Tag Archives: Prevention

Benchmarking preventive care utilization

Under the provisions of the Patient Protection and Affordable Care Act (PPACA), all health plans (other than those that choose to remain grandfathered) will be required to provide preventive services without copays, coinsurance, or other cost sharing. Although there is no way to tell exactly how the PPACA requirements will affect preventive care trends, it is safe to say that use of preventive services overall is likely to increase. This paper discusses existing preventive care utilization rates and compares them to a calculation of the recommended utilization rates.

Prevention rules introduce new complexity

We’ve blogged before about prevention and the difficulty of determining returns on preventive care investments. Now comes a new wrinkle: The inner details of the reform law. Atlantic Information Systems looks at prevention and health reform in a new article, “Health Reform’s Prevention-Services Rule Perplexes Health Plans With Coverage Mandates Open to Questions.” Here is an excerpt (and perspective from senior clinicial consultant Patricia Zenner):

Zenner cites numerous examples of practical challenges for plans trying to administer the new preventive-coverage mandates. Among them:

  • There are broad CPT codes for laboratory studies, such as an analytical technique called mass spectrometry, “that could test for absolutely anything,” Zenner says, “and there is no way to differentiate it on the claim. That could make it difficult for a plan to show it is providing the required specific screenings for newborns, she says.
  • The rule’s call for mammography screenings every one to two years for women over age 40 still presents a challenge despite coding differences for preventive mammograms and diagnostic mammograms. That is because “something might start out as a screening test and ultimately become a diagnostic test, and the billing process becomes complex,” she explains.
  • The rule calls for Rh factor incompatibility screening for all pregnant women and follow-up testing for women at higher risk. According to practice guidelines, such testing should be done at 24 weeks’ to 28 weeks’ gestation unless the father’s blood type is known to be Rh negative, Zenner says. “But how would you know the father’s status?” she asks. “In this case, I think health plans will just have to pay” for the screening at the first pregnancy visit and again at 24 weeks’ to 28 weeks’ gestation.
  • Various other complications are outlined in the full article.

    Don’t forget your teeth

    An op-ed by the dean of the NYU Dental School asked that dental care not be left out of healthcare reform. Dental care is often overlooked (kind of like flossing), but it does have larger health implications than just what goes on in your mouth.

    A recent white paper by Darcy Allen, George Berry, and Rob Pipich outlines the case for integrating dental care as part of the larger view of a patient’s health. While some insurers have started to recognize the symbiotic relationship between dental health and general medical health, few have taken advantage of it. Regardless of merit, dental health is perhaps a longshot as a healthcare reform priority.

    What we know about wellness and cost savings

    As we mentioned on Monday, the cost-savings potential of prevention and wellness is still uncertain. Milliman Principal Kate Fitch provides some perspective on this.

    Wellness is often mentioned as a key component of healthcare reform yet the success of these programs is mixed.

    We asked Kate Fitch for perspective based on lessons learned from the private sector.

    Q: What wellness programs are most effective? Do some programs work better than others?

    Kate Fitch: Program effectiveness goes beyond whether or not it “works.” Wellness programs should be evaluated in terms of both efficacy and value. Providing everyone with a personal trainer, personal nutritionist, and exercise equipment in the home might result in a few great outcomes. But if the cost becomes astronomical, or if the population affected by the program is insignificant, the value of the program comes into question.

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