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Speakers. Ronald Finch, EdD; National Business Group on HealthKathryn Phillips Campbell, MPH; National Business Group on HealthRichard Dixon, MD, FACP; Centers for Disease Control and PreventionAndy Lanza, MPH, MSW; Centers for Disease Control and Prevention. Background. Business Group is com
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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