Expanding Coverage of Preventive Services for Women: Institute of Medicine Committee on Preventive Services for Women Jud Richland, MPH President & CEO, Partnership for Prevention January 12, 2011 Introduction Good morning and thank you for the opportunity to contribute to this important session. The Commonwealth Fund and others have shown that many women delay or avoid preventive care for financial reasons. I think we all expect and are hoping that the Patient Protection and Affordable Care Act will be successful in reducing these barriers by requiring coverage of recommended preventive services with no cost-sharing. Your Committee s work can help ensure that women have access to important preventive services. You do need to proceed carefully, however. I m not here to advocate for or against any specific service. I do want to offer several comments, though, related to the criteria that you might use to make some of your difficult decisions. I also would like to offer some comments about how you might avoid some of the minefields that you may encounter in your work. 1
About Partnership for Prevention First, though, for those of you who may not know much about Partnership for Prevention, allow me to offer a brief description. Partnership was established to help make disease prevention and health promotion a higher priority in national health policy. We aim to offer passionate advocacy and guidance for prevention policy and practice fueled by adherence to the dispassionate appraisal of the evidence of prevention s value. Our members all of whom are committed to evidence-based prevention include nonprofit health associations, governmental public health agencies, and private businesses. Our message during the health reform debate was that Real Health Reform Starts with Prevention. The rest of our message, though, was that prevention needs to be done right. Partnership is best known for its work to prioritize clinical preventive services. Our work is intended to help decision-makers improve utilization rates. We established the National Commission on Prevention Priorities to oversee our efforts to rank clinical preventive services based on each service s health impact and cost-effectiveness. Over the past decade, we have worked closely with our collaborator, the HealthPartners Research Foundation, to develop and publish the rankings. We ll be releasing our next set of rankings later this year. In addition, Partnership works to advance utilization of the preventive services that score highly in our rankings. For example, we now have programs aimed at increasing delivery of tobacco cessation services, chlamydia screening, immunizations, and aspirin counseling. Criteria for Recommending Coverage Your Committee has been charged with making recommendations about coverage of women s preventive services beyond those already specified in the ACA. I m sure an important part of your work will include looking at the evidence base for a number of services. An analysis of the evidence base for adolescent preventive services conducted by the HealthPartners Research Foundation and Partnership underscores the point that you need to be 2
cautious in your approach. It is likely that many preventive services for women that your Committee will be considering do not have as extensive an evidence base as we would like. In our analysis, we identified 69 services that had been recommended by the five national groups that issue comprehensive recommendations for adolescents. Of the 69 services, the majority lacked enough evidence to even conduct a detailed evidence review. Twenty-four of the services had been reviewed by the U.S. Preventive Services Task Force, and of those, only 7 received an A or B grade. The point is that many groups and special interests advocate for a wide variety of preventive services, but many and likely most of the services have not actually been proven to be effective. Many of the services that you may be considering recommending for coverage likely do not have an extensive research base demonstrating effectiveness. If they did, there s a very good chance the USPSTF would have already reviewed them. That should be a red flag, and it tells me you need to proceed very cautiously. Having said that, it s important to note that the Task Force has not examined some sensitive topics, at least recently. That includes contraceptive and family planning services. These services are certainly good candidates for consideration by your Committee, not to mention by the Task Force itself. Turning to your work, specifically, I ll start by stating the obvious. If the USPSTF has given a service a D recommendation, do not recommend it. Your first obligation is to do no harm. Likewise, you should be very cautious about recommending any services that have received a C or I grade from the Task Force. For preventive services for asymptomatic persons, the evidence bar should be very high. Next, based on Partnership s experience and the experience of the National Commission on Prevention Priorities, I want to suggest several general criteria for you to consider in your decision-making. None of the criteria I suggest will come as a surprise to you. The challenge is 3
applying them when you do not have as much evidence as you would like about the effectiveness of the service. The first criterion is health impact, which is largely a function of the prevalence of the condition and whether the condition has serious or important health consequences. The second criterion is cost effectiveness, which, among other things, is related to how precisely the service can be targeted and to the cost of treating the condition the service aims to prevent. The absolute cost of the service is also very important in an era of limited resources, although it diminishes in importance if you are able to actually calculate cost-effectiveness. Proceed with Caution People who know Partnership for Prevention only as a strong advocate for prevention might assume that our view would be the more services the Committee recommends the better. In fact, our goal is to maximize prevention, minimize harms, and help create an effective and efficient health system. Thus, we believe your Committee needs to take extra care when it comes to recommending services with limited evidence about effectiveness and harms, especially for asymptomatic persons. This may be especially relevant for screening tests that lead to additional examinations, tests, or treatments. So, here are some thoughts as you make your recommendations. Again, my assumption is that the evidence base for many of the services you may be considering is often not as deep as might be required by, for example, the USPSTF. It s important that you define services and target populations as precisely as possible. In other words, consider carefully circumscribing your recommendations by age, periodicity, and patient risk factors. Consider making time-limited recommendations pending the development of additional evidence. One model you might consider exploring is the Coverage with Evidence Development model used by CMS. Coverage with Evidence Development is a method 4
of providing provisional access to medical services while generating the evidence needed to determine whether unconditional coverage is warranted. Certainly, the opportunity by HHS to periodically update coverage requirements will be important to continually improving coverage. Finally, I hope you ll recommend to NIH and/or AHRQ that they adopt your recommendations as a research agenda to ensure the effectiveness and cost-effectiveness of newly covered services and to continually improve the delivery of these services. My recommendations regarding expanding coverage of clinical preventive services may appear cautious, but it is not for lack of enthusiasm about the opportunity and about your charge. I expect that you ll make judgments about services beyond those specified in the Affordable Care Act where you believe evidence is sufficient to warrant coverage. Caution is important because if we over-reach or misstep along the way, we will not be upholding our responsibility to create as efficient and effective a health system as possible. Any missteps may also, given the highly charged political environment, make it much more difficult to keep moving forward. Health System Interventions to Support Delivery of Clinical Preventive Services I d like to offer one more thought, this one about delivering preventive services. Perhaps a more important question than which additional preventive services should be covered and one that would very likely lead to a greater improvement in overall health would be: how can we increase delivery of high impact preventive services that we know are effective, especially for those services that are delivered at low rates. The reason the National Commission on Prevention Priorities ranks clinical preventive services, as I described earlier, is that we spend billions of dollars on healthcare services of questionable value. At the same time, high-value, evidence-based services often do not get delivered. 5
A study that Partnership for Prevention and the HealthPartners Research Foundation conducted several years ago found that we could save over 100,000 lives each year if we increased delivery of proven clinical preventive services from their current levels to 90% of the target population. Utilization rates are under 50% for some of the highest value services, such as daily aspirin use, tobacco cessation, and colorectal cancer screening. If we increased Chlamydia screening from 43% to 90%, we could prevent 30,000 cases of PID each year. So, my final recommendation to the Committee, which you might at first blush consider outside of your charge, is aimed at increasing the delivery of high impact services. Specifically, the Committee should consider recommending reimbursement or incentives to healthcare organizations and providers for implementing evidence-based, systems approaches that improve delivery of recommended clinical preventive services. You all know the CDC-sponsored Task Force on Community Preventive Services. The Task Force has outlined many health system interventions to improve delivery of recommended preventive services, including for breast and cervical cancer screening. The interventions include such things as patient reminder systems, provider reminder systems, standing orders, and case management approaches. Incentiving health systems offers great potential for increasing delivery of many of the most important clinical preventive services. In many ways, real health reform is starting with prevention, and we need to continue to get it right. I thank the Committee for the opportunity to offer the views of Partnership for Prevention. 6