Accelerating the Adoption of Preventive Health Services · Accelerating the Adoption of Preventive...

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2” Building New Partnerships and Community Commitment

P R O C E E D I N G S F R O M A C O N F E R E N C E

1225 19th Street, NW

Suite 710

Washington, DC 20036

T E L 202.296.4426

FA X 202.296.4319

W E B www.nihcm.org

Division of Prevention Researchand Analytic Methods

4770 Buford Highway – K73

Atlanta, Georgia 30341

T E L 770.488.8188

FA X 770.488.8461

W E B www.cdc.gov

Accelerating the Adoption of Preventive Health Services

Executive Summary i

Introduction 1

Accelerating the Adoption of Preventive Health Services 3

Employer Strategies 4

Health Plan Strategies 9

Federal Government Strategies 14

State Government Strategies 17

Provider and Consumer Strategies 18

Conclusion 24

Endnotes 24

Appendices 25

A: The CDC Guide to Community Preventive Services 25

B: List of Conference Faculty 26

C: Medicare and Preventive Care Services 28

D: Resources and Links 30

Table of Contents

Credits

The National Institute for Health Care Management(NIHCM) Research and Educational Foundation convenedthe conference on which this publication is based. TheCenters for Disease Control and Prevention (CDC)sponsored the conference. It was held September 26-27,2002 in Washington D.C.

The NIHCM Foundation is a non-profit, non-partisanorganization whose mission is to promote improvement inhealth care access, quality, efficiency, and management.The Foundation is in Washington, D.C.

The CDC is the lead federal agency charged with promotingand protecting the health of the American people. It isbased in Atlanta, Georgia.

The following organizations also provided support for theconference: the American Association of Health Plans, theBlue Cross Blue Shield Association, the Alliance ofCommunity Health Plans, the National Business Coalitionon Health, and the Washington Business Group on Health

Larry Stepnick, president of The Severyn Group, a healthcare research and consulting firm, wrote this proceedingsreport. Steven Findlay, MPH, of the NIHCM Foundationedited it.

© 2003 National Institute for Health Care Management Foundation

Building New Partnerships and Community Commitment

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Executive Summary Preventive health services andpromotion of healthy lifestyles continue to beseriously underutilized health strategies in theUnited States. This report summarizes theproceedings of a conference convened toexplore: (a) the confluence of forces responsiblefor the underuse of many preventive healthservices, (b) the current science and evidence onthe value of preventive care, and (c) ways theadoption and use of preventive health servicesmight be accelerated. The conference broughttogether speakers and participants from healthplans, employers, medical groups, government,academia, benefits consulting firms, and thepublic health community.

Speakers and participants broadly concurredthat the evidence base for many preventivehealth services is growing stronger, and thatemployer, health plan, and governmentcoverage of preventive care services hasexpanded significantly over the last decade.Several speakers presented data showing a“return on investment” (ROI) for selectedpreventive services (such as smoking cessationand disease screenings) in the range of $2 to $4of value (e.g., in reduced illness, absenteeism,enhanced worker productivity) for every $1invested.

Despite this, speakers said that lingering doubtsconcerning the clinical benefit and cost-effectiveness of many preventive care services(at a time of heightened concern about healthcosts) remains an obstacle to even broaderprivate and public insurance coverage andprovider and consumer use of preventive care.Clinicians in particular are highly variable intheir embrace of preventive care and lifestylemodification counseling, even when services area covered benefit for their patients. Fewer thanhalf (44%) of primary care physicians, forexample, consistently review their patients’health behaviors.

At the same time, continuing lack of awarenessamong consumers about the health benefits ofpreventive care further impairs wider use.Workforce turnover also remains a potentobstacle to employers’ willingness to invest inpreventive benefits and work site healthpromotion and behavioral counseling programs.Finally, speakers agreed that the emerging ROIcase for some key clinical preventive andbehavioral modification services has not beenmade or communicated strongly enough toemployers, insurers, providers, and consumers.

Speakers supported the work of twogovernment initiatives – the United StatesPreventive Services Task Force (USPSTF, housedat the Agency for Healthcare Research andQuality) and the Centers for Disease Controland Prevention’s (CDC) efforts in creating theGuide to Community Preventive Services. Bothinitiatives make preventive servicesrecommendations based on systematic and in-depth reviews of the scientific evidence. (Formore information on the CDC guide, please seeAppendix A.)

Speakers urged health benefit managers andconsultants, health plan administrators, andclinicians to learn more about these initiativesand the evidence supporting the clinical andfinancial return from preventive care services.Payers, including Medicare, should considerexpanding coverage of preventive care servicesand aligning it with USPSTF and CDCrecommendations. Today, employer andMedicare coverage of preventive services isconsistent only about half the time with theserecommendations.

Speakers recommended that employers, healthplans, government, and provider organizationspartner to accelerate the adoption of evidence-based preventive health services among bothclinicians and consumers. New tools based oninformation technology and the internet shouldbe employed more aggressively in this context.


Other general points of agreement thatemerged:

Government could more effectively use thetools at its disposal to encourage evaluation,coverage, adoption, and consumer use ofevidence-based preventive services. Thesetools include public awareness campaigns,research, funding for demonstrationprojects, and tax incentives.

Employers could more effectively use theworkplace as a setting for preventive healthscreenings and identifying populations inneed of behavioral and lifestyle counseling.

Stakeholders need to collaborate at thecommunity level. Well-targeted,coordinated, mutually reinforcingprevention messages and campaigns almostalways achieve a larger impact and greatersuccess that do “stand-alone” initiatives.

Health plans could do more to communicatethe clinical value of covered, evidence-basedpreventive care services to doctors in theirnetworks and to their enrollees. They shouldconsider helping doctors build andimplement reminder systems and otherinformation technology-based tools that willenhance the delivery of preventive careservices.

Non-physician professionals are often idealproviders of preventive health andbehavioral counseling services, particularlywhen lengthy patient counseling andfollow-up is involved. Insurers andgovernment should consider coveringservices delivered by these individuals whenevidence supports it.

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Introduction This conference brought a diverse groupof health care stakeholders together to betterunderstand how to accelerate the adoption ofpreventive services and lifestyle modificationprograms in the U.S. Susan Dentzer, healthcorrespondent for The NewsHour with JimLehrer, moderated the event.

Nancy Chockley, MBA, president of NIHCMFoundation, set three goals for the conference:

To improve understanding of decision-making around coverage of preventive careservices.

To foster a dialogue among keystakeholders about the issues at hand.

To understand how to make the preventionmessage more compelling to eachstakeholder in an era of rising health carecosts.

Richard Dixon, MD, director of the Division ofPrevention Research and Analytic Methods atCDC, noted that despite years of mountingresearch and experience, a large gap remainsbetween what we know works in preventionand what is practiced. Even though studiesdemonstrate the benefits of standing orders toscreen – and when necessary immunize –hospitalized elderly patients for pneumococcaldisease, for example, relatively few hospitalshave such orders in place. Likewise, manyemployers and health plans still pay for onlyone smoking cessation intervention per year,despite strong evidence showing that multipleinterventions yield substantial benefits atrelatively low cost. Gaps like these need to beclosed.

In a keynote address, Richard Carmona, MD,MPH, FACS, Surgeon General of the UnitedStates, said fully 70% of annual health carespending in the U.S. pays for the care of peoplewith diseases, illnesses, and chronic conditionsthat could have been prevented. In particular,

increasing proportions of the U.S. populationnow live sedentary lifestyles that contribute toor exacerbate a variety of ailments. Obesityrelated to physical inactivity and excessivecaloric intake is today the fastest growingcause of preventable death, responsible formore than $150 billion annually in direct andindirect health care costs. And it’s not justadults that cause concern; childhood obesity isalso a major emerging social and public healthproblem. An estimated 300,000 Americans dieeach year prematurely as a result of beingoverweight or obese.

Cary Sennett, MD, PhD, vice president forscience and quality improvement at theAmerican College of Cardiology and editor-in-chief of Preventive Medicine in Managed Care,shone a spotlight on the role prevention hasplayed to date in cardiovascular disease (CVD)and diabetes – and the challenges that are stillunmet.

Some 60 million Americans have heart and/orvascular disease, including three-quarters ofthose over the age of 75, half of those age 55 to64, and one-third of those age 45 to 54. Thecost: $200 billion annually, 15% of the nation’shealth expenditures. But too little is spent onpreventing CVD despite mounting evidencethat the effort would produce benefits that faroutweigh the costs, Dr. Sennett told conferees.

A significant drop in premature deaths fromheart disease over the past 20 years, especiallyamong men, underscores the potential toreduce the burden of this leading killer. Aportion of these gains are due to increased useof procedures to diagnose and treat the disease(e.g., catheterizations, bypass surgery, andangioplasty). But a portion is also attributableto a reduction in adult smoking, lifestylemodifications, improved identification ofpeople with heart disease, and improvedpreventive care treatment of people with highblood pressure and high cholesterol levels.

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Despite these gains, however:

Only half of the 50 million Americans withhigh blood pressure have the conditionadequately under control with lifestylemodifications and medication. Fully 25%are not even taking a high blood pressuredrug. Untreated high blood pressure overtime doubles or even triples the risk ofhaving a heart attack or stroke.

Approximately 42 million Americans are athigh risk for CVD due to elevatedcholesterol levels (defined as a level above240 mg/dl). Studies suggest that themajority of these individuals are not beingadequately treated, and thus are at higherrisk of angina and heart attack. In addition,in 1999 roughly 30% of adult Americanshad not had their cholesterol tested in thepast five years.1

Almost half of all adults are overweight,with 44 million classified as obese. Obesityis now widely recognized as anindependent risk factor for premature heartdisease and premature death from heartdisease.

Three in four Americans do not reachtarget levels of physical activity.

Over 20% of the population smokes,including one in four men.

Dr. Sennett emphasized that even modestreductions in risk factors through a greateremphasis on prevention and lifestylemodification can have a huge impact onthe incidence and costs of CVD-relatedepisodes, including heart attacks andstrokes. For example, even a one-percentreduction in the prevalence of smokingamong adults age 35 to 64 would lead, overseven years, to 64,000 fewerhospitalizations for heart attack, 34,000fewer hospitalizations for stroke, and a $3.2billion reduction in health costs.2

Dr. Sennett said such an aspiration isentirely realistic. California, for example,has already achieved a significant decline

in smoking prevalence. (See Figure 1.) AndGroup Health Cooperative, a health plan in theSeattle area, reduced the prevalence ofsmoking in its enrolled population to 15%, fivepercentage points below the average in theSeattle area. Similar strides could be made toprevent and treat diabetes, and to lessen theburden of its complications. An estimated 17million Americans have diabetes, six million ofwhom do not know it. But better short- andlong-term glycemic control can reduce costsand improve functional status for patients whohave or are at-risk of developing diabetes. Astudy at Group Health Cooperative in Seattlefound that improvements in glycemic controlover a period of six years led to averagereductions in health care costs of $685 to $950per diabetic patient per year.3

But even short-term control of blood sugarlevels can provide significant benefits. Dr.Sennett cited a study on the impact of glycemiccontrol over a four-month period documentingimproved quality of life and functional statusand a roughly 50% reduction in workplaceabsenteeism.4

Figure 1:Accelerating the Decline in Smoking

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Suzanne Mercure, a consultant to theNational Business Coalition on Health(NBCH) and the Washington BusinessGroup on Health (WBGH), echoed Dr.Sennett’s plea with remarks onpreventing the onset of chronic disease.Employers are newly focused on thisstrategy, driven by recent researchshowing that a growing portion ofemployer health care costs are generatedby individuals with chronic (largelypreventable) diseases. (See Figure 2.) Suchindividuals represent about one in fourworkers but account for 42% of totalemployer health costs.

Catherine Gordon, RN, MBA, formerdirector of health promotion and diseaseprevention at the Centers for Medicare &Medicaid Services (CMS) and now seniorpublic health analyst in the Office of theDirector at CDC, said preventable chronicdisease is also now a major focus ofMedicare policy. A majority of Medicarebeneficiaries over age 75 have one or morechronic illnesses. (See Figure 3.) Ms. Gordonsaid CMS and CDC are keenly aware thatpreventive health measures and lifestylemodifications could enhance the health ofthe elderly population and help constraingovernment spending on health care.

Figure 2: Impact of Chronic Disease

Figure 3: Chronic Conditions AmongPersons Aged 70+

Accelerating the Adoption of Preventive Health Services Employers, health plans, andgovernment have significantly expanded theirpromotion and coverage of preventive healthservices in the past decade. This has increasedclinician use of such services and consumeraccess to them. But both provider andconsumer adoption are still sub-optimal for acomplex mix of reasons. This has promptedprivate payers, government, and providers tosearch for new ways to accelerate theappropriate use of such services and create ahealthier workforce and population.

Speakers generally concurred that prevention’spotential to enhance the health of thepopulation and constrain health care spendingwill not be realized until prevention’s “returnon investment” (ROI) is more clearlyarticulated and communicated. In addition,speakers agreed that major health stakeholderscould accelerate the diffusion of evidence-based preventive services through bettercollaboration and coordination of their efforts.

Source: Health Affairs, Nov/Dec 2001

Source: CDC/NCHS Health US, 1999

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Figure 4: Employer-Based Preventive Care Services - 2001*

Employer StrategiesMaris Bondi, MPH, senior health analyst withthe Partnership for Prevention, presentedresults from a survey of employers conductedin 2001. The study, funded by the Robert WoodJohnson Foundation, found high rates ofcoverage for most common preventive careservices. Over 80% of surveyed employers, forexample, provided coverage for physical/wellness exams, gynecological exams, andchildhood immunizations. Several otherpreventive health tests, procedures, andinterventions were covered at much lowerrates, including chlamydia screening, smoking

cessation programs, nutrition/diet counseling,and weight loss programs. (See Figure 4.)

Work site preventive care and wellnessprograms were far less universal. Only 5% ofemployers had a formal stress managementprogram. A similar small percentage ofemployers offered work site weight counselingand smoking cessation programs.

The survey found that employer coverage doesnot always follow the recommendations of theUnited States Preventive Services Task Force(USPSTF), a government-sponsored panel ofexperts affiliated with the Agency forHealthcare Research and Quality (AHRQ). (See

*Percent of employerscovering service through thehealth plans they sponsor.Source: Partnership forPrevention/William M. MercerNational Survey of Employers,2001. Results presented hereare preliminary. Final reportto be issued in 2003.

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box on page 8.) For example, task forcerecommendations include screening forcolorectal cancer but not for prostate cancer,yet more employers cover the latter. The taskforce also recommends routine chlamydiascreening for women under age 25, yet only40% of employers cover this service at all. Ms.Bondi and other conferees suggested thatemployer coverage of preventive services berefined based on USPSTF recommendations.

Peter R. Kongstvedt, MD, vice president atCap Gemini Ernst & Young, cautioned,however, that the current escalation in healthcare costs makes it difficult for employers andgovernment to contemplate expanding benefits– even in cases where evidence is growing thatthe benefit may save money in the long run.Health care costs are soaring again at a timewhen many employers’ ability to increaseprices, productivity, and earnings areconstrained.

Jon Gabel, MA, vice president for healthsystem studies at the American HospitalAssociation’s Health Research and EducationalTrust, concurred that rising health benefit costsare dampening employers’ willingness toenhance benefits. But many employers—andthe health benefit managers that help themdesign health coverage—are favorably inclinedto preventive care – believing that suchbenefits, particularly in managed care plans,are popular and foster good will amongemployees. On the other hand, benefitconsultants sometimes can be “the problem”when they advise clients against coveringspecific preventive services on the basis thatthey – the employers – will reap little or none ofthe benefit themselves. Indeed, employeelongevity on the job and workforce turnoverremain potent obstacles to top management’swillingness to invest in preventive care benefits.

Linda Bergthold, PhD, senior consultant andnational thought leader at Watson WyattWorldwide, agreed. Many benefit consultantsare unaware of the literature on prevention.For this reason, Watson Wyatt is in the processof evaluating the “science base” for manypreventive health services, and specifically the

work of the USPSTF. The aim is to pull togethera preventive benefits package based on the taskforce’s recommendations. Such a tool shouldhelp inform everyone and lead to increases incoverage and adoption of such services. Thecase is likely to be especially strong if thebenefits can be linked to specific chronicconditions, since employers increasinglyrecognize that identifying and managing high-risk individuals makes best use of their healthcare dollars.

Speakers said the “return on investment” (ROI)issue looms large for employers. It’s how theyevaluate their capital investments, and theytend to think the same way about the healthcare services they purchase. (See box entitledProjecting ROI on page 16.)

Ms. Bondi said that focus groups with largeand small employers show that employersaccept the premise that preventive healthservices should and often do reduceabsenteeism, enhance productivity, and savemoney. But they are nevertheless quite skepticalthat a clear ROI has been demonstrated formany if not most preventive care services.

Ms. Mercure said her experience working withlarge employers confirms this. Businessexecutives want to see “units of somethingproduced” – real costs, a real ROI calculation,and short- and long-term productivity gains. Ifemployers are going to increase coverage ofpreventive services, they must see evidence thatthey will realize short-term savings—eitherthrough reduced health care costs orreductions in lost work time—that outweighany incremental costs. Tami Collin, seniorconsultant at William M. Mercer, Inc., agreedthat ROI evaluations are important. But thedata need not be perfect or precise. ElizabethDudek, senior health consultant and vicepresident of The Segal Company, a benefitsconsultant firm, said that what employersreally care about is “presenteeism” – gettingworkers who are on the job to perform at100%. She and Ms. Collin agreed that there isan urgent need to put systems in place to trackthe impact of initiating coverage of preventiveservices on presenteeism, absenteeism, andoverall health costs.

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Case Studies: Employer StrategiesVirtually all large companies cover preventive care services and many also conduct work sitehealth promotion activities. But companies vary widely in their approach, as illustrated in thethree case studies that follow.

Dow ChemicalSteve Morgenstern, health plan manager atDow Chemical, said the company spent$290 million on health care in 2002. Aftermany years of not covering preventive care,Dow – “reluctantly” at first – began to coverselected services in the 1980s. Among thesewere pap smears and mammograms.

By the 1990s, the company’s leadershipbegan to see wisdom in promotingprevention more rigorously. As a result, Dowinitiated coverage for well-baby care andimmunizations, and began offering awellness benefit, disease management,demand side management, and fitnesscenters at facilities with a large number ofworkers.

In the last few years, Dow implementedcoverage for smoking cessation and weightreduction programs, began offeringdiabetes education, and developed a host ofweb-based tools to assist consumers inpursuing a healthy lifestyle. The Dow “mindset” has shifted from seeing preventive careas a personal (not a company) responsibilityto viewing prevention and wellnessprograms as a strategy for improvingproductivity and reducing health care costs.

That said, Dow may not be covering the“right” preventive services. While thecompany tries to use data from the CDC,vendors, peer companies, and others inmaking coverage decisions, much of whatthey decide is based on anecdotal inputfrom the company’s medical director, globalbenefits director, integrated healthmanagement program, and employees. Forexample, the company’s $200 wellnessallowance began as coverage for flexiblesigmoidoscopy; it was changed when many

employees—especially women—suggestedthat they had other, more pressingpreventive health needs. The company’sdecision to cover weight reduction andsmoking cessation programs at work siteswithout a fitness facility was an attempt tomake benefits more comparable foremployees across facilities, regardless ofsize.

Mr. Morgenstern and other company healthadministrators would like to see more datato continue to make the “business case” forprevention to company officials and to basetheir coverage decisions in the future onhard evidence.

RaytheonRaytheon is one of the few companies toget involved in the actual delivery of healthcare. The company operates 23 worksiteclinics in the U.S. and seven others aroundthe world. These clinics and the company asa whole are increasingly emphasizingpreventive services, Charles D. Hackett, MD,Raytheon’s chief medical officer, toldconference attendees. Most recently, thecompany’s preventive health interventionshave focused on flu vaccination andoutreach to individuals with depression. Dr.Hackett sees depression as the majorhealth issue facing Raytheon.

The company also has a wellness anddisease management program, and an e-health program to provide consumers withinformation to better manage their ownhealth. Raytheon is currently conducting anaudit of its health plans to find out whatthey cover in the area of preventive health.The ultimate goal is to get the plans to coverall the services now recommended byUSPSTF.

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Dr. Hackett is also pushing for the use ofevidence-based medicine to justify coverageof preventive services that go beyondUSPSTF recommendations. As a worldwidecompany with clinic operations overseas,Raytheon is also concerned about promotingprevention outside the U.S., a task thatrequires an understanding of the culturaldifferences that exist with respect toprevention.

Raytheon believes it gets a “return oninvestment” with its preventive healthactivities. To that end, the company uses six-sigma training and techniques with its healthcare vendors with the expectation that therewill be a “dollars-and-cents” return oninvestments in prevention and wellness.

Chevron-Texaco CorporationD’Ann Whitehead, PsyD, former manager ofhealth and productivity at Chevron-TexacoCorporation, said the company’s evolutionwith respect to preventive health care ischaracterized by three trends.

First, the company now outsources itspreventive health programs to vendors andhealth plans in lieu of its past approach,which was to organize and implement someof these initiatives in-house. For example, thecompany no longer offers on-site smokingcessation programs. Instead, the companyhas worked with its health plans and othervendors to develop and administer a modelbenefit covering a full range of smokingcessation options, including behavioral andpharmaceutical interventions.

Second, the company has sought to shiftfrom a “paternalistic” approach topreventive care to “employeeempowerment.” Chevron-Texaco isconvinced that employees respond muchbetter when educated thoroughly about thebenefits of behavior change to stay healthier

than they do when coerced to engage in suchactivities. Better tools are now available tohelp employees understand the benefits ofpreventive care and to give them incentivesto participate.

And third, the company has moved from“high touch” to “high tech.” The companysees huge potential for informationtechnology (IT) in the area of prevention. ITsystems can help identify and deliverinformation to individuals who might benefitfrom a particular service.

Because the company has a strong culture ofsafety, early prevention efforts focused onpersonal safety. Then in the early 1970s, thecompany began to expand its preventivehealth benefits, first with the development ofan in-house employee assistance program(EAP). In the 1980s and 1990s, coverage forpreventive exams, health risk appraisals,and smoking cessation programs wereadded. On-site fitness centers were alsolaunched.

As testament to its commitment and thesuccess of its programs, Chevron-Texaco in1998 won the C Everett Koop award for itsprevention programs.

In recent years, the company’s focus hasshifted to helping employees be wiseconsumers and managers of their personalhealth, with the goal of reducingabsenteeism. To that end, the company hascreated on-line tools (e.g., health riskappraisals and other educational tools) toassist employees and their families inaccessing preventive services and managingtheir health. Looking ahead, the companyplans to further integrate their on-lineprevention tools into programs where theycan be delivered on a “just-in-time” basis,such as through Integrated DisabilityManagement and on-site injury preventionprograms.

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Key Recommendations of the U.S. Preventive Services Task Force*

Breast cancer: Screening with mammography ofall women age 40 and older, with or withoutclinical breast examination, every 1-2 years.

Cervical cancer: Routine screening with Paptests of women under age 65 who have beensexually active.

Colorectal cancer: Routine screening of menand women 50 years of age and older.

Childhood infectious diseases: Immunizationschedule recommended by Centers forDisease Control & Prevention for all childrenagainst diphtheria, tetanus, pertussis,measles, mumps, rubella, hemophilus influenzatype b, hepatitis B, and chicken pox.

Flu: Annual vaccination for adults age 50 andover, and children, adolescents, and healthcare workers of any age who are at high risk.

Pneumococcal disease: One-time vaccinationfor all persons age 65 and over and thoseyounger than 65 who are at risk.

Cancer, multiple forms: Routine counseling of allsmokers to quit.

Diabetes: Routine screening for type 2 diabetesin adults with hypertension or hyperlipidemia.(Routine screening is not recommended ingeneral population.)

Depression: Routine screening of all adults inclinical settings that have systems in place toassure accurate diagnosis and effectivetreatment and follow-up.

Anemia: Screening of all pregnant women andhigh-risk infants.

Blood lead levels: Screening at age 1 of allchildren believed to be at high risk of leadexposure.

High blood pressure: Routine and periodicscreening of all adults age 18 and over.

Elevated cholesterol and lipid disorders: Routinescreening with blood tests of men age 35years and older and women age 45 years andolder; screening of men age 20 to 35 andwomen age 20 to 45 only if they have otherrisk factors for coronary heart disease.Measurement should be of total cholesteroland high-density lipoprotein cholesterol.

Heart disease: Intensive behavioral dietarycounseling for adult patients withhyperlipidemia and other known risk factors forcardiovascular disease, including overweightand obesity. Counseling can be delivered byprimary care clinicians or by referral to otherspecialists, such as nutritionists or dietitians.Clinicians should also discuss use of aspirinwith adults who are at increased risk for heartdisease.

Osteoporosis: Screening of all women age 65and older and women age 60 to 64 who are atincreased risk of osteoporotic fractures.

Hepatitis B: Screening of all pregnant women ontheir first prenatal visit. (Routine screening ingeneral population is not recommended.)

Chlamydia: Screening of all sexually activewomen who are age 25 years and younger, andother women considered to be at increasedrisk.

Syphilis: Screening of all pregnant women andother women considered to be at increasedrisk (notably those with multiple sexualpartners).

Gonorrhea: Screening of all women consideredto be at increased risk (notably those withmultiple sexual partners).

HIV: Screening of all sexually active peopleconsidered to be at risk.

*As of April 2003; this is not a comprehensive list of the Task Force’s recommendations. See www.ahrq.gov,the web site of the Agency for Healthcare Research and Quality (AHRQ), for a complete list and details aboutthe recommendations.

Sources: AHRQ web site (www.ahrq.gov); Guide to Clinical Preventive Services, Second Edition (U.S. Departmentof Health and Human Services, 1996); Clinician’s Handbook of Preventive Services, Second Edition (U.S.Department of Health and Human Services, 1998).

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Health Plan StrategiesManaged care plans pioneered the broaderapplication of preventive health care in the1970s. Indeed, keeping enrollees healthy andmaintaining their health over time wereorganizing principles of health maintenanceorganizations (HMOs). As the managed careindustry expanded and evolved in the 1990s,preventive care remained a core mission.Today, health plans are trying to determine thebest approach to integrating preventiveservices into the larger structure of health carebenefits and disease management programs.Health plans are working more closely withemployers to maximize the impact ofpreventive care services.

Robert E. Scalettar, MD, MPH, vice presidentof medical policy and corporate director atAnthem Blue Cross Blue Shield of Connecticut,presented data from a 2001 survey of health

plans conducted by the American Associationof Health Plans. The survey found that the vastmajority (over 90% in most cases) of healthplans both recommend and cover a core set ofpreventive care services, includingvaccinations, screenings for cervical andcolorectal cancer, and chlamydia screening.(See Figure 5.) Just short of 90% offer a free orlow cost or low-cost smoking cessationprogram and 81% recommend the use ofsmoking cessation aids to their enrollees whosmoke. At the same time, the survey found thatonly 48% covered the cost of smoking cessationdevices and medications.

HEDIS (Health Plan Employer Data andInformation Set) data also indicate that manyhealth plans, particularly HMOs, haveenhanced the use of preventive care over thelast five years. But the HEDIS data also revealwide variations in such care from one healthplan to the next. (See Figure 6 on next page.)

Figure 5:

Plan Recommendations and Coverage Related to Core Preventive Services

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Figure 6: Selected HEDIS Measures for 2001

Nicolas Pronk, PhD, vice president of theCenter for Health Promotion at HealthPartners, Inc., agreed that data indicate healthplans are providing more coverage ofpreventive services compared to a decade ago.But he said that data pertain primarily tocoverage of screening tests and can bemisleading when it comes to assessing broaderand sustained public participation in healthpromotion and lifestyle modification activities.One 1996 study, for example, found that only2% of health plan enrollees aged 18 to 64 inCalifornia participated in any kind ofcommunity- or health plan-based healthpromotion program. That percentage is likelyhigher in 2002-2003, Dr. Pronk acknowledged.But such low numbers indicate theconsiderable challenge plans and providersface in getting people to participate. Evenwhen services are free, participation rates areoften very low.

And while most physicians and nurses saythey value their role in motivating patients toimprove their health, Dr. Pronk and otherspeakers said the evidence reveals thatproviders often fail to play this role during thebusy everyday practice of medicine. One study,for example, found that fewer than half (44%)of primary care physicians always review theirpatient’s health behavior and providecounseling when needed.

Dr. Pronk presented a cost and risk profile ofthe U.S. population (see Figure 7 on facingpage) which indicates the wide disparity inannual expenditures between healthy andunhealthy people. Identifying those at high riskand with chronic conditions is key toprevention and disease management programs.

Dr. Kongstvedt noted that recent changes athealth plans should lay a firmer foundation forthe speedier adoption of prevention services.

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Namely, plans are now embracing a morecollaborative approach with both employersand providers. And they are increasingly usingmedical and disease management models thatemphasize prevention. These efforts haveevolved from loose and passive programs thatprovide information on a single disease to moreproactive and integrated strategies (e.g., phonecalls, home care visits, nurse interventions) thatfocus on the sickest and most costlyindividuals. To assist with these efforts, plansare increasingly outsourcing their diseasemanagement function to vendors. Diseasemanagement vendor revenues grew from lessthan $100 million in 1997 to roughly $500million in 2001, he said.

Ms. Mercure cautioned that the growth ininterest in so called “consumer-driven” healthbenefit plans poses issues for preventive careservices. Though a fledgling movement now,shifting costs and risk to consumers by makingthem personally responsible for the first $1,000

% of Population

Annual Cost of Care

Annual Number ofClinical Visits

Healthy/Low Risk

63%

$0 to $1,792

0 to 8

Poor Health/High Risk

30.1%

$4,042

14

ActiveDisease

6.9%

$11,618

24

Figure 7: U.S. Population Health Risk and Cost Profile

Source: Nicolas Pronk/Health Partners, Inc.

to $3,000 of their care before insurance kicks in(using in part dollars their employer givesthem) could serve to either undermine orstrengthen preventive health services. If, forexample, consumers have to pay more out-of-pocket for preventive services, they will almostcertainly use them less.

But if employers structure consumer-drivenplans such that preventive care benefits arecovered free (or with very low co-payments),enrollees may actually use the services morethan they would in other kinds of plans. So far,employers experimenting with consumer-driven plans are exempting some, but not all,preventive care screening tests from co-payments. There is a greater risk that routinebehavioral counseling will decline if it is notexempted. That’s because consumer-drivenplans aim to induce enrollees to go to thedoctor less, and fewer trips to the doctor meansless opportunity to reinforce preventive carecounseling, Ms. Mercure told conferees.

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Innovative Health Plan Initiatives to Promote PreventionHealth plans are using incentive programs, software, and other innovative tools to foster wider use ofpreventive care. Information technology often plays a critical role in improving the delivery ofpreventive services to plan members, providing vital information to both providers and patients in atimely manner. The three case studies below are illustrative of these types of innovative programs.

Univera HealthcareUnivera is a Buffalo, NY-based health plan thatserves 150,000 enrollees. The companyrecently launched a program that uses newcomputer-based tools to assess and promotethe use of preventive care services. KathleenCurtin, MBA, NP, MA, Univera’s vice presidentof quality management administration, told

conference attendees the program has putpreventive care services “front and center” forphysicians and made patient data easy forthem to use.

The program gives both doctors and enrolleescomputer-based information and data.Physicians, for example, get a quarterly reportthat includes their rates of use for a variety of

preventive services. Theirperformance is then comparedto a panel of physicians in thesame geographical area.

The health plan also givesdoctors a periodic update onthe preventive health servicesthey gave to each Univeraenrollee, based on claimsanalysis. Called a patientmanagement reminder, theform is a quick list of preventiveservices and recommendeddates for administering them.(See chart.) In addition,Univera sends patients andphysicians an annual “healthmaintenance report” thatcontains a list of plan-recommended clinicalpreventive services, andmatches that list against theactual services rendered toUnivera enrollees.

Univera also generates periodicdisease management reportsfor patients with certain chronicdiseases. For example, a reportfor a diabetic would contain arecord of tests to assess bloodsugar and cholesterol levels,and eye and kidney damage.

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Both doctor and patient get the report, whichindicates when the next round of tests are due.Univera also uses other systems and programsto promote adoption of preventive services,including regular mailings to physicians andconsumers, promotion of guidelines, andmeetings among panels of physicians.

Ms. Curtin told meeting attendees that theapproach is working, with rates of mostpreventive care services on the rise. Forexample, tests for LDL cholesterol levels haverisen from around 40% of enrollees in 1996 toabout 75% of enrollees by the end of 2001.Univera plans to improve the approach byincorporating financial incentives for physiciansbased on their performance.

Anthem Blue Cross Blue ShieldAnthem is one of the largest health plancompanies in the nation. It operates Blue CrossBlue Shield plans in nine states that collectivelyenroll almost 12 million Americans. Thecompany has become a leader in qualityimprovement and preventive care. Dr. Scalettartold conferees that Anthem has beenexperimenting with a number of preventivehealth benefits. He conveyed the results of onepilot project. In January 1998, Anthem’s BlueCross Blue Shield plan in Maine launched asmoking cessation benefit and program forenrollees in its HMO products. The programincluded coverage for counseling, tools forprimary care physicians, coordination withpharmacies, and a community outreachcomponent.

In February of 1999, 2000, and 2001,enrollees were sent follow-up informationpackets that included reminders about thesmoking cessation program. Primary careproviders and dentists were also givenreminders and asked for feedback on theprogram.

At launch, 18% of Anthem’s adult HMOenrollees smoked, less than the 21% in Maine’sadult population in general. The program’s goalwas to reduce the percentage of enrollees who

smoked to 15%. By May 1999, the rate ofsmoking among Anthem enrollees had declinedto 16.8% and by March 2000 to 13.1%—beating the target. By comparison, Maine’sadult smoking rate climbed to 23.8% of theadult population during this period. Dr.Scalettar believes the program has been anunqualified success. It has yielded a three-to-one ROI, generating $0.36 per member permonth (PMPM) in savings compared to just$0.12 PMPM in costs. Dr. Scalettar hopes toexport the program and its dramatic success toother Anthem plans and beyond.

WellPoint Health NetworksDawn Wood, MD, MPH, vice president andmedical director of state-sponsored programsat WellPoint Health Networks, spoke about herorganization’s efforts to boost childhoodimmunization rates.

The initiative was launched in 1995, at first withjust simple reminder letters and cards sent toenrollees and physicians. In 1996, the healthplan added an outreach component, with staffdirectly contacting enrollees or their parents. In1998, a call center was formally set up, withfaxes and reminders pouring out to patientsand providers. Then in 2001, WellPoint uppedthe ante – adding a “rewards” program thatgave enrollees gifts (from Wal-Mart) for keepingchildren up to date on immunizations and well-child visits.

Some 9,000 enrollees claimed the gifts afterjust the first five months of the program. Lastyear, WellPoint enhanced the program furtherby linking providers to a communityimmunization registry.

The program has successfully boostedimmunization rates. Between 1998 and 2002,rates for common childhood immunizationsincreased from around 23% to 61%. Theprogram garnered several awards, includingrecognition from the American Association ofHealth Plans and the Blue Cross Blue ShieldAssociation.

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Federal Government StrategiesThe federal government finances and coverspreventive health services through a variety ofprograms. The largest of these is Medicare,covering 39 million senior citizens and disabledpersons. The Office of Personnel Management’s(OPM) Federal Employee Health Benefits(FEHB) program covers 9 million active federalemployees, retirees, and dependents.

Ms. Gordon noted that the Medicare program’soriginal statute precluded coverage ofpreventive care. To this day, federal legislationis needed to incorporate preventive careservices into Medicare’s benefit package. As aresult, Medicare’s covered preventive benefitshave grown only slowly over time. (See boxbelow.)

Ms. Gordon said that Medicare coverage ofpreventive care services is not optimal and notin sync with the USPSTF recommendations.For example, the task force does notrecommend bone densitometry to screen forosteoporosis in people age 65 and over. ButCongress added densitometry coverage forMedicare in 1998. Likewise, the task force doesnot recommend prostate-specific antigen (PSA)testing, a benefit added to Medicare coveragein 2000. Indeed, of the 12 preventive care

services now covered under the Medicareprogram, only five have been recommended forthe elderly population.

A General Accounting Office report released inMay 2002 points to other problems as well. Thereport, Medicare – Use of Preventive Services isGrowing But Varies Widely, concluded that“although the use of preventive services isgrowing, it varies from service to service andby state, ethnic group, income, and level ofeducation.” Breast cancer screening rates, forexample, varied among states from 66% to 86%in 1999. And 57% of whites were immunizedagainst pneumonia, compared to just 37% ofAfrican Americans and Hispanics.

Ms. Gordon said CMS is working to acceleratethe uptake of preventive health services bysponsoring research on standing orders,clinical protocols, provider and patientreminders, and financial incentives. All of thesetools are underutilized today and are keyavenues to enhance preventive care. Thecurrent leadership at CMS and HHS is alsocommitted to the principles of healthy agingfor Medicare beneficiaries, and to being moreproactive in seeking Congressional approval ofappropriate, evidence-based preventive careservices.

Medicare Preventive Care Benefits and Year Benefit Was Added

Pneumococcal immunizations – 1981

Hepatitis B immunizations – 1984

Pap smear – 1990

Mammography – 1991

Influenza immunizations – 1993

Pelvic exam – 1998

Bone densitometry – 1998

Colon cancer screening – 1998

Diabetes self-management education –1998

Prostate cancer screening — 2000

Glaucoma screening – 2002

Nutritional therapy for diabetics andpeople with end stage renal disease –2002

For more detail on Medicare coverage of preventive services, see Appendix C.

Source: Centers for Medicare & Medicaid Services

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To that end, CMS recently created theEvidence-Based Center for Healthy Aging. TheCenter is housed at the RAND Corporationand is charged with translating what works topromote senior health into Medicare coverage,programs, and policies. Much of the Center’swork relates to preventive care services. TheCenter’s first report focused on smokingcessation. One in eight Medicare beneficiariessmokes, creating a burden of smoking-relatedillness for the program estimated at $800 billionover the next 20 years. The Center’s review ofthe evidence found that drugs can double quitrates, and that both provider counseling andtelephone counseling are effective. While theevidence suggests that seniors experience asharper functional decline from smoking thando younger individuals, the findings citedresearch showing that significant benefitsaccrue to smokers who quit at any age.

CMS is currently trying to determine the bestway to cover smoking cessation services as aMedicare benefit. To that end, CMS issponsoring a Stop Smoking DemonstrationProject among 43,500 beneficiaries in sevenstates. The results will help determineMedicare’s coverage policies.

The Center is also conducting a demonstrationproject with CDC that is designed to reducevaccine-preventable diseases in nursing homesthrough the use of standing orders that call forscreening and immunization without aphysician examination. Current regulationsprohibit this, but the demonstration facilitatesthe adoption of standing orders by waivingthese regulations in eight states and the Districtof Columbia. A second Medicaredemonstration project is evaluating the relativeeffectiveness of different types of health riskappraisal and follow-up programs. Thisproject, which got underway in Fall 2002, willevaluate the appraisal questionnaire androutine feedback to both beneficiaries andphysicians. The project also seeks to determineif CMS can facilitate self-care as well aseffective links among seniors, communityresources, and physicians.

Debate over Medicare reform in recent yearshas included discussion of preventive care.Speakers and discussants at the conferencewere strongly supportive of adding morepreventive benefits to the Medicare program.

Abby L. Block, MSW, MA, MBA, assistantdirector for insurance programs at OPM, saidher agency essentially operates as a largeemployer purchaser. It does not have to go toCongress to set health benefits for active andretired federal employees and theirdependents. OPM paid over $27 billion inpremiums in 2002 to more than 180commercial health plans around the countrythat are offered as options to governmentworkers. While there is no standard benefitspackage among FEHB plans, plans are requiredto cover certain preventive services. Theseinclude mammograms, PSA tests, colorectalcancer screening, and childhoodimmunizations. Most FEHB plans also coveradditional preventive services. These mostcommonly include blood cholesterol screenings,routine physicals, sickle-cell screening, andvision screening tests. With respect topreventive care for children, most FEHB plansadopt the recommendations of the AmericanAcademy of Pediatrics, which advocatescoverage for a wide variety of child careservices, including well-child care and certainimmunizations and vision screenings.

Ms. Block said OPM is continually reviewingguidelines on preventive care benefits andevaluating industry norms. In general, FEHBprogram coverage of preventive services tracksthe clinical recommendations of governmentand national organizations such as theNational Cancer Advisory Board of theNational Cancer Institute or the AmericanCancer Society. OPM encourages FEHB plansto review and adopt these recommendations.In 2002, for example, OPM sent out a “callletter” that encouraged FEHB plans to covernon-diagnostic colonoscopies, fastinglipoprotein profile tests, and certain tests forcolorectal cancer.

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Projecting ROI

Producing useful ROI measures is still a workin progress and challenging methodologically.But Ron Z. Goetzel, PhD, vice president ofconsulting and applied research at TheMedstat Group, emphasized that studiesalready show a positive ROI from prevention.One aggregate analysis of 32 studies, forexample, found 28 showing a positive ROI forprevention, averaging $3.48 in benefits forevery dollar invested. Health care costs andabsenteeism were the primary outcomes.5 Another study found a median benefit of$3.14 per dollar invested for healthmanagement programs, $4.50 per dollarinvested for demand management programs,and $8.88 per dollar invested for diseasemanagement initiatives.6

Anecdotal results back these findings up. Ahealth screening and promotion programsponsored by Citibank, for example,generated a net $7 million in savings over atwo-year period. The program cost $1.9million to implement and operate, generatingsavings of $8.9 million, or $4.70 in benefitsfor every $1.00 in costs. Half of thecompany’s 40,000 employees participated inthe program, which included an initialscreening of employees, computerized triageof subjects into high- and low-riskintervention programs, extensive follow-up

with the high-risk subjects, and generalhealth education.7

A long-term health and wellness programconducted at Johnson & Johnson between1990 and 1999 yielded similar results, withoverall savings of approximately $8.5 millionper year. Savings came from reducedmedical care use ($3.3 million) and loweradministrative costs ($5.2 million).8

Dr. Pronk said the cost savings produced byprevention can also be measured as costper life-year saved. Studies now show thatseveral preventive services fall into thecategory of saving lives at a “low” cost. Forexample, smoking cessation programs,including minimal (three-to-six minute)physician counseling, intensive (15-minute)physician counseling, nicotine replacementtherapy via patch or gum, and nurse-basededucation, cost less than $15,000 per life-year gained. Many exercise programs costless than $20,000 per year of life gained. Byany measure, the one-year productivitygains achieved through such interventionsfor employees in the middle of their careerswould well exceed implementation costs, Dr.Pronk said.9

But the incompleteness of data on the costof disease make ROI and cost-of-life-year

The federal government is also working tofoster preventive care through the work of theAgency for Health Care Research and Policy.Kenneth Fink, MD, MPH, a visiting scholar atAHRQ, said the agency oversees the activitiesof the USPSTF, supports a dozen Evidence-Based Practice Centers around the country,and administers the National GuidelinesClearinghouse, which includes numerousprevention-oriented services. In addition,AHRQ administers the Put Prevention intoPractice (PPIP) program. PPIP seeks to improvethe delivery of appropriate preventive services

based on the evidence-based recommendationsof the USPSTF. It consists of a package of easy-to-understand materials that assist physiciansin overcoming the barriers to effective deliveryof appropriate clinical services. These tools(which include waiting room posters,preventive care timelines, adult and childhealth risk profiles, preventive care flow sheets,and patient reminder postcards) help cliniciansdetermine their patients’ preventive care needsand administer needed services. In addition, aset of guidebooks helps patients understandand keep track of their preventive care needs.

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saved calculations iffy, noted Dr. Sennett.Patients in studies get lost to follow-up andindirect costs (e.g., lost productivity, traveltime to and from health care settings) areoften difficult to estimate. Productivity isparticularly difficult to calculate, due in partto a lack of standard metrics. These factorswould tend to result in an underestimation ofthe potential of prevention to reduce costs.

At the same time, other factors tend toinflate the projected savings fromprevention. For example, preventive servicesmay extend the life of some individuals bypreventing or delaying the onset of aparticular disease. But these individuals maywell fall victim to other diseases, especiallylater in life, noted Dr. Sennett. These ailmentsnever would have occurred—and theaccompanying, often costly treatment neverwould have been necessary—if it had notbeen for the life-extending preventiveservices. Of course, our society valuespreventive services because they contributeto more productive, satisfying lives for thosewho receive them. The point here is simply torecognize that these investments, thoughthey generate social and economic benefits,may also someday lead to increased healthcare costs.

In addition, Dr. Sennett said that any costsavings from preventive services should be“discounted” to account for the “time value”of money. Savings that occur in the future areintrinsically less valuable than immediatesavings due to the erosionary impact ofinflation on purchasing power. But setting anappropriate discount rate is complex. Finally,any calculation of the potential cost savingsfrom prevention must be estimated ratherthan observed (since one cannot observecosts that do not occur). Estimates tend to beless compelling than actual observations whenorganizations such as the government andlarge employers are trying to price out thecosts and benefits of their activities.

In terms of policy, the potential disconnectbetween who pays for preventive servicesand programs and who benefits from them isa major issue. The private sector—includingboth commercial insurers and employers—may be institutionally resistant to investingbroadly in prevention if they believe that thebenefits from such expenditures will accrue toanother employer or insurer. This issue isespecially important in the U.S., since almosteveryone becomes a Medicare beneficiary atthe age of 65, and the financial benefits ofpreventive services may not materialize untilthe post-retirement years.

State Government StrategiesStates (in partnership with the federalgovernment) finance health care coverage forthe poor through two programs – Medicaidand the State Children’s Health InsuranceProgram (SCHIP). In addition, states can anddo require commercial insurers to cover somehealth services, including a range of preventivecare services.

Medicaid and SCHIPRhonda Rhodes, MS, acting director of theDivision of Benefits, Coverage, and Paymentwithin Family and Children’s Health Programsat CMS, told conferees that the federalgovernment requires state Medicaid programsto cover a comprehensive set of preventiveservices and “early assessments” of the healthneeds of Medicaid-eligible children. Theprogram is called EPSDT (Early and Periodic

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Screening, Diagnosis, and Treatment). Itsframework is somewhat unusual. Essentially,any medically necessary treatment that resultsfrom the provision of EPSDT-mandatedprevention and screening services must also becovered, even if that treatment is not coveredgenerally in the Medicaid program.

Many states also cover preventive healthservices as a separate benefit under Medicaid.For example, many states have opted to coverfamily planning services, breast and cervicalcancer prevention and treatment, and diseasemanagement.

SCHIP covers a broad array of preventiveservices, but that coverage is designed andarrived at differently than under Medicare orMedicaid. Seeking to avoid the complexity ofadding coverage in a piecemeal fashion or“benchmarking” coverage to the private sector,states are required to cover well-baby and well-child care and to adopt one of the followingbenefits packages:

Existing state-based comprehensivecoverage, a provision that was“grandfathered” in for Pennsylvania, NewYork, and Florida.

Secretary-approved coverage, which areexemptions approved by the federalgovernment subject to certain ground rules.

While the current economic climate in statesmakes expansion of preventive servicescoverage difficult, some states have beenprogressive in this area. For example, NorthCarolina recently trained pediatricians toconduct oral health assessments and to applyvarnish, a treatment that is effective inpreventing tooth decay in children. A grantfrom CMS and the Health Resources andServices Administration (HRSA) helped tofinance the training. Another example comesfrom the state of Maryland, which recentlyinstituted comprehensive coverage for breastand cervical cancer screening.

Insurance MandatesState insurance mandates affect some 60million Americans whose insurance is providedby commercial health plans and insurersregulated by the states. Virtually all states havesome mandates, including those for preventiveservices. A 2002 study by the NationalConference of State Legislatures (sponsored byPartnership for Prevention) found widevariation in state mandates for preventive careservices. Of 23 preventive services studied,states ranged from covering just a few to 14.The two most widely mandated preventivehealth services were childhood immunizationsand mammography, followed by cervicalcancer and prostate cancer screenings. Moststates mandated fewer than eight preventiveservices. Ms. Bondi noted that, as with largeemployers and Medicare, most of the statemandates covering preventive care services donot track USPSTF recommendations. Forexample, colorectal cancer screening, stronglyrecommended by the USPSTF, is a requiredbenefit in only 15 states. In contrast, 27 statesmandate prostate cancer screening, which isnot recommended by the USPSTF. Only onestate (Maryland) specifically mentions theUSPSTF as a guide for its prevention mandates.

Ms. Mercure noted that state governmentmandates that require insurers and healthplans to cover certain medical services canincrease costs and effectively block health plansfrom being able to expand their coverage ofpreventive health.

Provider and Consumer StrategiesEfforts to help providers deliver preventiveservices and behavioral counseling must bestepped-up, speakers agreed. Likewise, therewas consensus that most Americans (a) still donot understand the importance of clinicalpreventive services and lifestyle counseling totheir health, and (b) do not have enoughinformation to access those services or findeffective programs to help them make lifestylemodifications.

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Christina Wee, MD, MPH, assistant professorof medicine in the Division of General Medicineand Primary Care at the Beth Israel DeaconessMedical Center and the Harvard MedicalSchool, said deep structural obstacles militateagainst physicians engaging in behavioralcounseling. She said these obstacles must beaddressed if such services are to be morewidely adopted. They include:

Lack of time

Short office visits do not permit physiciansor nurses to address the multiple behavioralchanges that are necessary for obese and/or physically inactive patients. Thephysician must do more than simply advisethe patient to eat less. Physicians mustrecognize that successful counseling mightrequire 20 in-person or over-the-phonecontacts.

Perception that behavioral counseling isineffective

Surveys indicate that most physicians(71%) do not believe that patients complywith dietary counseling and more than onein three (35%) do not believe thatcounseling will lead to a lasting change inpatients’ physical activity levels. Theseperceptions are wrong when structured,multi-session interventions and follow-upare employed, though the evidence isstronger for the effectiveness of weightcounseling than it is for physical activitycounseling.

Lack of training and knowledge

Studies indicate that a majority ofphysicians (60% in one study) feelinadequately trained to deliver advice onnutrition. This is exacerbated by fad dietsand ever-changing recommendations fromnational groups on appropriate diet. Inaddition, medical schools do not train newdoctors in how to provide effectivecounseling. Dr. Wee shared results from theWATCH study, which found that

physicians who get both training and officesupport are far more likely (by a factor ofroughly 2 to 1) to counsel patients onnutrition. At the same time, they are far lesslikely to feel the need to refer patientselsewhere for such counseling. (See Figure 8on next page.) The study also found thatpatients being treated by these physicianswere more likely to change their diet.

Inadequate resources

Physician practices need funding to buildnew models of care that emphasizeprevention. In particular they need bothmoney and help organizing counselingprograms, developing information systems,adopting team approaches to care, andimplementing office-based qualityimprovement initiatives. Training must alsobe funded, both for physicians and supportstaff. Dr. Wee urged physicianorganizations to take a leadership role insecuring government and privatefoundation funding for such efforts.

Inadequate reimbursement

Very few employers and health plansprovide full or adequate reimbursement forbehavioral counseling. And those that dousually cover only a single episode. In somecases, coverage is only available for patientswith co-morbidities. In addition, very fewplans provide coverage for telephonecounseling, making it difficult or impossiblefor a physician group to justify hiring aqualified individual to conduct telephonefollow-up with at-risk patients.

Dr. Wee and other speakers urged employersand health plans to play a larger role inhelping physician practices use preventiveservices. Some means to that end include:

Eliminating or reducing co-payments on acore set of evidence-based preventive careservices.

Paying physicians for the time they spendcounseling patients about lifestyle changes.

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Subsidizing the cost of office-basedsoftware that helps physicians track thedelivery of preventive care services,generate reminder notices, and the like.

Coordinating with physicians on remindersand information packets sent toemployees/enrollees.

Rewarding providers who exhibit strongperformance on standardized measures forthe delivery of preventive care services.

Figure 8: Results to WATCH*

Promoting collaboration among competinghealth plans. For example, 25 of thenation’s largest insurers, representing 25million Americans, have joined forces toform the Council for Affordable QualityHealthcare (CAQH). Via a public web site(www.caqh.org), this consortium is sharingthe best practices for promoting adoption ofpreventive services.

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White River Rates, 2001

(continued on next page)

Low- and High-Tech Provider Approaches to PreventionProviders are taking a variety of approaches to accelerating the adoption of preventive services,including some that rely on new technologies and others that focus on old-style approaches.

The White River Family PracticeWhite River is a six-physician primary carefamily practice located near the NewHampshire border in White River Junction,one of Vermont’s handful of mid-sized cities.The practice provides care to about 15,000individuals in a community of about100,000. Mark Nunlist, MD, runs thepractice. He and his colleagues believed untila few years ago that they were providingadequate, even state-of-the-art preventivecare. But a series of events in the late 1990sled them not only to change their minds butalso the way they practiced medicine.

It started when the practice’s largestmanaged care payer, Anthem Blue Cross,began to audit the practice’s delivery ofcertain services. The health plan first notedthat the group had no system in place totrack whether adults were getting tetanusshots. About the same time, Anthem beganreporting results (see chart at right) onthe proportion of their enrollees cared forby White River who were receivingmammography, cervical cancer screening,and well-child visits. In addition, Anthemmonitored the percentage of diabeticsgetting routine eye exams.

The results were “not great,” said Dr.Nunlist. “Let’s just say we had a lot ofroom for improvement…and thatsurprised us. We really thought we weredelivering pretty good preventive care.”

Dr. Nunlist and his colleagues went aboutdiagnosing the reasons for their poorperformance, and quickly focused on two:the lack of time committed to preventivecare in office visits and the practice’sinefficient, paper-based patient recordsystem.

The first change White River implemented wasto integrate preventive care assessments intomost office visits in a more rigorous andsystematic way. But they quickly realized theywould need a much better record system tosupport that approach and to track the deliveryof preventive care as well as other services.And that led them – after rejectingmodifications to their paper-based system – tomake the switch to (and investment in) anelectronic record system.

With financial assistance (roughly $7,000) fromAnthem, the group spent about $20,000 to buya software system called Medical Manager, nowsold by WebMD. The system was installed inthe summer of 2001. At the time, White Riverwas only the third practice in New England toadopt this type of system. Some 200 grouppractices in New England now have MedicalManager.

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Low- and High-Tech Provider Approaches to Prevention (continued from page 21)

Medical Manager promotes the use ofpreventive services in a number of ways.First, it prompts providers to offer due andoverdue preventive services at every patientencounter, and tracks any services that areadministered. The system can be customizedto prompt by disease or other patient-specific criteria. This approach is especiallyuseful for patients with chronic conditions, asit allows multiple providers to see whatservices the patient has received and needsat any point in time. The system also createspoint-of-care reminders for physicians (seebelow) and reminder notices for patients,along with practice-wide and individualprovider performance feedback reports.Underlying the system is agreement byproviders on a core set of scientifically-basedpreventive services.

Not surprisingly, White River has facedsome barriers in implementing the system.As with any new technology, physicians haveadopted the system at varying rates—somebeing early adopters, and a couple notcomplying at all. Dr. Nunlist noted thatphysicians needed training on how to raiseissues with patients and to offer services noton the patients’ agenda.

White River has also re-organized workflowto make better use of the reminderprompts. In addition, because the systeminitially flagged so many patients whoneeded preventive services, the practicehad to manage this influx by settingpriorities for follow-up preventive care visits.

Despite these barriers, Dr. Nunlist believesthat the new system is indeed yieldingincreased use of preventive services. (White

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issues, and lifestyle habits. Their diets arerich in fat, a high proportion smoke, andexercise is a foreign concept to most of them.Some have poor sanitation habitscomplicated by rural conditions that cancompromise sanitation.

Working in this environment, Dr. Benjamintakes on the role of health educator andlifestyle counselor as well as doctor. “It is theonly thing to be done,” she said. “I feelcompelled to do what I can to try and keepthem healthy.”

This approach has forced her to structure herpractice in a way that allows residents easieraccess to care. For example, Dr. Benjamindoes not require patients to schedule visits.She will see them even if they just “wanderin” at a time convenient to them. Even if sheis busy dealing with a patient who has a moreurgent problem, she tries to make time forthe walk-ins.

Dr. Benjamin views these visits asopportunities. They build rapport and trustwith the patient, laying the foundation forimparting lifestyle advice andrecommendations. Her experience is that thecloser she can get to a patient, the more likelythat the patient will heed her advice.

Dr. Benjamin counsels all her patients aboutprevention and lifestyle issues. Sheconsistently advises patients not to smokeand asks about family histories with respectto smoking and alcohol. She inquires aboutprevious preventive services, including Papsmears and self-breast exams. She usespatient-reminder “systems” for preventiveservices, encouraging women to get a Papsmear every year during their birthdaymonth and advising self-examination of thebreasts each month when the utility billcomes. She also urges wives to remind theirhusbands to go in for prostate exams. Shecounsels elderly patients to exercise by liftingcans of soup or one-pound packages ofsugar.

River had not yet collected data since thepractice had less than a year of experiencewith the system at the time of theconference.) Data from Dr. Paul Frame, afamily practitioner in New York whodeveloped the system and has studied itsuse, indicates that Medical Managerincreases compliance by an average of 15%at an estimated annual cost of $0.78 perpatient.

Looking ahead, Dr. Nunlist plans to improvethe reminder report format to increase itsusefulness and to provide preventive carereport cards to patients. White River alsoplans to compare its performance indelivering preventive services to that ofother group practices.

Bayou La Batre Rural Health ClinicThe experiences of Regina Benjamin, MD, MBA,and the Bayou La Batre Rural Clinic in Bayou LaBatre, Alabama, demonstrate that low-techapproaches are still critical. They also show how adedicated physician can make a difference.

Dr. Benjamin runs and is the sole physicianat the clinic, which caters to a predominatelypoor population. Half her patients areuninsured and “self-pay.” Twenty percentare Medicare or Medicaid beneficiaries andmost of the rest have insurance through thelargest local employer, a shipyard. Theshipyard’s plan is not particularly generous.For example, enrollees pay a $25 co-payment for a physician visit, even if it is foressential preventive care or a recommendedscreening test.

That $25 co-payment represents a seriousobstacle to preventive and routine care visitsfor her insured patients. As a result, many ofDr. Benjamin’s patients wait to see her untilthey feel they must, and sometimes that istoo late. But it is the uninsured patients sheworries most about.

Complicating her challenge and their owncare, Dr. Benjamin’s patients tend to havevery poor health status, knowledge of health

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Conclusion Clinical preventive care services andpromotion of healthy lifestyles continue to beunderutilized health strategies in the UnitedStates – for a complex array of reasons. Thoughemployer, health plan, and governmentcoverage of such services has expandedsignificantly in the last decade, coverageremains inconsistent with therecommendations of key expert bodies.

Providers and clinicians embrace prevention inprinciple but often fail to deliver specificservices even when they are a covered benefit.Consumers are largely still unaware of thevalue of many preventive services and often donot know when and where to access them.Systems are largely not in place that couldremind providers of a patient’s need for aservice. Nor are systems widely available toremind consumers of their need for a specificpreventive care service, such as a cancer orheart disease screening test. New tools basedon information technology and the internetshould make such systems easier and lessexpensive to build in the near future.

Skepticism of the near-term payoff and benefitfrom specific preventive health services is stillwidespread. This is despite growing evidenceof a positive return-on-investment (ROI) formany preventive services. Employers and

government remain reluctant to pay for someclinical preventive services in the absence ofeven stronger ROI data and clear guidelinesabout which services both benefit the health ofemployed or enrolled populations and alsosave money in a relatively short time frame.Speakers supported the process and recentrecommendations to emerge from the UnitedStates Preventive Services Task Force (USPSTF,housed at the Agency for Healthcare Researchand Quality). They also supported the work ofthe Centers for Disease Control and Prevention(CDC) in creating the Guide to CommunityPreventive Services.

Both initiatives make preventive servicesrecommendations based on systematic reviewsof the scientific evidence. Speakers urgedhealth benefit managers and consultants,health plan administrators, and clinicians tolearn more about these initiatives and morebroadly the evidence supporting the clinicaland financial return from preventive careservices. Payers, including Medicare, shouldconsider expanding coverage of preventivecare services, and aligning it with USPSTF andCDC recommendations.

Speakers strongly recommended thatemployers, government, health plans, andprovider organizations work in collaboration topromote prevention among both providers andconsumers.

Endnotes 1 Morbidity & Mortality Weekly Report 50. September 7,

2001. 35:31. 2 Lightwood JM and SA Glantz. 1997. Short-term

Economic and Health Benefits of SmokingCessation. Circulation. 96:1089-1096.

3 Wagner EH, Sandhu N, Newton KM, McCulloch DK,Ramsey SD, and LC Grothaus. 2001. Effect ofImproved Glycemic Control on Health Care Costsand Utilization. Journal of the American MedicalAssociation. 285(2):182-189.

4 Testa MA and DC Simonson. 1998. Health EconomicBenefits and Quality of Life During ImprovedGlycemic Control in Patients with Type 2 DiabetesMellitus. Journal of the American Medical Association.280(17):1490-1496.

5 For more information, see the article by Aldana inthe May/June 2001 issue of American Journal ofHealth Promotion.

6 For more information, see the article by Goetzel, et al.in AWHP’s Worksite Health, 1999, Volume 6, Number3.

7 For more information, see the article byOzminkowski, RJ, et al in American Journal of HealthPromotion, 1999, Volume 14, Number 1.

8 For more information, see the article by Goetzel, et al.in the Journal of Occupational Health andEnvironmental Medicine, May 2002, Volume 44,Number 5.

9 For more information, see Krumholz, et al. in theJournal of the American College of Cardiology, 2002,Volume 40, Number 4.

25


Appendix A

The CDC Guide to Community Preventive Serviceswww.thecommunityguide.org

The Centers for Disease Control andPrevention’s Guide to Community PreventiveServices provides recommendations onpopulation-based interventions to promotehealth and prevent disease, injury, disability,and premature death. The recommendationsare for use by communities and health caresystems. The Task Force on CommunityPreventive Services, an independent body ofexperts, makes the recommendations based ona comprehensive review of scientific evidence.The Guide is a federally-sponsored initiativeand is part of a family of federal public healthinitiatives that include Healthy People 2010 andthe Guide to Clinical Preventive Services (thereport of the US Preventive Services Task Force;see Appendix D).

The Community Guide is being developed overtime and is thus a virtual, web-basedpublication. Chapters on different preventiveservices are added as they are developed. Eachchapter has extensive links to back-up scientificinformation as well as practical information oninterventions for providers. Community Guidechapters are also published as supplements inthe American Journal of Preventive Medicine.

As of July 2003, seven chapters have beenproduced on the following topics:

• Tobacco Product Use, Prevention, andControl

• Physical Activity

• Vaccine Preventable Diseases

• Diabetes

• Motor Vehicle Occupant Injury

• Oral Health

• Social Environment

Chapters now in preparation will cover thesefive topics:

• Cancer (Fall 2003)

• Mental Health (Spring 2004)

• Alcohol Abuse (Winter 2004)

• Sexual Behavior (Spring 2004)

• Violence (Summer 2003)

All dates of future publication are tentative.

26


Appendix B

List of Conference Faculty with Contact Information(In alphabetical order)

Regina Benjamin, MD, MBACEO and FounderBayou La Batrie Rural Health [email protected]

Linda Bergthold, PhDSenior ConsultantWatson Wyatt [email protected]

Abby Block, MSW, MA, MBAAssistant Director, Office of InsuranceProgramsOffice of Personnel [email protected]

Maris Bondi, MPHSenior Policy AnalystPartnership for [email protected]

Nancy Chockley, MBAPresidentNIHCM [email protected]

Tami CollinSenior ConsultantWilliam M. Mercer, [email protected]

Kathleen CurtinVice President, Quality ManagementUnivera [email protected]

Richard Dixon, MDDirector, Division of Prevention Research andAnalytic MethodsCenters for Disease Control and [email protected]

Kenneth Fink, MD, MPHVisiting ScholarAgency for Healthcare Research and [email protected]

Jon Gabel, MAVice President, Health System StudiesHealth Research and Education TrustAmerican Hospital [email protected]

Ron Goetzel, PhDVice President for Consulting and AppliedResearchThe MEDSTAT [email protected]

Catherine Gordon, RN, MBASpecial Assistant, Office of the DirectorCenters for Disease Control and [email protected]

27


Charles Hackett, MDChief Medical OfficerRaytheon [email protected]

Kathy Higgins, MSSenior Director, Community RelationsBlue Cross and Blue Shield of North [email protected]

Peter Kongstvedt, MDVice PresidentCap Gemini Ernest & [email protected]

Suzanne MercurePrincipalBarrington & [email protected]

Steve MorgensternHealth Plan ManagerDow [email protected]

Mark Nunlist, MDPrimary Care PhysicianWhite River Family Practice, [email protected]

Nicolas Pronk, PhDVice President, Center for Health PromotionHealthPartners, [email protected]

Rhonda Rhodes, MSActing Director, Division of Benefits andCoverageFamily and Children’s Health ProgramsCenters for Medicare and Medicaid [email protected]

Robert Scalettar, MD, MPHVice President, Medical PolicyAnthem Blue Cross Blue Shield of [email protected]

Cary Sennett, MD, PhDVice President for Science and QualityImprovementAmerican College of [email protected]

Christina Wee, MD, MPHAssistant Professor of MedicineHarvard Medical [email protected]

D’Ann Whitehead, PsyDFormer Manager, Health and ProductivityChevron-Texaco [email protected]

Dawn Wood, MD, MPHVice President and Medical Director, StateSponsored ProgramsBlue Cross of [email protected]

28


Appendix C

Medicare and Preventive Care ServicesSummary of Medicare Coverage, USPSTF Recommendations, National Use Rate Targets, Current UseRates, and Frequency and Cost to Patient for Selected Clinical Preventive Services

PreventiveService

MedicareCoverage

(YearCovered)

USPSTFRecommendation

Healthy PeopleTarget Use Rate

Current Use RateAmong Medicare

BeneficiariesOver 65

Frequency and Cost toPatient

Immunizations

PneumoccalCovered(1981)

Recommended at leastonce for individuals age 65

and over

90 percent ofadults over 65

60 percentOnce, or repeat if needed;

no copay or deductible

Hepatitis BCovered(1984)

Recommended at leastonce for individuals at high

risk of infection

90 percent of high-risk populations

35 percent ofhemodialysis

users2

3-shot series; 20% copayafter $100 deductible

Influenza Covered(1993)

Recommended annually forindividuals age 65 and over

90 percent ofadults over 65

66 percentOnce a year; no copay or

deductible

Screening Services

Cervical cancer(Pap Smear)

(Pelvic Exam)

Covered(1990)

(1998)

Recommended every 3years for all women who

are or have been sexuallyactive**

Not recommended

90 percent of allsexually active

women within thepast 3 years

72 percent

Every 24 mo, high riskevery 12 mo; 20% copay,no deductible for pelvic

exam and Pap collection;no lab copay or deductible

Breast Cancer(Mammography)

Covered(1991)

Recommended every 2years for women over 40

70 percent ofwomen over 40

within past 2 years75 percent

1 baseline age 35-39, thenevery 12 mos; 20% copay,

no deductible

Vaginal Cancer(Pelvic Exam)

Covered(1998)

Not reviewed No target set N/A

Every 24 mo, high riskevery 12 mo; 20% copay,

no deductible for pelvic andbreast exam

Colorectalcancer(Fecal-occultblood test)

(Sigmoidoscopy)(Colonoscopy)

Covered(1998)

Recommended for adultsover age 50: Every year

Every 5 yearsEvery 10 years

50 percent ofadults over age 50within past 2 years

50 percent ofadults over age 50

ever in lifetime

26 percentwithin the past

year1

44 percentwithin past 5

years1

Every 12 mo; no copay ordeductible on test

Every 48 mo; 20 or 25%copay after $100 deductible

Every 10 y, every 24 mo ifhigh risk; 20 or 25% copay

after $100 deductible

Osteoporosis(Bone MassMeasurement)

Covered(1998)

Routine screening isrecommended for women

over age 65No target set N/A

Every 24 mo, or morefrequently if necessary;

20% copay for $100deductible

Prostate Cancer(Prostatespecific antigentest and/or digitalrectalexamination)

Covered(2000)

Insufficient information torecommend for or against

routine screeningNo target set 63 percent

Every 12 months; no copayor deductible for PSA test;

20% copay after $100deductible for exam

Glaucoma

Covered(2002)

NHIS

Recommended referringhigh-risk patients for an

evaluation

Developmentalmeasure with no

target setN/A

Every 12 months; 20%copay after $100 deductible

1 Data from BRFSS.2 Data from Annual Survey of Chronic Hemodialysis Centers.** According to the USPSTF, there is insufficient evidence whether to continue Pap smear testing for women over 65 with consistentlynormal results, but a case can be made to discontinue screening based on other grounds.Sources: Adapted from Partnership for Prevention, A Better Medicare for Healthier Seniors: Recommendations to Modernize MedicarePrevention Policies; MedPAC, Report to Congress: Assessing Medicare Benefits. Washington, DC, 2002; United States General AccountingOffice, Medicare: Beneficiary Use of Clinical Preventive Services. Washington, DC, 2002; Department of Health and Human Services,Healthy People 2010. Washington, DC, 2002 (available at http://www.healthypeople.gov); US Preventive Services Task Force, “Screeningfor Prostate Cancer: Recommendations and Rationale,” Annals of Internal Medicine. 2002, 37(11): 915-6.

29


Cost to Medicare of Covering Three New Preventive Services

ServicesNet Cost

(average per year over 10years)

Return On The Investment(cumulative over 10 years)

Cholesterol Screening$82 Million

(savings begin in years 7-10)

62,362 Heart AttacksPrevented

44,912 Strokes Prevented

Tobacco CessationCounseling

$19.5 Million(savings begin in years 9-10)

95,000 Life Years Saved

Vision Screening$18 Million

(savings begin in years 4-10)

21,000 Hip FracturesPrevented

4,400 Forearm FracturesPrevented

Services recommended by the U.S. Preventive Services Task Force for persons 65 years and olderthat are not currently covered by Medicare.

Net Cost is the cost of the service minus the cost avoided by the service. The numbers in this columnrepresent the average cost per year over a 10-year period in 2002 dollars. The costs of lipid-loweringdrugs for cholesterol screening, the costs of nicotine replacement therapies for tobacco cessationcounseling, and the costs of eyeglasses for vision were not considered since these services are notcurrently covered by Medicare.

Returns On The Investment: These represent the expected benefits over a 10-year period. Fortobacco cessation counseling, deaths prevented (thus, life years saved) is the best measure availableto represent this services’ health benefits; the life years saved are the result of cancer cases, heartattacks, strokes, and other fatal diseases avoided.

Source: Adapted from Partnership for Prevention, Covering Preventive Services Under Medicare: A CostAnalysis.

30


Appendix D

Resources and LinksGovernment Agencies and Resources

Centers for Disease Control and PreventionHome pagewww.cdc.gov404-639-3311

CDC Recommends, Prevention Guidelines SystemA searchable database of CDCrecommendationswww.phppo.cdc.gov/cdcrecommends

CDC Division of Prevention Research andAnalytic Methods (DPRAM)770-488-8188

CDC Guide to Community Preventive Services(See Appendix A)www.thecommunityguide.org

Department of Health and Human Services(DHHS)Home pagewww.hhs.gov

DHHS Office of Disease Prevention and HealthPromotionhttp://odphp.osophs.dhhs.gov

DHHS “Healthier US Initiative”www.healthierus.gov

DHHS “Healthy People 2010”Detailed goals for the nationwww.healthypeople.gov

DHHS HealthfinderSearchable database of government health-related information and activitieswww.healthfinder.gov

Agency for Healthcare Research and Quality(AHRQ)Home pagewww.ahrq.gov

AHRQ’s United States Preventive Services TaskForce (USPSTF)www.ahrq.gov/clinic/uspstfix.htm

AHRQ’s “Putting Prevention into Practice”Initiativewww.ahrq.gov/clinic/ppipix.htm

Organizations

Partnership for PreventionWashington, DCwww.prevent.org

American College of Preventative MedicineWashington DCwww.acpm.org

American Public Health AssociationWashington, DCwww.apha.org

American Association of Health Planswww.aahp.org

Blue Cross Blue Shield Associationwww.bcbsa.com

Washington Business Group on Healthwww.wbgh.org

National Institute for Health CareManagement Foundationwww.nihcm.org

31


Selected Books, Reports, Issue Briefs, Papers

Addressing Tobacco in Managed Care: A ResourceGuide for Health Plans (2001, 75 pages)A publication by the American Association forHealth PlansCan be obtained at www.aahp.org

Guide to Clinical Preventive Services (2nd Edition;1996, 933 pages)Report of the U.S. Preventive Services TaskForce, U.S. Department of Health and HumanServices, Office of Disease Prevention andHealth PromotionCan be ordered from AHRQ atwww.ahrq.gov/clinic/prevenix.htmContains complete text of recommendations asof 1995

Clinician’s Handbook of Preventive Services (2nd

Edition, 1998, 524 pages)U.S. Department of Health and HumanServices, Office of Disease Prevention andHealth PromotionA publication of AHRQ’s “Put Prevention intoPractice” ProgramCan be ordered at www.ahrq.gov or by calling1-800-358-9295

Medicare: Use of Preventive Services is Growingbut Varies WidelyU.S. General Accounting Office Report 02-777TReleased May 23, 2002Can be obtained at www.gao.gov

Selected ArticlesDavid Atkins, et al., “The Third U.S. PreventiveServices Task Force: Background, Methods, andFirst Recommendations,” Supplement to theAmerican Journal of Preventive Medicine, April2001;20(3S).E-mail: [email protected]

Ashley B. Coffield, et al., “Priorities AmongRecommended Clinical Preventive Services,”American Journal of Preventive Medicine,2001;21(1).E-mail: [email protected]

David E. Nelson, et al., “State Trends in HealthRisk Factors and Receipt of Clinical PreventiveServices Among US Adults During the 1990s,”Journal of the American Medical Association, May22/29, 2002; Vol. 287, No 20: 2659-2667.

Government

Childhood Obesity — Advancing EffectivePrevention and Treatment: An Overview forHealth Professionals (2003, 48 pages)A publication of the National Institute forHealth Care Management FoundationCan be obtained at www.nihcm.org

A Better Medicare for Healthier Seniors:Recommendations to Modernize Medicare’sPrevention Policies (77 pages)See also: Covering Preventive Services UnderMedicare: A Cost Analysis (8 pages)Two reports by Partnership for Prevention,May 2003Can be obtained at www.prevent.org

Preventive Services: Helping States ImproveMandates (2002, 20 pages)A report by Partnership for PreventionCan be obtained at www.prevent.org

Prevention Priorities: A Health Plan’s Guide tothe Highest Value Preventive Health Services(2002, 5 pages)A report by Partnership for PreventionCan be obtained at www.prevent.org

Prevention Priorities: Employers’ Guide to theHighest Value Preventive Health Services (2002, 5pages)A report by Partnership for PreventionCan be obtained at www.prevent.org

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Job No.10057 Name severyn group Cyan Magenta Yellow Black

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2” Building New Partnerships and Community Commitment

P R O C E E D I N G S F R O M A C O N F E R E N C E

1225 19th Street, NW

Suite 710

Washington, DC 20036

T E L 202.296.4426

FA X 202.296.4319

W E B www.nihcm.org

Division of Prevention Researchand Analytic Methods

4770 Buford Highway – K73

Atlanta, Georgia 30341

T E L 770.488.8188

FA X 770.488.8461

W E B www.cdc.gov


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