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 National Business Group on Health March 23, 2007

2. Background Membership group of large public and private employers Develop education tools to inform benefit design, policies, services, programs Changing the paradigm From a focus on treatment to a focus on prevention and behavior change

3. Rethinking Current Approaches

4. 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

5. The Value of Prevention Short-term and long-term cost benefits Smokers who successfully quit smoking reduce potential medical costs associated with cardiovascular disease by $47 during the first year and $853 during the following 7 years.1 Productivity Workforce engagement, recruitment, and retention Resource allocation Community-health (i.e., reduced transmission of communicable diseases) Clinical preventive services avert healthcare costs by: Reducing beneficiary health risks Catching disease early, when treatment is most effective and least expensiveClinical preventive services avert healthcare costs by: Reducing beneficiary health risks Catching disease early, when treatment is most effective and least expensive

6. Coverage Among Large (500+) Employers Coverage of physical exams, screening, and immunizations is fair (50%+) but coverage of lifestyle modification services/counseling is poor1: Healthy diet -21% Weight loss -18% Alcohol misuse - 19% Comprehensive tobacco treatment benefits � 4%

7. Why is Coverage so Important?

8. The Purchaser�s Guide

9. Purpose of the Purchaser�s Guide Promote preventive medical benefits that are based on medical evidence U.S. Preventive Service Task Force (USPSTF) CDC / U.S. Department of Health and Human Services Professional organizations Provide information needed to select, define, prioritize, and implement preventive medical benefits 72 CPS recommendations in 46 topic areas Summary plan description language (SPDs) & CPT codes Evidence-statements

10. 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

11. Tobacco Use Treatment Screening Coverage begins at age 18 (coverage provided for younger populations depending on medical need) Eligible at every medical encounter Counseling Brief counseling (in-person) and intensive counseling (in-person or telephonic) 2 courses of 6 counseling session each calendar year (total of 12 sessions per year) Treatment All FDA-approved nicotine replacement products and tobacco cessation medications, as prescribed by a clinician

13. Evidence-Statements for Recommended Clinical Preventive Service Benefits Epidemiology, risks & benefits, value of prevention Economic burden, workplace burden Economic benefit of prevention 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)

14. Other Sections Prioritization methods Employer action in the absence of evidence-based guidelines: I statements & C/D recommendations Community-level interventions Employer case examples and success stories

15. Resources & Tools Benchmarking crosswalk HEDIS� measures, NCQA State of Healthcare Quality Report, Healthy People 2010 Goals Cost-calculators Recommended schedules of preventive care

16. Value of the Purchaser�s Guide Closes the gap between knowledge and practice �Plug and play� Appropriate for different organizations, workforces, priorities, and resources Precise SPD language and codes: both screening and intervention Up-to-date cost, cost-effectiveness, and ROI estimates Trustworthy: Authoritative sources Evidence based: What works and what doesn�t work Cover the right services; not just more services

17. Free Access PDFs and preventive services search engine: www.businessgrouphealth.org/prevention/purchasers For more information, contact: Kathryn Phillips Campbell, MPH National Business Group on Health 50 F St NW, Suite 600 Washington DC, 20001 Phone (direct): 202-585-1800 E-mail: PhillipsCampbell@businessgrouphealth.org