A Purchaser’s Guide to Clinical Preventive Services:

Moving Science into Coverage

National Business Group on HealthMarch 23, 2007

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

Rethinking Current Approaches

80% ofCosts

Stem from preventable

chronic conditions75% ofcosts

20% ofclaimants

Primary cost drivers are chronic disease and serious acute conditions; many are preventable.

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. MMWR 2005;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.

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.

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.

Why is Coverage so Important?

Source: 1. NBGH (2006) “Smokers in the Workplace Study” conducted by StrategyOne

• 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

The Purchaser’s Guide

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

1. Offer a structured set of clinical preventive service benefits.

2. Inform employees, dependents, and retirees about the availability of preventive benefits and promote consistent and appropriate use.

3. Implement programs that promote healthy lifestyles and provide opportunities for employees to engage in disease prevention and health promotion outside of the clinical setting.

4. Support community-based and worksite-based preventive service interventions.

Employer Action

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

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

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)

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

Resources & Tools

• Benchmarking crosswalk– HEDIS® measures, NCQA State of Healthcare Quality

Report, Healthy People 2010 Goals• Cost-calculators• Recommended schedules of preventive care

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

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