 |
|
Health Care Plan Decisions Regarding Preventive Services
Dan Merenstein, MD;
Howard Rabinowitz, MD;
Daniel Z. Louis, MS
Arch Fam Med. 1999;8:354-356.
ABSTRACT
| |
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.
INTRODUCTION
DURING THE past decade, we have witnessed a major change in how medical decisions are made. Decisions that were primarily the domain of the physician and patient are now influenced, and occasionally dictated, by health plans. The solo practitioner and traditional indemnity fee-for-service insurance are being replaced by group practices, managed care organizations, and prepaid care. In addition, Medicare and Medicaid are increasingly moving toward managed care in their cost containment efforts.1
One of the most important decisions a physician makes is choosing a preventive service to recommend to a patient. According to Phillip R. Lee, MD, former US assistant secretary for health, "It is no longer questioned that appropriate preventive care belongs at the top of the list of effective interventions that must be available to all Americans."2 Therefore, one of the major challenges for primary care is to determine which tests and procedures to provide to patients. For example, should a physician recommend to all eligible patients that they receive a prostate-specific antigen (PSA) test recommended by the American Cancer Society,3 the American Urological Association,4 and the American College of Radiology5 but by neither the Canadian Task Force on the Periodic Health Examination6 nor the US Preventive Services Task Force (USPSTF)?2
Increasingly, decisions regarding preventive services recommendations are no longer solely the domain of the physician but are strongly influenced by health plans. In the rapidly changing health care environment, it is important for both the family physician and patient to know what decisions health plan medical directors and/or task forces make regarding preventive services recommendations and to understand how these decisions are made. Screening procedures could be a simple and important first measurement of the decision-making process since there are evidence-based standards for screening. The objectives of this study were to determine the protocols for specific screening by various types of health plans and to identify the methods that the health plans relied on for developing these protocols.
PARTICIPANTS, MATERIALS, AND METHODS
During September 1996, a survey was conducted to study how preventive services decisions are made by health plan medical directors. The survey was conducted using ten 20-minute telephone interviews. Seventeen health plan medical directors received a faxed message explaining the project. All interviews were conducted by one of us (D.M.) using specific questions followed up with in-depth explanations. The final number of participants were contacted after being identified as representatives of 6 different types of health plans: (1) for profit staff model, (2) nonprofit staff model, (3) for profit independent practice associations (IPAs), (4) nonprofit IPAs, (5) for profit indemnity insurance, and (6) nonprofit indemnity insurance. Plans were selected at random from a list provided by the American Association of Health Plans; most were located in the greater Philadelphia metropolitan area, which includes bordering regions of New Jersey, Delaware, and other areas of Pennsylvania.
Each participant was questioned about 6 different preventive medicine services that had been chosen by the grade the service received from the USPSTF Guide.2 A grade A indicates good evidence to recommend the procedure; B, fair evidence; C, insufficient evidence; and D, fair evidence to exclude. The specific procedures are listed in Table 1.
|
|
|
|
Type of Health Plan vs Recommended Test and/or Procedure*
|
|
|
Each medical director was asked the following questions: (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? Health plans covered all of the preventive services that were recommended; plans also covered some of the preventive services that were not recommended.
RESULTS
Thirteen of the 17 medical directors initially agreed to the interviews; the remaining 4 did not respond. Ten of the 13 interviews were completed; the remaining 3 medical directors could not be reached during the survey period. The final 10 participants were employed by 3 health plans in Pennsylvania; 3, in Delaware; 2, in New Jersey; 1, in Connecticut; and 1, in Washington State. Five of these health plans have a national presence. All 6 types of health plans were represented.
Each medical director indicated their plan had at least 1 preventive medicine task force to review and propose tests for the plan to support and cover. These task forces comprised medical directors, physicians, nurses, pharmacists, and business executives, although actual constituents of each task force differed among each health plan.
All of the preventive services addressed in this study were considered by the 6 plans except for routine ultrasound (US) screening for abdominal aortic aneurysm (AAA). Only 1 task force, a national for profit IPA, had considered USs for AAA. The for profit IPA's preventive medicine task force generally tried to evaluate as many tests as possible. In all but one of the plans, a new service is generally considered only after a physician or patient initiates a claim for the test, rather than proactively establishing a standard.
All plans support and encourage mammography and will pay for any performed (Table 1). Four of the plans begin targeting women older than 40 years for mammography and continue to target them throughout their lives. The 2 exceptions, a for profit IPA and a nonprofit IPA, recommend mammography for women between 50 and 69 years. The USPSTF gives a grade A for mammography for women between 50 and 69 years and gives a grade C for women younger than 50 and older than 70 years. Most of the medical directors said they picked 40 for the youngest age to recommend mammography and defined no upper age limit at which they discourage mammography as they considered this to be the conservative medical recommendation. All of the health plans require that reminders be sent to all women targeted for mammography.
All of the health plans recommend sigmoidoscopy for patients older than 50 years. None of the plans require reminder cards for sigmoidoscopy, although 2 plans do place announcements in a patient newsletter. None of the plans have any set standard for frequency of sigmoidoscopies. One medical director said, "We don't see this as a test that patients will take advantage of."
Influenza vaccination for patients older than 65 years was recommended by all health plans. All of the plans required reminder cards except for 1 that relied on the newsletter as a reminder. This high rate of reminders for influenza vaccination contrasts with the low rate of reminders for sigmoidoscopy, even though both procedures received the same grade (B) from the USPSTF.
Routine US screening for AAA after age 60 was not covered by any of the health plans and was only addressed by one preventive medicine task force. All of the medical directors were surprised that this question was even asked, and many asked if other health plans recommended that this test be done.
Routine PSA testing after age 50 was only encouraged by 1 health plan. Two plans required abnormal findings on rectal examination before recommending the PSA test. The PSA test had been discussed by many of the plans, and numerous medical directors stated that they believed the test might cause more harm than good.
COMMENT
These results show little difference among health plans regarding various screening tests and procedures (Table 1). Although financial structures likely differ among the various types of plans, there is almost no difference in the services recommended and covered. While physicians are encouraged to practice evidence-based medicine, many are concerned that medical decisions are being taken out of the their hands. In addition, it is not clear in our study whether these decisions are based on available evidence. For example, only 1 of the health plans recommends routine US for AAA, although evidence for the use of US screening for AAA may be as strong as—or stronger than—evidence for routine mammography for women younger than 50 or older than 70, which most health plans recommend. In fact, nearly all of the medical directors were surprised that US screening for AAA was even considered, though it has been shown by some to be cost-effective.7
We had anticipated that health plans might have a more rigorous protocol and might be better equipped than a solo practitioner to approach preventive services in an evidence-based manner. However, it appears that health plans may be influenced by consumer demand and public opinion, considering the strong support for mammography at all ages and the lack of support for US screening for AAA. Others8 came to a similar conclusion regarding health maintenance organizations in a study that looked at health promotion programs. Although many of the health maintenance organizations offered numerous health promotion programs, it appeared to be solely used as a marketing vehicle. This is contrary to what we had anticipated, as the health plans did not appear to be approaching preventive medicine in an evidenced-based manner.
All health plans in our study have both a preventive medicine task force and some type of executive committee; however, none of the plans use any one set of guidelines to determine which tests to support. Thus, a health plan may follow the American Cancer Society guidelines for mammography but disregard its guidelines for PSA. Furthermore, health plans may follow the USPSTF recommendations for mammography for certain age groups but not follow the same recommendations for others. In addition, many of these national guidelines followed by health plans are not developed under the guidance of evidence-based medicine. Many medical directors said they take the conservative outlook to avoid controversy.
As a qualitative research project, we focused in depth on a relatively small, purposefully selected sample.9 Instead of drawing on large populations for quantitative research, we used key informants who had special knowledge of our subject.10-11 One limitation of this project was that we did not examine the health plans' success in accomplishing recommendations, though we addressed which preventive services the health plans recommended. In addition, we did not fully address the issue of coverage but instead concentrated on plans' recommendations. With such a small qualitative project, there is room for selection bias, and because this is a pilot project, further qualitative or quantitative research is necessary to clarify this subject.
The question for future family physicians is not only are the best health care decisions being made, but also is the decision-making process reflective of evidence-based medicine and sound medical practice. Thus, as national organizations change recommendations and new medical information becomes available, health plan medical directors and/or task forces must continue to re-evaluate recommendations and further integrate evidence-based medicine into these recommendations.
AUTHOR INFORMATION
Accepted for publication August 22, 1998.
Corresponding author: Dan Merenstein, MD, Fairfax Family Practice, 3650 Joseph Siewick Dr, Suite 400, Fairfax, VA 22033 (e-mail: merenst1{at}juno.com).
From the Fairfax Family Practice, Fairfax, Va (Dr Merenstein); and Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pa (Dr Rabinowitz and Mr Louis).
REFERENCES
| |
1. Levit KR, Lazenby HC, Braden BR and the National Health Accounts Team. National health spending trends in 1996. Health Aff (Millwood). 1998;17:35-51.
ABSTRACT
2. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.
3. American Cancer Society. Guidelines for the Cancer-Related Checkup: An Update. Atlanta, Ga: American Cancer Society; 1993.
4. American Urological Association Executive Committee. Executive Committee Report. Baltimore, Md: American Urological Association; 1992.
5. American College of Radiology.. Resolution 36; approved October 1991.
6. Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa, Ontario: Canada Communication Group;1994:812-823.
7. Frame PS, Fryback D, Patterson C. Screening for abdominal aortic aneurysm in men ages 60 to 80 years. Ann Intern Med. 1993;119:411-416.
FREE FULL TEXT
8. Schauffler HH, Chapman SA. Health promotion and managed care. Am J Prev Med. 1998;14:161-167.
FULL TEXT
|
ISI
| PUBMED
9. Quinn MP. Qualitative Evaluation and Research Methods. London, England: Sage Publications; 1990:169.
10. Gilchrist VJ. Key Informant Interview: Doing Qualitative Research. Newbury Park, Calif: Sage Publications; 1992:70-89.
11. Elder NC, Miller WL. Reading and evaluating qualitative research studies. J Fam Prac. 1995;41:279-285.
ISI
| PUBMED
RELATED ARTICLE
The Archives of Family Medicine Continuing Medical Education Program
Arch Fam Med. 1999;8(4):291-293.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Ultrasonographic Screening for Abdominal Aortic Aneurysms
Lederle
ANN INTERN MED 2003;139:516-522.
ABSTRACT
| FULL TEXT
|
