New options, requirements for preventive care
While some "front runner" Medicaid programs have made expansion of preventive care a priority to improve quality of care and reduce costs, most have only started to look at these possibilities. "Utilization rates remain low for preventive services that are very cost-effective and have been recommended for years," says Georges C. Benjamin, MD, executive director of the American Public Health Association.
Health reform presents some concrete opportunities to help states to move forward with these initiatives. "There is language in the health reform bill that promotes quality improvement across the clinical spectrum," says Dr. Benjamin. "Medicaid and Medicare are both required to improve the quality of their programs."
An August 2009 Government Accounting Office study, Concerted Efforts Needed to Ensure Beneficiaries Receive Services, pointed out that additional efforts were needed to strengthen the receipt of needed preventive services to beneficiaries.
"We actually know a lot about the benefit of preventive services," says Dr. Benjamin. "Overall, we know that even modest degrees of cost-sharing result in reductions in utilization of preventive services. We also know that only half of the population receives the recommended preventive services."
In December 2009, the Washington, DC-based National Committee for Quality Assurance released a Medicaid Managed Care Toolkit, in an effort to give Medicaid managed care plans better ways to improve the quality of their programs.
The U.S. Preventive Services Task Force, the Advisory Committee for Immunization Practices, and the Community Services Task Forces are three federal advisory groups that are used to define the evidence base for preventive services.
"These groups look at the science around how well they work and their effectiveness," says Dr. Benjamin. "There is compelling evidence that better care coordination using medical homes and similar models of comprehensive care teams results in better health outcomes for people who have medical conditions."
Coverage is inconsistent
For children in the Medicaid program, the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service provides screening for a range of potential medical problems. It requires that the program provide referral and treatment for any issues that need correction.
"EPSDT is designed to address the needs of low-income children who have a higher incidence of low birth weights, developmental delays, and medical problems," says Dr. Benjamin. "As one example of this higher risk, as many as 80% of children in foster care are found to have medical problems."
Vision screening is an example of a procedure that identifies early problems, thereby preventing blindness and improving school performance, with a cost savings up to $15,000 per quality adjusted life year, says Dr. Benjamin.
For adults, coverage of preventive services in the Medicaid program is inconsistent across states. "This is because many prevention benefits are considered an optional service," says Dr. Benjamin.
The Affordable Care Act will require states to provide comprehensive Medicaid coverage for counseling and pharmacotherapy for tobacco cessation by pregnant women. It prohibits cost-sharing for these services. "Tobacco use during pregnancy results in several problems for both mother and baby. This will improve both pregnancy and maternal outcomes," says Dr. Benjamin.
The law gives states the option to include diagnostic, screening, preventive, and rehabilitation services graded "A" or "B" by the U.S. Preventive Services Task Force in their Medicaid program benefits, without cost-sharing requirements.
For adults, it authorizes all immunizations and their administration recommended by the Advisory Committee on Immunization Practices. "States that cover these additional services and vaccines, and also prohibit cost-sharing for such services and vaccines, will receive an increased FMAP of one percentage point for these services," says Dr. Benjamin.
Missed opportunities
The August 2009 GAO study reviewed both child and adult preventive services.
"It found that on certain measures, states were not performing as well as expected," says Dr. Benjamin. "For example, as many as 40% of children did not get the required well-baby check. For adults, preventable opportunities were being missed."
The Washington, DC-based Partnership for Prevention looked at what increasing prevention could do to improve the nation's health. "It found that increasing the use of five preventive services would save 100,000 lives each year," says Dr. Benjamin. Here are other key findings:
45,000 additional lives would be saved each year if the number of adults who take aspirin daily to prevent heart disease was increased to 90%. "Today, fewer than half of American adults take aspirin preventively," notes Dr. Benjamin.
42,000 additional lives would be saved each year if the percentage of smokers who are advised by a health professional to quit, and are offered medication or other assistance, was increased to 90%. Today, only 28% of smokers receive such services.
12,000 additional lives would be saved each year if the percentage of adults 50 and older who are immunized against influenza annually was increased to 90%. Currently, the percentage is just 37%.
The Washington, DC-based Trust for America's Health and the New York City-based New York Academy of Medicine found that an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save over $16 billion annually within five years.
"This is a return of $5.60 for every $1," says Dr. Benjamin. "In addition, out of the $16 billion, Medicare could save more than $5 billion, Medicaid could save more than $1.9 billion, and private payers could save more than $9 billion."
Preventive services in Medicaid are "in a variety of stages," says Dr. Benjamin. "States with long-term managed care programs have been doing quality for some time," he says. "EPSDT is uniform across the country. However, there are differences in performance. Adult access to preventive services likewise could be improved."
The August 2009 GAO study found that access to prevention benefits wasn't consistent across state Medicaid programs. "The report recommended that [the Centers for Medicare & Medicaid Services] and the states provide better oversight to ensure these benefits are received," says Dr. Benjamin. "Budget cuts and the recession have had an uneven effect across the nation. It is too early to see how many of the states will benefit from the enhanced FMAP to expand prevention coverage."
Contact Dr. Benjamin at [email protected].
While some "front runner" Medicaid programs have made expansion of preventive care a priority to improve quality of care and reduce costs, most have only started to look at these possibilities. "Utilization rates remain low for preventive services that are very cost-effective and have been recommended for years," says Georges C. Benjamin, MD, executive director of the American Public Health Association.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content