We strongly urge our customers to cover preventive services because it makes sense from a medical, health, and financial perspective, and that it’s critical to maintain these services and offer access that’s as easy as possible to members.
Editor's note: Nancy K. Klotz, MD, MBA, FACP, is chief medical officer at Brighton Health Plan Solutions.
There’s a lot of news from the courts these days. So you may have missed a decision in late March by a U.S. District Court judge in the Northern District of Texas that struck down a provision of the Affordable Care Act requiring most private health plans to cover a range of preventive services at no cost to the member. That ruling has been stayed, but should it be upheld, over time, many millions of people might lose access to services proven effective at improving health.
Recently I spoke on a HealthLeaders panel about this issue and the potential problems it could create if organizations are not required to continue to provide free or discounted preventive services. If they’re not required to, they may decide not to.
Because we provide TPA services, our customers are not required to abide by the provision because it applies only to fully insured plans. Despite this, many if not most of our customers choose to provide a wide array of preventive services at low or no cost. After a detailed analysis of their population during onboarding, we advise them to provide a robust suite of preventive services their members can access without co-pay or charges against their deductible. Why? Because our analysis shows in great detail how to tailor those programs to each customer’s member population, and how they pay off. Here’s how you can do the same.
- Design benefits for long-term health
Benefit design varies from organization to organization. When onboarding a new benefits partner, work collaboratively and make recommendations for prior authorization requirements, allowing certain preventive services at low or no cost and decide whether and how much of a copay should be involved. Everything from high-cost drugs, chemotherapy, drug benefits, behavioral health benefits, diabetes management, and more should be considered.
Indeed, preventive services do exactly what their name says they do—they prevent more debilitating and expensive costs down the road and keep employees healthy and available to work. Make sure your benefits partner can make detailed recommendations based on a deep analysis of your previous claims, and identify what could have been prevented under a robust set of services aimed at better managing the chronic conditions that, unmanaged, can lead to catastrophic health outcomes.
- Tailor preventive services to your population
Insist on an analysis of the high-cost diseases that might have been avoided had preventive services in those areas been previously available. For example, good control of diabetes is important in improving cardiac outcomes. So, designing your program around the services likely to have prevented past escalations is a good place to start. Work with your benefits partner on pharmacy design as well. For example, using a mail-order pharmacy helps avoid missed doses. For behavioral health, it’s often worthwhile to deploy a case management team that can access contracted preferential rates for members and expedite and even reserve appointments for members.
In addressing each population based on what they need, borrow from NCQA and use its guidelines to inform recommendations on preventive care. These recommendations are aimed at managing those who do have a chronic disease like diabetes, or cardiac issues or kidney problems to make sure their disease does not progress to the point it affects their ability to function. Part of preventive care may include screenings to identify pre-diabetics or cancer screenings based on age and sex to identify cancer in its early and treatable stages. Also manage the drug formulary to maximize preventive care and encourage recommended immunizations at no cost.
The recent court cases are concerning because since the ACA passed, the waiving of cost sharing has led to an increase in preventive care services being administered. The reality is given the barriers around access that may include factors such as cost, transportation, and lack of time to go to appointments, most people will avoid these activities if there’s a cost involved. If they don’t feel sick, they don’t go to the doctor, and that’s a problem no-cost preventive care can help solve.
3. Achieve better outcomes
For those who recognize the value of preventive care, the resolution of this court case probably won’t have much of an impact on them. We continue to strongly urge our customers to cover preventive services because it makes sense from a medical, health, and financial perspective, and that it’s critical to maintain these services and offer access that’s as easy as possible to members.
But providers are used to providing care on an individual level. Now, at a system level, we’re asking them to administer population health, of which preventive health strategies are a critical aspect. To operate that way, practices need to change. That’s difficult to do when covered preventive services are all over the map. If, however, preventive services are widely covered and your practice is rewarded for, say, keeping your diabetics managed to a certain level, you might hire a nurse practitioner to manage the population to ensure those optimal outcomes. Covering preventive services at no cost is a way to give providers the tools they need to structure incentives and achieve better outcomes. Widespread preventive coverage is part of what we need to fully realize the transformation from providing sick care to truly providing healthcare.
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Nancy K. Klotz, MD, MBA, FACP, is chief medical officer at Brighton Health Plan Solutions, where she is responsible for clinical strategy across the company's various business segments. Previously, she served as chief clinical officer at HealthCare Partners, and Heritage NY Medical, PC.
Whether the ruling striking down no-cost preventive care stands or not, making the decision to cover those services can yield long-term benefits for a health plan.
By designing benefits for long-term health and tailoring preventive services to your population, health plans can provide a suite of preventive services for members to access without out-of-pocket costs.