HHS has approved eight recommendations(www.hhs.gov) proposed in an Institute of Medicine, or IOM, report(www.nationalacademies.org) issued last month that are expected to expand women's access to clinical preventive services.
New health plans (i.e., plans that are established on or after Sept. 23, 2010) must cover the following services without cost-sharing for plan years beginning on or after Aug. 1, 2012:
- well-woman visits;
- screening for gestational diabetes;
- human papillomavirus, or HPV, DNA testing for women ages 30 and older;
- sexually transmitted infection counseling;
- HIV screening and counseling;
- FDA-approved contraception methods, contraceptive counseling and sterilization procedures;
- breastfeeding support, supplies, and counseling; and
- domestic violence screening and counseling.
"Between the preventive services task force and these eight new recommendations, women's prevention really has been advanced a great deal," said Al Berg, M.D., of Seattle, referring to recommendations for clinical services for women already made by the U.S. Preventive Services Task Force, or USPSTF. A professor of family medicine at the University of Washington, Seattle, who served on the IOM committee, Berg is a former chair of the USPSTF.
The Patient Protection and Affordable Care Act of 2010 requires new insurance plans to cover evidence-based recommended services that have received an A or B grade(www.uspreventiveservicestaskforce.org) from the USPSTF. At the request of HHS, the IOM committee was charged with identifying gaps in existing preventive service recommendations, as well as proposing other measures that would help ensure women's health and well-being.
- New recommendations developed by the Institute of Medicine, or IOM, and approved by HHS will require new health insurance plans to cover certain preventive services for women without cost sharing with plan years beginning on or after Aug. 1, 2012.
- The IOM's recommendations are for services that should be covered when indicated and are not recommendations for routinely providing the services.
For example, the USPSTF and the AAFP both recommend that physicians "promote and support breastfeeding," and the task force gave that guidance a B recommendation. However, Berg said the IOM committee found the wording of that recommendation to be vague and, thus, took it a step further, recommending that counseling and equipment should be covered by insurance.
"Support means more than just the physician saying, 'You ought to do this,'" Berg said, "so we added some detail to it. Support could mean a lot of things. We wanted to make clear that the evidence shows that to make breastfeeding happen, you have to provide a lot of support, up to and including renting breast pumps for women."
Berg, who was a member of USPSTF from 1992 through 2004, said the task force has not had a recommendation regarding contraception since the early 1990s.
"The evidence, the science, showing that contraception works is extremely strong, and at the time, the task force didn't think we had anything to add about the science," Berg told AAFP News Now. "The policy issue, of course, is whether you cover contraception. That turned out to be the hot button issue."
When the IOM released its report July 19, much of the mainstream media attention focused on the recommendation regarding contraception. However, many of the media reports failed to clarify that the IOM's recommendations were about coverage, not routinely providing the services in question.
The American College of Obstetricians and Gynecologists, or ACOG, recently issued new guidelines(www.guideline.gov) that recommend women be offered mammography screening each year beginning at age 40. ACOG previously had recommended mammograms every one to two years starting at age 40 and annual mammograms beginning at age 50.
The ACOG recommendations conflict with those of the U.S. Preventive Services Task Force, or USPSTF, and the AAFP, which recommend biennial screening mammography for women ages 50-74. The Academy and the USPSTF recommend that the decision to conduct screening mammography before age 50 should be individualized and take into account patient context, including a woman's individual risks and values regarding specific benefits and harms.
ACOG also recommended that health care professionals screen all women for a history of sexual assault, as well as for alcohol use at least annually and within the first trimester of pregnancy.
The AAFP and the USPSTF recommend screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.
"Those eight new conclusions we reached don't mean all those things should be done for all woman in all settings," Berg explained. "It means that if they're indicated, they should be covered. These are permissive but not prescriptive. The fact that we recommended that HIV testing ought to be covered doesn't mean that everyone in all circumstances ought to have it done."
Recommendations regarding whether or not the benefits of a service outweigh its potential harms remain the purview of the USPSTF, which happens to be considering topics related to three of the IOM recommendations. The task force's list of topics in progress(www.uspreventiveservicestaskforce.org) includes cervical cancer screening, family violence screening and HIV screening.
USPSTF Co-vice chair Michael LeFevre, M.D., M.S.P.H., of Columbia, Mo., said the task force likely will publish a draft recommendation regarding cervical cancer that includes an assessment of HPV status within the next six to 12 months.
"The IOM's assessment of coverage won't have any influence over the timing, the assessment of evidence or our conclusions," said LeFevre, who is a professor and assistant chair in the department of family and community medicine at the University of Missouri, Columbia.
LeFevre told AAFP News Now that the IOM committee's recommendations were well thought out and justified as covered services. Like Berg, however, he is concerned that the difference between an endorsement of coverage and an endorsement of routinely providing a service will be lost on many doctors and patients.
"We have to acknowledge that there are many doctors out there who would use a coverage decision as an endorsement to routinely provide a service," said LeFevre, "and I'm troubled by that.
"Some women will look at a coverage decision as a recommendation to have a test done. I expect women will be coming into my office and saying, 'The Institute of Medicine is telling me I should have an HPV done,' when that's not really what the Institute of Medicine is saying. What they are saying is there may be enough legitimate reasons to do this in some women that it should be a covered service."
Coverage requirements will be limited to new plans in the short term. However, Berg said he expects the percentage of insured women who have access to these services without cost-sharing to increase rapidly as health plans change and become subject to Affordable Care Act requirements.
"If health care reform survives and this whole program moves ahead, the hope is that just about all women covered by insurance will have this coverage within the next five to 10 years -- and it could be sooner than that," Berg said. "If current plans feel they're being left behind because all the new ones are covering these services, some people believe that current plans will change very quickly."
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