A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage

1. A Purchaser’s Guide to Clinical Preventive Services:Moving Science into Coverage National Business Group on Health March 23, 2007

2. 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

3. Rethinking Current Approaches Primary cost drivers are chronic disease and serious acute conditions; many are preventable. 20% of claimants 80% of Costs Stem from preventable chronic conditions 75% of costs

4. 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. MMWR2005;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.

5. 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.

6. 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.

7. Why is Coverage so Important? • 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 Source: 1. NBGH (2006) “Smokers in the Workplace Study” conducted by StrategyOne

8. The Purchaser’s Guide

9. 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

10. Employer Action • Offer a structured set of clinical preventive service benefits. • Inform employees, dependents, and retirees about the availability of preventive benefits and promote consistent and appropriate use. • Implement programs that promote healthy lifestyles and provide opportunities for employees to engage in disease prevention and health promotion outside of the clinical setting. • Support community-based and worksite-based preventive service interventions. Source: NBGH (2006) “Smokers in the Workplace Study” conducted by StrategyOne

11. 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

13. 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)

14. 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

15. Resources & Tools • Benchmarking crosswalk • HEDIS® measures, NCQA State of Healthcare Quality Report, Healthy People 2010 Goals • Cost-calculators • Recommended schedules of preventive care

16. 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

17. 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