The recently enacted health care reform legislation, which calls for eliminating financial barriers for many preventive services, likely will create a greater demand for these services and give physicians a better opportunity to provide preventive care, according to analysts interviewed by AAFP News Now.
The Patient Protection and Affordable Care Act(www.opencongress.org) will require new health plans (i.e., plans that are established on or after Sept. 23, 2010) to cover and eliminate copays, deductibles and coinsurance amounts for preventive services rated "A" or "B" by the U.S. Preventive Services Task Force(www.uspreventiveservicestaskforce.org). According to the law, new plans also will have to eliminate copays, deductibles and coinsurance for other preventive services and vaccines whose health benefits are strongly supported by scientific evidence and recommended by agencies such as HHS.
The same provisions will apply to the Medicaid and Medicare programs as of Jan. 1, 2011. Both programs will be required to eliminate copays, deductibles and coinsurance for the same recommended preventive services and vaccines. This requirement is expected to boost patient access to dozens of services, including cholesterol screening tests, routine vaccinations, many cancer screenings, prenatal care, and regular wellness visits for infants and children.
HHS has moved quickly to supply details regarding this part of the health care reform legislation. It issued interim final rules(www.healthcare.gov) for the preventive services provisions on July 14. However, the full impact of the provisions is not altogether clear because Medicaid and Medicare and many private plans were already in the process of eliminating cost-sharing for several of the recommended preventive services. In some respects, the new law will accelerate this existing trend. In fact, HHS estimates that the provisions will eliminate financial barriers for 41 million people within the next year(www.healthcare.gov). However, this fact likely will lead to a much greater demand for preventive services, thus creating challenges, along with opportunities, for primary care physicians.
"There is very good evidence showing that when you eliminate cost-sharing and copays for evidence-based services, people are more likely to use them," said Ann O'Malley, M.D., M.P.H., senior researcher at the Center for Studying Health System Change.
The Patient Protection and Affordable Care Act seeks to promote the provision of preventive care services by putting in place mandates to ensure the coverage of recommended preventive measures in the public and private sectors.
The law requires new health plans -- plans established on or after Sept. 23 -- to cover and eliminate copays, deductibles and coinsurance for preventive services rated "A" or "B" by the U.S. Preventive Services Task Force(www.uspreventiveservicestaskforce.org). According to the law, new plans also will have to eliminate copays, deductibles and coinsurance for
- routine vaccines, including standard vaccines recommended by the CDC's Advisory Committee on Immunization Practices that range from routine childhood immunizations to periodic tetanus shots for adults, and
- prevention services for children, including preventive care for children recommended under the Bright Futures guidelines(brightfutures.aap.org) developed by the Health Resources and Services Administration and the American Academy of Pediatrics.
Meanwhile, the federal government plans to convene a panel of experts composed of physicians, nurses and scientists who will issue guidelines on prevention for women on Aug 1, 2011. New health plans will have to cover the services recommended by this panel, as well.
Medicaid and Medicare will have to adhere to the preventive coverage requirements as of Jan. 1, 2011. The new law waives the Part B deductible and the 20 percent coinsurance that would apply to most preventive services under Medicare. It also waives the Part B deductible for tests that begin as colorectal cancer screening tests but become diagnostic or therapeutic interventions based on findings during the test. In addition, the law requires coverage for annual wellness visits that entail personalized prevention plan services for patients.
The new law's provisions could lead to patients having a difficult time getting an appointment with an increasingly small pool of primary care physicians. But they also will mean that primary care physicians will be able to catch many chronic problems before they become acute.
With the new law, it will be easier for primary care physicians to provide the recommended services, said Herbert Young, M.D., director of the AAFP's Scientific Activities Division.
"It should alleviate the frustration that many physicians face when patients say they cannot afford the copay or other costs associated with preventive services," said Young.
Although the preventive coverage provisions apply only to new health plans in the private sector, older plans -- those established before Sept 23 -- will lose their exempt or grandfathered status if they make significant changes that reduce benefits or increase costs to consumers, according to the law.
"Plans do make changes," said Paul Fronstin, Ph.D., director of the health research and education program at the Employee Benefit Research Institute, which focuses on health care coverage in the workplace. "They increase deductibles. They increase copayments, coinsurance and what is covered by the plans."
"If the plan is changed enough and is not the same plan anymore, it is no longer grandfathered and that triggers these (preventive) mandates," added Fronstin.
HHS issued rules(edocket.access.gpo.gov) on the grandfathered status of health plans on June 17. The agency estimates that nearly 70 percent of all private employer plans could lose their exempt status by 2013.
For their part, primary care practices should examine their systems of care to make sure patients are receiving the recommended preventive services, said Young. This type of analysis will underscore the need for the patient-centered medical home, making it even more important to health care system reform, he added.
The medical home model employs a system-based approach to care that uses health care teams and electronic health records to, for example, manage care and identify patients who need screenings or immunizations, Young said. The law itself should help primary care practices become better medical homes.
The AAFP is reviewing and will comment on HHS' interim final rules regarding preventive services for which coverage will be required under the new health care reform law. Staff members will assess the covered preventive services and the implications for physicians' billing practices. The AAFP also will develop materials to help educate members about what the HHS regulations require of them in terms of preventive services.
"One of the roles of good primary care is to address a patient's preventive health care needs, as well as their acute (and) chronic care management," said O'Malley. "The fewer obstacles to getting patients to go forward with these preventive services, the better. That is one of the jobs of primary care doctors -- to try and get people the services that are recommended and evidence-based."
Despite the benefits of the preventive care provisions in the health reform bill, they have raised some concerns. For example, insurance plans might shift costs to compensate for the mandated coverage of preventive services, resulting in higher insurance premiums.
"With any new requirements -- whether it is limits on copays, changes in deductibles or other benefit requirements -- there are costs associated with those," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, the nation's largest insurance lobby. "That will more than likely be reflected in the cost of health care coverage."
Some analysts worry that the requirements will establish a coverage ceiling, requiring health plans to cover mandated services but encouraging them to drop coverage for services that are not highly recommended but that may be beneficial in some patients. According to O'Malley, however, the law requires coverage for preventive services that have been shown to improve health while also reducing morbidity and mortality rates.
"The irony is that health care coverage has often paid for things where we don't have good proof," said Young. "Here is a case where science is being properly paid for."