[Skip to Navigation]
Editor's Note
January 14, 2019

The Case for Implementing the Centers for Medicare & Medicaid Services’ Shared Decision-Making Mandate: Where the Rubber Meets the Code

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco School of Medicine, San Francisco
  • 2Editor, JAMA Internal Medicine
JAMA Intern Med. 2019;179(5):718-719. doi:10.1001/jamainternmed.2018.6440

In 2014, the US Preventive Services Task Force gave lung cancer screening a grade B recommendation, largely based on the National Lung Screening Trial. The Medicare Evidence Development & Coverage Advisory Committee evidence review found a low likelihood that benefits would exceed harms for low-dose computed tomography for lung cancer screening in the Medicare population. To provide coverage of this screening for Medicare beneficiaries (privately insured persons would be covered as mandated by the grade B US Preventive Services Task Force recommendation) despite the lack of data showing net benefit, the Centers for Medicare & Medicaid Services required a shared decision-making visit before lung cancer screening. Previous work has shown that shared decision-making visits are happening rarely in the privately insured population and that the conversations that are occurring about lung cancer screening are woefully inadequate and do not discuss harms.1 In this issue, Goodwin and colleagues2 add to our knowledge of lung cancer screening by showing that the majority of Medicare beneficiaries are also not having the mandated shared decision-making visit before they undergo a computed tomographic scan for lung cancer screening. Furthermore, of the people who have a shared decision-making visit and presumably learn of the harms and benefits, approximately 40% opt not to have lung cancer screening. The high percentage of patients choosing not to undergo lung cancer screening after an informed discussion is consistent with the findings of the Veterans Health Administration trial of lung cancer screening.3 It is likely that patients’ decisions not to undergo low-dose computed tomography for lung cancer screening are driven by the high false-positive rate, high chance of incidental findings and subsequent need for invasive procedures, and small chance of benefit—the same concerns that led the Medicare Evidence Development & Coverage Advisory Committee to its vote. These data suggest that the current use of resources for lung cancer screening should be reexamined and efforts should be refocused on smoking cessation and smoking prevention to prevent lung cancer and improve health.

Add or change institution
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words