An important part of before sickness health care is preventive health care. The goal of preventive health care is to prevent or delay chronic diseases and conditions (and the disability they cause) through various measures so that Americans can lead healthier lives and payer of health care can save money in the long term. In addition, preventive health care also serves to detect existing disease prior to the appearance of symptoms when it is more easily treatable. Some of these measures involve paid healthcare professionals and others can be accomplished by healthcare consumers directly. Until recently, paid healthcare professionals were largely responsible for administering vaccinations against infectious diseases and screenings for cancer. Obamacare (PPACA) has enlarged what preventive health care services healthcare professionals get paid to do.
The most common chronic diseases (heart disease, stroke, cancer, COPD, and diabetes) are associated with unhealthy diets and physical inactivity (called modifiable risk factors). These modifiable risk factors lead to increased blood pressure and blood glucose levels, as well as abnormal blood lipids (cholesterol), and obesity.
Let’s look at a few facts before proceeding to our discussion on preventive health care:
- preventable chronic diseases are linked to 7 out of 10 premature deaths
- diabetes is the leading cause of kidney failure
- smoking causes lung diseases like COPD, cancer, heart disease and stroke
- nearly 70% of first heart attacks and 77% of first strokes occur in people with high blood pressure
- obesity, a known risk factor for heart disease, stroke, diabetes, and cancer cost $147 billion (in 2008 dollars) and is projected to increase $48 billion annually
- the five most costly and preventable chronic conditions cost the U.S. nearly $347 billion (30% of total health spending in 2010)
Brief History of Preventive Health Care in the USA
While vaccinations against infectious diseases have been around since 1905 (with compulsory smallpox vaccinations), the concept of preventive health care did not take off in the United States until 1984 when the U.S. Preventive Services Task Force (USPSTF) was established to provide recommendations about preventive health care for health professionals to consider when practicing medicine. The USPSTF is our country’s watered-down version of NICE in the United Kingdom.
Prior to the early 1960s, there was no formal nationwide vaccination program for Americans and if someone wanted one, they usually paid out-of-pocket. In 1962, the Vaccination Assistance Act brought us national vaccination at public health clinics funded directly by the federal government. Preventive health care services like annual wellness examinations and disease screening tests did not start to appear in health insurance plan coverage until decades later. In 1988, less than half of all health insurance plans included even the most basic covered preventive care services.
Since the 1990s, health insurance coverage for preventive health care services has been increasing steadily with the recognition that people will not (or cannot afford to) pay for them on their own and these services save on health spending in the long term. In addition to an increase in cancer screenings, the concept of the annual wellness visit with a medical doctor was introduced. Under Medicare, the Centers for Medicare & Medicaid Services (CMS) began covering the “Welcome to Medicare” visit in 2005 and annual wellness exams in 2011 (under Obamacare (PPACA)). This annual wellness visit differs from what is called an annual physical and there is some controversy over whether it conveys any benefit.
In 2011, Obamacare (PPACA) introduced two major changes to paid preventive health care:
- it required health insurance plans to cover a specific set of preventive health care services
- these preventive health care services would be provided at zero cost-sharing (i.e., free to the healthcare consumer).
The specific set of paid preventive health care services included screening and counseling for several unhealthy lifestyle habits (overeating, alcohol abuse, and smoking). It is reasoned that some people are incapable of improving their unhealthy lifestyle habits without the paid services provided under the direction of a medical doctor. By introducing zero cost-sharing, Obamacare (PPACA) removed an important financial barrier that kept many Americans from taking advantage of preventive health care.
Preventive Health Care and Money
No discussion of preventive health care services in our for-profit healthcare system would be complete without a discussion about money (i.e., who pays for it?). If you wish to use preventive health care services of a healthcare professional, you need to be aware of what services are covered by your insurance company and which are not. Uncovered services will have to be paid out-of-pocket.
The figure below identifies the things that have to happen BEFORE the healthcare consumer can get covered (“paid”) preventive health care services from healthcare professionals. The preventive health care service has to be spelled out in a health insurance policy with appropriate medical codes for the healthcare professional to use for payment. The health insurance company puts preventive health care services into their policies for one of two reasons: (1) it is dictated by law or (2) the insurance company has determined that the preventive service reduces after sickness health spending and thus increases insurance profits (i.e., reduces medical loss ratio).
Both lawmakers and insurance companies use evidence-based, preventive care recommendations from four groups of experts. the Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force (USPSTF), the Bright Futures (BF) Guidelines (for people 21 years old and younger), and the Health and Medicine Division’s Clinical Preventive Services for Women. These groups use evidence-based medical data balancing benefits and harms, values and preferences of the people affected, and health economic analyses to derive recommendations.
Recommendations for preventive health care do not apply to all healthcare consumers. Factors such as gender, age, race, personal history of disease, and genetic predisposition determine one’s need for preventive health care services. For example, colorectal cancer screening is recommended for people 50-75 years old every 10 years. If you have a personal history that increases your risk of getting colon cancer (inflammatory bowel disease, a previous adenomatous polyp, or colorectal cancer), or a genetic predisposition for the disease, then colorectal cancer screening before age 50 (and more often than every 10 years) is recommended.
Doctors in the United States are not required to incorporate the recommendations offered by these groups into their practices if they so choose and many providers do not address the full range of recommended preventive care services with their customers.
Insurance companies incorporate various recommendations into their plans and it is important to know that even with government mandated preventive care requirements, variations from plan to plan exist. Just because a healthcare provider business offers a “preventive” screening, test, and service, this does not mean that your insurance company will also call it “preventive”. For example, lung cancer screening (using low-dose CT scans), many blood tests, and certain doctors’ office visits (e.g., total body skin exams by dermatologists) are often not considered preventive services for reimbursement purposes. Although each plan is required to include a minimum set of services free of cost sharing thanks to Obamacare (PPACA), variations in coverage beyond what is defined by law exists today. For example, my insurance plan does not cover the FIT-DNA colorectal cancer screening test as an in-network provider, but does cover the more involved (and expensive) colonoscopy as well as other stool-based tests. Before getting a particular service your doctor calls preventive, check with your insurance company to make sure they will reimburse it before agreeing to it.
Healthcare Professionals who provide Preventive Health Care
Under Obamacare (PPACA) and medical coding definitions, the medical doctor (often the primary care doctor) is in control of reimbursable preventive health care services. The AMA’s CPT® medical codes are written so that preventive care services are doctor-centered (and not patient-centered). Given that many preventive health care services require the expertise of several non-physician health professionals (e.g., care managers, psychologists, dietitians, exercise physiologists, and social workers), the medical doctor will either have to hire them as employees or create financial relationships that acknowledge the doctor’s control of reimbursement. Additional education of doctors delivering preventive health care services is also required given that they are trained to deliver after sickness care.
The Healthcare Consumer’s Contribution to Preventive Health Care
While the medical doctor may be in control of reimbursable preventive health care services, the healthcare consumer plays a major role in what preventive health care is practiced and utilized. People who eat nutritious meals, maintain a normal weight, exercise regularly, do not smoke, and limit alcohol consumption are practicing preventive care every day. While some people are able to practice healthy lifestyle habits on their own without the direction of a medical doctor or other paid healthcare professionals, others cannot.
It is easy to say no to preventive health care services for a number of reasons. People can rationalize postponing or foregoing preventive services when they have no symptoms of sickness (i.e., are “healthy”). Other “healthy” Americans simply cannot afford to pay for preventive services unless they come with zero cost-sharing. The Centers for Disease Control and Prevention estimates that Americans access preventive services at only about half the recommended rate. Our government needs to do more to “incentivize” the healthcare consumer to get the appropriate preventive health care services most beneficial for them.
All medical procedures include risks and many preventive care screenings are no exception. The healthcare consumer needs to weigh the risks against the benefits of a particular screening before making a final decision about having the screening and when. For example, taking tamoxifen to reduce one’s risk of breast cancer requires careful evaluation based on your health and lifestyle, scientific recommendations, your personal values, and your doctor’s advice. The final choice is yours.
Several years ago when an annual mammogram was recommended for breast cancer screening, I weighed the scientific recommendations (in England, the recommendation was for biennial screening) against my risk (no personal history of breast cancer and none in my family) and decided to take the screening every other year. My decision was also based on my desire to minimize my x-ray radiation exposure from the mammogram. After a discussion with my doctor, he agreed with me after I assured him that I understood the risks. Today, I smile when I see that the latest breast cancer screening recommendation calls for having a mammogram biennially. I was ahead of my time!
Final Words on Preventive Health Care
We have in our power to delay or reduce the incidence and severity of chronic diseases and conditions by taking advantage of preventive health care. Preventive health care is a win-win relationship between healthcare consumers and payers–the consumers gets to live healthier, less painful lives and the payers save money on after sickness care.
While you are still healthy and not in need of after sickness care, make every effort to lead a healthy lifestyle, get your recommended immunizations, avoid tobacco, and have the cancer screening tests that are appropriate for you. In addition, get your blood pressure, cholesterol, and glucose tested before chronic diseases and conditions take hold. I also encourage everyone to get more knowledgeable about your own health care.