Free Preventive Services - Will Free Make A Big Enough Difference?

Provision in the PPACA Law

A provision in the Patient Protection and Affordable Care Act (PPACA) requires insurance plans to provide coverage for preventive health services without cost-sharing for:

• Services recommended by the US Preventive Services Task Force
• Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC
• Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration
• Preventive care and screenings for women supported by the Health Resources and Services Administration

New Rules

In July, the Internal Revenue Service (IRS), the Employee Benefits Security Administration (DOL) and the Department of Health and Human Services issued 40 pages of interim final rules regarding the implementation of the preventive services provision of the PPACA.  The new rules take effect when an insurance plan begins a new plan year after September 23, 2010.  Here is the link to the new rules: http://www.healthcare.gov/center/regulations/prevention/regs.html

Group and individual insurance plans covered by these rules must offer comprehensive coverage for a range of preventive services without imposing any cost- sharing requirements.  Specifically, the preventive services include:

• Evidence-based preventive services: Preventive services with a letter grade of A or B as determined by the U.S. Preventive Services Task Force which ranks preventive services on the basis of the strength of the scientific evidence documenting their benefits. Preventive services like cancer screenings, screening for vitamin deficiencies during pregnancy, screenings for diabetes, high cholesterol and high blood pressure, and tobacco cessation counseling will be covered under these rules.
• Routine vaccines: Health plans will cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices ranging from routine childhood immunizations to periodic tetanus shots for adults
• Prevention for children: Health plans will cover preventive care for children recommended under the Bright Futures guidelines, developed by the Health Resources and Services Administration with the American Academy of Pediatrics.  The types of services that will be covered include regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight.
• Prevention for women: Health plans will cover preventive care provided to women under both the Task Force recommendations and new guidelines being developed by doctors, nurses, and scientists, which are expected to be issued by August 1, 2011.More information about the preventive services provisions can be found here: http://www.healthcare.gov/law/provisions/preventive/index.html

Extending Benefits

According to the Healthcare.gov Website [1], the new preventive services regulations will extend prevention benefits up to 88 Million Americans.  This estimate is based on an estimated 31 million people in new employer plans and 10 million people in new individual plans benefiting from the new rules. By 2013, the number of individuals in employer plans who will benefit from the prevention provisions is expected to rise to 78 million, for a total potential of 88 million Americans whose prevention coverage will improve due to the new rules.  According to the Website, many of the 98 million people already in group health plans that are expected to be “grandfathered” under the provisions of the PPACA [2], already have preventive services coverage.

Costs

The Healthare.gov Website estimates the effect of the preventive services rule on health insurance premiums to be, on average, an approximate 1.5 % increase to premium costs.   It is anticipated that this additional cost will be more than offset by significant out-of-pocket savings for Americans who currently have no or limited coverage for preventive services, or their coverage is subject to co-insurance, deductibles, or co-pays.  Therefore, the new rules could provide significant savings for Americans who are in need of and who could benefit most from preventive services.

Proven Benefits

The proven benefits of preventive services encompass three areas:

1. Improving people’s health
2. Employee productivity
3. Health care costs

• Improved health: One study found that effective delivery of just five preventive services –colorectal and breast cancer screening, flu vaccines, and counseling on smoking cessation and regular aspirin use – could avert 100,000 deaths each year.[3]  In addition, effective cancer screening and early and sustained treatment could reduce the cancer death rate by 29 %.[4]
• Greater employee productivity: The increased use of preventive services will hopefully impact the 69 million workers who report missing work days each year due to illness, resulting in an economic output reduction of $260 billion per year.[5]

Reduced health care costs: A review of 25 clinical preventive services by the National Commission on Prevention Priorities found that, “Health outcomes in the U.S. could be improved at less expense if the health care system, clinicians, and patients gave priority to services that were most beneficial and offered the greatest value.” [6]  Zhou, et al found that “regardless of the perspective, the current routine childhood immunization schedule results in substantial cost savings.” [7

Barriers to Achieving Preventive Benefits

Unfortunately, just removing financial barriers may not be enough to significantly increase utilization.  Employee Benefit News in Brief recently reported on a Midwest Business Group on Health employer survey regarding preventive care services.  According to the survey results reported, “Employers state that the top barriers to get employees to use preventive benefits are a lack of understanding of their value (88%), no motivation to get healthy (56%), and difficulty taking time during the work day (47%). [8]

In 2008, I reviewed the prevention literature in preparation for a presentation I delivered on Linking Prevention, Benefits and Wellness. I found barriers could be attributed to three different causes: financial, knowledge and utilization.

A number of the studies showed that the use of preventive services was sensitive to the type of payment mechanism used.  Removing financial barriers to preventive care is an important and significant step to increasing utilization levels. A number of research studies have noted that many people do not take advantage of preventive care services because of the associated costs.

An interesting note about costs is that the Rand Health Insurance Experiment found that the use of preventive care remained lower than the recommended level even when the care was free. [9]  The Insure Project on Lifecycle Preventive Health Services found that even when physicians were paid to provide preventive care on a negotiated fee, utilization rates averaged only 30 – 40%. [10]

The knowledge barrier involves the individual, the employer and the healthcare provider.  For the employer, the barriers include knowledge of the preventive services available and how to incorporate them into their health plan design, though this barrier will now be somewhat offset by the PPACA law and rule.

The individual faces a number of knowledge barriers including: knowing what benefits are available through their insurance policy, the need for service, the benefits associated with receiving the available preventive services, fears or concerns about the preventive services and forgetting that they are due for a service.

Knowledge barriers for healthcare providers include: knowledge of available preventive services, not knowing all the preventive benefits their patient’s plan covers, not being comfortable with providing patient counseling or coaching services and not enough time due to patient scheduling to adequately address preventive services.

Utilization barriers include both undercare and overcare. Undercare results from:

poor access, lack of awareness and the provision of the wrong type of service too briefly, too infrequently, too late or some combination thereof.  Overcare results from: provision of the wrong type of services or the provision of too many services for too long, too frequently, too early or some combination thereof.

Conclusion

While the PPACA law and rule might remove the financial barriers, the other identified barriers will remain in place.  With just the financial barriers removed, it will be interesting to watch and see how utilization of preventive services changes, if at all.  As new insurance plan years begin and the rule takes effect, employers, wellness professionals and public health officials are being presented with a significant opportunity to raise awareness and to educate individuals about preventive services and their value to the individual, the employer, the healthcare system and to society as a whole.

References:

[1] HealthCare.gov. Available electronically at: http://www.healthcare.gov/index.html. Accessed: August 19, 2010.

[2} More information about the definition of a grandfathered plan can be found at: http://www.healthreform.gov/newsroom/keeping_the_health_plan_you_have.html.

[3] Woolf, S.  A Closer Look at the Economic Argument for Disease Prevention. JAMA 2009; 301(5):536-538.

[4] Curry, S.J., Byers, T. and Hewitt, M., eds. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: National Academies Press. 2003.

[5] Davis, K. Collins, S.R., Doty, M.M. Ho, A., and Holmgren, A.L., Health and Productivity Among U.S. Workers. The Commonwealth Fund, August 2005.

[6] Priorities for America’s Health: Capitalizing on Life-Saving, Cost-Effective Preventive Services. Executive Summary. Partnership for Prevention. Available electronically at: http://www.prevent.org/data/files/initiatives/prioritiesforamericashealthexecutivesummary.pdf. Accessed: August 20, 2010.

[7] Zhou, F et al. Economic Evaluation of the 7-Vaccine Routine Childhood Immunization Schedule in the United States. Archives of Pediatric and Adolescent Medicine 2005; 159(12): 1136-1144.

[8] Employers Stand Behind Preventive Care at the Worksite. Employee Benefit News in Brief, By the Numbers Blog, August 23, 2010. Available electronically at: http://ebn.benefitnews.com/blog/bythenumbers/. Accessed: August 24, 2010.

[9] Information about the Rand Health Insurance Experiment can be found at: http://www.rand.org/health/projects/hie/

[10] Logsdon, Donald. Rosen, Matthew and Demak, Michele. The INSURE Project on Lifecycle Preventive Health Services. Public Health Reports, July-August1982, 97 (4): 308 – 317.

About The Author

William McPeck, MSW, CWWPC, WLCP, is currently Director of Employee Health and Safety for Maine State Government.  Bill also serves as Chairman of the Maine Leadership Group on Worksite Wellness.  Bill is nationally certified as a Worksite Wellness Program Consultant, Work-Life Professional, Holistic Stress Management Trainer, Wellness Inventory Coach and Retirement Preparation Coach.  Available for trainings, consulting and coaching, Bill can be reached at:

williammcpeck@gmail.com.