Preventive Services: Research and Dissemination Steven Ornstein, MD Cara Litvin, MD August 23-25, 2012 PPRNet 2012
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
PPRNet Research on Preventive Services Delivery in Complex Patients The Enhancing Comparative Effectiveness Research Capabilities in PPRNet study funded by grant number R24HS019448 from the Agency for Healthcare Research and Quality (AHRQ) 8/23/2012
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
METHOD X-sectional analyses of 10-1-2011 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
Preventive Service 8 RESULTS Interval (Years) August 23-25, 2012 PPRNet 2012 Age (Years) # of Eligible Patients Percentage Up to Date Blood pressure measurement 2 18 667,379 96.80% At-risk drinking assessment 2 18 667,379 22.57% Depression screen 2 18 667,379 18.75% Total and HDL-cholesterol 5 35 45 446,502 73.16% Blood glucose measurement if last 18 348,084 76.10% 3 blood pressure > 135/80 mmhg Colorectal cancer * 50-74 274,716 43.71% Pap smear 3 21-64 268,850 42.63% Mammogram 2 50-74 150,452 52.95% Bone density Any 65 86,200 47.71% Urogential chlamydia 1 18-24 43,762 13.39%
Chronic condition # patients with % of patients with condition condition Hypertension 223,653 33.51% Hyperlipidemia 220,053 32.97% Depression 124,596 18.67% Gastroesophageal reflux 99,658 14.93% Diabetes mellitus 79,641 11.93% Obesity 79,407 11.90% Osteoarthritis 66,255 9.93% Asthma 58,900 8.73% Osteoporosis and osteopenia 43,700 6.55% Migraine 37,756 5.66% Coronary disease 32,867 4.92% Atherosclerosis 31,638 4.74% 8/23/2012
Chronic condition Number of patients with condition COPD 29,005 4.35% Chronic kidney disease 22,496 3.37% Cerebrovascular disease 19,227 2.88% Atrial fibrillation 14,487 2.17% Heart failure 11,241 1.68% Alcohol use disorders 8594 1.29% Dementia 7361 1.10% Peptic ulcer 7242 1.09% Chronic liver disease 6951 1.04% Epilepsy 6893 1.03% Rheumatoid arthritis 8/23/2012 6357 0.95% Parkinson's disease or syndrome 1886 0.28% Percentage of patients with condition
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
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
August 23-25, 2012 PPRNet 2012
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
Updated US Preventive Services Task Force recommendations To review principles of prevention and how the USPSTF grades PS To present recent (2010-12) USPSTF recommendations for adults To discuss the USPSTF recommendations in PPRNet reports 8/23/2012
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). www.ahrq.gov/clinic/prevenix.htm August 23-25, 2012 PPRNet 2012
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
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
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
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
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
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.
epss Electronic Preventive Services Selector August 23-25, 2012 PPRNet 2012
epss for ipad August 23-25, 2012 PPRNet 2012
epss Widget August 23-25, 2012 PPRNet 2012
Screening Recommendations: 2010-12 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
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
Counseling Recommendations: 2010-12 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
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
Developing a Draft Recommendation Thyroid cancer screening Breast cancer preventive medication Hepatitis C HIV Oral cancer Suicide risk August 23-25, 2012 PPRNet 2012
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
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
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
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
Preventive Services under the Affordable Care Act 8/23/2012
Preventive Services and Affordable Care Act of 2010 SEC. 2713. 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
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
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
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
Details about Preventive Services Provision applies to people enrolled in jobrelated health plans or individual insurance policies created after March 23, 2010. 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
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
Coding for a Preventive Care Visit August 23-25, 2012 *From Family Practice Management, Jul/August 2012
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
Providing a preventive service at a problem-oriented visit: Counseling may be billed as 99401-99409 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
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)
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.
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 http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf August 23-25, 2012 PPRNet 2012
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 http://www.aafp.org/online/etc/medialib/aafp_org/doc uments/prac_mgt/codingresources/medicarepreventi ve012012.par.0001.file.dat/medicarepreventivejanu ary2012.pdf
What are your experiences with providing preventive services under the ACA?
Other Questions and Discussion August 23-25, 2012 PPRNet 2012