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Panel: Expand preventive services with no cost-sharing for women

By MICHELLE ANDREWS

For Kaiser Health News

The list of preventive services that women can receive without paying anything out of pocket under the health law could grow if proposed recommendations by a group of mostly medical providers are adopted by federal officials later this year.

The draft recommendations, which are open for public comment until Sept. 30, update the eight recommended preventive services for women. That list was developed by the Institute of Medicine — now called the National Academies of Sciences, Engineering, and Medicine — to build on existing recommendations and fill in gaps that weren’t addressed in the health law. Under the IOM list, which took effect in 2012, most health plans are required to cover well-woman visits, screening and/or counseling for sexually transmitted infections, domestic violence and gestational diabetes as well as breastfeeding support and supplies.IOK

In addition, most health plans must cover, without cost-sharing, all methods of contraception that have been approved by the Food and Drug Administration. That controversial requirement led to numerous lawsuits by religious institutions and employers that object to providing such coverage, including several cases that reached the Supreme Court.

When it developed the initial list, the IOM advised that the guidelines be reviewed and updated at least every five years in order to stay current with scientific evidence. This year, the review panel also weighed in on breast cancer screening, coverage of follow-up testing or procedures as part of the preventive services and male methods of birth control.

The proposed new recommendation would allow women at average risk for breast cancer to begin screening as early as age 40 and receive a mammogram every one or two years. That is a more liberal standard than the guidelines that insurers rely on for free screening from the U.S. Preventive Services Task Force, which recommends women generally be screened every other year starting at age 50.

“We have really confused the heck out of women,” said Dr. Hal Lawrence, executive vice president and chief executive officer of the American Congress of Obstetricians and Gynecologists. “Do I start at age 40, do I start at 50, do I do it every year or do I do it every other year? We wanted to get some uniformity.”

ACOG was awarded a 5-year grant to manage the review process, working in conjunction with a steering committee of nearly two dozen provider groups from different women’s health disciplines.

In addition to the breast cancer screening itself, the ACOG working group proposes that if imaging tests, biopsies or other interventions are required to evaluate the mammogram findings that those be considered an integral part of the screening, which would mean they would be provided without charge to women.

Such follow-up care emerged as a theme from the panel: If additional testing or procedures are necessary following a preventive service, it should be covered as part of the service. The recommendations also clarify that some of the preventive services may require more than one visit and provide other specifics on coverage requirements.

“It’s critically important for plans and people to recognize that the well-woman visit [required under the current guidelines] could happen in multiple places and require multiple visits,” said Mara Gandal-Powers, senior counsel at the National Women’s Law Center, which participated in the ACOG working group. “If you’re a woman who needs a Pap test and a colonoscopy, you’re probably not getting them from the same providers and you’re hopefully not getting them at the same time.”

The recommendations’ specificity is important: The original IOM guidelines left implementation details vague, leading to scuffles between patient advocates and insurers over precisely what was covered, and that ambiguity required ongoing guidance from the federal government. For example, if a plan covers oral contraceptives without cost sharing, could it charge for other hormonal methods such as the contraceptive patch? Answer: No.

“It’s helpful to get the real-world piece,” said Dania Palanker, assistant research professor at Georgetown University’s Center on Health Insurance Reforms. “For insurers, what do we mean when we say you have to cover a service?”

A spokesperson for America’s Health Insurance Plans said that the trade group will likely submit comments on the proposed recommendations and declined to comment before then.

The working group recommended expanding the scope of what’s covered without cost sharing in some important ways. The contraceptive coverage requirement, for example, would cover over-the-counter methods of birth control without a prescription and allow women to receive a full-year supply of contraceptives all at once, which has been shown to improve adherence.

The ACOG group also proposes covering contraception methods used by men, including condoms and vasectomy.

“The best contraceptive method for a woman at a particular time may be her partner,” said Adam Sonfield, a senior policy manager at the Guttmacher Institute, a reproductive health research and policy organization.

The working group will submit its final recommendations to the Health Resources and Services Administration, part of the Department of Health and Human Services, by Dec. 1, and HRSA will make the final decision on adoption of the recommendations. If adopted before the end of the year, they would go into effect for most plans at the beginning of 2018.

 


Many pre-colonoscopy office visits called unneeded

By MICHELLE ANDREWS

For Kaiser Health News

 

Nearly a third of patients who get colonoscopies to screen for cancer visit a gastroenterologist before having the procedure, at an average cost of $124, even though such visits may be unnecessary, a new study found.

Primary-care doctors are generally in a good position to alert their patients that they should be screened, discuss the risks and benefits of the procedure with them and order the test, said Dr. Kevin Riggs, an internist at Johns Hopkins University School of Medicine who co-authored the study, which appeared this week in the Journal of the American Medical Association. Such “open access” programs, which allow providers and sometimes patients to schedule the screening test without first sitting down with a gastroenterologist for a consultation, are becoming routine.

The gastroenterologist’s office can then contact the patient to discuss how to take the bowel- preparation mix to clean out the colon before the test. The patient can simply show up for the colonoscopy on the scheduled day, without taking more time off work and saving the cost of a specialist office visit.

“These are things that streamline the care processes and lead to a better patient experience,” Riggs said. “We should be thinking about ways to make the process more efficient.”

Colorectal cancer screening is recommended by the U.S. Preventive Services Task Force for most people beginning at age 50. Under the health law, insurers are required to cover preventive services without charging consumers. But although the federal government has clarified that insurers can’t charge people for anesthesia received during a colonoscopy, the rules don’t state how insurers should handle other services, including office visits and facility fees.

The study analyzed the claims data of 843,000 patients between the ages of 50 and 64 between 2010 and 2013 who had a screening colonoscopy. They all had employer-sponsored coverage.

Twenty-nine percent of patients visited a gastroenterologist in the six weeks prior to a screening colonoscopy, the study found. It wasn’t possible to determine the precise reason for the office visits, and some may have been clinically necessary, said Riggs.

The average office visit payment was $124, including both patient and insurer portions. Across all patients, the office visits added an average $36 to the total cost of a colonoscopy.

“It’s nickels and dimes, but when you add it up over 7 million colonoscopies annually, it’s a pretty significant cost,” said Riggs.

 


Plan to discourage routine prostate-cancer screenings fought

prostate

There has been a lot of pushback to a proposed plan by the Centers for Medicare & Medicaid Services to penalize doctors who order routine prostate-cancer screening tests. It’s part of a federal effort to define and reward quality in health-care services and to advance evidence-based medicine.

The Wall Street Journal reports that some complain that the measure “would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.”

“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” David Penson,  M.D., chairman of public policy and practice support for the American Urological Association,  told the WSJ. The association urged  the CMS not to implement the proposal.

The U.S. Preventive Services Task Force  opposes routine screening for prostate cancer for men of any age because, it says,  the benefits don’t outweigh the harms.

 

 

 


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