Preventive Services: Research and Dissemination. Steven Ornstein, MD Cara Litvin, MD

Transcription

1 Preventive Services: Research and Dissemination Steven Ornstein, MD Cara Litvin, MD August 23-25, 2012 PPRNet 2012

2 Presentation Goals Present findings from PPRNet research on preventive services delivery in complex patients Present updated US Preventive Services Task Force recommendations Provide update on reimbursement for preventive services under the ACA PPRNet 2012

3 PPRNet Research on Preventive Services Delivery in Complex Patients The Enhancing Comparative Effectiveness Research Capabilities in PPRNet study funded by grant number R24HS from the Agency for Healthcare Research and Quality (AHRQ) 8/23/2012

4 BACKGROUND Competing demands vs. parallel opportunities for PS delivery in PC for patients with chronic illness Existing studies conflict and limited by # of practices, patients, PS and chronic illnesses August 23-25, 2012 PPRNet 2012

5 METHOD X-sectional analyses of PPRNet database 148 practices, 667,379 pts > 18 y.o. # of any of 24 chronic illnesses Up to date with 10 Grade A&B PS August 23-25, 2012 PPRNet 2012

6 Preventive Service 8 RESULTS Interval (Years) August 23-25, 2012 PPRNet 2012 Age (Years) # of Eligible Patients Percentage Up to Date Blood pressure measurement , % At-risk drinking assessment , % Depression screen , % Total and HDL-cholesterol , % Blood glucose measurement if last , % 3 blood pressure > 135/80 mmhg Colorectal cancer * , % Pap smear , % Mammogram , % Bone density Any 65 86, % Urogential chlamydia , %

7 Chronic condition # patients with % of patients with condition condition Hypertension 223, % Hyperlipidemia 220, % Depression 124, % Gastroesophageal reflux 99, % Diabetes mellitus 79, % Obesity 79, % Osteoarthritis 66, % Asthma 58, % Osteoporosis and osteopenia 43, % Migraine 37, % Coronary disease 32, % Atherosclerosis 31, % 8/23/2012

8 Chronic condition Number of patients with condition COPD 29, % Chronic kidney disease 22, % Cerebrovascular disease 19, % Atrial fibrillation 14, % Heart failure 11, % Alcohol use disorders % Dementia % Peptic ulcer % Chronic liver disease % Epilepsy % Rheumatoid arthritis 8/23/ % Parkinson's disease or syndrome % Percentage of patients with condition

9 Among the 667,379 active patients, the proportion with zero, one, two, three, four, or five or more chronic conditions was 34.6%, 20.1%, 14.9%, 11.2%, 7.7%, and 11.5%, respectively August 23-25, 2012 PPRNet 2012

10 Number of chronic problems among 667,379 patients Percentage of Patients 5, 11.5% 4, 7.7% 0, 34.6% 3, 11.2% 2, 14.9% 1, 20.1% August 23-25, 2012 PPRNet 2012

11 August 23-25, 2012 PPRNet 2012

12 CONCLUSIONS For each PS other than urogenital chlamydia screening, there are strong associations between the odds of being up to date and the # of of chronic illnesses, even after adjustment for visit frequency The presence of chronic illness provides opportunities, not barriers to PS delivery in PPRNet practices

13 Updated US Preventive Services Task Force recommendations To review principles of prevention and how the USPSTF grades PS To present recent ( ) USPSTF recommendations for adults To discuss the USPSTF recommendations in PPRNet reports 8/23/2012

14 The U.S. Preventive Services Task Force (USPSTF) An independent panel of non-federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, OB- GYN, nurses, and health behavior specialists). August 23-25, 2012 PPRNet 2012

15 The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements." August 23-25, 2012 PPRNet 2012

16 For the USPSTF to recommend a service, the benefits of the service must outweigh the harms. The USPSTF focuses on maintenance of health and quality of life as the major benefits of clinical preventive services, and not simply the identification of disease. August 23-25, 2012 PPRNet 2012

17 USPSTF decisions based on evidence of effectiveness and benefit: When there is evidence of benefit, do it When there is evidence of no benefit or harm, don t do it When there is insufficient evidence to determine if there is benefit, be conservative: use individual discretion, but if there are harms or costs, don t do it August 23-25, 2012 PPRNet 2012

18 Why be Strict about Recommendations When Evidence is Insufficient?: Promising does not mean effective ; the treatment could be ineffective or harmful We are often wrong Premature acceptance undermines the ability and incentive to do the research necessary to determine effectiveness Resources spent on ineffective treatment increase the cost of care with no benefits and remarkable harms August 23-25, 2012 PPRNet 2012

19 Potential Harms of Screening False negative test (false reassurance, delay in diagnosis of treatable condition) False positive test (unnecessary and potentially harmful diagnostic tests, treatment, and labeling) Over-diagnosis (true positive, but disease wouldn t progress and treatment unnecessary) No benefit from early detection (diversion of resources from effective services) Harms intrinsic to the test itself August 23-25, 2012 PPRNet 2012

20 A B C D I USPSTF Recommendation Grades The USPSTF recommends the service. There is high certainty that the net benefit is substantial. The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Note: The following statement is undergoing revision. Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service. The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. The USPSTF concludes that current evidence is insufficient to assess the balance of benefits & harms of the service.

21 epss Electronic Preventive Services Selector August 23-25, 2012 PPRNet 2012

22 epss for ipad August 23-25, 2012 PPRNet 2012

23 epss Widget August 23-25, 2012 PPRNet 2012

24 Screening Recommendations: Service Bladder cancer Cervical cancer Pap q3yr (21-65 y.o.) or Pap+HPV (30-65 y.o.) Age <21 or >65, hysterectomy w/o CIN 2 or higher, or HPV < 30 y.o. Prostate cancer (PSA) Testicular cancer Fall prevention in older adults (exercise or PT +Vit D patients at risk) Hearing loss in older adults Obesity in adults (Screen; BMI>30 refer intense behav. intervention) Osteoporosis (>65 y.o. female or younger with = fracture risk) Screening EKG (resting or exercise) low risk/interm high risk August 23-25, 2012 PPRNet 2012 Grade I A D D D B I B B D/I

25 Screening Recommendations out for Public Comment Service Chronic kidney disease in all adults Screen women of childbearing age for IPV, such as domestic violence, and provide or refer women who screen positive to intervention services Screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect Grade I B I August 23-25, 2012 PPRNet 2012

26 Counseling Recommendations: Service Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults Counseling those with fair skin about minimizing exposure to u.v. radiation to reduce risk for skin cancer Grade C B (Age 10-24) I (Age >24) August 23-25, 2012 PPRNet 2012

27 Finalizing Recommendation Statements Menopausal hormone replacement therapy for the primary prevention of chronic conditions Ovarian cancer Vitamin D supplements to prevent osteoporotic fractures and cancer August 23-25, 2012 PPRNet 2012

28 Developing a Draft Recommendation Thyroid cancer screening Breast cancer preventive medication Hepatitis C HIV Oral cancer Suicide risk August 23-25, 2012 PPRNet 2012

29 Grade A and B in PPRNet Reports AAA screening by ultrasound in men aged 65 to 75 who have ever smoked Alcohol misuse screening and counseling BP screening Breast cancer screening (ages 50-74) Cervical cancer screening Cholesterol screening in men>=35 and women>=45 Colorectal cancer screening Depression screening in adults Diabetes screening in pts with BP >135/80 Osteoporosis screening Tobacco use screening and smoking intervention August 23-25, 2012 PPRNet 2012 *New or Updated since 2010

30 BRCA screening counseling Grade A and B Not in PPRNet Reports Breast cancer preventive medication Depression screening in adolescents Folic acid supplementation in women capable of pregnancy GC screening in women at increased risk August 23-25, 2012 PPRNet 2012

31 Grade A and B Not in PPRNet Reports HIV screening in adolescents and adults at increased risk Intensive behavioral dietary counseling for adults with hyperlipidemia/ other known risk factors for CVD and diet-related chronic disease Obesity screening and counseling for those >=6 years STI counseling for all adolescents and adults at high risk Syphilis screening adults at high risk August 23-25, 2012 PPRNet 2012

32 Grade A and B in PPRNet Reports Some Discrepancies with Guideline Aspirin to prevent CVD Chlamydia screening (ages 16-24) August 23-25, 2012 PPRNet 2012

33 Preventive Services under the Affordable Care Act 8/23/2012

34 Preventive Services and Affordable Care Act of 2010 SEC COVERAGE OF PREVENTIVE HEALTH SERVICES. (a) IN GENERAL. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for (1) evidence-based services (with) a rating of A or B in the current recommendations of the USPSTF (2) immunizations that have in effect a recommendation from the ACIP (CDC) August 23-25, 2012 PPRNet 2012

35 16 Covered Preventive Services for Adults Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked Alcohol Misuse screening and counseling Aspirin use for men and women of certain ages Blood Pressure screening for all adults Cholesterol screening for adults of certain ages or at higher risk Colorectal Cancer screening for adults over 50 Depression screening for adults Type 2 Diabetes screening for adults with high blood pressure Diet counseling for adults at higher risk for chronic disease HIV screening for all adults at higher risk Immunization vaccines for adults-- doses, recommended ages, and recommended populations vary: Obesity screening and counseling for all adults Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk Tobacco Use screening for all adults and cessation interventions for tobacco users Syphilis screening for all adults at higher risk 8/23/2012 PPRNet 2012

36 22 Covered Preventive Services for Women Anemia screening for pregnant women Bacteriuria screening for pregnant women BRCA counseling about genetic testing for women at higher risk Mammography screenings every 1 to 2 years for women over 40 Breast Cancer Chemoprevention counseling for women at higher risk Breastfeeding comprehensive support Cervical Cancer screening Chlamydia Infection screening Contraception Domestic and interpersonal violence screening and counseling Folic Acid supplements for women who may become pregnant Gestational diabetes screening Gonorrhea screening Hepatitis B screening for pregnant women Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older Osteoporosis screening for women over age 60 depending on risk factors Rh Incompatibility screening for all pregnant women Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users Sexually Transmitted Infections (STI) counseling for sexually active women Syphilis screening for all pregnant women or other women at increased risk Well-woman visits to obtain recommended preventive services for women under 65

37 27 Covered Preventive Services for Children Alcohol and Drug Use assessments for adolescents Autism screening for children at 18 and 24 months Behavioral assessments for children of all ages Blood Pressure screening for children Cervical Dysplasia screening for sexually active females Congenital Hypothyroidism screening for newborns Depression screening for adolescents Developmental screening for children under age 3 Dyslipidemia screening for children at higher risk of lipid disorders Fluoride Chemoprevention supplements for children without fluoride in their water source Gonorrhea preventive medication for the eyes of all newborns Hearing screening for all newborns Height, Weight and Body Mass Index measurements for children Hematocrit or Hemoglobin screening for children Hemoglobinopathies or sickle cell screening for newborns HIV screening for adolescents at higher risk Immunization vaccines for children from birth to age Iron supplements for children ages 6 to 12 months at risk for anemia Lead screening for children at risk of exposure Medical History for all children throughout development Obesity screening and counseling Oral Health risk assessment for young children Phenylketonuria (PKU) screening in newborns Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Tuberculin testing for children at higher risk of tuberculosis Vision screening for all children

38 Details about Preventive Services Provision applies to people enrolled in jobrelated health plans or individual insurance policies created after March 23, Grandfathered plans existing on March 23, 2010 are not required to comply with all provisions Health plans are required to provide preventive services only through an innetwork provider August 23-25, 2012 PPRNet 2012

39 Coding for a Preventive Care Visit Providing a preventive service visit: Preventive visit must be documented and coded separately from a problem-oriented visit (Do not link problem-oriented ICD9 code with preventive CPT code) Preventive service may not be covered if the service is not the primary purpose of the visit or if the services is billed separately from the office visit. Modifier 25 may be used when providing a preventive visit with a problem-oriented E/M service or procedural service on same day August 23-25, 2012 PPRNet 2012

40 Coding for a Preventive Care Visit August 23-25, 2012 *From Family Practice Management, Jul/August 2012

41 Providing a Preventive Service Visit Documentation requires: Comprehensive history and PE findings- no CC or HPI Description of the status of chronic stable problems (not significant to required additional work) Notes concerning management of minor problems Notes concerning age-appropriate counseling screening labs and tests Orders for vaccines appropriate for age and risk factors August 23-25, 2012 PPRNet 2012

42 Providing a preventive service at a problem-oriented visit: Counseling may be billed as in addition to E/M office visit code Synopsis of counseling should be documented ICD-9 codes for preventive counseling should be paired with CPT code Visit requires use of modifier 25

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44 Medicare Preventive Services Expansion Affordable Care Act expanded preventive care benefits available under Medicare Part B - Welcome to Medicare Visit - Annual Wellness Visit for personal prevention plan - Covers 100% of payment for A or B recommended US Preventive Services Task Force preventive services (no- deductible or copays)

45 Providing a Medicare Preventive Care Visit Initial Preventive Physical Examination(IPPE): G0402 once in a lifetime must occur within 12 months of date of first coverage Annual Wellness Visit- G0438, with personalized prevention plan (PPPS)-1 st visit G0439, with personalized prevention plan, subsequent visit Requires health risk assessment Referrals for screening laboratory tests can be made as part of the visit Problem oriented services may be billed on same day using modifier 25 but could required additional time.

46 Providing Preventive Services outside the AWV Services must be linked to specific ICD9 codes (e.g. Lipid panel (80061) with V81.2- Screening for other unspecified cardiovascular conditions MLN/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf August 23-25, 2012 PPRNet 2012

47 New Medicare Preventive Services Annual alcohol misuse screening Brief counseling for alcohol misuse Annual depression screening High intensity counseling to prevent sexually transmitted infections Behavioral therapy to reduce cardiovascular risk Behavioral counseling for obesity uments/prac_mgt/codingresources/medicarepreventi ve par.0001.file.dat/medicarepreventivejanu ary2012.pdf

48 What are your experiences with providing preventive services under the ACA?

49 Other Questions and Discussion August 23-25, 2012 PPRNet 2012