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

A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage. National Business Group on Health March 23, 2007. Background. Membership group of large public and private employers Develop education tools to inform benefit design, policies, services, programs

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

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  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 Primary cost drivers are chronic disease and serious acute conditions; many are preventable. 20% of claimants 80% of Costs Stem from preventable chronic conditions 75% of costs

  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 Sources: 1. Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1997–2001. MMWR2005;54(25):625-628; 2. American Heart Association. Heart disease and stroke statistics: 2006 update. Dallas (TX): American Heart Association; 2005; 3. Silverstein MD, Pitts SR et al. Abdominal aortic aneurysm: cost-effectiveness of screening, surveillance of intermediate sized AAA, and management of symptomatic AAA. Proc (Bayl Univ Med Centr) 2005 Oct; 18(4): 345-67; 4. HCUP. National Inpatient Sample. Rockville, MD: Agency for Healthcare Research and Quality.

  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) Source: 1. Lightwood JM, Glanz S. Short-term economic and health benefits of smoking cessation. Circulation 1997; 96(4): 1089-1096.

  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% Source: 1. Results from survey completed by 2,180 employers in 2001.Bondi MA, Harris JR, et al. Employer coverage of clinical preventive services in the United States. American Journal of Health Promotion 2006; 20(3): 214-222.

  7. Why is Coverage so Important? • Coverage increases access; access increases utilization • Case-example – Tobacco Use Treatment • Smoking is among employers’ top 3 health issues1 • 88% of employees report having tried to quit1 • Less than 5% are successful in unaided attempts1 • Benefits support successful quit attempts Source: 1. NBGH (2006) “Smokers in the Workplace Study” conducted by StrategyOne

  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. Employer Action • 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. Source: NBGH (2006) “Smokers in the Workplace Study” conducted by StrategyOne

  11. Summary Plan Description (SPD) Language 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

  12. 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)

  13. 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

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

  15. 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

  16. 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

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