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Editorial | Less Is More

Can We Stop Ordering Prostate-Specific Antigen Screening Tests?

Mitchell H. Katz, MD
JAMA Intern Med. 2013;173(10):847-848. doi:10.1001/jamainternmed.2013.1164.
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I run the second largest safety-net system in the United States. As is true of all safety-net systems in the United States, we have a finite budget; overwhelmingly, our patients are uninsured or publicly insured, so we cannot raise our rates to pay for emerging populations and treatments. Instead, I see our mission as trying to provide the best health care we can for the available funding (highest value).

Few would disagree with the mission of providing the highest-value health care possible. Unfortunately, the consensus dissipates when a particular practice is targeted for elimination because it provides little or no value. Such is the state of the prostate-specific antigen (PSA) test for prostate cancer screening. Although the US Preventive Services Task Force (USPSTF) recommended against its use for men 75 years or older in 20081 and in 2012 concluded that there is insufficient evidence to recommend routine screening for anyone,2 the test is still being ordered every day in every health care system including mine, reimbursed not only by private insurance but by public insurance (Medicare and Medicaid) and scarce county health dollars for the uninsured. Why is this? If the test is so unhelpful, why are we not able to devote the money to higher-value care?

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