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Health Care Plan Decisions Regarding Preventive Services
Dan Merenstein, MD;
Howard Rabinowitz, MD;
Daniel Z. Louis, MS
Arch Fam Med. 1999;8:354-356.
Background Medical decisions previously made by physicians and patients are increasingly influenced by health plans. It is important to understand how these decisions are made and who makes them.
Objectives To determine protocols used by health plans for recommending preventive services and to identify methods used to develop these protocols.
Methods An interviewer conducted semistructured telephone interviews with medical directors from 6 major types of health plans regarding coverage of certain procedural preventive services. Each medical director was asked: (1) Is this procedure paid for by the health plan? (2) What is the frequency recommended for this procedure? (3) What age groups do you recommend for this procedure? (4) Do you encourage patients to receive this procedure, and if so, how? (5) Who developed these preventive services recommendations? (6) How were these recommendations developed?
Results Ten interviews were completed representing 6 chosen types of health plans. While the different plans varied little regarding the preventive services recommended, there was variation in efforts to promote recommended services to members. There were also differences among the plans in the decision-making process for developing preventive services recommendations.
Conclusions Managed care organizations promote certain preventive services to members. All health plans had at least 1 preventive medicine task force charged with making coverage decisions about preventive services. However, more could be done to rationalize development of preventive services recommendations, primarily, implementation of evidence-based guidelines.
From the Fairfax Family Practice, Fairfax, Va (Dr Merenstein); and Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pa (Dr Rabinowitz and Mr Louis).
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