August 17, 2020
Primary care accounts for less than 10% of total health care expenditures: however, primary care providers (PCPs) are often seen by their patients as their most trusted health advisors. Therefore, PCPs can influence members to adopt healthier habits and improve adherence to preventive screening guidelines.4 Furthermore, preventive services are delivered within the primary care setting. The most basic form of preventive care is an annual preventive exam performed by the patient’s PCP to assess their overall health and screen for health risks. Basic screenings, including those for cholesterol, blood pressure and blood sugar, allow a PCP to identify any issues that may become medical concerns in the future.
The growing acceptance of accessing care through telemedicine may provide an additional venue for improving access to timely care and preventive service utilization. As broader utilization of telemedicine continues to become the norm, several telemedicine providers are beginning to offer virtual primary care services with the goal of developing ongoing relationships between the patient and the provider. Building these longitudinal relationships can create a better connection between patients and their PCPs. In addition, positioning primary care to maximize its convenience may be an important step to improving overall compliance with primary care guidelines.
In contrast to annual preventive visits or biometric exams, an annual wellness visit (AWV) is focused on conversations between the patient and physician about their mental health, home situation and other social determinants of health.5 Increasingly, research has shown that AWVs in some cases may be more effective than annual preventive exams, which may not be necessary for individuals without chronic conditions. A March 2019 study of Medicare patients estimates that reaching out to patients to conduct AWVs led to 5.7% downstream savings. Such downstream savings may be achieved by addressing gaps in care, mitigating issues in the home that may present health risks and deepening the patient’s bond with their PCPs. This facilitates more appropriate utilization of primary care and emergency room visit avoidance.3
Keeping up with preventive screening guidelines has been a challenge for consumers and plan sponsors alike. For consumers, issues include determining when and how often to go in for certain procedures and understanding what their health plan will cover. Timing may become an issue as well: Employees often lose track of the last time they completed a screening, particularly when guidelines change and less frequent services are required. This can lead to unintentional overutilization as employees switch to a new provider or underutilization as they delay preventive services beyond the recommended frequency. Simple reminders based on claim data generated by either the health plan or the provider’s office and improved data interoperability, as well as the ability for personal health records to be transferred effectively when an individual changes health plans, can alleviate these challenges.
Another challenge is differentiating between diagnostic versus preventive services. While preventive services can be covered without cost sharing, any follow-up tests or screenings administered due to the presence of symptoms, higher risk level or inability to determine health status based on initial screenings are deemed diagnostic and therefore may lead to out-of-pocket costs. The most common examples of such a surprise cost are sonograms performed after a mammography. Because these services may serve different purposes (diagnostic versus preventive) in certain scenarios, communication and education are important to preventing employees from receiving bills for services they may have thought would be 100% covered by their plan.
It is important for patients to understand why a test or service is ordered: the same test can be preventive, diagnostic or routine chronic care depending on the reason it was ordered.6 There are several tests and services that are not recommended as appropriate screening for individuals with low risk for a specific condition; for example, both the USPSTF and American Academy of Family Physicians cautions providers against ordering electrocardiography (EKG) on an annual basis for low-risk patients without symptoms.7 For this population, health plans may not cover the screening as a preventive service, potentially leading to unexpected out-of-pocket costs to the member.
- 1 | United States Preventive Services Task Force (USPSTF). Recommendation Topics. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics. Accessed July 8, 2020.
- 2 | Business Group on Health. ACA Preventive Services Chart. https://www.businessgrouphealth.org/resources/aca-preventive-services-chart. Accessed July 31, 2020.
- 3 | Business Group on Health. HSA/HDHPs Can Now Provide Pre-Deductible Coverage for Insulin and Other Chronic Condition Treatments. https://www.businessgrouphealth.org/resources/hsa-hdhps-can-now-provide-pre-deductible-coverage-for-insulin-and-other-chronic-condition-treatments. Accessed July 8, 2020.
- 4 | Primary Care Collaborative. Spending for Primary Care Fact Sheet. https://www.pcpcc.org/sites/default/files/resources/PCPCC%20Fact%20Sheet%20PC%20Spend%20Aug%202018.pdf. Accessed July 31, 2020.
- 5 | Beckman AL, Becerra AZ, Marcus A, et al. Medicare Annual Wellness Visit association with healthcare quality and costs. Am J Manag Care. 2019;25(3):e76-e82. Published 2019 Mar 1.
- 6 | Medical Mutual. The Difference Between Preventive and Diagnostic Medical Care. https://www.medmutual.com/For-Individuals-and-Families/Healthy-Living/What-Is-Preventive-Healthcare/The-Difference-Between-Preventive-and-Diagnostic-Medical-Care.aspx. Accessed July 8, 2020.
- 7 | American Academy of Family Physicians (AAFP). Choosing Wisely® annual EKGs for low-risk patients. https://www.aafp.org/patient-care/clinical-recommendations/all/cw-ekg.html. Accessed July 8, 2020.
- 8 | Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018;137:e67–e492.
- 9 | Pippitt K, Li M et al. Diabetes mellitus: Screening and diagnosis. Am Fam Physician. 2016 Jan 15;93(2):103-109.
- 10 | United States Preventive Services Task Force. Final Recommendation Statement: Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening. October 26, 2015. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes. Accessed July 8, 2020.
- 11 | United States Preventive Services Task Force. Screening for Cardiovascular Disease Risk with Electrocardiography: Recommendation Statement. https://www.aafp.org/afp/2018/0915/od1.html. Am Fam Physician. 2018 Sep 15;98(6):online.
- 12 | United States Preventive Services Task Force (USPSTF). Final Recommendation Statement: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medicine. November 13, 2016. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication. Accessed July 31, 2020.
- 13 | United Kingdom National Health Service (NHS). Diagnosis: Chronic kidney disease. August 29, 2019. https://www.nhs.uk/conditions/kidney-disease/diagnosis/. Accessed July 8, 2020.
- 14 | United States Preventive Services Task Force (USPSTF). Understanding Task Force Recommendations: Screening for Chronic Kidney Disease. August 2012. https://www.uspreventiveservicestaskforce.org/Home/GetFileByID/1881. Accessed July 31, 2020.
- 15 | Business Group on Health. New ACA Preventive Service Coverage Requirement for HIV (PrEP). https://www.businessgrouphealth.org/resources/new-aca-preventive-service-coverage-requirement-for-hiv-prep. Accessed July 8, 2020.
- 16 | Business Group on Health. HIV/AIDS: Despite Progress, Much Work Remains. https://www.businessgrouphealth.org/en/resources/hiv-aids-despite-progess-much-work-remains. Accessed July 31, 2020.
- 17 | Centers for Disease Control and Prevention. Breast Cancer Screening Guidelines for Women. https://www.cdc.gov/cancer/breast/pdf/BreastCancerScreeningGuidelines.pdf. Accessed July 8, 2020.
- 18 | National Institute of Health: National Cancer Institute. Dense Breasts: Answers to commonly asked questions. https://www.cancer.gov/types/breast/breast-changes/dense-breasts. Accessed July 8, 2020.
- 19 | Mayo Clinic. Virtual Colonoscopy. https://www.mayoclinic.org/tests-procedures/virtual-colonoscopy/about/pac-20385156. Accessed July 8, 2020.
- 20 | Centers for Disease Control and Prevention. Colorectal (Colon Cancer): Screening Tests. https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm. Accessed July 8, 2020.
- 21 | Simon S. Colorectal Cancer Screening: What Are My Options? American Cancer Society. March 2, 2020. https://www.cancer.org/latest-news/understanding-tests-that-screen-for-colon-cancer.html. Accessed July 8, 2020.
- 22 | Cavallo J. Solving the mystery of why colorectal cancer Is on the rise in young adults: A conversation with Kimmie Ng, MD, MPH. The ASCO Post. https://www.ascopost.com/issues/june-25-2019/solving-the-mystery-of-why-colorectal-cancer-is-on-the-rise-in-young-adults/. Accessed July 8, 2020.
- 23 | Centers for Disease Control and Prevention. Lung Cancer: Who Should Be Screened for Lung Cancer? https://www.cdc.gov/cancer/lung/basic_info/screening.htm. Accessed July 8, 2020.
- 24 | American Cancer Society. Can lung cancer be found early? https://www.cancer.org/content/cancer/en/cancer/lung-cancer/detection-diagnosis-staging/detection.html. Accessed July 8, 2020.
- 25 | Business Group on Health. Webinar Presentation: A conversation about the Impact of the expanding field of genetic testing on employers and key considerations for coverage. February 4, 2020.
- 26 | United States Preventive Services Task Force (USPSTF). Final Recommendation Statement: BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing. August 20, 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing. Accessed July 8, 2020.
IntroductionEmployers' Guide to Preventive Care
Part 1Preventive Care: Regulatory Framework
Part 2Preventive Care: "Annual" Visits and Preventive Screening Considerations
Part 3Preventive Care: Role of Preventive Screenings in Managing Chronic Conditions
Part 4Preventive Care: Cancer Screening Guidelines
Part 5Preventive Care: Emerging Preventive Care Coverage Considerations
Part 6Preventive Care: Opportunities for Employers