we come to these recommendations made by the united states preventive service task force and they've made a pretty dramatic statements regarding breast cancer screening ..

not necessarily a peer-reviewed scientific journals, but the articles of the day which are of interest to practicing ob/gyn's are discussed in they had a story that ironically was the day before the task force recommendation came out bessette headline breast cancer deaths high gear without routine screening and this was from a report given to the american cancer society in san francisco and a rather startling statistic that dr. katie reported to this group some of the 345 brass cancer deaths which was nearly three-fourths of the total or in women who were not regularly screened. women who work regularly screened had 25% of the cancer deaths. women who did not have regular screening 75% of the cancer

deaths. i think that is trying to tell us something and i think again the 2,000-pound gorilla in the room is the brave new world of health care which congress is going to dictate how things are happening and the recommendations the preventive task force now carry the weight of law if you will under the auspices of the secretary of health and human services or ever they designate, so i think we are having this hearing and i think it is extremely important and extremely timely and i look forward to the testimony of our witnesses, dr. brawley always good to see you and i yield back the balance of my time. >> thank you mr. burgess. the gentlewoman from california, ms. capps. >> thank you chairman pallone ferc holding this hearing. i am so pleased that you and we all have responded quickly to the release of the task force recommendation because there has been a lot of confusion.

underscoring the value of having hearings like this in our house of representatives. i just returned as we all have from our thanksgiving break and i was with my family, and in fact as an aside, receive my own annual during that time. i can assure you that the message is out there but i'm afraid it is not necessarily accurate one so i am looking forward to hearing in greater detail today how the task force arrived at its conclusions and what the recommendations really mean in a practical sense. unfortunately there are people who have completely twisted with the task force is, what the task force does and what its recommendations mean. the scare tactics eyewitnessed have been deplorable. quite frankly the recommendations are based on scientific findings. this is so important to underscore. now we no there is not always consensus within the scientific

community where within the advocacy community. both groups so important to us in setting public policy but we in congress owe it to our constituents and the public to listen to what a reputable group of experts in evidence-based medicine and prevention have to say. for the more we owe it to them to refrain from engaging in partisan rhetoric about what these recommendations mean. the united states preventive services task force issue a whole range of preventive services. they do not make coverage determinations for insurance companies public or private and ultimately all decisions should be made between patients and their health care professionals. the task force's web site of firms their purpose is to present health care providers with information about the evidence behind each recommendation following clinicians to make informed decisions about implementation. at the end of the day this information that clinicians should use to make decisions and consultations with their patients and nothing more.

so i look forward to hearing in greater detail what the task force concluded and how they arrived at these conclusions and i hope it can stop the false accusations. before i yield back i ask unanimous consent to mentor a letter from the partnership for prevention into the record. the partnership is a group of reputable organizations, the american academy of family physicians, physicians' assistants and on and on, there are about ten of them and they are calling attention to our committee on the three most common misstatements that have appeared in the media. when being that's the task force recommends that women aged 40 to 49 not received mammograms. this is the were in the report. the intention was to reduce costs and this is nowhere in their analysis and they are not qualified. these are some of the misstatements in the public that this task force is not qualified to make recommendations are that they have other agendas in play

and i asked the letter be made part of the record and i yield back. >> without objection, so ordered. thank you ms. capps. next is the gentleman from georgia, mr. gingrey. >> mr. chairman i thank you. we have heard already some comments from the democratic side regarding the danger of ignoring signs if we go down that road. i don't think we are talking about newton's third law here by the way. we are not talking about exact science. we are talking i think about an opinion that a judgment is made by the united states preventative services task force, 15 or so members based on looking at a lot of studies. i will tell you as a practicing ob/gyn physician like my colleague from texas, dr. burgess i have spent 26 years practicing medicine.

in that specialty i am very proud member of the american college of obstetrics and gynecology and i am a board certified fellow. we take our recommendations from that organization, and from the standard of care in the community, my community, the greater atlanta area about what our best practices and the american public and particularly the american women, they know who the american cancer society is. they know who the susan g. komen for the cure organization is. many of them helped raise money for that organization by ferry few of them have never heard of the united states prevented the it services task force or in what departments they are embedded and how much power they have and how much authority they may have mr. chairman. they will find out pretty darn soon and i would refer them to

pages in both the house and the senate bill, the senate bill for spending, the house bill 3962 and let them just connect the dots and to see the power that this organization, this u.s. preventative services task force, no matter what they call come to tell physicians basically that this is not an a or b recommendation. this is a c recommendation. if the president had followed through, if the congress have followed through on the present recommendation of having meaningful medical liability reform in these pending health care bills, then maybe physicians like myself would not have to worry too much if we decide to follow the united states preventive services task force guideline cannot order a for our patients between the ages of 40 and 49 or not

recommended to them that they do breast self-examination, and we missed a breast diagnosis of cancer and they died from that disease, or on the other hand, if we decided to ignore the recommendation and we did the and a lump was detected or suspicious marking, the patient had a needle biopsy and it turned out to be benign but unfortunately she developed a breast abscess and then the physician gets sued for not following the recommendations in doing something that is unnecessary. so you put doctors in an untenable position and you put their patients at risk of death so i think-- i can't wait to hear from susan g. komen and the american cancer society and obviously from the preventive services task force and the others on the panel. mr. chairman with that i will yield back.

>> thank you. the gentlewoman from the virgin islands, ms. christensen. >> thank you chairman pallone and given the confusion and the uncertainty with the updated recommendation on screenings by the united states preventive tests scores i hope will bring clarity which i feel is needed on both sides and i thank you for holding it. i've only read the executive summary but i have several questions like why now, did the task force not receive the reaction that has occurred and why was a just released as an article, as important as it is and not as a briefing with present stakeholder organizations? as an african-american woman who has had friends and family diagnosed in their 20s, their 30's and 40's many with no known risk factors, some with good out guns and some a died because of the aggressiveness of the disease and as a physician who came to care very late stage carcinomas like the 24 black

women we are going to be reporting on later diagnose in the city in a recent 18 month period, 24. i am not pleased to say the least with the report not specifically addressing those of us to die most often from the disease. mammograms are not perfect and perhaps lease so in the 40 to 49 each group but as part is the fall armamentarium in the mammogram and a full part of a full armamentarium it is the best we have today. we have never told women that they are all that there is. as ms. deray and dr. brawley will attest our main concern not tb in prevention our main concern ought to be the gaps and out guns and the lack of access to exams and other diagnostic modalities and while this is most evident in the uninsured, co-pays create equal barriers to women with insurance.

neither is the federal government doing enough. aetna example the virgin islands scored high on the breasting cancer exam application but was never funded. and tell everyone has access you can well imagine we will, i will not welcome these kinds of narrow recommendations, what is next colonoscopies training four colon cancer. it probably saved my life in not having one has caused me to lose to many fronts. the task force is dependent which i consider a good thing and it is very important to base recommendation like these on signs but the task force is not as the versus the needs to be to adequately and appropriately address the health care needs of all americans. the recommendations may have been very different orderlies more expensive that some of the recommendations that the american cancer society offered had been accepted. they are similar to ones we recommended for h.r. 3962 i welcome all the panelists and look forward to their testimony.

>> i thank the gentleman. the gentleman from pennsylvania, mr. pitts. >> thank you mr. chairman for convening this hearing. on november 16, the u.s. preventive services task force released an updated brass cancer screening recommendations for women in the general population. several of the recommendations have cents caused widespread confusion and concern. primarily its recommendations for women aged 40 to 49. the task force recommended against routine screening mammography in women aged 40 to 49 based on individual factors should be screened. this is a change from the task force, task forces 2002 recommendation that all women aged 40 and older receive

screening mammography every one to two years. the u.s. preventive services task force was first convened by the public health service in 1984 and since 1998 it has been sponsored by the agency for health care research and quality division of the department of health and human services. it is instructive therefore to pay attention to what the secretary of health and human services had to say about the task force recommendations. on november 19, secretary sebelius said, my message to women as simple. mammograms have always been an important lifesaving tool in the fight against breast cancer and they still are today. keep doing what you have been doing for years, takfir dr. but your individual history, ask questions and make the decision that is right for you. basically she told women to ignore the task force recommendations. the good news for women aged 40 to 49 is that they can talk to their doctors and determine

whether not routine mammograms are best for them. the bad news is that if the house passed health reform bill, h.r. 3962 becomes law a woman in that age range may not be allowed to have a mammogram. the house-passed reform bill renames the u.s. preventive services task force the task force on clinical preventive services. as part of the bills essential benefits package, preventive services including those services recommended with a grade of the a or b by the task force on clinical preventive services must be covered but according to the task force's just released recommendations routine mammograms for women aged 40 to 49 received only a grade of c. should the health reform bill become law the new task force will make recommendations to the health benefit advisory committee which will determine what is and is not covered in the essential benefits package. i think we should ask ourselves

how likely is that one benefit advisory committee will recommend including services in the essential benefits package that another government board, the task force, has recommended not be covered. it is important to know that all private plans in the exchange will have to meet the essential benefits package. but, they cannot exceed it. a private insurer cannot add additional benefits above and beyond what the government requires in the essential benefits package except to premium plus plans and then only if the added benefit is approved by the health benefits commissioner. so, for example of the essential benefits package did not cover routine mammograms for women aged 40 to 49 insurance plans would be for bidded from covering them. it requires all plants cover mammograms for women aged 40 to 49. with this bill were to become law in the secretary were to adopt these breast cancer

screening recommendations as is as part of the essential benefits package pennsylvania would either have to change its benefit mandates law or reimburse the government for the added cost of screening this population. these recommendations should be a wake-up call that a government-run health care will come between patients and their doctors. i look forward to hearing our distinguished witnesses, thank you cannot yield back my time. >> thank you mr. pitts. the gentleman from florida, ms. castor. >> thank you mr. chairman very much for the hearing today because it's not only gives us an opportunity to further understand the recommendations as to breast cancer screening but affords us an opportunity to raise awareness about the real issue involving women's health in america and that is access to care, plain and simple.

for women in america, access to care, affordable health care, including screenings of all kinds, eclipses' the debate over what age when men and their doctors should begin routine mammograms. for millions of women across america, this debate has no application whatsoever. they are not receiving screenings at age 50. they are not receiving screenings at age 60. they simply do not have access to affordable health care because our health care system in this country is broken. it is very basic. we know that if you do not have affordable health care you are less likely to receive the vital preventative screenings that women with insurance have. the american cancer society reports that in my home state of florida, if you don't have health insurance yours simply not going to receive any

screening whatsoever. women in this country just do not have access to affordable care. maybe one quarter of women in the state of florida that do not have health insurance will receive some mammogram during v-8 40 to 60 and it is much worse if you are african-american or latino. the disparities in screenings, diagnosis, treatment exist and i think this is a critical issue that dr. christenson has raised that really deserves a great deal of attention and debate and it is the proper place for our outrage over women's health in america, because regardless of your insurance status if you are african-american you are 1.9 times more likely to be diagnosed with an advanced stage of breast cancer than white women and hispanic women are almost 1.5 times more likely to

be diagnose than white women because of the real concern here and the proper place for outrages access to care in and of itself. are broken system prevents millions of women in america from even being part of this debate over screening. fortunately due to the efforts of many over the past year, we are on the road to correcting this problem and i hope that we can focus on the true issues of our broken health care system in america. it affects brass cancer screening but it really is the heart of the problem in our fight to making america a healthier country. thank you. >> i thank the gentleman. next is the gentleman from michigan, mr. rogers. >> thank you mr. chairman. science is a whole host of disciplines and now this one of them. when you look at what the task force recommendations have done, it is absolutely disingenuous to

say costed not play a role. let me quote from the american cancer society. the task force says screening 1,003 and 39 women in their fifties to save one life makes the screening worthwhile yet the task force also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. when you look at their executive summary clinical breast examinations talk about cost, the principal cause the vaisse the e is the opportunity cost incurred by the patient and counter. clearly cost of the consideration. digital mammography is more expense and then fell mammography and talks about the cost benefit analysis. magnetic resonance imaging, magnetic resonance imaging is much more expensive than film or digital mammography. to say that cost is not a factor in this is not being on this. it is just not.

it clearly was the reason than to say they don't have any authority, wait until the insurance company comes out and says we based it on this task force, a government task force recommendation says i don't have to pay for mammography for women between the ages of 40 and 49. as a matter affecting your 2,000 page bill that is exactly what you do. they health benefitted fisa recommitting is created to do exactly that. how do we know that? the national institute of clinical effectiveness, the nice board in great britain is the very organization that limits things like pap smears. they raised it from 23 to 25 for young women. why did they do it? because science told them, to save money. what the math part of your si antiquation is, we think that we are willing to accept that more women will be diagnosed later on

in the later stages of cancer, we are willing to accept the higher mortality rate to save money. that is what this report says and that is what we are getting to foist on the american people. that is not a scare tactic, that is reality and it happens in great britain and it happens in canada and it happens in france. what we are saying is we can and should do better. i am a cancer survivor because of early screening. i know mr. blunt is a cancer survivor because of the early screening. buy we wit voice to this kind of an ugly system and hide behind the fact that we will have more deaths, more mortality because of it is beyond me. what we are saying is this 2,000 page bill and its 118 new boards, commissions and other government agencies that will dictate your health care policy is wrong and we can and we should by these women in their

40's do much better and that would yield back the remainder of my time mr. chairman. >> thank you mr. rogers. next is-- i am having a hard time seeing who is here. the gentlewoman from illinois, ms. schakowsky. >> thank you mr. chairman for moving so quickly to convene a hearing on the recommendations of the preventive services task force. i appreciate it. this committee has talked a lot about the ed for evidence-based science of the the last year but it is important particularly when it comes to something as critical as breast cancer screenings that we do look carefully into the justification for these recommendations and their ramifications for individual women. many of my constituents have questions as to i and i look forward to asking them but i do want to say right now that this

is not something that should become a political football or in my view an attack on the need for health reform that guarantees access to comprehensive health care for women. we all want to ensure women, especially women threatened with life-threatening diseases like breast cancer and make sure that they have access to the health care that they need. without preexisting condition exclusions, gender rating and denials that exist today but among the questions that have been asked is how do we reduce the number of unnecessary screens while insuring that we do not provide disincentives for mammograms that will save women's lives? how do we empower women to ask for a screening when they suspect a problem? how do we ensure we are getting their research and science on breast cancer prevention and treatment right? what improvements are needed to obtain more accurate screenings?

how did the grades provided by the task force mash with the recommendation that doctors and there patients be able to make individual choices particularly when it comes to high risk women and how do we make sure inadequate coverage or high cost-sharing don't prevent barriers to screening in all appropriate follow-up care. women across the country are getting, are concerned about getting access to mammograms and other essential services and women's groups across the nation have endorsed comprehensive health reform for this very reason, because they know that millions of women's lives depend on it. i am eager to hear from our witnesses and discuss the task force's recommendation and again mr. chairman thank you for having this hearing and i yield back. >> thank you. the gentleman from arizona, mr. shadegg.

>> thank you mr. chairman and thank you. i want to also thank you for holding this hearing so quickly on this important topic. i believe i have mentioned to this committee that my older sister is a 20 year breast cancer survivors so i have a keen interest. the guidelines released on november 16th by the u.s. preventive services task force that created a firestorm across the country giving rise to concerns about women's access to lifesaving screening. some of commented these recommendations are merely guidelines for insurance company-- companies and government officials to assess the relative value of mammography, a clinical breast exams and breast self-exams. in a written statement health and human services secretary kathleen sebelius said the guidelines had caused a great deal of confusion and worry among women and families across this country and stressed they were issued by an outside independent panel of doctors and scientists who do not set

federal policy and don't determine what services are covered by the federal government. i am here to tell you today and to tell every woman in america that under this bill, h.r. 3962 which has already passed this congress, that statement will not be true. indeed, under this bill, the recommendation would become binding law. and if so, it would be devastating to access mammograms and nothing short of catastrophic for women's health in this country. in their recent report, mammograms for women aged 40 to 49 or given a grade of c. under this bill and the procedure given a grade of less than a or b cannot be covered by the public plan. so the women that my colleague worried about you have no access

to care today for mammograms could not legally get mammograms once this bill becomes law. but the panel also found insufficient evidence to determine whether it is worth screening women over the age of 74. again, because the grade was neidert and a or a b, it was an i, insufficient under this bill those women could not get mammogram screening legally under any public plan budget is important to understand precisely how far this bill goes. because it does not just prohibit mammogram screening. if this were the finding of the same task force after h.r. 3962 becomes law, it would prohibit private insurers, making it illegal for private insurers to provide mammogram coverage to women in these age groups.

that is what the law says. let me explain. under the house bill, private insurers can offer for health plans. one, a basic plan. two, an enhanced plan. three, a premium plan and for a premium plus plan. under section 303 of the h.r. 3962 women purchasing insurance under the first three categories, basic, enhanced or premium would not be allowed to purchase because the insurance company would not be allowed to offer a policy covering mammogram services. that is right. it would be illegal for a private insurance company in any one of those first three categories, the basic common hamster premium to offer coverage for mammograms because mammograms were not given either an a or 8b freighting. with regard to the top category,

a plan, and insurance company could offer coverage for mammograms but if and only if the health choices commissioner specifically allow the policy to cover mammograms. i don't suspect that many of my colleagues on the other side of the aisle understand that aspect of this bill and i hope before this bill or anything like it were to become law they would study it closely and recognize what is wrong with it. certainly having the government prohibit people who choose to be able to buy mammogram coverage is not what was intended by the authors of this legislation but in fact that is what the bill does. the government would prohibit the millions of women from buying coverage for mammograms. the government would forbid private plans from offering mammogram coverage to millions of clements. pour in middle-class americans would be prohibited from getting

mammogram coverage under the insurance exchange. >> the gentleman is two minutes over. >> i thank the gentleman for his indulgence and had not realized i had gone over time. >> thank you. the gentleman from maryland, mr. sarbanes. >> thank you very much mr. chairman for holding this hearing. i expect we are going to hear a lot about rationing today from the other side. to me, the discussion today is not about rationing. it is about being a rational in looking at all of the evidence that is available to us and making smart decisions about what kind of treatment we should deploy and what kind of coverage there should be and i think the jury is out on this. that is why we are having a hearing. barabas and recommendations that have been put forward. they appear to me to be based on very extensive studies, research

and science and i think we ought to approach them with an open, with an open mind. i am glad we are having this hearing. this is exactly the kind of thing we should be doing, and the fact of the matter is that as science advances, it causes us to revisit treatment, and that is a good thing. now there may be other considerations in play here. one of them is clearly the high attention that there is to mammography screening and the education effort that is going on with women across this country to make them more sensitive to this as a screening tool so all of those considerations ought to be fed into the mix and i would expect that the secretary of hhs will be considering all of those going forward. but to put our head in the sand

and not look to the science it seems to me would be a serious mistake. so we ought to review these recommendations with a sober and dispassionate consideration. i think that is what we are called upon to do. i would assume that that is what the health benefits advisory committee would do in receiving recommendations from any other government body. the notion that-- and we have heard this theme again as well today, the notion that one government body will accept without any kind of independent judgment or redo the recommendations of another government body. i don't think it makes any sense. i think the health benefits advisory committee will look at all of the factors in determining what ought to be the policy when it comes to treatment. so, i think this is a good

conversation to be having and i thank the commission for putting their recommendations forward, for basing them on science and now we are going to have to consider those in the light of many many factors in judging how to move forward. so i look forward to the testimony of the witnesses and the yield back my time. >> i thank the gentleman. the gentlewoman from tennessee, ms. blackburn. >> thank you mr. chairman and i want to say thank you so much to where witnesses for being here. i am really appreciative of the opportunity for us to have this hearing today and i have a formal statement that i will submit for the record but i do want to make a few comments as we began this. this is an issue of tremendous concern to me. i think all of us are concerned about the welfare and the health of women. we are concerned about what you well as the task force brought

forward. sure we are concerned about the science and i want to discuss with you that science, where you true that from an your process. i also want to explore with your task force structure and look at the linkages that you bear and what would happen if h.r. 3962 were to be passed and read into law. you all have a portfolio of 105 topics. that gets to the heart of the issue. because, when you start reading on h.r. 3962, on page 1296, into title iii and you look at section 2301 of this bill, the decisions you make to end up having the weight of law placed behind them, and when you read specific leon pages 1317 end

1318, you see exactly what is going to happen with your recommendations. and then you go in and you look at how it becomes the standard of the block, so i encourage everyone to take this bill down and read it and read that title. look at section 3101, look at section 2301. go back in look gun pages 110 to 112, at how what you do and how you give priority and preference to certain treatments and certain categories is going to carry the weight of law. now eating is of concern to me by members of congress that we are going to deploy certain treatments or certain health care. that ability should rest with the patients and their

physician. we do not need a bureaucrat and that exam room. and yes indeed, when you read this bill we do have concerns, that it will lead to rationing, because the decisions appear that they are being made on costs, and not on health care, so i welcome you all. i appreciate your time. we are going to have a link the number of questions and mr. chairman i yield the balance of my time. >> i thank the gentlewomen. chairman dingell, the gentleman from michigan. >> i flew back this morning from michigan, hoping to have a rather informed hearing on a very important point. i find that i have come back to listen to some very tales coming from the other side of the aisle. and i find myself of then did by the lack of attention that my republican colleagues have given

to the health bill. and i find myself very much offended to listen to the kind of distorted logic and reasoning with which i am being afflicted as i enter this room. i have great affection and respect for my friends on the other side of the aisle and i am willing to assume that their behavior this morning in making the comments i am hearing about these recommendations and how they will play with the bill is a lack of attention, steadied, knowledge or diligence and understanding idid the bill or the recommendations of the u.s. preventive services task force. it has been a little bit like listening to the fairytales of the brothers grimm, but to set the record straight i want my colleagues to understand the bill does not in its provisions

be made as my republican colleagues would have us believe. it does not use these kinds of recommendations to suppress treatment or interfere with the relationship between the patience and the doctors. this is the kind of scare tactics that i have heard from that side of the aisle, always with great personal offense. they talk about how we are going to pull the plug on grandma, how we are going to push euthanasia forward, how we are going to deny health care to deserving people because of this legislation. these recommendations that we are going into this morning our recommendations and nothing more. and to say anything different than that is either to transmit the grossest kind of carelessness, and i hope this is not the case, or to just plain

it out right deceit. it is time for us to look at these recommendations as they are. the recommendation of the scientific panel created to make advise on what is the best medical and how we can see to it that we best protect our women with regard to things like pap smears and mammograms. now i will yield to no one on either subject because this committee and the oversight subcommittee, when i was chairman of each, were responsible for seeing to it that both mammograms and pap smears were made in the safest way for the benefit of patients i lost a mother to cervical cancer, and i have lots lots of friends to breast cancer and

other things, and i am grossly offended by the statements that i've heard coming from the other side in which they tell us how these recommendations and the health bill which we are working so hard are going to deny women mammograms, proper mammography and pap smears and other needed services. that is offensive. it is just plain wrong. it is absolutely false and i would urge my friends on the other side to go off and take a look at the bill, to read it carefully and if they need any assistance in understanding what the bill does i will be happy to volunteer to provide time so that they may come to have a better understanding of what the bill does and they made then make more informed statements on these matters. we need to deal with our health

problems in a responsible way. we need to see to it that we address the honest defects which are in the bill. but not to manufacture a lot of fears and faults which do not exist. i am affronted mr. chairman and i hope that this record and this hearing will correct some of the unfortunate misapprehensions' and misstatements that have been flowing thickly from the other side of the aisle this morning. i ask unanimous consent to revise and extend my remarks. >> so ordered. ranking member, the gentleman from texas, mr. barton. >> thank you chairman palone for holding this hearing. i listened with great affection and with great interest to my good friend from michigan, former chairman and current chairman emeritus dingell's opening statement.

i think it goes without saying the personal esteem and professional respect that i have for him. having said that, there are no fairytales being told on this side of the aisle this morning. here is the bill. it passed the house. i want to, in this bill, on page 1762, the u.s. preventive services task force is given the authority, and i quote, to determine the frequency, the population to be served, and the procedure or technology to be used for breast cancer screenings covered under the health service. section 3 of three, legislation states and i quote, the commissioners shall specify the benefits to be made available

under the exchange, participating health plans. in plain english mr. chairman what this means is new health choices commissioner will determine what preventive services, including mammography, are covered under the health insurance based that is then this bill. now, we also know that the u.s. preventive task force is an outside independent counsel of doctors and scientists who make recommendations. they do not set federal policy and they don't determine what services are covered by the bill, but their recommendations are not going to be seriously listen to. now, i have an aunt who passed away in her early 50s as a consequence of breast cancer.

i have a sister who was diagnosed with breast cancer in her 30's. luckily, receive proper treatment, had a mastectomy, and so far in the last ten years is cancer free. i have a wife, a beautiful wife who was under the age of 50 and she has annual mammograms every year. i have a good friend, who was just diagnosed with breast cancer who is in her mid-40s. again, she is undergoing treatment. hopefully she is going to have a good outcome. to have a task force make the recommendations that have been made into have in this bill the authority that is given to various unelected bureaucrats to make health care decisions including coverage and frequency

in my opinion is wrong. it is wrong. now, on a bipartisan basis, this subcommittee and the full committee repeatedly has passed bills increasing and supporting their early detection of breast cancer, the prevention, the research. we do it almost every congress. so, we are starting down a path in my opinion of socialization of medicine in this country with the passage of this bill out of this committee with its passage on the house floor. it is awaiting approval in the senate. this is an excellent time to hold this hearing and i appreciate the chairman and the full chairman of the subcommittee in full committee chairman's personal attendance but let's don't talk about

fairytales. let's talk about the facts, the plain english of these bills, and if we continue to agreed rhetorically, then we need to begin to make substantial changes in the legislation to prevent what we all say we oppose. we don't want rationing of health care in america. we don't want to intervene between the doctor patient relationship. we don't want young women or for that matter more mature women over the age of 74 developing breast cancer because they are not allowed a mammogram. my good friend to my right, mr. rogers, had an amendment passed in committee that explicitly prevented the rationing of care and it mysteriously disappeared in the bill that got reported out of the rules committee in the dark of the night. some staffer on the majority

side or may be a member, i don't no, decided it was the will of the committee and it didn't mean anything. it disappeared. maybe we need to put that back in. i don't know. so, i have great respect for this committee and i have great respect for the leadership on the committee. but let's don't talk about fairytales when we can read these bills. now i am not saying the bill is a fairytale but i will say the bill is not reflective of the policy that members on both sides of the aisle say they support. with that mr. chairman i yield back. >> thank you. next is, mr. green. >> thank you mr. chairman and i appreciate the opportunity you have been in so quickly dealing

with this. first of all i want to thank the chairman emeritus for his offer, chairman dingell willing to conduct a class on remedial health care comprehension and my only question is that it be mandatory or permissive, and hearing my colleagues on the other side talk about unelected bureaucrats, unelected insurance companies do this every day right now and i will give you an example. when i moved to be a member of congress, my wife had been getting annual mammograms and yet our new insurance in congress refused it after the first year. and she was a survivor. her mom was a 40 year survivor of breast cancer. sushi fit the exception and it took me as a member of congress saying i can't practice law but believe me i will file suit against our carrier it they don't continue to pay for those mammograms. you have to fight for the care that you want and to say that

the house bill that passed would set up this unelected group to do it, it all rests on their shoulders and i think that decision ought to be made by elected officials. this group will take recommendations from everyone but ultimately it is going to be our decision and we will continue to provide legislation. the statement i have, in 2000 to the task force change their breast cancer screenings to a mammograms every one to two years for women 40 to 75. that was only seven years ago and yet now the task force is making a change. a few weeks ago they revised it and made it a great c. and that is the issue i think that my colleagues are talking about. that women at the age of 40 would not be automatic but should not be denied. again it does go back to the doctor and patient's decision.

i have dr. some bull's-eye dent i have doctors tell me all the time that they have battles with insurance companies saying we need to do this than the insurance company won't allow it and they are the ones that are practicing medicine and that is the battle every day no matter what happens, if we pass the national health care bill. to use this opportunity to pick of the national health care bill i think it's interesting because the task force will be given an opportunity to clarify their statements and i am glad we had the testimony here today. >> adverse reaction in the wording of the recommendation obviously is not going unnoticed by our committee and the members of the committee and in fact i contacted and had been contacted by a number of constituents in my district including the cancer center in houston about the recommendations and they were very public that they were opposed to the task force's recommendations. along with many other groups

unlikely the state of texas has a mandate that all private insurers must cover annual breast cancer screenings beginning of the a40 but this new screening recommendation will cause some access problems barriers for women. it is especially sensitive because the reform bill 3962 states the u.s. preventative task force recommendations anpr mandating benefits in the bill also including report language saying a and b recommendations for the floor for benefits not a ceiling. the a and b r.a. floors of the task force recommendation would be considered that the decision should be made still whether, no matter what the task force says cell that is what we are here today to talk about. i have concerns about jeopardize in access to preventative screenings for women especially since i represent a majority latino underserved and i worked for years to expand the coverage of mammograms and our

communities and for primary and preventative care services. it is designed to keep politics out of medical recommendations because i can be an expert for 30 seconds on anything but i do depend on the experts to make those decisions and again i look forward to the testimony mr. chairman and i ask unanimous consent my full statement be placed into the record. >> without objection, so ordered. thank you mr. green. next is the gentlewoman from north carolina. >> thank you mr. chairman. thank you for holding the hearing today. i understand that scientific and statistically this information is not new in nidel that mammography is not perfect by any stretch of the imagination but i want to talk to this full report from a preventive side. because coming to me it is sending the wrong message to women. aidid saying you don't have to be vigilant, and you don't have

to take care of yourself, you don't have to do preventive care and the reason that concerns me if i am a ten year breast cancer survivor. i am one of those who persevered literally to find my own cancer because i knew something was wrong with my body. and i had good doctors who helped me. but, because of that i am here today and we all know that earlier detection means longer survival. i mean, that is a no-brainer. many women really say to me i don't want to get a mammogram, it hurts or whatever, i just don't want to do it. i have heard that over and over again ever since i started to get active on this issue and a lot of women have told me, i don't want to no, i really don't want to know if i have cancer. my whole point is you had better find else sooner rather than later because of what i said before.

so i am very concerned that we are saying hey you don't have to take care of yourself. women let for an excuse not to do this anyway and not to do self-exams and especially under women today. there are so many women in my areas that are in their 20's and '30's that have their own support group and that never used to happen. so when we talk about what we need to do, i hope that we will very seriously consider, and i'm glad the panel is going to be here to explain why they did what they did but i know that some of the groups are going to continue to recommend they do the same thing and with digital mammography now things have changed especially with younger women so mr. chairman i appreciate this opportunity very much and look forward to hearing their recommendations from the panel. >> thank you. the gentlewoman from wisconsin, ms. baldwin. >> thank you mr. chairman. i appreciate your calling this

hearing of the house subcommittee to discuss whether it is both a deeply personal and deeply political issue for myself and as you have heard many of our colleagues in this room. >> hanna preventative services task force was authorized by congress to deliver recommendations regarding the clinical preventive services. ideally these recommendations will be used to inform primary medical care. on november 16th the task force delivered new recommendations regarding breast cancer screenings incorporating the most extensive scientific evidence available. among the more controversial findings were the great c recommendation for mammography in women over 40 which means that because defines does not point to any significant harm for tremendous benefit that the provision of the services should be a decision between individual and a doctor.

and independent rigorous examination of the science behind clinical preventive services is an essential part of delivering effective health care. the task force was doing its job. and as they may admit today they could have done much more around such a sensitive topic by educating and explaining their recommendations to women across the country. they could engage community and advocacy groups to be messengers of this information rather than combatant. moving forward with additional recommendation in sensitive areas i would encourage them to do just that. i came away from this report in the surrounding controversy with two additional thought that i would like to quickly share. first we clearly need better screening and diagnostic tools. mammography is not a precise enough tool. we need advancements in technology that can help us understand what conditions require further tests, which

requires treatment and how we can best help women to live long and healthy lives. some of these advancements in technology are being developed in my state of wisconsin, >>host: selves said that five types of tissue with more precision improving the efficacy of an x-ray screening for breast cancer. my second point is that we urgently and desperately need health care reform. we must ensure that every woman and every american has access to regular source of care. if the best approach is to discuss the option of mammography or other screening with your doctor you have to have a doctor. the villain is the lack of coverage and access to care. otherwise women who are shut out of the health care system whether by stigma or lack of resources or even abusive been discriminatory insurance industry practices, these women have the potential of dying of breast cancer or other conditions before we even have a chance to intervene.

again mr. chairman thank you for allowing us this then you to discuss and clarify this critical topic. it has bearing not only on the health of women but the health of all americans. >> thank you. the gentlewomen from colorado, ms. degette. ..

rather than a population by a recommendation for routine screening. that makes sense to me. number two, by any mammography for women age 50 to 74 years. number three, insufficient evidence to assess the additional benefits and screening of women over -- at 75 years or older and then the others. so we leave you back to look at the recommendations they probably do make sense from a scientific standpoint. but i've got to say it is no wonder why the women of america are are on believably confused

as to what these recommendations are saying because what they are saying is most women need to talk to their care provider and figure out for themselves based on their health and family history what is appropriate for them. it's not a one-size-fits-all testing that makes sense to me. but if you look at the 24-hour news cycle that's not what is being said to people. they are scared, confused, and when you add them misinformation we hear from some of my friends on the of the site they are confused and scared because they think now when we have the health care plan that applies to everybody suddenly they are going to be told they don't need -- that they can't have tests they need and that is simply not the case. so, mr. chairman, that is why i came down and sat through the opening statements and in looking forward to the testimony because i think we need to clear it up.

but is it that we are seeing should be done with mammography and testing for women, and what is it women need to be talking to their physicians about the? ultimately it is going to be the decision of the physician and the woman what the need and the need to figure that out and then they need to feel secure they are getting the level of testing the need. thank you, mr. chairman. >> i thank the gentleman. next is the gentleman from ohio, mr. speakes. >> thank you, mr. chairman for taking the time to hold this hearing on this important issue. cancer is a terrifying specter for all americans and almost all of us have had a loved one or friend who has been affected by it. it certainly is a disease that strikes fear in the heart of all of us, and i want to preface my remarks by saying i have heard

some things from the other side of the aisle but have made a lot of sense and i specifically point to congresswoman am i rex comments and if i find them three consistent with those just provided by my colleague from colorado, congresswoman degette. but we have heard things from the other side of the ogle today that i think cause us, certainly me considerable concern. i think that it's wrong to use that fear that we all share of cancer to intimidate the people of this country into fear of comprehensive legislation that has some of our witnesses will testify today is good for people with cancer to read in following up with some of the remarks made by chairman dingell some things built are not do that need to be

clarified. these task force recommendations will not lead to rationing care. that is simply not true. i think it is tactics like these but we can defeat of the american people not in any of one particular party but in the institution of congress. nothing in this legislation prohibits insurers from covering mammograms in fact the legislation gives the secretary leeway to add to the minimum benefits package as needed. i think it is disingenuous to the one hand defend the status quo which sees the insurance industry every day making decisions about the lives of insured based on financial -- strictly financial considerations. and then on the other hand condemn the system because you speculate that these kind of recommendations will lead to the rationing of care.

second with this bill does do is provide some benefit insurance to the millions of americans that don't have it and falling on with what dr. christiansen engender earlier it's not just those americans that don't have insurance that benefit from this bill when it comes to preventive care and access to mammograms it's those who have insurance but can't afford the co-payment specifically those who are in the middle class americans that makes a difference for them. this bill makes preventive care a basic and fundamental right for every american. that means again my constituents 65,000 of them have no access to coverage right now and tens of thousands more who can't afford co-pays will now have access to things like mammograms when they wouldn't have otherwise had that. these are questions we all

should be asking. what is the net benefit of this legislation to our constituents. rather than jumping to the irrational conclusions adding confusion to the public in politicizing an issue which should transcend politics we should be asking these rational questions again as my colleague from maryland indicates based on reason and science. with that i thank you once again for calling this hearing and keeled back. >> thank you. the gentleman from ohio, ms. sutton. >> thank you for holding this hearing on the u.s. preventive service task force on mammograms for women in their 40's. as we have all heard and as has been described the task force is no longer recommending 14 mammograms for women in their 40's, and as someone who cares deeply about women's health i, like others, was surprised by

this change. breast cancer is to say the least a terrible disease. it's the leading cause of death for the women between the ages of 40 and 59. we all know people have been touched by breast cancer. people that we love and care about. and we all know people who have benefited from early detection. so this is such an important hearing and i look forward to hearing the discussion of the panel. and with the recommendations basically are in stat a woman should talk to her doctor and make decisions accordingly for their care. but many women house has been pointed out don't have doctors and many women don't have access to health care and women and should get mammograms either under the old recommendations or the new recommendations do not

get the mammograms. and 2007 only 70% of the women in the country to should have been screened for breast cancer were screened for breast cancer and part of the reason when whether they are 40 or 60 arnall screen this because they did not have insurance. and because they don't have insurance they don't have access to the care that the needy and when they needed including preventive care. so let's be clear providing access to health insurance means providing access to preventive care which means saving lives. so what's important is patients and doctors are able to consult and access to care that patient needs and when they needed and that the patients and doctors together will decide the best course of care whether that includes a mammogram, but in order to do that people have to have access to doctors. women of all ages under the

health care bill that has been passed by the house will have improved access to coverage. that should not be lost and it certainly should not discussions of their wives and presentations otherwise should not be used as we debate and discuss this very important issue to the real -- de real efforts to access women need in this country. i don't think that serves wim in a while and i don't think that serves our country well and frankly >> thank you. the gentleman from iowa, mr. braley. -- before, mr. chairman and thank you for allowing this hearing. i also want to commend my colleague the gentleman from north carolina for her eloquent and thoughtful statement on a very important topic. and yy disagreed with what some

of my colleagues from georgia said i have great respect for his real world experience on women's health issues and appreciate the concern he brought to this hearing. but i also want to talk about the comments made by the chairman emeritus and others on this committee. if people don't believe rationing takes place right now in our private insurance system every day and every state and every congressional district they are sorely misguided. it does happen every day under the current system which is failing to meet the needs of the american people. give you a good example of a friend of mine who was diagnosed with prostate cancer and conferred with his physician of treatment options and agreed proton beam therapy was the best choice of treatment for him and he went to his private insurance company, which also is the medicare administrator in my city of iowa and his treatment was denied on the basis that it

was experimental. well, guess what, under the medicare plan that same private insurance company had been mastered it was considered on an experimental and even though he was eligible for medicare because of his age she was still covered by a private plan for his employer and was denied coverage for the same treatment he would have gotten if he had been a member of medicare. that is what is wrong with our work broken health care delivery system, and that is why comparative effectiveness research is such a critical part of a rational discussion about health care policy making. in an earlier hearing in the same subcommittee i talk about a hearing that took place in this very room years ago when a researcher advocating high dose chemotherapy with bone marrow transplant for metastatic breast cancer patients was the only path to cure for those women even though it had not been

tested by rigorous academic research, than his years after that we came to the realization many women were actually harmed and died because of being subjected to that treatment. and that is why by the way it is so important that the plan language amendment i put in the health care bill be implemented and people dealing with health care issues. i think that in its position paper the u.s. preventive service task force highlights with edison important. they indicate on one page of the statement that the problem was a matter of communications because the ausley with the task force meant to say, that the communication of the mammography screening recommendations was poor. i agree with that and all you have to look is the next two sentences to find out why. this is what to of the sentence is say. what we said is screening

started at age 40 should not be automatic nor should it be denied. that does not make sense. the next sentence says what we are saying is that a decision to have a mammogram for women in their forties should be based on a discussion between a, women, her doctor. if you don't communicate for your intended audience in language that they can capri and easily these barriers of communication between highly technical scientific and medical information will be a problem. but the debate we are having is a healthy debate about what the most effective use and treatment for breast cancer treatment is and that is what we need to focus on going forward and i yield back my time. >> ra thank the gentleman. next is the gentleman from utah, mr. mathis. >> thank you, mr. chairman. i am looking forward to hearing from our two panels on this topic. in my state of utah the incidence of breast cancer is lower than most however the

mortality rate is high because women in utah are diagnosed in cancers later stages. as a witness on the panel votes in the testimony the recommendations provided by the u.s. preventive service task force november 16th have sparked concern and is a granite among providers, patients as well as sparked a public debate has led to further confusion and anxiety as we can see from the testimony before the committee there is not consensus on screening particles but there does seem to be consensus any screening and treatment discussion as an individual one between the provider and patient so i hope today's hearing can provide concrete information on the evidence based decision making process. i'm also interested to hear from the cancer community and medical providers on their next steps for outreach and patient education on the limitations of the mammography screening. thank you, mr. chairman. i yield back my time. >> thank you. i believe that concludes the opening statements by the

members of the subcommittee. so, we will now turn to our witnesses, and if our first panel would come forward i would appreciate that. thank you. we have two witnesses both from the u.s. preventive services task force to read to my left is dr. mant calonge, i hope i'm pronounced in that correctly, president of the task force, and next to him it is dr. diana petitti, petitti? petitti. who is the vice chair of the u.s. preventive service task force. now i will mention as i think you know we have five minute opening statements as they become part of the record and each of you may end the discussion of the committee submit additional statements and writing for inclusion of the

record and i would now recognize first doctor calonge. >> good morning, mr. chairman and distinguished members of the committee. on behalf of fellow task force members we thank you for the opportunity to discuss the task force at our work. our recently published recommendations on breast cancer screening after all remarkable attention. we recognize the communication of what the recommendations say was poor. and the timing of the release was unfortunate. we wish to explain the process and timeline for creating these recommendations and clarify what we intend to say. health care clinicians and scientists on the task force fully understand the personal experience impact of breast cancer on the lives of women and their families. our job is to review scientific evidence, politics played no part in our process these, costs were never considered in the considerations. we voted on these recommendations long before the last presidential election. the timing of the release of the findings last month was

determined not by us but the publication schedule of the research journal which peer reviewed. the current task force was greeted by a congressional mandate as independent body with a mission of receiving the scientific evidence or clinical preventive services and developing evidence based recommendations for the health care community. our primary audience for recommendations remains primary care conditions. the task force has 16 volunteer members representing diverse array of expertise and primary-care prevented if disciplines including adult, child, preventive and peter matthiessen, women's health, search methods. the ahrq recommends to from the public process. given the scope of topics covered some specialists will consult on or care for those identified through a screening by primary-care clinicians may not necessarily be regarded as members but instead consultant to review and comment on work at

critical points in the process. our current portfolio includes broad array of 105 clinical preventive services that are listed on the website. we strive to update topics every five years which is what prompted the new breast cancer screening recommendations. to address a topic, does it need task force working group members and scientists have an evidence based practice center collaboratively develop and analytic framework key questions. a stricter systematic review of evidence for each key question is conducted and evidence report is created with work eckert consultation. based on the evidence review and explicit methodology the work gorbachev's a recommendation statement and at an in person meeting the evidence of the draft statement are presented and discussed and the task force votes on the recommendation. there is careful attention to conflict of interest such members with the interest recused from discussion and vote or otherwise restricted and

participation. representatives of 24 partner organizations including all primary-care specialty is the key federal agencies and other key stakeholders specified in written testimony and on the website are invited to participate in the discussion. at three key points in the process work products are sent for review and comment by the partner organizations, buy sub specialty expert consultants from the relevant deceased areas such as oncologist and by other stakeholders such as sub specialty professional organizations and advocacy groups. these products include and of the framework and key questions, draft systematic evidence review and draft recommendation statement as voted on. all comments are considered in creating the final products. final recommendations statements that evidence reviews are published in peer reviewed medical journals. recommendas on two factors only. the magnitude of net benefit or balance of benefits in harm's of

providing the service and the scientific certainty about whether the service works. cost and cost effectiveness are not addressed in the deliberations and making a recommendation. over the past several years we have discussed with your cost jennifer influence a recommendation and we have repeatedly said no. for a and b recommendations there's sufficient net benefits such as primary-care conditions are recommended to provide the services for all appropriate patient spigot if there is no net benefit or met harm we assign a bdy recommendation indicating to not provide the service. if gaps in the evidence prevent the net benefit from being determined we assign the statement reflecting insufficient evidence indicating that more research is needed. finally the recommendation is assigned when there is a small net benefit. for the sea recommendations we recommend the patient be informed about the potential benefits and harms and then be supported in making his or her

own and formed twice about being tested. the specifics we recommend vision was intended for consideration by primary-care conditions. but unfortunately has played out in on the intended ways in the public interpretation of the breast cancer recommendation. congress the republic will section 915 mandates ahrq convenes the task force. the role of the ahrq is to support activities and process these at ahrq stuff and the director of ahrq do not vote or otherwise influence our decisions. i will have to add to the committee that breast cancer is of particular concern to me. i lost both my mother-in-law to breast cancer and my sister is currently undergoing therapy. i fully understand this issue and have to rely on this audience as we provide our recommendations. with that, i would like to turn the testimony over to

dr. petitti to testify specifically at the breast cancer screening recommendation. >> i'm sorry, i just wanted to thank dr. calonge. and i now ask dr. petitti to begin. >> im diana petitti, the vice chair of u.s. preventive service task force. i'm a physician and epidemiologist. i have spent my entire 32 year career as a scientist working on issues of women's health. i've published on the topic of mammography screenings. i served as vice chair of the national council policy board and i have expertise in evidence of systematic review and in offices. i participated in this process from the beginning. i would not sign off on any recommendation that i did not believe reflected the best possible use of evidence for the benefit of women. i appreciate the opportunity to clarify for members of the subcommittee the task force

recommendations and evidence and the weighting of the evidence that led to these recommendations. in specific, the task force recommends the following. women age 5374 should have mammography's every other year. the decision to start regular by annual screening mammography before the age of 50 should be an individual one and take the patient context into account including the patient values regarding specific benefits and harm. that is the task force is saying screening starting at 40 should not be automatic nor should it be denied. many doctors and women perhaps even most when it will decide to have mammography screenings starting at age 40. the task force supports those decisions. the task force acknowledges the language used to describe its secret recommendation about breast cancer screening for women 40 to 49 did not say what the task force meant to say. the task force communication was poor.

the task force is committed, really committed to improving its communication. the task force first address to the screening mammography topic in 1989 at that time the task force recommended screening women 5375 everyone to two years. with regard to screening younger women that task force stated it may be prudent to begin screening of an early age for women at high risk of breast cancer in its 1996 guide the task force recommendation was in favor of screening women 50 to 59 everyone to two years a lot of the screening for women 40 to 49 was given the siegfried. at that time c great mant in sufficient evidence. in 2000 to the task force recommended screening women 40 to 69 every one or two years, stating the benefits for smaller and it took looker to emerge for the women who were first screened in the 40's. on november 16th this is the committee knows the task force issued its updated recommendations and on breast cancer services. i wish first to clarify the

timing of issuance of these recommendations and late 2006 to discussion of a plan for updating recommendation began. the breast cancer topic canada for the review at the regularly scheduled time a network of the topics started in 2007. when the recommendation statements came up for the vote in november, 27, the members could not come to agreement about what to recommend because the agreement about what to say about the balance of benefits and harm. in this context the task force asked for additional evidence from its evidence based practicing. the task force considered this evidence at its july 14th, 15th 2000 meeting. in making its final recommendation that has force considered evidence identified in a systematic review of evidence for six key questions. the results of the analysis from the breast cancer screening consortiums and results of a study commissioned by the task force and conducted by the cancer intervention surveillance modeling at work. the systematic review identified

almost 3,000 studies and 550 of these were used to make the recommendation. the final recommendations were made based on the waning of the benefits and harms of screening mammography. the task force concluded from the evidence the screening mammography for women 40 to 64 has a benefit in reducing death due to breast cancer. the benefit is larger and older women and younger women. i would like to speak specifically to the issue of harm in this net benefit equation. preventive services are provided to a cinematic individuals for the sole purpose of preventing or delaying morbidity, delaying functional decline or postponing death. the promise of service delivery is net benefit. benefit negative harm. the benefits of mammography have been easy to communicate. the harms and potential harms have been difficult to communicate. the easily identifiable and commonly used definition of harm

is a physical injury. these physical injury direct arms are very, very small. but task force considers part of a screening test not just physical harm but psychological harm. a great deal of disagreement -- for the controversy has centered on the task force use of consideration of anxiety and psychological debt distress as a harmid a false positive test. in particular, the psychological distress has been ridiculed to understand the consequences of false positive tests, it is necessary to consider how women enter the screening cycle, what happens and what might happen to a woman who has a positive test. no matter how hard the concept of screening is explained in positive mammograms screening test means cancer until cancer is proven not to exist. for some women have a positive

test the time between a positive test and a stated there is no cancer is mercifully short. for other women to follow what involves more than one additional task perhaps clinical breast examination along with the task of a trip to the search of every perk of time it is always short and over a period of time it is unpredictable and not within the control of the woman. some women eventually need a biopsy. cancer's terrifying prospect carries special emotional weight because of the consequences of the diagnosis have in the past not only of death but the prospect of mutilating surgery. anxiety and psychological distress and women who've had positive screening tests is amply documented in the evidence. the task force wants only the screening mammograms to be done with full knowledge of these potential harms, the frequency of these arms and what is to be gained by being screened at an earlier compared with a later age. false positive tests are more

frequent other harms of mammography include ones that are less well documented, some women are diagnosed in their 40's with cancer that could have been trading just as well diagnosed leader. these women may have on necessarily be exposed to the harms of treatment including surgery, chemotherapy -- >> doctor, i didn't want to stop you because it's so important but your two minutes over, so keep going but -- >> i'm only going to say that to my final statement, mammography starting at 40 should not be automatic. the task force recommends women in their forties decide on an age to begin screening that is based on conversations with their doctor and individual. i apologize for going over. >> i'm going to apologize for trying to stop you because it's so important that you clarify a lot of these things, and i appreciate that. our procedure now is that we have questions from the members

of the panel i mean from the members of congress, and i will start with myself. let me say that have actually clarified some of the questions i was going to ask very well but i still want to kind of review this if i could in my own mind and if i say anything you disagree with, tell me. but i do want to ask you some questions as well. but look, there is a lot of myths out there that have been spread both today and certainly the last few weeks since you came out with your recommendations. and the way i understand, the current task force uses these abc ratings. these are the same kind of ratings that would be used under a different task force that's in the legislation, the larger health care reform legislation that we passed. in other words you are the u.s. preventive service task force the new task force in the bill we pass has a different name clinical preventive services.

but abc ratings are the same or similar. but right now the cdc ratings have no force. they are just recommendations. and what some of my colleagues have said is that these insurance companies now don't have to cover a b or c, they don't have to cover anything and in fact what we are getting is a lot of insurance companies right now don't cover -- don't prefer to cover any screenings because of you do a screening and have to pay for treatment it costs money which they try to avoid. and so what i see right now is that in some cases the states have required certain screenings like my own state but on the other hand we heard the gentleman from utah talk about utah, where my understanding is they don't require any screenings. so, the point i am trying to make is that the bacon advantage of the health care reform bill that we pass is that h.r. 396 will for the first time create minimum standards for required

preventative benefits. so private insurers would be required under that bill to cover surfaces with a grade a or b recommendation. right now they don't have to cover anything. what we are doing in the bill is basically saying that a minimum if you or your successor task force says this is a or b it has to be required which is it is not now. the other thing that we do in the bill was we say this as the secretary could require a c rating to covered under but the public option or private insurance plans. in fact my understanding is that the task force, i mean the secretary under the bill could even required c rating under the basic benefit package. now that is contrary to what some of my colleagues have been saying on the other side of the ogle. my whole point is to say the truth is if enacted into the

law, h.r. 3962 would result in a lot of people who are not getting mammograms, pap smear, colonoscopy is. a lot of people don't get that at all because insurance companies basically don't have to do it unless the state requires. now under this bill, they but have to do anything that you read as a or b and the secretary could even require c either in the public option were in the private plan under the basic benefit package. i mention this because the bottom line is that women's ability to continue to obtain mammograms' increases in these house and senate bills being passed. and when i look at the republican bill on the other side it sets no four whatsoever. there would be no minimum requirement benefits for insurance to provide on the republican bill essentially would be just like the status quo that we have now. so, i listen to the debate that we have had today at the bottom line is the bill that we passed

in this house provides a lot more coverage, has a lot more guarantees, the status quo doesn't provide any guarantee of the federal level nor would the republican alternative that we've been given on the other side. my question is, again, mention that when hugh recommended c, it says that it has a small net benefit and women are supposed to make their own decisions. so you have made it quite clear today that even if it is a c, there is some net benefit and the secretary could decide under the new bill to say okay that's going to be required as well so you're not in any way with the c recommendation saying that the screening is not a good thing. in fact directly say there is a net benefit by you would like individual women to make the decision with their doctors because it is only a small net benefit; is that accurate? if you explain it a little bit.

>> mr. chairman, i am going to speak to the science, and the science is that this the recommendation does mean the small benefit, and we wrap that c recommendation to advice that women make the decision with their doctors about whether or not to undergo. i think this committee is dealing with incredibly complicated issues about health reform and coverage but the task force is not a coverage and health care reform and policy committee scientists. >> but the bottom line is, and i will lead with ms. come evin would you recommend c you're saying there is a small net benefit. so, again, let's not talk about today but let's talk about if the bill we passed in the house and this committee becomes law. even then, the secretary could say there is a small net benefit and so we do want to require this as a basic benefit. , and you know, you basically leave it up to the insurance

companies to decide the way they do today. but the misinformation out there is i think even under the bill that we've passed, for once there is going to be a requirement that some of these screenings occur. if you read it as a has to be done, if you read it as a b it has begun to read if you raise it is a c the psychiatry can say it has to be done. right now there's nothing, nothing at all. and the republicans and their alternative would continue the status quo that says you don't have to cover anything. and i would appreciate because i think that you felt clarify. i yield now to the gentleman from illinois, mr. shimkus. >> thank you, mr. schramm because what we need in this country is a debate on the failed health care bill that we passed on the floor of the house. that's what we really need to do, and that's what we're doing today. and we are using obviously what

happened through your process to make the claim, the short term concern of a public auction which many of my colleagues on the other side have said is the gateway to the one payer system. so when the government controls all the health care decisions in the country, they will be eventually default to control costs through rationed care. now the process, the scientific process you just admitted to said there is a small net benefit. when there is decrease revenue available, the default will be based upon 3962 just what you say on your website. door website recommends against routine screening mammography in women aged 40 to 49. do you think that this statement would be received by younger, women younger than 50 that they

should not get a mammogram? on your website? >> we have communicated very poorly about the c recommendation. it is clear that many women, many physicians and certainly the media interpreted that language as if we were recommending against women in their 40's ever having a mammogram. that was not our intention. >> we understand, but we are concerned of commissions commissions, bureaucracy, rationed care. we are concerned about bureaucrats saying there is no real net benefits -- es, that is why pete exactly what we are concerned about and that is why we are having this debate. in the bill, chairman pallone i think adequately talked about the differences. we know that surfaces with a rating of a or b must be

included in a beneficial package. with the highest rating of c women would not receive correctly if this was law as is today women in the c category would not receive this is a covered benefit. under 3962. and that is part of our concern and discuss segue into the full health care debate that the commissioner on the part of the bill and i don't have the whole 2,000 pages. i just pulled out excerpts, the commissioners shall specify the benefits to be made available under exchange participating health benefits plans during each year. and then you can go further on. basic enhanced and premium and than the premium plus. a, approved by the commissioner. and then you can go to the c section, which was again, highlight it. and we continue to have preventive services including the services are committed with a great a or b on clinical

preventive services. so, the -- this is again, for a lot of us, an important date. to any of you know an individual who has been diagnosed for cancer between the ages of 40 to 49? personally? >> yes i know many individuals have been diagnosed with cancer -- >> dr. calonge? >> yes. >> and then the other question what about over the age of 74? >> anyone who's been diagnosed -- >> yes. >> because although we are focusing on 40 to 49 in your report, over 74 has the ai category. and we don't even know if it is. so what are we saying to those over the age of 74?

>> i speak to the evidence and the mapping of the evidence to the task force recommendations. >> i appreciate that and i fully got 38 seconds. i'm going to be comfortable on my time. part of this concern with h.r. 3962 is as we said the public option, the gateway to the one payer system. eventually a rationed care, and then the decision made based upon the financial ability of the country to fund care across the spectrum also seniors and our country. and again, this incomplete aspect for 74 speaks to the concern that if you are elderly in this country and we get to a one peer system there will be decisions made not based upon health care but on cost and i yelled back my time. >> thank you. mr. waxman, chairman waxman. >> thank you, mr. chairman.

the health care bill that the republicans are complaining about is not law. yet your agency preventive task force is an operation. this is set up under, is that set up under law? >> yes. >> and your job isn't to make recommendations to insurance companies, is it? >> that is correct. >> your job is to make recommendations on preventive services so that the latest science and information about the science is communicated to clinical practitioners; is it that your top? >> that is correct. >> and this is very useful information. now we are focused on the breast cancer issue. but that is not the only area where you have made recommendations; isn't that true? >> that is correct. >> have any other areas have the task force made recommendations the last couple of years? >> our current portfolio is 145 total and we take up around 15 new or updated topics annually.

>> you've recommended the teenagers be screened for mental illness? >> yes that was a new recommendation this year, congressman, that we just came out with, so this is new services that have not been recommended -- >> and there is a breast feeding behavioral intervention recommendation? >> that is correct. >> and you've had a recommendation that asked for the prevention of cardiovascular disease as a way to prevent the disease; is that right? >> that's correct. -- you have had a range of 103? >> 105 total. >> on hundred five total. i assume none of the others have been as controversial as this particular one. >> that is correct. >> so we have a controversy will issue because it challenges the accepted notion about the frequency of breast cancer screening, and we are going to hear all lot more about that from the next panel. but i want to have us look at the challenges being raised by some of the republicans, which i

think is all political. they are acting as if your recommendations based on bringing the scientists who have the expertise, which are directed at clinical people will be used to ration care. that is their argument. we are going to ration care. and then they say that's because there's going to be a health care bill that will provide a requirement for minimum benefits. minimum benefits that he should have access to hospitals. he should have access to doctors. he should have access to pharmaceuticals. your area is in the preventive area. and nothing can be more important to me than having the latest science on how to prevent diseases because if we can prevent illness, we won't pay to treat them leader. your task force will continue in operations. you will convene the scientists who were experts in different

areas of prevention. now, i guess the question i'm not raising this to you but the question is how will it your recommendations affect the minimum benefits that will be required for health care insurers, health care insurers can be public insurance that survives in this legislative process and certainly private insurance. right now private insurance doesn't have to abide by your recommendation; isn't that true? >> that is correct. >> some of them cover these preventive services and some of them don't; isn't that true? >> that is correct. >> it's their decision but if we are going to provide subsidies for people to get insurance and we are going to try to get a market where insurance companies compete against each other based on price and quality we ought to make sure all of them provide a least a minimum set of benefits one of the issues for republicans is to have a lot of insurance plans that don't

provide any minimum benefit at all and they can be cheaper if they don't provide minimum benefits. well, i find that troubling but let's say we will have minimal benefits and to make a recommendation. is your recommendation under the proposed bill automatically going to be in effect for all insurance? do you know whether that to be the case? >> the congressmen, not -- >> or not an expert on the bill but let me explain what the new bill will do. the new bill will take your recommendations. they will go to the secretary. the secretary will review them. the secretary will have a notice of royal and comment and a public process and then decide whether it is a minimum benefit. a minimum benefit is a minimum benefit. this isn't a maximum benefit. so if there is a recommendation as you propose on breast cancer screening, that will be not a

requirement of insurance to do no more than that. it would be a recommendation that will be required, that will require insurance companies to do that as a floor, not a ceiling. i just wanted to set this out because i think some people watching this hearing may get confused when they hear stories about bureaucrats or rationing care or the health care bill being the gateway to single-payer. we expect a bill with competition and people to make choices between insurance plans. but we don't want the choice is between insurance plans to be those who cover breast cancer screening and those who don't but those are if least the minimum of preventive services that we can hope will prevent diseases and the need for paying for care for those diseases. thank you, mr. chairman. >> thank you, chairman waxman. next is the gentleman from

texas, mr. burgess. >> thank you, mr. chairman. let me ask you a question. i have got the political guidelines, and i guess this is a reprint from the internal medicine to three of the last page of which is an appendix which lists the members of the u.s. prevented of tasks services and number of individuals are listed there. their specialties are not. is anyone on the list of a board certified ob/gyn? >> yes. there are two board certified ob/gyn on the task force. and that is -- we usually have at least two of them. >> which of those two or on the list that i have in front of me? >> kimberly gregory and wanda

nicholson. >> and they both participated in this decision? >> kimberly gregory was on the task force when this decision was voted. wanda was not. there was another ob/gyn on the task force when this was voted and that was george, a professor of ob/gyn at the university of california san francisco. >> were these anonymous votes? >> no, the votes were not unanimous. >> do we know of the individuals though to the? >> i can't require. that is in the record and we could make that information available to the committee of that is important. >> i would like to see it. i don't know of the kennedy would deem it important but i would appreciate the opportunity to see. nor is there a radiologist in this group? >> no, no there is no radiologist in this group. >> is that a problem? >> the expertise of this panel has been called in question. the experts are individuals who

have experience and screening science and prevention. radiologists were consulted and reviewed. the documents and recommendations provided input. >> let's wait until it finishes. it bothers me, too. [buzzer sounding] on thus -- on this task force than of the majority of these individuals primary care, doctors was there a general search on the board or on the task force? >> well, there again, the experts are experts in primary care and prevention and yes there were and i would have to count them, for primary-care physicians on the task force correctly and for at the time these were voted. >> was the original surgeon who specializes in the localization of breast biopsy? >> no, there wasn't. >> they were consulted. >> they were consulted? all right. i apologize for being in and

out, but we are doing negative simultaneous hearings today and the financial services make over requires some attention and thought of as well. on the issue of talking about you said you factored in the psychological event surrounding the call back on a positive mammogram. you factor in the psychological costs if you will to the patient in that exchange. do i understand that correctly? >> the issue was of qualitative assessment, anxiety, psychological distress, and convenience are all considered to be potential harms, and again it is a part of the net benefit equation. >> when i was in school back in the 1970's i realize that is a long time ago but the demographic screening was not above, that was not something

that was done. you send someone for a mammogram, it is kind of a big deal because he felt something or -- but it wasn't done as part of a routine screening in fact i don't think as i recall looking back it was probably the mid-80's when that became a standardized screening test and in fact in texas i don't know whether this is true nationwide but in texas i know women can sell for mammography. when that all happened, that psychological cost was one of the arguments that was used by people who felt that routine screening would not be a good idea. so, how is it we have come to the point now we rejected in the 1980's but now in 2009 this is a factor again that is worthy of consideration? >> again, this is not determined in its information that we want women to know about. we want them to know how common

it is. again, the false positive rate is much lower as women get older and that's part of the net risk benefit equation. we would not women to be afraid of having a mammography. this is again one piece of information that women and their physicians should discuss when deciding when to start screening. >> and does that same rationale apply to the self examination? >> the task force recommended against clinicians' teaching women breast self examination. they did not recommend that women not pay attention to their bodies, that the aid or lumps or ignore problems that might come up with the find a lump. again, the task force recommendation was against

doctors teaching women breast self examination. >> how are women supposed to get that knowledge? they can't just get it by intuition. somewhere along the line someone has got to provide them some guidelines, some proper time to do the exam and how to do it and what to be concerned about and what not to be concerned about. as i recall, i may be wrong on this but i don't recall coating and being compensated for teaching breast self exams. i wasn't a cost center i wasn't a cost driver. my only inference from that could be that you're worried people will find things that then the lead to procedures and we are better off if we don't ask, don't tell. >> again, the evidence -- there has been too well conducted randomized clinical trials in which women were taught how to do breast self examinations and

both of those trials found no overall benefit in terms of reducing mortality from breast cancer. again, we go to the evidence. >> i will say anecdotally as an liben statement -- >> mr. burgess, you are to meds over. >> it does strike me -- >> mr. burgess >> this was brought to the patient herself -- >> dr. burgess, your time is expired. >> i will be interested in what some of the other clinicians tell when they get their chance to testify. >> dr. burgess, you were almost three minutes over and we are about to vote. i think we have time for one more set of questions and we are going to vote. we have five votes. we will take one more set of questions and then adjourn and come back after the five votes. next is chairman dingell. did you want to proceed now? >> i think i will proceed rather quickly, mr. chairman comegys,

please. i would like to welcome you both to the committee and tell you how helpful it is to have you here. from the things i've heard sit on the other side of the aisle about you folks at the agency i was afraid you would appear with fornes, a tale, fangs and a red suit breathing fire demanding we immediately eliminate for the weak, sick, poor and with regards to mammograms and pap smear so i am very much comforted and want to welcome you to the committee this morning. i just have really one question that i think is important. i find it curious the task force has repeatedly over the years voted to leave cost out of its deliberations on whether to provide or not improving preventive service. why? >> thank you, congressman. this is a key question.

the task force believes from congress and responsibility to the primary care clinicians and patience is that we set the evidence based stake in the ground immune from much it costs to achieve the benefits associated with the given effective preventive service. so, -- >> so your short answer is that you were recommending the needed services, the needed tests, the needed treatments as opposed to looking at the cost; is that it? >> that's correct. >> to assist my colleagues on the other side of the aisle and i do this out of affection and respect. you address this question on your statement and you say here, and i am reading this for the benefit of my colleagues on the other side use a task force recommendations are based on consideration in the health benefits and health harms of providing the preventive service

and of scientific certainty of whether the preventive service works. cost effectiveness of specific prevention services are not addressed by the task force and its deliberation. then you say this, the task force only, and that is underlying, considers scientific evidence of health benefits and health harm. the task force has specifically discussed whether the costs should influence recommendation and was repeatedly voted to leave costs out of the deliberations on whether or not to provide preventive service. is the right? >> that is correct. >> now, when your recommendations are made are they used to put a ceiling on benefits or are they used to describe a minimum level of benefits that people should get?

>> congressman, i must admit that it's outside of the scope of our recommendations how they are used by either entities. >> now, your recommendations are not expected to be substituted for the need of the patient or the concerns and expertise of the doctor and they are not intended to intrude into the doctor-patient relationship. >> that is correct in fact if you read our statement has published it says the task force recognizes the clinical war policy decisions involved more considerations than this body of evidence alone. clinicians should understand the evidence and individualized decision making to the specific patient or situation. this actually proceeds all recommendations. it is a recommendation statement

that we expect questions to do what they are trained to do in order to address the needs of the individual patient for his or her best interest. ..

>> the task force is currently moving towards increased private citizen input with the resources we have available to consider and i can identify those. we have prior to this time done more with and put through specific groups that we invited to comment because we think they are important stakeholders. this is an issue that the task force believes that in the interest of the enhanced transparency and responsibility to the american public and patients, whose physicians may consider our recommendation needs to be improved. >> thank you mr. chairman. >> thank you chairman dingell. we have five votes. i would say about an hour but when they are done we will come back in reconvene. the committee stands in recess.

>> the subcommittee will come to order. mr. gingrey. >> mr. chairman, thank you. my first question is-- about having ob/gyn currently on the task force. i wanted to specifically ask you how many ob/gyn oncologist server on the task force? [inaudible] >> let me read to you from a

testimony we will hear from the second panel. in fact the president of the national breast cancer coalition framed this note, attorney fran visco which she states in her testimony, we want to know that the attacks against the makeup of the task force are misplaced. screening is an issue of primary care. it is a health intervention for a healthy population. the experts in this area, those with the scientific training and objectivity to do the necessary analyses are primary care health professionals and methodologist, such as epidemiologists and biostatisticians. notch radiologists or medical oncologist. and i am quoting directly from her statement which we will hear later. what is your opinion on that?

>> the task force expertise in this area of is sufficient to weigh the evidence that led to its recommendations. the recommendations are made by the task force with the input of a variety of other specialty groups. they are not made in a vacuum. in this case they were submitted to, i can't remember the number of partner organizations but it was at least ten. each of these pardon organizations sent them out to experts and those experts provided an opinion. >> and some of those experts would be cancer specialists, a female cancer specialists? so come up by that response i guess you would take exception to the comments by ms. visco bet we were hair from her later. let me ask you another question. on your web site, and either you or dr. calonge, on the web site

come a clearly states that the united states task force recommends against routine screening mammography of women aged 40 to 49 for good to you think this statement could be perceived by women younger than 50 that they should not get a mammogram? >> we need to immediately figure out how to get that statement of the web site. i think it could be misconstrued. it has been misconstrued and we need to fix our web site. >> dr. suband i thank you for that response and i hope that you will do that. i agree with you. i want to ask you dr. calonge are you aware that the senate version of health care reform specifically section 4000 four, i think it is on page 1150, requires the secretary of hhs to create a national prevention awareness campaign based on all of your taskforce hurrah's emendations, both those that you

favor, the a's and p's and those you recommend against. do you think that this national awareness campaign could be perceived by women younger than 50 that they should not get a mammogram or perform a self-examination? >> congressman i wonder if it would be okay if you restated your question because the second party did not here. >> what i am saying is, in the senate bill if it prevails the senate language in the conference report becomes law and it specifically says and i named the section, that the secretary would require the creation of a national prevention awareness campaign. television ads, tv spots based on all of the past-- tasa gore recommendations pope that you are in favor of in those you recommend against. do you think this national awareness campaign could be perceived by women younger than

50 that they should not get a mammogram nor should they perform self examinations? >> thank you for the clarification congressman. i can't speak specifically to the bill or to the policy. i will speak to the communication of the recommendation which we believe needs to focus on the decision by annual screening before the age of 50 should be in in debuckle-- individual one including the patient's values regarding specific arms and so that message which i realize is preceded by the recommends against the statesman is one we feel communication needs to be improved and that clear message of what the task force intended needs to leave that. >> thank you doctor. mr. chairman if you will bear with me for 15 seconds i have one other point i want to make. the united states preventive services task force concludes the current evidence is insufficient to assess the

additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. that is saying that you don't recommend that the clinician, a physician, primary care physician, ob/gyn specialists should routinely do a breast examination as part of a complete physical in his or her patients, that that has no value? >> the evidence does not provide support for clinician doing a clinical breast exam. >> i think what that response and your honesty mr. chairman i know i have gone beyond my time and i appreciate that that is terrible and something needs to be done about that. >> next is our vice chair, the gentlewoman from california, ms. capps. >> thank you mr. chairman. i just want to say thank you for both of you for being here for

your excellent testimony and for being among the few capitol hill who apologized occasionally and it is not a habit that we do as well so the fact that i would not call it an apology as much as it millage jing the communication which is that occurred and for me, i think it was a lot of being timing. but i don't take it as in negative thing. i think we are seen as a very positive overall experience happening in our country. not to minimize the confusion that many women experience but i think we can use it as the teachable moment. let's put it that way. the timing of the release of the report and the debate on health care reform has been seized by many to want to be tracked from the health care legislation to use your testimony and widely misconstrued ways and i want to

take a minute of my time to mention one very important distinction but it is also an important point of what the health care reform bill is. which actually will be augmenting a lot of the preventive work that you are doing because women will be able to have an occasion to understand more about cancer prevention and its wider forms and their behaviors and their body changes which are all essential part of the essential benefits package and the exchange consists of 11 benefit categories including inpatient hospital services as examples, outpatients and as well as preventive services, but with regard to preventive services the bill says the recommended items and services with a grade of a or b from the task force shall be covered as part of the essential benefits practice. a rifle designation of the importance of your studies and your recommendations but, not a

conclusive piece of it. that this be something which we highly recommend that there be no cost-sharing for this great a and b of your recommendations. ebenefits advisory committee, part of the health reform will be able to recommend to its public standards setting process that additional preventive services such as mammograms for women under 40 be covered without cost-sharing. there is an additional recommendation that can come as part of the health care bill. this secretary may also approve such coverage. the essential thing here is that the benefits package, is essential benefits package is a floor, not the ceiling and that is important i want the record to state that very clearly. once the exchange goes into effect and there is real competition between private insurance plans, they may wish to offer more attractive

packages to win more coverages, so that it may well be understood more fully as we go along and i just want to make sure that be in the record. i wanted to give you even more opportunity, both of you or one of you, to talk about what could the future hold. you see i think this is an opportunity, a wild moment is one of the advocate groups but it's and i want to commend all of the breast cancer advocacy groups who have brought as to a level in this country were when a recommendation, set of recommendations like yours comes out there is a more intelligent audience receiving it, able to understand it and able to use it in abdicate even more in a wide range of ways which i think it's very healthy for our country to be a part of. i am only giving you about a minute but i would like you to

elaborate further on ways that your task force can communicate in the future in ways that maybe we can access and use more efficiently. >> well, what i thought what happened with these recommendations is that it would move the discussion more towards the notion of individualized decisionmaking. what i thought might initiate a dialogue where we decided to work harder and finding out who really is at higher risk so we could make more tailored recommendations for screening and among those groups we really have ignored our african-american women. and women of ashkenazi jewish background, some who have a high risk-based strictly on their membership in this group. again what i thought would happen would be a move towards individualized tailored risk decision-making and not the sort of rehashing of a bunch of old data.

>> mr. calonge would you like to add anything to that and i know i am squeezing a few more seconds. i think this is really important. >> i want to echo the issue about individualized decisionmaking. we hear a lot about personalize medicine and i think the basis of personalized medicine can be and should be individualize based decision-making and it is really what we were hoping the language for the younger age group would start engendering, this issue about we as consumers of health care should kind of understand and that every test we have and every treatment we have has both the inherent risks and benefits and we should make our decisions based on understanding those and what is important to us. >> that underscores the value of the work you do in this topic and in every other topic and the importance of having educated in the areas of health population

that can seized the material as well as primary care providers and other doctors who use your information every single day to make the kinds of informed decisions that they and their patients need to have before them so i hope this can be the beginning. i again want to thank our chairman. this is the kind of setting, this hearing setting that is so important for us to take it been a judge then use your expertise and your research and have this kind of the bate if you will, the discussion so i thank you again for your being here. >> thank you. mr. rogers. >> thank you for being here and i have some quick yes or no questions. were you familiar with the references to your task force in the bill introduced in july? >> no. >> so, you knew nothing about the over a dozen references to

your task force in this bill? >> you know, i hate to say but i was busy preparing the course and biostatistics and the answer is honestly, no. >> is that consistent to the whole task force or any of its representatives or administration there of? >> i hesitate to have the two of us represent the opinions of the entire task force. >> but it wasn't part of your discussions? >> in july? absolutely not. >> are you aware in this particular bill and the chairman emeritus was mistaken. this was not necessarily a new committee. they may have created a new name but in the bill and i will just reread from the bill. the preventative services task force convened under section 915 of the public health service act and the community preventive services and as subsection task forces were in existence the day

before the enactment of this act shall be transferred to the task force and clinical preventive services and the task force on community preventative and then it goes on to say whatever your recommendations were prior to that enactment are in effect. are you aware of that, sir or maam? >> certainly-- >> yes or no. i am sorry. >> yes. we were aware of that. >> were you aware that during our deliberations? >> no. >> would that change deliberation at all? >> i cannot speculate on what might happen. >> interesting. so what you are saying is according to the love which this committee wants to enact you have now taken ages 40 to 49 and made them a category c which means they will not be paid for under this committee. you say you did not consider cost. is every appendix attached to your task force recommendation,

is that something that would then review by the individuals who would make the determination? is that something of value and that is why do you attached as an appendix i imagine? >> all of the material and evidence is germane. >> are you familiar with appendix c1, that assigns a dollar value by quality of years of life. are you familiar with this? is clearly is a cost effectiveness portion of your study. clearly you cannot tell this committee you did not consider cost because you just told me every piece of information according to your study is considered. this is a dollar value and the non-mammography screening. would you remove this from a task force study as well as your recommendation? >> i am sorry but i am trying to see what you are pointing at. >> appendix c. mac one of your own task force recommendation that clearly considers cost just by your own testimony and again you can see why the women of

america and those of us who are very concerned about bureaucracies interacting between health care on your web site again. comment you say that you recommend against using screening and you say you are going to take that off. you say we did not consider costs but on your own report it said you consider cost. you can see why after creating 118 brand new commissions just like yours all of your authority will now be enacted into law according to their own bill by the reference i have just read. that is pretty serious and let me ask you another question. as a part of this it says and i'm going to read this again from the bill because i think some of my members on the other side either have not read the bill or maybe misunderstand their own language but this is the indian health care section, section 206 that i would encourage you to read on mammography and other cancer screening. the secretary shall ensure that screening provided for under

this paragraph complies, meaning you have got to do it, with the recommendations of the task force with respect to a frequency, the b population to be served in c the technology to be used all of which is referenced in your report. imagine when this passes your report now becomes a matter of law according to their own language in this bill right here. would that change your consideration as a scientist knowing by your own testimony it did not pass unanimously? you say sites in evidence but clearly people equally as learned as both of you believe that that was the wrong answer? is this something you should reconsider? >> mr. rogers-- >> i would like an answer. >> i am going to ask you to go beyond that. you have used your five minutes. you can take what time is necessary to respond because i'm not sure you even know what the questions are. >> there were a number of

different questions and i am not sure which one to respond to. what i would like to say and i want to say it again on the record that when we voted the recommendations for mammography screening ab kinsey mac we regard it without cost effectiveness analysis. i can say honestly absolutely the word caused was not in the room. it was not mentioned. it was not uttered and it did not in any way determine-- >> but it was part of your study. was it not? you just told me everything in your study was considered, appendix c1 considered cost. >> mr. rogers' time is up but you can respond and say what you want. >> i have nothing more to say. >> mr. rogers i am just trying to make sure she is able to respond but i think we should move on and we are a minute over and she does not want to say anything else. >> my lai costin here is-- i do

believe the intention of the other side is real id believe that but the language of the bill which i believe most members of congress have not read-- >> she has repeatedly said, she did not even know was in the bill and their deliberations were done under the previous administration the for president obama was even president of the united states. >> mr. chairman the point is she did save the cost was not part of their voting but it certainly was part of their steady. that is very important-- >> you made your statement and she responded to it. let's move on but i can't help but repeat that their deliberations as i said even preceded the current administration but whatever. let's move on. next on the democratic side is the gentlewoman from the virgin islands, ms. christensen.

your mic is not working there? >> it is on now, right? thank you for your presentations and your answers thus far. i want to go back to the issue of african-american women. some years ago many of us worked to ensure that mammograms would be recommended and covered for women of african descent under age 40. and, given that even though we may have lower breast cancer incidence we are more than likely to be diagnosed and have a higher mortality rate and even in younger women, we find that younger african-american women

are more likely to be diagnosed with breast cancer. so in the recommendations why wouldn't the task force single out this particular group and maybe give them a different recommendation rabid then lumping all women between 40 and 49 or younger under c or i? >> you make an excellent point, and i think again what i expected to happen with these recommendations is that we would begin to focus on how to make more stratified and new ones recommendations that would identify those groups who are on recognized as being at high risk of consequences of breast cancer. >> so even though the bill says that your recommendations would be applied comment you might look at the native american population as a group and decide

maybe a different grade for different age groups and that particular age group and make that recommendation. might that not happened? >> i think the accompanying editorial to our recommendations pointed in the direction that we thought we would be going. we are not in congress-- congress trying to defend the but moving to the point where we have more individualized risk and i would say that based on my understanding of the science, which i followed very closely, that breast cancer in young african-american women is a topic which is not widely appreciated as being one which perhaps needs a different kind of recommendation. again, we need to do better at their risk stratification and individualized risk. i can say the task force will immediately be able to go back.

>> i understand that you recognize it and this is not the final answer. >> this is definitely not the final answer. i think people wish that we may have not ever open this topic up again after 2002. >> especially not now. >> that was an accident. >> in response to the article and the press taking it up and how it has been interpreted, have you looked at other ways of presenting recommendations that might be controversial? i have never really liked the fact that the press gives these to advance notices then they start to tell us what is coming up in the next medical journal because they don't really understand. >> we communicated very poorly. we should have spent more time talking with our stakeholder groups. we should it have a formal communication plan both to our consumers in physicians. >> i agree. can you explain how the over

diagnosis is a bit confusing. can you explain how over diagnosis occurs when early stage lesions especially a young girl individual is diagnosed and treated because my understanding on the dcis is likely a precursor to invasive cancer. is the task force saying it might be better to not diagnose it dorothy think it is there to leave alone and not to further investigation or remove it? because i would think and anxiety is one of the issues that you raise. i think it would be more anxiety provoking to think i had an in situ or in early, stage cancer and sit and wait on it rather than to have it biopsy been removed? >> here we are definitely getting way out of my range of expertise. this is a topic which i would want to have addressed by a medical oncologist, and those

who are now working so hard to understand better how we separate and differentiate those tumors that are going to progress rapidly and those tumors that are not but this is outside my area of expertise. >> speaking to a surgical oncologist actually yesterday bayfield that these many times are a precursor to invasive cancer and i am surprised it is listed as one of those things that maybe we are over diagnosing or overtreating but i think my time is up so thank you for your answers. >> the gentleman from arizona, mr. shadegg. >> thank you mr. chairman. first i have to express sympathy for you. you stepped into a controversy which has been made much larger because of the overall health care smoking for the and i think to a certain degree you have been socked into a much larger battle than your own efforts to try to make recommendations would have otherwise merited osi

understand your recommendation you base it on science and you say look here is what we have concluded based on that science. which should be automatic for kodak to be something you think truant here are our recommendations. i presume from that that he believed that it should be a decision between the patient and her doctor and that for example if a patient, a particular patient had a history of cancer or breast cancer, then you might get screening at the younger age or categories where you did not believe should be automatic, but under those circumstances it should occur, is that correct? >> yes, that is correct. >> you would then agree with me that if the government were to prohibit an insurance plan from providing coverage for someone who after consulting with their doctor or looking at their family history thought she needed it, that would mean it is not an censurably that, correct? >> i am not here to get involved

in the coverage and the health care reform coverage issue. >> fair enough. i will just then stay for the record that in my view the government should never prohibit someone and the government should never be able to prohibit someone from offering mammogram coverage or as an insurance company or a public plan nor should it be able to prohibit an individual woman or her family from deciding they want to purchase mammogram coverage and i am deeply troubled that this bill, which seems to be the larger context into which your work has been reported, does precisely that. i do want to say it is important mr. chairman that facts, and unfortunately in a piece of legislation this size is subject to interpretation and it is subject to quick review without people being very precise in their language. i want to make it very clear, i

mean no personal offense but there ben thing stated in this event that are flat untrue. for example the chairman said if they c option, you have your a, your b and now your c is determined by the secretary to be covered it is to be covered. that is just flat not true. the only way a c option can be covered under the language of this bill is for two things that happen. for the health care benefits adviser recommitting hess to say contrary to what the bill says we think should be covered and then the secretary has to say it so it is not a single decision by the secretary. second and i am sorry that he is not here but the chairman of the full committee came and made in adamat argument which is then repeated several times here today that the bill prescribes minimum benefits and therefore to say that coverage of mammograms is not prohibited as untruth, that all the bill does

is prescribe minimum is. that also is flat not true. if you go to page 169 of the bill passed by the congress you will discover as i mentioned earlier that there are four levels of plans. there is a basic plan and an enhanced plan, a premium plan n/a premium plus plan. the basic plan can only cover a's and p's. it could cover a c of the two exceptions i just pointed out were to occur but the basic plan as of those two things happening this not cover anything but a's in p's. but more important than that the definition of an enhanced plan and the definition of a premium plan, both for habit additional benefits. they say you could have been enhanced plan and you can have lower costs. you can have a premium plan and a lower cost learning but it can only cover the basic services

though all three of the first levels of plants are prohibited from covering any service other than an a or a b. only until you get the definition of the premium plus plan and i would point to the chairman of the full committee, page 169, lines 2325 tepid save premium plus plan is a premium plan that also provide additional benefits. that is the only plant that can provide a benefit beyond the basic plan and therefore the first three levels of plants are prohibited from covering mammograms by law insurance company. they are prohibited and that may not be the intent as the ranking member mr. bart made very clear, we need to deal with what the bill says and if it does not reflect our intent and i would hope in this case it doesn't

because i don't think the government ought to be in the business of telling people you cannot buy coverage for mammograms but we need to fix the language of the bill or at least talk truthfully and the gentleman of the full committee was wrong when he said this said his only minimum. there are words at the beginning of the bill which referred to minimums but the words of the bill specifically say can only cover those items with the exception of when both the secretary and the health benefits adviser recommitting decide to cover a c and i appreciate the opportunity to put that in the record. thank you mr. chairman. >> thank you. i don't want to keep belaboring the point that the reason i responded to your statement and said that the worst situation is where the secretary and now you are saying it fisa read that you could add to a basic benefit package was because in your opening statement you stated it

could not be done that way, that you could not do it. i don't want to disagree with you but you are disagreeing with yourself. >> if the gentleman would deal. i actually did not say they could not add it. i said the basic plan cannot offer and it cannot offer it absent extraordinary circumstances which are to other things. >> i think-- you see. we are probably saying the same thing but i am not going to get into it. i don't think there's any difference between what you said and what i said. >> let's agree on that but let's agree to fix it so the bill does not say someone can choose to buy a plan and for that matter let's allow people to get mammogram coverage. >> i'm not willing to continue to belabor it because i think we are not necessarily disagreeing on whether it could or could not be included. the next person is the gentleman

from florida, ms. castor. >> thank you mr. chairman and thank you very much for your testimony today. i believe the larger issue is the lack of access to any screening or health service for millions of american women of all ages and i would like you to comment upon the implications on the millions of women who are not being screened at all. what do you say to them, no matter their age? >> you know, again the task force can't fix these problems. i am here as a member of the taskforce speaking to mammography guidelines in speaking to the evidence we used to make them. they are clearly huge issues facing this country about health care and health insurance and health policy but i'm not an

expert in that area. >> at fica just add to the point that it is clear that the provision of mammography, screening for breast cancer extends life. and so that is the service that we recommend, and i think everyone in the room knows that and needs to keep in mind that if the idea is to maximize held to extend life than the services that are recommended should be considered for provision. >> i mean, your recommendations talk about how for example the age 4249 how it is important for women and their doctors to have a personalized plan with their trusted physician but there are many, many women out there who don't have they trusted physician. they don't have-- they are not

receiving their check-ups. certainly you all have something to say to women all across america and no matter their age, and being as proactive best they can end taking personal responsibility. you must have something to say on five-year risk groups to help us communicate in a better way. you have already acknowledged that you did not do a good job in communication but here's your chance today to bring all of your expertise and to provide a message to women on the importance of taking personal responsibility and getting insurance. they may not have access to care but there are wonderful nonprofit groups, where they provide some services in communities. can you at least go that far and provide a proactive message to women in this country on the

importance of taking care of themselves and seeking out these things? >> again, i feel uncomfortable in being asked to put on a personal, a personal that rather than my task force that. i would be remiss if i didn't encourage women to be interested in their health, to take care of themselves but i am here is a member of the task force to speak to the mammography guideline recommendations and not to go beyond my expertise. i have friends who have no insurance. my daughter is uninsured. i know women who are uninsured and can't get surgery's they need but that is thought my role here. my role here is to speak to mammography guidelines. >> you are familiar with the huge disparities in screening diagnosis and treatment among

various income levels and if you are african-american, you are latina, correct,? >> there are disparities in health care throughout all services. >> if you could go back, or will you go back and review your recommendations along the lines of high-risk groups? what we know in disparities of screening diagnosis and treatment, don't you think you could have done a better job in fleshing out some of those recommendations? >> i think on many levels we know we could have done a better job and among them is the communication. we have tried for a number of years to make our recommendations more risks stratified. for breast cancer this has been

perhaps a little more difficult than for some other topics like osteoporosis but again what i thought would happen with these recommendations is we would start having exactly this kind of discussion. how do we find women who wore at extremely high risk, how do we communicate with them effectively, how do we make screening mammography something that is more individualized and tailored? >> i would only add to that a plea or a consideration of research where of preventive services in these specific populations who are underrepresented in screening and other prevention studies. we often fail in this area and i will inform the committee that we have a discussion about health disparities associated with nearly every recommendation votes and the frustration on our

point is the lack of evidence of efficacy in a specific trialed ame debt high risk populations. so, i think this is a consideration of the task force and as we are evidence-based, this is a real plea on our part for researchers and funders of research to consider adequate studies that include disparate groups for where we are concerned there may be differences and require different recommendations. >> the gentlewomen complete? alright, thanks. the gentlewoman from tennessee, ms. blackburn. >> thank you mr. chairman.

i guess you are not women speaking a little bit more quickly and being a little bit more since then so maybe that is why we have time left, many times. i want to thank you all for your patience in your inference today and i really want to thank you for being here. this is an issue that is of tremendous concern to us and as we look at what your findings were, and as we look to the language of the bills that are before us i think what we want to make certain we do is, if there is pending language in the bill we want to get it alton the course we want to make certain we have a clear understanding of what you brought forward end of your intent and i am going to try to be succinct on this because i do know you are ready to move on and we have another panel. dr. burgess ask that you submit the votes from your committee as you will arrive did your finding and your guidance that he made

public. as you submit that float, who voted and how, one thing i would like for you to do for the record is also submit to u.s. your science or evidence upon which you placed these recommendations. what was refute? what studies, what findings, what groups? if we could have that as part of the record so that we could look at it, i think that would be a very instructive to what as we decide how to best move forward so i would like to ask you all to do that. i would also like to know what period of time, how long did you spend on this? how long was this up for discussion and under refute? what was the process and the matrix you worked from to come to this decision? let us see a little bit about why do you went through and how you went through it and how you

worked, what your process is. how you arrived at those decisions. i do honestly believe that be helpful to us with an understanding. i will have to say teel i agree with some of my colleagues, you probably stepped into a bit of a quagmire it that you did not expect as you released these findings. and i would like to ask you, were you all aware of how the h.r. 3962, how it would affect you, how your task force would be drawn into that bill, that the language of 3962 actually polls u.n. and renamed celia and then gives credence to these findings through statutes her? >> well, as unbelievable let it is it may seem to those who are so caught up in washington, i was writing my by a statistic lectures and have been actually,

woefully and naively oblivious to what has been going on in the health care reform are rina. certainly from the point of view of specific statutory language in this that what i know it's the 2,000 page bill, i knew nothing and quite honestly when i found out that these recommendations were being released the week of the vote, that is the big boat, i was sort of stunned and also terrified. i think my being terrified was actually the right reaction. >> dr. calonge. >> i would like to add again speaking specifically to the timeline for the consideration of this recommendation that it was completed prior to any sense that the role of the task force might change under the upcoming health care reform. i will say that earlier this year we became aware of language

in the house bill regarding the recommendations of the task force. however this recommendation was considered, done with our explicit scientific methods well before then. >> i appreciate that and, i do thank you all for your sensitivities to this. i think the linkage that exist with the language of changing your title and then giving credence and the force of law basically to the priority assignments he would make is of concern to us and to our constituents. i thank you all and i'm only going to yield back 18 seconds but i yield that back mr. chairman. >> thank you. i am sorry. the gentleman from ohio, mr. space. >> thank you mr. chairman. just so i understand this correctly, the task force has been charged with developing a

scientifically determined floor for preventative services in this bill. is that your understanding of your role? >> you know i am realizing that i really don't understand the bill so i should not speak to the bill. >> the bill itself does in fact that's that kind of power to develop a scientifically determined floor, in other words a minimum threshold under the basic coverage. those recommendations then follow to the benefits advisory committee. your recommendations will establish a floor under which the benefits of speiser rhee committee cannot go. they canville hizer however. once the benefits adviser rhee committee, and the benefits and the advisory committee consists of dennis, and representatives

of relevant government agencies and is chaired by the surgeon general. once it issues its recommendations, those recommendations then are the floor. the secretary then has the discretion to increase or enhance the coverage available in the basic essential benefits package. once that has been established private insurers have the additional option of offering more coverage. so the suggestion that because your task force has issued the recommendations that it has, no insurance policies will cover mammograms for women in these categories or even the suggestion that the essential benefits package as established by this bill will not cover them is preposterous. there is no truth in it. i do have a specific question i would like to ask you regarding some confusion that your

findings have created at home in my district. there was a recent letter to the editor, a widely distributed, regarding your findings that have created some confusion and i would ask that you try to clear this up for us. the author of this letter rights, this is a quote, what is most troubling about the federal panel's recommendations is that they are based mainly on cost saving end of quote. she also expresses concern that the recommendations are quote cost-saving measures, end of quote. can you tell us today in no uncertain terms what the role of costs mammograms have played in your investigation and findings? >> this is an easy question. caused played no role in our recommendations. and again, and i've said it publicly in other settings and i

will say again here. i think i have said it three times here, cost was not a consideration in the recommendation. >> thank you and finally the author of that same letter pointed out that the task force contains quote no cancer specialists, and that quote. this is obviously a point that will be disconcerting to many. is it true that no members of the preventative task force have any experience working with cancer? >> that is incorrect. members of the task force consists of myself. i was the vice chair for the national cancer policy board. one member is-- another current member is a professor, let's see he is the associate director of population sciences for the

dartmouth hitchcock comprehensive cancer center and in dad share of in college he. again, the members of the task force have the expertise that permits them to make the kinds of recommendations they made within the rina of screening and preventive services. >> thank you doctor. i yield back my time. >> thank you. the gentleman from texas, mr. green. >> thank you chairman and that will be as quick as i can. i want to welcome our doctors. i guess having served on the subcommittee for 12 years now, and the release from the esp t.f. probably got more coverage than anything our subcommittee has done other than the health care bill and there was a lot of misinformation about it but in your testimony you say individuals representing the views of the national college of obstetricians and gynecologists and the american family of

physicians weight in on your recommendations and expressed concerns with the wording of the recommendations. do you believe in the future would be a good idea for the task force to actually have individual organizations such as these as actual reviewers instead of commenters? >> well, i want to clarify that there were official review words. first of all there were two gynecologist on the panel. they were official-- ricci words were official review words. they mated number of comments. one of their comments which was the most substantive comment in retrospect was about the, there anticipation of misperception of our c recommendation then they were right, and we should have listened more carefully to them and i am sure we will listen more carefully in the future. >> i think there was

misinformation i guess on the self-exam. the information in from your testimony earlier, that physicians need to be able to provide this expertise so women can do the self-exam. it is not perfect. if there is a question then they ought to talk to their physician and that is where it goes from there so that is why i don't understand the fear of the self-exam. my last question is a major concern i have is a lack of transparency in the process within the usps t.f. for deciding whether not to changer create new screening recommendations and depending on what happens with the health care bill your initial decision could make a big difference. hobgood the task force be more open to outside input and feedback and what changes would be making the future after what you have learned from this experience? >> thank you for this question. the task force understands the criticisms regarding transparency as our profile has

been increased during the discussion of health care reform. we believe it is incumbent upon us to increase our transparency. in such a way that people understand, as previous congress, and asked how we get to the decisions that we get to. the task force is already working on new transparency approaches including allowing internet based public comment on different work products. we think that is a good step. we are cautiously trying to expand into areas of trying to-- transparency to include potentially public commentary during meetings and other approaches that we believe meets the intent and the requirement for transparency so that the decisions are made in such a way that we are not spending time in front of the public trying to help people understand the

processes so we understand this criticism. we actually started working on enhancing transparency about a year-and-a-half ago and i will only tell the congressman ours low working has to do with understanding the resourced impact of becoming more transparent but we absolutely believe we need to do it and we are working towards that end. >> thank you. thank you mr. chairman. >> thank you and i think that concludes our questions but let me just thank you both really. i think that you did a tremendous job of clearing up a lot of misunderstandings, and as someone who has been in politics i guess i could say my entire life, i think it is kind of refreshing to find out that you know you really where independent and not aware at all of what we were doing. i think we give ourselves too much importance. we all think we are so important

and everybody is paying so much attention to everything we do. it is kind of refreshen to know that you were not. thank you and i will ask the next panel to come forward. let me welcome our second panel and introduce the panel, the beginning on my left is dr. peter orszag who is chief medical officer for the american cancer society, and next is jennifer lou rhee, who is president of the susan g. komen for the cure advocacy alliance and then we have dr. donnan

petitti of the clinical assessment efficacy committee and finally fran ned calonge who is president of the national breast cancer coalition. i know some of you that in here before and thank you for being here. you know i won't repeat that, we ask you to keep your comments it decanted five minutes. they will become part of the record and if you want to you can submit additional comments later but let's start with dr. orszag. >> could after mcminn mr. chairman. i am the chief medical officer of the american cancer society. on behalf of the 11 million patient's and survivors in america today this society think as you for your continued leadership in your commitment to enacting health care reform legislation this year. i appreciate the opportunity to