Improving Preventive Health Care for Older Americans

1. Improving Preventive Health Care for Older Americans Marcel Salive, MD, MPH, FACPM Division of Geriatrics and Clinical Gerontology, NIA

2. Coverage "First we'll find out if your insurance covers the magic wand treatment.”

3. One time “Welcome to Medicare” physical exam Physical Exam (yearly “Wellness Visit”) Starts 2011 Abdominal aortic aneurysm screening* Bone mass measurement Cardiovascular disease screenings Colorectal cancer screenings Diabetes screenings EKG Screening* Flu shots Glaucoma tests Hepatitis B shots HIV Screening Mammograms (screening) Pap test/pelvic exam/ clinical breast exam Prostate cancer screening Pneumococcal shots Smoking cessation Medicare Preventive Services ACA Section 4103 *When referred during Welcome to Medicare physical exam

4. 2008 LAW: MIPPA, section 101 Authority for Medicare to cover additional preventive servicesthat are • Reasonable and necessary for the prevention or early detection of an illness or disability based on the national coverage determination process; • “Strongly recommended” (A) or “recommended” (B) by the United States Preventive Services Task Force; and • Appropriate for Medicare beneficiaries.

5. Medicare National Coverage Timelines Reconsideration Preliminary Discussions 6 months 30 days 60 days Final Decision Memorandum and Implementation Instructions National Coverage Request Staff Review Draft Decision Memorandum Posted Public Comments External Technology Assessment Staff Review Medicare Evid Dev & Coverage Advisory Committee 9 months

6. Reasonable & Necessary? • Sufficient level of confidence that evidence is adequate to conclude that the item or service: • improves health outcomes; prevents disease • generalizable to the Medicare population • Evidence assessed using standard principles of evidence-based medicine

7. Affordable Care Act (2010) Medicare: • 4103: Annual Wellness Visit Providing Personalized Prevention Plan Services • 4104: Waives deductible and coinsurance for preventive service--UPSPSF A or B Health Plans: • 2713: new plans must cover A/B services, ACIP vaccines without cost sharing

8. Coordination in the health care system (Woman at desk with a sign that says, 'Wait Coordinator.') Wait Coordinator

9. Coordination of Preventive Services • Annual Wellness Visit (proposed) and Welcome to Medicare Visit • Coordinates the preventive services already covered by Medicare like cancer screenings, bone mass measurements and vaccinations • May be a written plan or checklist • Short/long term (5 yrs)

10. Translating recommendations into coverage policy • Population • Frequency • Duration • Settings • Payment • Other limitations Remaining Gaps: Certain provider types Non-health services

11. Translation: Other Limitations Based on the wording of the USPSTF recommendation, with a grade of A or B by the USPSTF. Some services have multiple recommendations, including other letter grades (C, D, I)

12. COUNSELING Alcohol Misuse Screening and Behavioral Counseling Interventions Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing Diet, Behavioral Counseling in Primary Care to Promote a Healthy Diet SCREENING Depression Hepatitis B Virus Infection Sexually transmitted infections Obesity in Adults (incl counseling) CHEMOPREVENTION Breast Cancer, Chemoprevention counseling Aspirin to prevent CVD Possible prevention NCDs

13. How to Set Priorities? • Amount of disease and premature death prevented in the U.S. population (5=best) • Cost-effectiveness (5=best). Am J Prev Med 2006; 31(1):52-61.

14. 10-Discuss daily aspirin use — men 40+, women 50+ Childhood immunizations Smoking cessation advice and help to quit — adults 8-Problem drinking screening and counseling — adults Colorectal cancer screening — adults 50+ Hypertension screening and treatment—adults 18+ Influenza immunization—adults 50+ 7-Vision screening — adults 65+ Cervical cancer screening — women Cholesterol screening and treatment — men 35+,women 45+ Pneumococcal immunizations — adults 65+ Top Ranked Clinical Preventive Services for the U.S. Population Source: Maciosek MV, Coffield AB, Edwards NM, Goodman MJ, Flottemesch TJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med 2006; 31(1):52-61.

15. Prioritization: Other dimensions • Legal authority • Is it a health service? • Impact • Is it already available? • e.g. ASA to prevent CVD • Feasibility of decision-making • How widespread is public support? • Generalizability of evidence of benefit

16. Further Information • Marcel Salive, MD, MPH • 301/435-3044 • Marcel.Salive@nih.gov