Prevention is said to be the best medicine, even better than a cure; and as we’ve been told time and again, prevention pays. This is clearly the reasoning behind the health law’s new provision that aims to eliminate financial barriers to preventive services like mammograms and diabetes testing. Health and Human Services Secretary Kathleen Sebelius has said that Americans use preventive services at only about half the recommended rate; studies find that minorities and the poor are far more likely to be barred from these services by high out-of-pocket costs.

The new provision, which went into effect on September 23, requires that insurers provide 45 preventive services to beneficiaries without charging co-pays or deductibles. For now it applies only to new group and individual policies. Many health plans are “grandfathered” in; meaning that that they are exempt from the requirement until they make significant changes to their policies—something that most insurers will likely do before 2013. Medicare and Medicaid plans will have to remove deductibles and co-pays for the designated preventive services by 2011.

HSS estimates that in the coming year some 31 million people in new employer plans and 10 million people in new individual plans will benefit from the prevention provisions under the Affordable Care Act. By 2013, HHS expects some 88 million Americans will see their access to prevention coverage improve.

So the big question is; will prevention really pay in the end? From a social and public health standpoint; the answer is decidedly yes. According to a study last year in the Journal of the American Medical Association, effective delivery of just five preventive services –colorectal and breast cancer screening, flu vaccines, and counseling on smoking cessation and regular aspirin use – could avert 100,000 deaths each year.

But as far as bending the health care cost curve, the jury is still out: Some studies predict that long-term savings from increased preventive services could reach the billions; others predict just the opposite. The answer seems to lie somewhere in between—preventive services each come with a cost-benefit estimate that depends on which portion of the population is tested and how often. For example, Rutgers economist Louise B. Russell, author of “Is Prevention Better than Cure?” calculated that Pap smears for cervical cancer screening every three years cost $41,000 per healthy year, compared with no screening. Screening every two years adds $1.3 million to the tab, and yearly Pap smears cost an additional $3.3 million per healthy year gained. According to Russell, “While some preventive methods buy many years of healthy life, others don’t. And we want to spend our money so we can produce as much health as possible.”

Joseph Stubbs, President of the American College of Physicians, agrees;

“Experts suggest that only about 20% of preventive measures, such as counseling a smoker to quit smoking, vaccinating against influenza, and screening men for colorectal cancer, actually generate true cost savings. The other 80% cost money.” But, Stubbs continues; “prevention is a social good resulting in better health. As such, the important question is not ‘Can we save money through prevention? but ‘How can we get the most ‘value’ from prevention for the dollars spent?’”

With one important exception, the government has done a pretty good job of identifying essential and beneficial services backed by “scientific evidence” to include in their coverage mandate. A complete list of these 45 services can be found here and include:

–Preventive services given a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force.  
–Childhood immunizations recommended by the CDC
–Preventive care/screenings for children/adolescents that are expressed in comprehensive guidelines supported by the Health Resources and Services Administration.

–Preventive services for women (additional care and screenings) also to come from guidelines from HRSA

The one glaring exception to the “backed by scientific evidence” is the mandate to cover screening mammography every 1-2 years for women age 40-50. Last year, the Preventive Services Task Force recommended that only women over 50 have routine screening mammograms; for those under 50 with no risk factors or prior cancers, the procedure was given only a “C” recommendation. The bulk of evidence finds very little benefit for regular screening at the earlier ages, and may even cause harm by exposing women to radiation and over-treatment of tiny cancers that might never progress or go away on their own. In fact, the Task Force found that in women under 50, the decision to have regular screening mammograms should be decided on a personal basis.

Instead, under pressure from breast cancer advocates (as well as General Electric, top maker of mammography equipment), those crafting the legislation chose to use a recommendation that the Task Force issued in 2002 that gave a “B” rating to mammography screening every 1-2 years for women 40 and over. This episode gives a hint of the power lobbyists might yield in future preventive coverage decisions.

HHS estimates that the new preventive services policy will cause insurance rates to rise by about 1.5%. This cost will likely be passed on to consumers—although the agency predicts that many people with insurance may see significant individual savings. For example, HHS guidelines recommend that a 58-year old woman who is at risk for heart disease should get a mammogram, a colonoscopy, a Pap test, a diabetes test, a cholesterol test, and an annual flu shot. The agency estimates that under a typical insurance plan, these tests could cost the woman more than $300 out of her own pocket . “The new rules could provide significant savings for Americans in greatest need of important, potentially life-saving preventive services.”

John Goodman, President and CEO of the National Center for Policy Analysis, a conservative think-tank worries that the influx of more patients seeking preventive services will overwhelm the medical system. He writes in a recent commentary; “Overall, it's probably fair to say that if everyone took full advantage of all of the services the task force recommends, we would need every family doctor in America working full-time on the task — leaving no time left over for any other medical services."

Goodman’s prediction is clearly hyperbolic, but he is right that if everyone accessed every recommended preventive service at the recommended time intervals, primary care doctors would be overwhelmed with patients, and wait times for recommended services would rise. Several provisions in the Affordable Care Act—tuition help for medical students choosing primary care; increased reimbursement for preventive and primary care services, etc.—could eventually help boost the supply of  primary care physicians and nurse practitioners to meet increased demand.

But the influx of new patients seeking preventive care is likely to be gradual. First of all, some 16.7% of Americans currently do not have health insurance and until they do, they will not be joining the throngs initially lining up for colonoscopies and similar services. After all, if you’re 50 and feeling healthy, what’s the impetus to have a colonoscopy that can cost $3,000 instead of paying rent and college tuition for your kids?

This kind of rationing by necessity is well documented and at least for a few years, will continue to be an issue. For example, according to a report published by the Robert Wood Johnson Foundation, Hispanic Americans (nearly 40% of who are uninsured) are less likely than better-insured non-Hispanic whites and African Americans to use 10 key (and cost-saving) preventive services. Some examples from the report;

•    Hispanic smokers are 55 percent less likely to get assistance to quit smoking from a health professional than white smokers.

•    Hispanic adults age 50 and older are 39 percent less likely to be up to date on colorectal cancer screening than white adults.

•    Hispanic adults age 65 and older are 55 percent less likely to have been vaccinated against pneumococcal disease than white adults.

Another concern some experts have about the new prevention provisions is that they could be used by insurers as a “blunt instrument,” for measuring physician performance, according to Brenda Sirovich, an internist who works on outcomes research at the VA Medical Center in White River Junction, NH and also is affiliated with the Dartmouth I
nstitute. “My concern is really that it seems to be a slippery slope between mandating coverage and mandating a service. Mammography, Pap smear testing, a lot of these screening tests are not as effective as they are cracked up to be.”

“I completely agree with the concept that income and ability to pay shouldn’t be what stops somebody from getting preventive services that they want and that they can benefit from,” says Sirovich. But she worries that insurers (both public and private) will measure a doctor’s performance by looking at how many of their patients receive the recommended preventive services. “When working in a system with performance measures, it can be hard to do invidualized care and when we forget about individualizing we lose something.”

What Sirovich is getting at is that beyond affordability, there are other reasons people fail to access preventive services. Some smokers just don’t want to quit, many obese people aren't interested in following nutritional advice from their doctors. And when the preventive service in question involves wide-spread screening for cancer or heart disease some consumers (especially those at low risk) reject them because they don’t want to deal with the anxiety about false positives or risk over-treatment for pseudo-disease. In the case of mammograms, (as well as for other screening tests like PSA that thankfully wasn’t included in HHS’s list) some people will rightly feel that the risks of the mammogram (radiation exposure, false positives, over-treatment, etc.) or PSA screening (debilitating treatment) outweigh the benefits in their individual cases. Doctors shouldn’t be penalized for respecting patient’s informed decisions.

The key then is to make sure that preventive services are being utilized for the right reasons on the right people. Financial incentives and perceived fear of malpractice suits have, in the past, driven an epidemic of over-testing and treatment. In a recent post on the blog KevinMD, George Lundberg, former editor of MedScape and JAMA, compiles an extensive list of reasons doctors give for ordering lab and other diagnostic tests that have nothing to do with medical benefit. These include such non-essential reasons as: curiosity, insecurity, public relations, documentation, peer pressure, patient pressure, pressure from recent literature, frustration at nothing better to do (don’t know what’s wrong with this patient, better get some lab tests) etc. These findings compelled Lundberg to suggest the health care community have a conversation about how to “ration rationally;” an idea that should also extend to preventive services.

So far, the USPSTF has done an excellent job of rating the effectiveness of many preventive services that are included in the new coverage mandate. But as this once-obscure agency—which does not have the power to enforce its recommendations—has gained prominence, so has it become a target for special interests. After facing the backlash over its recent mammography recommendations, the Task Force responded to critics’ calls for more transparency by agreeing to accept public comment before finalizing its recommendations. According to an article published jointly by the Washington Post and Kaiser Health News in July, these comments “may provide one tool for ‘people who are eager to figure out ways to influence the task force,’ said Paul Bonta, associate executive director of the American College of Preventive Medicine.’”

The new prevention provision is “good news for patients, who will no longer face cost-sharing for these services, but it puts [the USPSTF] in the crosshairs of lobbyists and disease advocates eager to see their top priorities – including routine screening for Alzheimer’s disease, domestic violence, diabetes or HIV – become covered services.”

The article mentions that if the Preventive Services Task Force “does back a service – such as it did earlier this month when it suggested wider screening for osteoporosis – it might increase patients' access, as well as create new business opportunities.”

Lobbyists for diabetes and HIV/AIDS have already started putting pressure on the Task Force and HSS to include specific preventive services under the new coverage rules. In one instance, the American Diabetes Association is arguing that the current recommendation—which calls for diabetes screening only when a patient has elevated blood pressure—is too limited, and will be a barrier to care if insurers decide not to pay in full for testing of others. ADA lobbyist Tekisha Everette called the current guideline "a shark in the water" and said her group is pressing HHS and the USPSTF to broaden coverage for diabetes screening.

The HIV Medicine Association is making a similar argument. Currently the Task Force recommends HIV testing only for people who are considered “at risk.” HIV and AIDS advocates are worried that insurers will then fail to offer full coverage for testing people who are not included in this “at risk” group. The HIV association delivered a memo to the USPSTF explaining that one reason 20% of people with HIV don't know they are infected is that screening isn't reimbursed by many insurers. The task force could help with that problem, the memo said, by recommending routine screening for everyone, which insurers would have to cover.

According to a another recent post on Kevin MD,  “The risk of exposing the Task Force to lobbying interests like these is that it could undermine the Task Force’s tradition of neutrality and scholarly dedication to science. ‘If you want to be evidence-based, lobbying just doesn’t fit,' Ned Calonge, the panel's chairman told Kaiser HealthNews.”

It remains to be seen how much influence disease advocates and lobbyists for other special interests like diagnostic test and equipment makers (GE, for example) will have as more preventive services are considered for coverage. Saving money (at least in the short term) is not the only goal of the prevention provisions. The Robert Wood Johnson Foundation's  2007 paper rates preventive services on two measures: “clinically preventable burden (CPB), or the disease, injury or premature death that would be prevented if the service were delivered to all people in the target population,” and “cost effectiveness (CE), which compares the net cost of a service to its health benefits.” These measures were each on a scale of 1 to 5; added together the top score for a particular preventive service would be 10.

Only three of the evidence-based clinical preventive services recommended by the USPSTF and the CDC’s Advisory Commission on Immunization Practices received the top rating: Discuss daily aspirin use—men 40+, women 50+ ,  childhood immunizations, and smoking cessation advice and help to quit for adults. At the lower end are several services that are also included in the new mandated preventive services; including osteoporosis screening—women 65+  (a total rating of 4) and diabetes screening—adults at risk (total of 2).

With its blanket inclusion of 45 preventive services that must be covered without co-pays or deductibles, the new legislation does not give weight to preventive services that might offer the most benefits—both through reducing death and disease rates and by reducing costs—over those that might be less beneficial. And that means that there is the risk that mandating coverage for all these services, for all indicated Americans (vs. just for those in Medicaid, Medicare or those who qualify for government subsidies) will lead to overuse. In the year
s ahead, the job of HHS will be to monitor and continually evaluate the benefits–both in cost and public health–of existing and new preventive services. Remaining unbiased in the face of intense lobbying and politicking will surely be a challenge.