! Unfortunately I cannot recall his name right now, but the scientist greatly involved with the PSA and PCa link does not advocate use of PSA for testing.
I'm sure you can suggest a way out of our healthcare mess.
There are better screening protocols than not screening asymptomatic men like the 2012 recommendation. Or the vague nothing new 2018 recommendation.
Pay attention to the healthcare policy around prostate cancer screening and the players involved.
There was no evidence to stop screening all asymptomatic men of all ages for the best shot at getting ahead of prostate cancer. The experts of the disease reached out to the USPSTF and expressed their concerns and 10 - 15 years later we have prostate cancer diagnosis up 3% year over year and advanced disease at diagnosis up 5% year over year since 2014!
Have you ever dug into the healthcare policy around prostate cancer?
There has been multiple tools to stack for screening for prostate cancer that the USPSTF and some healthcare providers have failed to recognize and use.
The unfortunate USPSTF recommendations to discourage the use of PSA to screen for prostate cancer has led to many more men showing up already metastatic and incurable. In addition to the misery that these men were forced to suffer how many billions more did Medicare and other insurers have to shell out for treatments? Penny wise and pound foolish to the max.
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