A Purchaser s Guide to Clinical Preventive Services: Moving Science into Coverage

1. A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage Council on Employee Health and Productivity (CEHP) 12/1/2006

2. Speakers Ronald Finch, EdD; National Business Group on Health Kathryn Phillips Campbell, MPH; National Business Group on Health Richard Dixon, MD, FACP; Centers for Disease Control and Prevention Andy Lanza, MPH, MSW; Centers for Disease Control and Prevention

3. Background Business Group is committed to prevention and health promotion Existing prevention-related toolkits Consumer-driven Healthcare for Children and Adolescents Improving Health. Improving Business Reducing Child & Adolescent Obesity

4. What is Prevention?

5. Types of Prevention Primary prevention Immunizations Aspirin therapy Secondary prevention Hypertension treatment Mammography Tertiary prevention Medical foods for children with PKU Osteoporosis treatment

6. Evidence-Based Preventive Services Abdominal Aortic Aneurysm, Screening Alcohol Misuse, Screening and counseling Aspirin Therapy for the Prevention of Cardiovascular Disease, Counseling Breast CancerScreening, counseling, testing, preventive treatment, preventive medication Cervical Cancer, Screening Childhood Health Promotion Child Development, Screening Dental Caries, Preventive medication Immunizations Lead, Elevated Blood Level, Screening Newborn Screening for Genetic and Endocrine Disorders, Screening, medical foods, and treatment Newborn Hearing, Screening Vision, Screening Colorectal Cancer, Screening Contraceptive Use, Counseling and preventive intervention Depression, Screening Diabetes (type 2), Screening Healthy Diet, Counseling Healthy Pregnancy Alcohol Misuse, Screening and counseling Asymptomatic Bacteriuria, Screening Breastfeeding, Counseling Folic Acid Supplementation, Counseling and preventive medication Group B Streptococcal Disease (GBS), Screening and preventive medication Hepatitis B Virus (HBV), Screening, immunization, and treatment Human Immunodeficiency Virus (HIV), Screening, counseling, and preventive medication Influenza, Immunization Preeclampsia, Screening Prenatal Diagnosis of Chromosomal Abnormalities and Neural Tube Defects (NTDs), Screening and testing Rh (D) Incompatibility, Screening and preventive medication Rubella, Screening Syphilis, Screening Tetanus, Immunization Tobacco Use Treatment, Screening and counseling Hypertension, Screening, counseling, and treatment Immunizations (Child, Adolescent, Adult) Lipid Disorders, Screening, counseling, and treatment Motor Vehicle-Related Injury Prevention, Counseling Obesity, Screening, counseling, and treatment Osteoporosis, Screening and treatment Sexually Transmitted Infections (STIs) Counseling to Prevent STIs, Counseling Chlamydia, Screening Gonorrhea, Screening Human Immunodeficiency Virus (HIV), Screening and counseling Syphilis, Screening Tobacco Use Treatment, Screening, counseling, and treatment Tuberculosis, Screening

9. Why Prevention?

10. Rethinking Current Approaches

11. Economic Burden of Preventable Health Problems At the population level……. Tobacco Use Direct medical and lost productivity costs exceeded $167 billion per year between 1997 and 2001.1 Cardiovascular Diseases Indirect costs will total over $145 billion in 2006.2 At the individual level……. Emergency surgery for AAA (major risk factor is smoking) costs $50,000.3 Cost of treatment for all conditions with MI diagnosis (heart attack) = $45,076 per discharge.4

12. The Value of Prevention Multiple ways to determine the “value” of a preventive service Objective Subjective “Value” is determined by the service’s ability to prevent illness and death in relation to the cost of providing the service Real (monetary) and opportunity costs

13. The Value of Prevention Clinical preventive services avert healthcare costs by Reducing beneficiary health risks Preventing disease and injury Catching disease early, when treatment is most effective and least expensive Short-term and long-term cost benefits Most clinical preventive services are cost-effective; some are cost-saving

14. The Value of Prevention Cost-saving: intervention is effective and costs less in the long run than the cost of not intervening Cost-effective: intervention provides a health benefit at an acceptable cost High-value: intervention prevents a significant amount of illness and death and is cost-effective Quality-adjusted life year (QALY) Common currency that permits comparison among different people and across conditions

16. Other Benefits of Prevention Complete value assessment needs to include other factors Productivity Decreased absenteeism Decreased presenteeism Engagement of workforce and employee loyalty Recruitment and retention Resource allocation Community-health (i.e., reduced transmission of communicable diseases)

17. Changing Paradigms to Support Health and Promote Prevention

18. Traditional Approach The human body is the most complex machine on earth and it does not come with a service manual1 Employers devote substantial resources to required or recommended preventive maintenance on a wide variety of corporate assets, but choose to wait until employees become broken and then spend vast company funds on repair2

19. Wellness - How Does It Impact Employees and Family Members?

20. Changing the Business Paradigm Preventive services are necessary for improving productivity and controlling labor costs for employers Function: Change focus from absenteeism to performance

21. Changing the Healthcare Model Care Model: From “Treatment Focused” to “Prevention and Behavior Change Focus” Medical Model: From “Individual” to “Population” Interventions: From “Single-Risk Focused” to “Multiple-Risks Focused” Health Framework: From “Employer-, Condition, and Program-Centric” to “Employee-Centric”

22. Changing the Metrics Cost Metrics: From Medical Costs to Economic Outcome Health Metrics: From “Disease Status” to “Health Status” Management Systems: From “Separated Programs” to “Integrated Systems

23. Current State of Coverage Among Employer-Sponsored Plans

25. Employer Coverage of Clinical Preventive Services Survey completed by 2,180 employers in 2001 90% all employers listed “increased productivity” and “reduced healthcare costs” as prime reasons for offering clinical preventive services 49% require health plans to cover preventive services 21% offer employees financial incentives

26. Coverage Among Large (500+) Employers Coverage of physical exams, screening, and immunizations generally exceeded 50% but coverage of lifestyle modification services averaged less than 20%. Healthy behavior counseling services most poorly covered: Healthy diet -21% Weight loss -18% Alcohol misuse - 19% Comprehensive tobacco treatment benefits – 4%

27. Coverage Unknowns How many employers cover “new” preventive services? HPV vaccine Tamoxifen therapy Genetic testing How many employers provide comprehensive coverage based on evidence? Case-examples aren’t promising: only 4% cover comprehensive tobacco treatment benefits

28. The Evidence for Clinical Preventive Services

29. Evidence Used in the Purchaser’s Guide U.S. Preventive Services Task Force (USPSTF) CDC Other U.S. Department of Health and Human Services U.S. Public Health Service U.S. Surgeon General NHLBI, NIAAA, etc Professional Organizations American Academy of Pediatrics (AAP) American Academy of Family Physicians (AAFP) Many others Respected associations

30. Evidence: USPSTF A - Strongly recommend Good evidence that the benefits substantially outweigh harms B - Recommend At least fair evidence that benefits outweigh harms C - USPSTF makes no recommendation Fair to good evidence that the benefits and harms are closely balanced D - Recommend against routine use Ineffective or harms outweigh potential benefits I - Insufficient evidence to make a recommendation No evidence or poor quality evidence

31. Criterion for Coverage Why use evidence as a criterion? What are other criterion for coverage? Address beneficiary needs Specific enough to be administered How do we proceed in the absence of evidence or in the face of conflicting evidence?

32. A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage A Tool to Improve Clinical Preventive Service Coverage

33. Purpose of the Purchaser’s Guide Promote preventive medical benefits that are based on evidence Provide information needed to select, define, prioritize, and implement preventive medical benefits Shift benefit criteria from arbitrary thresholds and cost sensitivities to beneficiary need

34. Overview 7 part reference book 46 condition-specific evidence-statements, SPDs, and CPT codes Provides screening, counseling, testing, immunization, preventive medication, preventive treatment recommendations Includes all USPSTF “A” and “B” recommendations plus equivalencies from other groups (CDC, DHHS, AAP, etc) as of March 2006

35. Offer a structured set of clinical preventive service benefits. Inform employees, dependents, and retirees about the availability of preventive benefits and promote consistent and appropriate use. Implement programs that promote healthy lifestyles and provide opportunities for employees to engage in disease prevention and health promotion outside of the clinical setting. Support community-based and worksite-based preventive service interventions. Employer Action Items

36. SPDs communicate health benefits to beneficiaries Covered benefit (i.e., the type of screening test or counseling) Initiation, cessation, and interval (i.e., frequency) Applicable CPT codes Summary Plan Description (SPD) Language

39.

40. Benefit Structures Federal regulation and preventive services Employers can shape plans to delivery and use HDHPs and “safe-harbor” coverage Preventive medications and preventive treatments

43. Evidence-Statements for Recommended Clinical Preventive Service Benefits Overview Recommendations Information sources Epidemiology Risk factors Value of Prevention Economic burden of disease Workplace burden of disease Economic benefit of preventive intervention Estimated cost of preventive intervention Estimated cost of treatment Cost-effectiveness / CBA Purpose Benefits and risks Initiation, cessation, interval Intervention process Treatment information Evidence box References

46. Evidence-Statements for Recommended Clinical Preventive Service Benefits Estimated cost of preventive intervention 2004 paid claims average from the Medstat Marketscan database (commercially insured population) e.g., flexible sigmoidoscopy averaged $174 (95% of all paid claims fell within the range of $54 to $392) e.g., tobacco use treatment counseling averaged $39 (95% of all paid claims fell within the range of $0 to $129) e.g., chlamydia screening averaged $42 (95% of all paid claims fell within the range of $0 to $87)

47. I Statements and C and D Recommendations of the USPSTF Recommended employer action in the absence of strong evidence/ evidence against a particular service I, C, D ratings Information provided to help employers understand which services they currently offer should be re-evaluated Why evaluate existing preventive service benefits?

48. Strategic Implementation through Prioritization

49. Prioritization of Clinical Preventive Services in a Strategic Implementation Plan Tailor implementation through prioritization Four methods of prioritization Provide economic and health value Address demographic needs Address beneficiary risk and reduce specific healthcare costs Four (4) employer scenarios based on: Beneficiary age and sex Employer motivation (e.g., address risk) Available data (e.g., disability claims)

50. Employer B 7,000 employees, 4,000 retirees, and 42000 dependents Average age = 53 73% of beneficiaries are male

52. Leveraging Benefits

53. Leveraging Benefits: Opportunities to Promote the Delivery and Use of Preventive Services Actions employers can take to strengthen prevention efforts Medical home Smoking ban Fitness centers Lactation program Community-level interventions Employer case examples and success stories

54. Leveraging Benefits: Opportunities to Promote the Delivery and Use of Preventive Services The Purchaser’s Guide helps maximize value and the investment of health coverage. Educate employees and other beneficiaries about the availability and use of preventive services Encourage providers, health plans, and health systems to deliver services Empower beneficiaries to seek preventive services

55. Leveraging Benefits: Opportunities to Promote the Delivery and Use of Preventive Services Growing body of science about what works for population-level health interventions CDC’s Community Guide to Preventive Services Evidence-based recommendations on population-level services that improve community health

56. Provide referrals to community-based support and prevention programs, such as tobacco quitlines Increase preventive service access points for worksite immunization programs Support healthy worksites, through point of decision prompts to increase stair use; support healthy environments by policy decisions such as smoke free campuses

57. Leveraging Benefits: Opportunities to Promote the Delivery and Use of Preventive Services Considerable gap between what we know works and what we think may work Employer case examples and success stories included to fill in that gap Employers should think about preventive services as a key human resource investment and think about leveraging these benefits in the same way they might market or promote a new product line

58. Resources & Tools Life Course Charts (3) Recommended Schedules of Preventive Care Crosswalk Comparison of the Purchaser’s Guide recommendations, the USPSTF recommendations, NCQA HEDIS® measures, NCQA State of Healthcare Quality Report, Healthy People 2010 Goals Cost-calculators Clinical preventive services glossary Links to additional information Index

59. What is the Value of the Purchaser’s Guide?

60. Value of the Purchaser’s Guide Closes the gap between knowledge and practice “Plug and Play” ease of use Appropriate for different organizations, workforces, priorities, and resources Precise SPD language: both screening and intervention Precise codes Up-to-date cost, cost-effectiveness, and ROI estimates Valuable with or without: Medical Department Benefit consultants Trustworthy: Authoritative sources Evidence based: What works and what doesn’t work Will have a dramatic benefit for employees and their families

61. Benefit Structures: Promoting Prevention

62. Employer Solutions Preventive Care Primary Secondary Tertiary Where Healthcare Plan Disability Management Employee Assistance Program Health Improvement/Wellness Program Evidence-Based Programs Standardized Integrated

63. Create an Integrated and Sustainable Approach

64. Informing Disability Management Links between prevention, health promotion, and effective disability management Tertiary prevention Important prevention opportunities exist for employees “disabled” for work Tobacco Use, Screening, counseling, and treatment Depression, Screening Osteoporosis, Screening and treatment Obesity, Screening, counseling, and treatment

65. Follow-up Webinars and solutions seminars (Jan – Feb 2007) Employers Healthcare consultants Health plans and healthcare companies Evaluation EMPAQ PDFs and preventive services search engine: www.businessgrouphealth.org/prevention/purchasers

66. Contact Information Kathryn Phillips Campbell, MPH Manager, Center for Prevention and Health Services National Business Group on Health 50 F ST NW Suite 600 Washington, DC 20001 E-mail: PhillipsCampbell@businessgrouphealth.org Direct line: 202-585-1800