sign in sign up
<<
Home , Health care, Health care reform, Health policy

MATHEMATICA POLICYISSUE RESEARCH BRIEF

TIMELY INFORMATION FROM MATHEMATICA Improving public well-being by conducting high quality, objective research and surveys

MAY 2010 REFORMING CARE ABOUT THIS SERIES NUMBER 2 This brief is the second in a series highlighting issues Encouraging Appropriate Use related to reform that policymakers of Preventive Health Services may want to consider as they implement the federal health reform law. The list of forthcoming titles by Jill Bernstein, Deborah Chollet, and G. Gregory Peterson is on page 4. For more information, contact Deborah Chollet at [email protected]. Federal health reform focuses on expanding the use of preventive care including screening to identify identified 13 vaccines (such as those for hepatitis B potential medical conditions, counseling, immuniza- and , mumps, and rubella) for which the tions, and to prevent illness. Evidence health benefits outweigh any associated risks for strongly indicates that preventive services can sub- children, adults, or both.4, 5 stantially improve health outcomes. However, some services can do more harm than good when provided The USPSTF has also identified 29 preventive to populations at low risk of developing a particular services for which the risks, such as or . Some preventive services can reduce health physical harm from invasive screening processes, are care costs, but many do not, and some can increase believed to outweigh the benefits for particular popu- health care costs over a lifetime. This brief summarizes lations. For example, it recommends against routine the evidence on the benefits ovarian screening for asymptomatic women, and cost-effectiveness of preventive health services, because a high rate of false-positive results can lead and points out significant new opportunities under unnecessarily to further tests or procedures with 6, 7 health reform to improve access to preventive care. serious complications. The USPSTF has identified many other services for which evidence of net health benefits is insufficient to make any recommendation.8, 9 Net Health Benefits Differ

Like all health care, preventive services entail Cost-Effectiveness Varies both benefits and risks to consumers. The U.S. Preventive services have intuitive appeal: if a disease Preventive Services Task Force (USPSTF) recom- can be detected early or prevented altogether, the cost mends 35 clinical preventive services, many of them of treating it can be reduced or eliminated. However, only for particular populations for whom empirical relatively few services have been shown to reduce evidence shows benefits of preventive care outweigh- lifetime total health care costs.10 ing risks.1, 2 For example, it strongly recommends screening for colorectal cancer for adults between The National Commission on Prevention Priorities ages 50 and 75, based on compelling evidence that reviewed 21 services that the USPSTF recommended appropriate screening, testing, and treatment can through December 2004 and four immunizations decrease the incidence of colon cancer and associated recommended by ACIP.11, 12 Of these, it found five death rates.3 Similarly, the Advisory Committee services, including tobacco-use screening and child- on Immunization Practices (ACIP), of the Centers hood immunizations, that reduced costs.13 The other 16 for Disease Control and Prevention (CDC), has services increased costs.14 Many preventive services are WHY MIGHT PREVENTIVE SERVICES RAISE COSTS? program design can affect whether con- sumers use preventive services. Cost sharing (includ- Preventive services might increase health care ing deductibles, coinsurance, or ) reduces costs for the following reasons: the likelihood services will be used. For this reason, • If relatively few people are likely to contract has minimized or eliminated cost sharing a disease, the costs of screening for that for some services including influenza immuniza- disease can outweigh the cost of caring for tion, blood tests for cardiovascular screening, and those who would become ill. screening. Similarly, employer-sponsored • Some interventions targeted at personal insurance (including high-deductible plans) often behavior (such as intensive diet counseling) cover preventive services before enrollees reach their may not change behavior enough to offset deductibles.24 However, neither private insurance nor the costs of the intervention.15 Medicare benefits systematically reflect the USPSTF • Better health care helps people with serious recommendations—in particular, some preventive chronic illnesses (especially the elderly) services that are not evidence-based or efficiently to live longer and accumulate more health targeted may be covered.25 care expenses.16 Considerations for Policymakers

The Protection and (P.L. cost-effective, however—providing good value, mea- 111-148), or ACA, focuses on expanding the use of sured as improvements in health per dollar spent— preventive services in private insurance plans, Medi- even when they do not reduce lifetime total cost.17, 18 care, and . With respect to private insurance coverage of preventive services, it requires group Efforts that combine targeted access to preventive health plans to cover without cost sharing at least the services with more comprehensive programs to following preventive services, effective in 2010: improve may yield significant cost savings. For example, by one estimate, investing • Evidence-based items or services that the USPSTF in well designed, community-based disease preven- recommends (with an “A” or “B” rating), as well as tion programs throughout the country could yield breast cancer screening (including mammography) a national rate of return of at least 500 percent over and prevention26 19 five years. • Immunizations for particular populations, as recom- mended by ACIP Use Depends on Coverage and Cost Sharing • Evidence-based preventive care and screenings for People with are more likely than infants, children, adolescents, and women, as indi- those without to obtain preventive services in a cated in the comprehensive guidelines supported by timely manner.20 For example: the Health Resources and Services Administration

• Insured people are four times more likely to have ACA expands Medicare coverage of preventive their blood pressure checked regularly than people services as well. As of January 1, 2011, Medicare who are uninsured.21 will cover an initial and periodic health risk assess- ment and development of a personalized prevention • Insured women are 17 times more likely to receive plan without cost sharing. These services will include mammograms than woman who are uninsured.21 updating a beneficiary’s medical history, inventorying • Insured people are much more likely to be screened providers and suppliers regularly involved in providing for different types of cancer and, as a result, are more a beneficiary’s care (including a list of all prescribed 22 likely to have their cancer diagnosed in earlier stages. medications), furnishing personalized health advice, However, many people do not use preventive services and providing appropriate referrals to health educa- at recommended rates, even when they are insured. tion or preventive counseling services or programs Nationally, Americans use preventive services at aimed at reducing identified risk factors and improving about half the recommended rate.23 self-management. In addition, the law will eliminate 2 cost sharing for an annual wellness visit and all other • Charging the secretary of the U.S. Department preventive services Medicare covers. of Health and with developing a national public-private partnership for prevention ACA also seeks to improve access to preventive and outreach and education. This services for adults and children enrolled in Medicaid.27 initiative will include a national media campaign; As of 2013, state Medicaid programs that cover the development of a website; and communication with preventive services and vaccines required of private providers to disseminate -based informa- plans will have their federal medical assistance per- tion on health promotion and disease prevention, centage enhanced by one percentage point for those including , exercise, , expenditures. By October 2010, Medicaid coverage obesity reduction, and disease screening. for pregnant women will include comprehensive tobacco cessation services—including applicable • Calling for a five-year national public education prescription drugs without cost sharing. campaign focused on preventive oral health care and education and establishing grants to demon- ACA authorizes significant grant funding for states that strate the effectiveness of evidence-based disease implement evidence-based local or statewide programs management activities in preventing dental caries. to encourage Medicaid beneficiaries to stop smoking; control their weight, cholesterol, or blood pressure; State and Local Leadership or avoid or manage diabetes. Additional funding is available for the development of school-based health ACA recognizes the ongoing roles of state and local centers offering comprehensive services, leaders in a number of ways. First, it significantly especially those serving large numbers of children eli- expands the number of low-income adults eligible gible for Medicaid or the Children’s Health Insurance for coverage and provides additional Medicaid Program (CHIP). payments to states that expand coverage for pre- ventive services. These provisions present new Emphasis on Evidence opportunities for states to prevent and more effec- tively manage chronic illness in this population. ACA promotes the ongoing development and dis- For example, states might monitor whether enrolled semination of science-based information about the adults actually receive effective preventive care and development and use of appropriate preventive identify problems that contribute to disparities in services by: access to preventive services and vaccines, particularly • Establishing a national Prevention, Health Promotion, in underserved communities. and Council composed of cabinet- Second, ACA creates new partnerships with states and level agency officials to provide federal leadership communities to prevent illness and improve population with respect to prevention, wellness, and health health. For example, it requires the national Preven- promotion practices; the public ; and tion, Health Promotion, and Public Health Council to integrative health care in the . establish processes to obtain continual public input • Establishing an independent Preventive Services from the states, regional and local leadership commu- Task Force to review the scientific evidence nities, and other relevant stakeholders. Third, as part related to the effectiveness, appropriateness, and of the national prevention and health promotion out- cost-effectiveness of clinical preventive services; reach and education campaign, each state will design develop recommendations for the health care com- a public awareness campaign to educate Medicaid munity; and update previous clinical preventive enrollees about the availability and coverage of recommendations related to specific populations services aimed at reducing the incidence of obesity. and age groups. Finally, the availability of grant funds to develop • Developing the role of the independent Community school-based will challenge state and local Preventive Services Task Force at CDC in reviewing policymakers to identify neighborhoods and com- scientific evidence about the effectiveness, appro- munities where children are underserved and work priateness, and cost effectiveness of community creatively with school programs to improve the delivery preventive interventions.28 of primary and preventive care to these children. 3 OTHER TITLES IN SERIES Cancer: Brief Evidence Update. Rockville, MD: AHRQ, 2003. 8Services in this category include some that may provide net ben- • How Does Insurance Coverage Improve efits, but because rigorous evaluation has not been conducted Health Outcomes? or completed, the net benefits have not been quantified. 9U.S. Preventive Services Task Force 2009; and Salinsky 2005. 10Cohen, J., and P. Neumann. The Cost Savings and Cost-Effec- Forthcoming Titles: tiveness of Clinical Preventive Care. Research Synthesis Report • Basing Health Care on Empirical Evidence No. 18. Princeton, NJ: Robert Wood Johnson Foundation, 2009; Congressional Budget Office. Letter to Representa- • Medical Homes: Will They Improve tive Nathan Deal. August 7, 2009. Available at [http:// Primary Care? www.cbo.gov]; Cohen J., P. Neumann, and M. Weinstein. “Does Preventive Care Save Money? Health • Disease Management: Does It Work? and the Presidential Candidates.” The New England Journal of , vol. 358, no. 7, 2008, pp. 661–663; and Maciosek, • Financial Incentives for Health Care Providers M.V., A.B. Coffield, N.M. Edwards, T.J. Flottemesch, M.J. and Consumers Goodman, and L.I. Solberg. “Priorities Among Effec- tive Clinical Preventive Services: Results of a Systematic Go to www.mathematica-mpr.com/health/series.asp Review and Analysis.” American Journal of Preventive Medicine, to access briefs in this series. vol. 31, no. 1, July 2006, pp. 52–61. 11The National Commission on Prevention Priorities, estab- lished by the Partnership for Prevention, is a 24-member Mathematica® is a registered trademark of Mathematica Research, Inc. panel of decision makers from health insurance plans, employer groups, academia, clinical practice, and govern- ment health agencies. Partnership for Prevention is a Notes: membership organization of businesses, nonprofit organi- zations, and agencies advancing and 1Housed at the Agency for Healthcare Research and Qual- practices to prevent disease. ity (AHRQ), the USPSTF is the most prominent panel 12Maciosek et al. 2006. of experts in prevention and primary care in the United 13The other three services are the discussion of using aspirin States. The agency conducts rigorous, impartial assess- to prevent cardiovascular events for men over age 40 and ments of scientific evidence for the effectiveness of a women over age 50, pneumococcal immunization, and broad range of clinical preventive services, including vision screening for adults. screening, counseling, and preventive medications. 14Maciosek et al. 2006. 2U.S. Preventive Services Task Force. The Guide to Clinical 15Ibid. Preventive Services. Rockville, MD: AHRQ, 2009; and Agency 16An analysis of Medicare data based on a sample of about for Healthcare Research and Quality. “Electronic Preven- 100,000 beneficiaries found that interventions to reduce tive Services Selector (ePSS).” Available at [http://epss. and diabetes among the elderly—interven- ahrq.gov/ePSS/]. tions that are cost-effective—did not reduce health care 3Among all , colorectal cancer ranks third in inci- spending overall. Interventions to reduce obesity, however, dence (52 cases per 100,000 people) and second in cause were found to result in overall savings. See Goldman, D., of cancer deaths for both men and women. Screening D. Cutler, B. Shang, and G. Joyce. “The Value of Elderly enables to detect colon cancer at early stages Disease Prevention.” Forum for and Policy, and remove polyps before they become life threatening. vol. 9, no. 2, 2006, p. 1. See Agency for Healthcare Research and Quality. Screening 17For example, 15 of 24 preventive services recommended by for Colorectal Cancer: An Updated . Rockville, the USPSTF cost less than $35,000 per quality-adjusted life MD: AHRQ, 2008. year, or QALY—a measure of disease burden that takes 4ACIP is an independent panel of 15 immunization experts into account both the quality and quantity of life years that provides recommendations to the U.S. Department of (Maciosek et al. 2006). Many common treatments for exist- Health and Humans Services on routine administration ing illnesses cost more than $35,000 per QALY (Cohen et. of vaccines to children and adults. al. 2008). Cost-benefit analyses commonly use $75,000 per 5Centers for Disease Control and Prevention. “Recom- QALY as a cutoff point for determining whether a mended Immunization Schedule for Persons Aged 0 is cost effective (Salinsky 2006). Through 16 Years—United States 2010.” Morbidity and Mor- 18Goetzel, R. “Do Prevention or Treatment Services Save tality Weekly Report, vol. 58, no. 51-52, January 2010. Avail- Money? The Wrong Debate.” Health Affairs, vol. 28, no. able at [http://www.cdc.gov/mmwr/preview/mmwrhtml/ 1, January/February 2009, pp. 37–41; and Woolf, S.H. mm5851a6.htm]; Centers for Disease Control and Preven- “A Closer Look at the Economic Argument for Disease tion. “Recommended Adult Immunization Schedule— Prevention.” JAMA, vol. 301, no. 5, February 2009, pp. United States 2010.” Morbidity and Mortality Weekly Report, 536–538. See also Health Systems Change. “The Dol- vol. 59, no. 01, January 2010. Available at [http://www.cdc. lars and Sense of Prevention: A Primer for gov/mmwr/preview/mmwrhtml/mm5901a5.htm]; Sal- Makers.” Washington, DC: HSC, June 8, 2009. Available at insky, E. “Clinical Preventive Services: When Is the Juice [http://www.hschange.org/CONTENT/1066/#1]. Worth the Squeeze?” National Health Policy Forum Issue 19Levi, J., L. Segal, and C. Juliano. Prevention for a Healthier Brief 806, August 24, 2005, pp. 1–30. America: Investments in Disease Prevention Yield Significant Sav- 6Although screening can correctly identify ovarian cancer at ings. Washington, DC: Trust for America’s Health, 2008. early stages, it often falsely identifies women as having the 20Institute of Medicine. Coverage Matters: Insurance and Health disease (U.S. Preventive Services Task Force 2009). Care. Washington, DC: Institute of Medicine, 2001; Powell- 7U.S. Preventive Services Task Force 2009; Salinsky 2005; and Griner, E., J. Bolen, and S. Bland. “Health Care Coverage U.S. Preventive Services Task Force. Screening for Ovarian and Use of Preventive Services Among the Near Elderly

4 in the United States.” American Journal of Public Health, vol. clinical services will be covered as optional benefits, and 89, no. 6, June 1999, pp. 882–886; and Sudano, J.J., Jr., and these determinations vary. For example, in 2009, 39 states D.W. Baker. “Intermittent Lack of Health Insurance Cov- covered cholesterol tests for men ages 35–64 with risk erage and Use of Preventive Services.” American Journal of factors for heart disease, and 43 covered diabetes screening Public Health, vol. 93, no. 1, January 2003, pp. 130–137. for adults ages 21–64 with high blood pressure. See U.S. 21DeVoe, J.E., G.E. Fryer, R. Phillips, and L. Green. “Receipt Government Office. Medicaid Preventive Ser- of Preventive Care Among Adults: Insurance Status and vices: Concerted Efforts Needed to Ensure Beneficiaries Receive Ser- Usual Source of Care.” American Journal of Public Health, vices. GAO-09-578. Washington, DC: GAO, August 2009. vol. 93, no. 5, May 2003, pp. 786–791. Available at [http://www.gao.gov/new.items/d09578.pdf]. 22Ward, E., M. Halpern, N. Schrag, V. Cokkinides, C. DeSan- 28The task force recommendations will be published in its tis, P. Bandi, R. Siegel, A. Stewart, and A. Jemal. “Asso- Guide to Community Preventive Services, which is intended ciation of Insurance with Cancer Care Utilization and to assist primary care professionals, medical groups, and Outcomes.” CA: A Cancer Journal for , vol. 58, no. organizations—such as health care systems, employers, 1, January/February 2008, pp. 9–31. professional or community organizations, schools, public 23McGlynn, E.A., S.M. Asch, J. Adams, J. Keesey, J. Hicks, health agencies, and Indian tribes and tribal organiza- A. DeCristofaro, and E.A. Kerr. “The Quality of Health tions—that deliver population-based services. The Guide Care Delivered to Adults in the United States.” The New to Community Preventive Services is available at [http://www. England Journal of Medicine, vol. 348, no. 26, June 26, 2003, thecommunityguide.org/index.html]. pp. 2635–2645. 24Henry J. Kaiser Family Foundation and Health Research and Education Trust. Employer Health Benefits 2007 Annual ABOUT THE AUTHORS Survey. Chicago: KFF and HRET, 2007. 25 Salinsky 2005. Jill Bernstein consults with private- and public- 26The USPSTF grades its recommendations according to one of five classifications reflecting the strength of evidence sector organizations on matters related to health and magnitude of net benefit (benefits minus harms). An insurance coverage, health care cost and quality, “A” rating indicates services that the USPSTF strongly recommends—that is, for which there is good evidence and access to care. She holds a Ph.D. in sociology that they improve important health outcomes and that ben- from Columbia University. efits substantially outweigh harms. A “B” rating indicates services that the USPSTF recommends that clinicians pro- Deborah Chollet, a senior fellow at Mathematica, vide to eligible —that is, for which there is at least conducts and manages research on private health fair evidence that it improves important health outcomes and that benefits outweigh harms. For other services (with insurance coverage, markets, competition, and a C, D, or I rating) the USPSTF makes no recommenda- . She has a Ph.D. in economics from tion or recommends against clinicians routinely providing the services. See U.S. Preventive Services Task Force. Task the Maxwell School of Citizenship and Public Force Ratings. Available at [http://www.ncbi.nlm.nih.gov/ Affairs at Syracuse University. bookshelf/br.fcgi?book=hscps3edrec&part=A27000]. 27Federal law requires coverage of some preventive and G. Gregory Peterson, a research analyst at screening services for children enrolled in state Medicaid programs, generally a battery of services that include Mathematica, focuses on issues related to well-child checkups to identify health and development accountable care organizations, , problems as well as immunizations, blood pressure and and improving for Medicare benefi- cholesterol screening, nutrition counseling, lab tests, and other diagnostic tests. Although federal law does not ciaries. He has an M.P.A. in from generally require Medicaid programs to provide preventive Princeton University. services to adults, states can determine whether and which

Visit our website at www.mathematica-mpr.com

Princeton, NJ • Ann Arbor, MI • Cambridge, MA • Chicago, IL • Oakland, CA • Washington, DC

5