Help People Follow the Doctor's Orders: Insurers Must Expand Coverage of Prevention

04/17/2013 03:25 pm ET | Updated Jun 17, 2013

Most of us only go to the doctor a few times a year -- and in between that, we are left alone to figure out how to best follow our doctor's advice in our daily lives. If you have pre-diabetes, most days you're left to manage that condition and try to prevent it from developing into full-blown diabetes in a world that's stacked against you, where nutritious foods cost more and are less available, and it is hard to find time and convenient, safe places to fit physical activity into your day.

Traditionally, private and public insurers have focused on covering care after we've already sick or hurt. But the research shows that increasing preventive "well care" and providing the support to help make healthier choices easier in our daily lives gives us a chance to follow doctor's orders and actually improves health. And, this approach translates into less need to return to the doctor and should bring down health care costs.

For too long, our system has been set up to focus on "sick care," instead of helping us all stay healthier in the first place. This needs to change and, thankfully, it has begun to.

A portion of the Affordable Care Act (ACA) actually calls for attention to prevention, requiring increased coverage of "well care" and prevention at the doctor's office and providing new opportunities for insurers to expand coverage for proven community-based programs.

In fact, the ACA requires private and self-insurers to cover, in new plans, the most health- and cost-effective, strategic prevention screenings, counseling services and immunizations with no co-payments -- as well as annual well visits under Medicare and provides incentives for state Medicaid programs to cover more preventive services. This will save lives and money: according to Health Affairs, a greater use of 20 proven clinical preventive services would save more than two million lives annually and could result in savings of $3.7 billion annually.

Now, we need to make sure that Americans know about and are taking advantage of these benefits because they are currently underused. Close to half of the U.S. population does not access the commonly recommended clinical preventive services. In addition, all insurers, including every Medicaid program, should expand coverage to include these services.

To go along with this increased preventive care, we now also need to expand coverage of proven, community-based programs that make it easier for Americans to make healthier choices in their daily lives.

Unfortunately, many efforts to cover these programs have been constrained by the outdated and faulty "sick care" model that focuses on individual beneficiaries and fee-for-services. However, we're at a turning point -- the ACA is beginning to open up a new world, with increased attention and incentives for improving health and controlling costs paired with greater understanding that achieving these goals means providing support to Americans outside the clinical setting in neighborhoods, schools and workplaces.

For instance, the National Diabetes Prevention Program (DPP) is showing big payoffs for improving health and bringing down costs. The DPP is a 16-week lifestyle improvement program for individuals at high-risk for diabetes. This program engages individuals in group education with a trained lifestyle coach, focusing on improved eating habits, increased physical activity and other behavior modifications. UnitedHealth Group began partnering with the YMCA in 2010 to replicate this program, working with pharmacist-led education and behavioral intervention initiatives within the pharmacy setting at Walgreens. Some states help support DPP via public-private partnerships with Medicaid. Participants in the Y's program lost an average of 4.8 percent of their body weight, while hundreds of individuals lost an average of 7 percent of body weight. Now, thanks to new funding from the Prevention and Public Health Fund, the Centers for Disease Control and Prevention (CDC) is helping to bring this program to an even larger scale.

In addition, a number of public and private insurers are starting to cover evidence-based prevention programs in communities. For instance, Blue Cross and Blue Shield (BCBS) companies are using their resources, including hundreds of employee volunteers, to promote wellness and the prevention of disease through programs tailored to meet the needs of rural, urban and targeted ethnic and cultural communities. Also, Kaiser Permanente funds community health initiatives (CHI) that take a preventive approach to health care through targeted grantmaking and convening and partnering with community organizations.

As insurance companies, they understand both the health and economic savings that can be achieved if we start investing in prevention and improving health.

It's a good start, but the legacy systems are still working against us. Outdated regulations and billing systems make it harder for insurers to find ways to support programs that are not directly delivered by doctors and licensed medical providers or that help support the health of an entire neighborhood rather than focusing on a specific individual who is tied to a specific billing code.

It's time for the Center for Medicare and Medicaid Services (CMS) and private insurers to get with the "health care" program -- and clarify to states and within their policies that they may reimburse community-based organizations, public health departments and other entities (such as schools) for community-based prevention, health education and counseling activities.

The Medicaid program has taken a first step in this regard with a proposed rule that would give states greater flexibility in what kinds of prevention programs they can cover. To assure this new flexibility is translated into practice, CMS, the CDC and Medicaid health plans need to work together (along with private insurers) to document and provide information about the best practices, implementation tools and health and cost saving outcomes of community prevention activities -- and provide specific examples supported by Medicaid or by their insurance plan.

As the whole health system is reforming - it's important that coverage for prevention be a top priority if we're ever going achieve a healthier America.

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