More services, tests and counseling recommended to be reimbursed by health “insurance” at 100% by Institute of Medicine

25 Jul

The Patient Protection Affordable Care Act requires that many services classified as preventative be covered at 100% with no deductible or co-payment. While it is up to HHS to determine which services are to be covered in this manner, HHS relies on the Institute of Medicine and several other organizations to make ongoing recommendations of services, etc. for reimbursement at 100% by health insurers and employer self-insured plans.

This expansion of services covered at 100% seems curious given that in the realm of Medicare new studies say the lack of cost sharing by Medicare beneficiaries (you can’t prove that by me) encourages over-utilization.

In addition, it has long been known for years that mandates for health insurance coverage at the state level have driven up premiums from 15% to as much as 25% over the years. The PPACA is now doing the same thing in the name of prevention (and with the nebulous assumption that covering such services at 100% will lead to lower costs sometime in the future).

Health “insurance” is rapidly becoming a misnomer. There is no insurance when you determine when to incur the expense and you have, in effect, no financial risk.

Many employers voluntarily voided their grandfathering status under PPACA thus subjecting themselves to these preventive and other requirements. More than that, they lost all control over what new services will be added to their programs without employee cost-sharing, something that is counter to years of cost management strategies.

The objective of all this, of course, is not to drive up costs and if you ask the IOM I venture to say they are trying to improve health care and health in general. They identify gaps in coverage, but does filling those gaps require an employer or insurer to carry the full cost and the patient none (not entirely true, the hidden cost will be higher premiums).

Somehow we have developed the mindset that unless someone else is paying, no health care no matter how routine or inexpensive is our responsibility.

Among the new services recommended for 100% coverage are:

  1. counseling on sexually transmitted infections,
  2. counseling and screening for HIV,
  3. contraceptive methods and counseling to prevent unintended pregnancies,
  4. lactation counseling and equipment to promote breast-feeding,
  5. screening and counseling to detect and prevent interpersonal and domestic violence,
  6. yearly well-woman preventive care visits to obtain recommended preventive services.

Call me stupid if you will, but I thought everyone knew what “equipment” was involved in breast-feeding. And as for preventing unintended pregnancy, perhaps the elimination of unintended sex would help. What qualified obstetrician does not now screen his or her patient for diabetes during pregnancy and why would it need separate treatment as a covered medial expense? The concept of preventive care and its relationship to health “insurance” has run amuck.

I can see it all now, new businesses will abound: “Counseling Available – You Pick the Topic (as long as it is covered at 100%) Call Your Insurer Today”

Here is the full text of the Institute of Medicine press release.

July 19, 2011


WASHINGTON — A new report from the Institute of Medicine (IOM) recommends that eight preventive health services for women be added to the services that health plans will cover at no cost to patients under the Patient Protection and Affordable Care Act of 2010 (ACA). The ACA requires plans to cover the services listed in the U.S. Department of Health and Human Services’ (HHS) comprehensive list of preventive services. At the agency’s request, an IOM committee identified critical gaps in preventive services for women as well as measures that will further ensure women’s health and well-being.

The recommendations are based on a review of existing guidelines and an assessment of the evidence on the effectiveness of different preventive services. The committee identified diseases and conditions that are more common or more serious in women than in men or for which women experience different outcomes or benefit from different interventions. The report suggests the following additional services:

• screening for gestational diabetes
• human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
• counseling on sexually transmitted infections
• counseling and screening for HIV
• contraceptive methods and counseling to prevent unintended pregnancies
• lactation counseling and equipment to promote breast-feeding
• screening and counseling to detect and prevent interpersonal and domestic violence
• yearly well-woman preventive care visits to obtain recommended preventive services

“This report provides a road map for improving the health and well-being of women,” said committee chair Linda Rosenstock, dean, School of Public Health, University of California, Los Angeles. “The eight services we identified are necessary to support women’s optimal health and well-being. Each recommendation stands on a foundation of evidence supporting its effectiveness.”

Deaths from cervical cancer could be reduced by adding DNA testing for HPV, the virus that can cause this form of cancer, to the Pap smears that are part of the current guidelines for women’s preventive services, the report concludes. Cervical cancer can be prevented through vaccination, screening, and treatment of precancerous lesions and HPV testing increases the chances of identifying women at risk.

Although lactation counseling is already part of the HHS guidelines, the report recommends comprehensive support that includes coverage of breast pump rental fees as well as counseling by trained providers to help women initiate and continue breast-feeding. Evidence links breast-feeding to lower risk for breast and ovarian cancers; it also reduces children’s risk for sudden infant death syndrome, asthma, gastrointestinal infections, respiratory diseases, leukemia, ear infections, obesity, and Type 2 diabetes.

HHS should consider screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes. The United States has the highest rates of gestational diabetes in the world; it complicates as many as 10 percent of U.S. pregnancies each year. Women with gestational diabetes face a 7.5-fold increased risk for the development of Type 2 diabetes after delivery and are more likely to have infants that require delivery by cesarean section and have health problems after birth.

To reduce the rate of unintended pregnancies, which accounted for almost half of pregnancies in the U.S. in 2001, the report urges that HHS consider adding the full range of Food and Drug Administration-approved contraceptive methods as well as patient education and counseling for all women with reproductive capacity. Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy. Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which raise their chances of health and developmental problems.

HHS’s guidelines on preventive health services for women will need to be updated routinely in light of new science. As part of this process, HHS should establish a commission to recommend which services health plans should cover, the report says. The commission should be separate from the groups that assess evidence of health services’ effectiveness, and it should consider cost-effectiveness analyses, evidence reviews, and other information to make coverage recommendations.

The report addresses concerns that the current guidelines on preventive services contain gaps when it comes to women’s needs. Women suffer disproportionate rates of chronic disease and disability from some conditions. Because they need to use more preventive care than men on average due to reproductive and gender-specific conditions, they face higher out-of-pocket costs, the report notes.

The study was sponsored by the U.S. Department of Health and Human Services. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.

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