Prevention Matters

A new study commissioned by Partnership for Prevention finds that too little attention is paid to improving the delivery of clinical preventive services to adolescents by addressing problems unique to that population. The review article in the American Journal of Preventive Medicine also finds that most of the clinical preventable services that are recommended for adolescents  don’t have good evidence to support their effectiveness.

Among the unique problems:
• The time typically allocated for routine adolescent exams is quite short and is unlikely to be extended, given Medicaid’s recent reductions in preventive visit reimbursements relative to other services.
• Many clinicians feel that adolescents are less likely to heed their recommendations because they believe adolescents are less interested in their long-term health than adults and more likely to engage in risk behaviors.
• Delivery of clinical services to adolescents tends to be driven by tradition, expert opinion, and the very limited needs of particular required preventive visits (e.g., school or sports physicals)

“We need to encourage both more clinical effectiveness research on clinical preventive services for adolescents and changes in the ways medical practices serving adolescents approach improving delivery rates,” said Leif I. Solberg, MD, the study’s chief author who is Associate Medical Director for Care Improvement Research, HealthPartners Medical Group. “It’s important that healthcare providers use every medical encounter, not just ‘well-child visits,’ which not all adolescents receive regularly, to address their clinical preventive services needs.”

U.S. health plans "appear to be getting the message" that they should offer free tests to encourage prevention, but they aren't rushing to embrace a proposed government mandate of first-dollar coverage of clinical preventive services.

Phil Galewitz of Kaiser Health News talked to insurance officials to get their take on first-dollar coverage.

"Aetna, one of the nation’s largest insurers, this year began introducing health plans for small employers that charge patients no co-pays for preventive care such as routine physicals, vision and gynecological exams, and well-child visits," Galewitz wrote.

"The company says it is pricing that new plan the same or nearly the same as what the existing plans would have cost, although it has increased co-pays on certain other benefits.

"Aetna spokesman Mohit Ghose on Friday said the company strongly supports efforts to promote prevention in health reform. He declined to say whether the company would support a government mandate eliminating copayments for preventive services.

"America’s Health Insurance Plans, the industry’s top lobbying group, opposes the mandate, said spokesman Robert Zirkelbach. He cited the need to give insurers flexibility in designing benefit packages.

"Wellpoint, the largest Blue Cross and Blue Shield company, said it sees the benefit for waiving cost sharing but doesn’t want the government mandate.

“'Many of WellPoint’s affiliated health plans’ benefits already offer preventive services with no co-pay or deductible as we feel these are important services,' said spokeswoman Cheryl Leamon. 'We also believe it is important for our members and others to have the choice in the type of health plan and benefits that fit their needs.'”

President Obama recently cited "no cost sharing for preventive services" as one of eight protections he wanted a health reform bill to provide.

The bills currently working their way through Senate and House committees all mandate Medicaid coverage of clinical preventive services. The House Energy and Commerce Committee last week approved an amendment by Rep. Lois Capps, D-Calif., that would prohibit cost-sharing for clinical preventive services provided to Medicaid patients.

The House Energy and Commerce Committee on Friday unanimously approved an amendment to health reform legislation that would prohibit cost-sharing to Medicaid patients for recommended clinical preventive services. The amendment by Rep. Lois Capps, D-Calif., was supported by Partnership for Prevention, the American College of Preventive Medicine, the American Heart Association, and the Trust for America’s Health.

“This amendment will make it easier for some of the poorest and most underserved Americans to obtain services that will help keep them healthy, instead of waiting for expensive treatment once they get sick,” said Partnership for Prevention President Robert J. Gould, PhD. “These services are currently under-utilized, and cost-sharing requirements would put them out of reach for many families.”

Capps’ amendment would eliminate cost-sharing requirements for Medicaid clinical preventive services that have been recommended by the U.S. Preventive Services Task Force (USPSTF). The USPSTF reviews scientific evidence on clinical preventive services and rates them according to their effectiveness.

“Congresswoman Capps’ knowledge of these issues has been honed by her years of service as a public health nurse,” Gould said. “The American people are indeed fortunate to have a leader like her who understands that real health reform starts with prevention, and that prevention saves much more than money.”

A report by Partnership for Prevention's National Commission on Prevention Priorities was cited in a column in the July 23 New York Times as proof of the value of preventive services.

Dr. Pauline W. Chen said the study showed prevention has value beyond cost-efficiency calculations.

"Last fall, the National Commission on Prevention Priorities found that by increasing just five preventive services, clinicians could save more than 100,000 lives per year," Chen wrote. "These services include breast cancer screening in women 40 and older, flu immunizations in adults 50 and over, colorectal cancer screening in adults 50 and over, smoking cessation counseling, and a daily aspirin in high risk cardiovascular patients."

As Congress tackles health reform, a new public education campaign by Partnership for Prevention notes that more than 100,000 lives could be saved every year by investing in five basic preventive services. That includes 45,000 deaths that would be prevented each year if people who could benefit were advised by their doctors to take a daily dose of aspirin to prevent heart disease and 42,000 lives that could be saved a year if doctors offered tobacco cessation counseling.

A print ad in Roll Call, a popular Capitol Hill newspaper, this week asks members of Congress - “If You Could Save 100,000 Lives, Would You Do It?” It spells out how increasing the widespread use of just five services available through a doctor’s office – aspirin counseling, tobacco cessation counseling, adult influenza immunization, colorectal screening, and breast cancer screening - would save an estimated 117,600 additional lives a year.

More information is available online at www.prevent.org/healthreform . Partnership has also launched a "How to Save 100,000 Lives" interactive quiz for Facebook at http://tinyurl.com/100kquiz.

"Impending health care reform could take advantage of the extensive medical services system, at little additional cost, to accomplish many previously unattainable health goals for the nation. We could eliminate causes of disease and offer protection to all citizens," Anthony Robbins and Phyllis Freeman, co-editors of the Journal of Public Health Policy, noted recently in The Pump Handle. "Repeated references to “access to prevention services,” however, belie a failure to understand the difference between insuring personal health services and assuring public health gains. The distinction is a strategic one."

The pair resurrected a piece they authored for the Journal back in 1994 in the midst of Hillary Clinton's health care initiative. The piece spelled out specific steps for having the medical care system contribute to protecting the health of the population, more than just treating people seeking care. Those steps were 1) detecting problems in patients that may provide early warning of health threats to others in the community and reporting these to public health authorities for investigation; 2) acting on public health alerts–based on studies of harmful exposures in the environment– to target preventive, diagnostic, and therapeutic services to members of the population at risk; and 3) being part of systematic efforts to assure that every patient receives services of high public health value, such a vaccination, even if the patient is not sufficiently aware of the risks and benefits to seek these services.

"If our new President and the Congress accept the pervasive perception that universal access to medical services will address all important health needs, our nation will miss a magnificent opportunity to prevent disease and to hold off unnecessary medical care expenditures," they write in 2009. "Moreover, if Congress and the President do not get it right now, the door of political opportunity may not open for many years for a second chance."

Partnership for Prevention's Chairman today urged Congress to increase and stabilize resources for the U.S. Task Force on Community Preventive Services.

"...The Task Force on Community Preventive Services, supported by CDC staff, has had erratic and consistently insufficient funding. It has only been able to cover a minority of the possibly effective community policies and programs, and it has had virtually no funding to disseminate its findings," Jonathan Fielding, MD, MPH, testified before the Senate Subcommittee on Health, Education, Labor and Pensions.

Fielding, who is Director and Health Officer at the Los Angeles County Department of Public Health, also serves as the chairman of the community preventive services task force. He said the clinical services group "has been more comprehensive because it has a clearly delineated domain (clinical medicine) and has had a sustained, although inadequate, funding base." He urged more funding for both groups. While Fielding didn't specify a funding source, the $2.35 billion in CDC funding proposed in the House's version of the economic stimulus bill could be one possible source.

Fielding also echoed Partnership's recommendation that Congress enact legislation identifying a specific source and a specific annual amount for the sustained funding of core public health activities at the state and local levels. Using tobacco control as an example, he said many state and local health departments "have no sustained funding, and almost none have sufficient funding to implement the recommendations of the Centers for Disease Control and Prevention."