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CME/CE

Preventive Services for Adults: Are Your Patients Taking Advantage of These Benefits?

  • Authors: Daniel J. Derksen, MD
  • CME/CE Released: 10/26/2012
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 10/26/2013
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Target Audience and Goal Statement

This activity is intended for internists, family physicians, obstetricians, gynecologists, pharmacists, nurses, nurse practitioners, and physician assistants.

The goal of this activity is to describe the extensive preventive services for which many adult patients are now eligible at no cost under the Affordable Care Act.

Upon completion of this activity, participants will be able to:

  1. Review the recommendations for preventive services for adults issued by the US Preventive Services Task Force
  2. Educate patients who may be unaware of changes to their preventive service coverage
  3. Examine ways to incorporate available screenings and preventive services into the care offered to adult patients


Disclosures

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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author

  • Daniel J. Derksen, MD

    Professor, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM

    Disclosures

    Disclosure: Daniel J. Derksen, MD, has disclosed no relevant financial relationships.

    Dr Derksen does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Derksen does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editors

  • Jane Lowers

    Group Scientific Director, Medscape, LLC

    Disclosures

    Disclosure: Jane Lowers has disclosed no relevant financial relationships.

  • Priscilla Scherer, RN

    Scientific Director, Medscape, LLC

    Disclosures

    Disclosure: Priscilla Scherer, RN, has disclosed no relevant financial relationships.

  • Neil Chesanow

    Senior Clinical Editor, Medscape, LLC

    Disclosures

    Disclosure: Neil Chesanow has disclosed no relevant financial relationships.

Writer

  • Jill Taylor

    Freelance Writer, Atlanta, Georgia

    Disclosures

    Disclosure: Jill Taylor has disclosed no relevant financial relationships.

CME Reviewer

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

Nurse Planner

  • Laurie E. Scudder, DNP, NP

    Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC

    Disclosures

    Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.


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CME/CE

Preventive Services for Adults: Are Your Patients Taking Advantage of These Benefits?

Authors: Daniel J. Derksen, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME/CE Released: 10/26/2012

Valid for credit through: 10/26/2013

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This activity has expired.

The accredited provider can no longer issue certificates for this activity. Medscape cannot attest to the timeliness of expired CME activities.

Moreover, because statutes, regulations, and policy information may change over time, the information available in this course may be out-of-date. If you need additional information concerning CMS programs, we recommend that you access www.cms.gov.

Introduction

Today millions of adults have expanded coverage for preventive services as a part of the sweeping changes being implemented under the Affordable Care Act (ACA).

Private insurers and employment-based plans are now required by the ACA to cover a variety of preventive health services with no cost-sharing for enrollees who have coverage that is not grandfathered.[1-4] (Grandfathered coverage is coverage that was in effect when the ACA was enacted on March 23, 2010, and has not been modified in certain ways since then.) Although some private plans already covered these services, millions of Americans were previously enrolled in plans that did not; in fact, the US Department of Health and Human Services estimates that approximately 54 million Americans received expanded coverage of at least some preventive services in 2011 due to the ACA.[4] 

According to Daniel J. Derksen, MD, professor, Department of Family and Community Medicine at the University of New Mexico, although preventive services are the hallmark of high-quality primary care, they can be confusing to patients. "It's important for patients to ask their primary care providers -- family physician, general internist, family nurse practitioner, pediatrician, or physician assistant -- about which preventive services are appropriate for the person's age, gender, and other risk factors," says Dr Derksen." The new ACA provisions bring a welcome balance to caring for patients, not just when they are sick, but also to keep people healthy and to promote wellness."

Although the cost of healthcare in the United States topped $2.7 trillion in 2011,[5] the nation continues to rank below other developed countries in life expectancy, infant mortality, and several other key health indicators.[6] Many of the country's pressing health problems are preventable, elevating the importance of preventive care as a strategy to improve the health and productivity of the American public. Indeed, the ACA addresses preventive care in detail, providing funding for a variety of initiatives and stating specific requirements designed to improve public access to these services.[1-3]

Furthermore, the expansion of covered preventive services is not limited to those with private insurance; it is also extended to beneficiaries of Medicare and, starting in 2014, Medicaid,[1-3] creating an improved level of consistency in coverage among payers. "I don't have to spend as much time sorting through by payer, whether it is public or private or some combination, to learn whether a patient is covered for preventive services," states Dr Derksen. "Pretty much if a service is included in the US Preventive Services Task Force recommendations, it is going to be covered."

Overview of Current Recommendations

The following table delineates US Preventive Services Task Force (USPSTF) recommendations for preventive services for adults, which private insurers and employment-based plans are required to cover under the ACA.[4,7] Patients and healthcare providers may be unaware of a portion or all of the expansion in covered services. Increasing awareness could encourage patients to adopt proactive behaviors in protecting or improving health status, and help physicians and other providers to be reimbursed by private payers for preventive services.

US Preventive Services Task Force Recommendations for Preventive Services for Adults
Topic Description
Abdominal aortic aneurysm screening: men The US Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm by ultrasonography in men aged 65 to 75 years who have ever smoked.
Alcohol misuse counseling The USPSTF recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.
Anemia screening: pregnant women The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women.
Aspirin to prevent cardiovascular disease (CVD): men The USPSTF recommends the use of aspirin for men aged 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage.
Aspirin to prevent CVD: women The USPSTF recommends the use of aspirin for women aged 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage.
Bacteriuria screening: pregnant women The USPSTF recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later.
Blood pressure screening in adults The USPSTF recommends screening for high blood pressure in adults aged 18 years and older.
BRCA screening, counseling about The USPSTF recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing.
Breast cancer preventive medication The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention.
Breast cancer screening The USPSTF recommends screening mammography for women, with or without clinical breast examination, every 1-2 years for women aged 40 years and older.
Breastfeeding counseling The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.
Cervical cancer screening The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix.
Chlamydial infection screening: non-pregnant women The USPSTF recommends screening for chlamydial infection for all sexually active, non-pregnant young women aged 24 years and younger and for older non-pregnant women who are at increased risk.
Chlamydial infection screening: pregnant women The USPSTF recommends screening for chlamydial infection for all pregnant women aged 24 years and younger and for older pregnant women who are at increased risk.
Cholesterol abnormalities screening: men 35 years and older The USPSTF strongly recommends screening men aged 35 years and older for lipid disorders.
Cholesterol abnormalities screening: men younger than 35 years and women younger than 45 years The USPSTF recommends screening men aged 20 to 34 years and women aged 20 to 44 years for lipid disorders if they are at increased risk for coronary heart disease.
Cholesterol abnormalities screening: women 45 years and older The USPSTF strongly recommends screening women aged 45 years and older for lipid disorders if they are at increased risk for coronary heart disease.
Cholesterol abnormalities screening: women younger than 45 years The USPSTF recommends screening women aged 20 to 45 years for lipid disorders if they are at increased risk for coronary heart disease.
Colorectal cancer screening The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.
Depression screening: adults The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.
Diabetes screening The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.
Fall prevention: vitamin D The USPSTF recommends vitamin D supplementation for community-dwelling adults 65 years or older at increased risk for falls.
Fall prevention: exercise/physical therapy The USPSTF recommends exercise or physical therapy for community-dwelling adults 65 years or older at increased risk for falls.
Folic acid supplementation The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.
Gonorrhea screening: women The USPSTF recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors).
Healthy diet counseling The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.
Hepatitis B screening: pregnant women The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit.
HIV screening The USPSTF strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection, and for all pregnant women.
Obesity screening and counseling: adults The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.
Osteoporosis screening: women The USPSTF recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures.
Rh incompatibility screening: first pregnancy visit The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.
Rh incompatibility screening: 24-28 weeks' gestation The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative.
Sexually transmitted infections (STIs) counseling The USPSTF recommends high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs.
Tobacco use counseling and interventions: non-pregnant adults The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.
Tobacco use counseling: pregnant women The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling to those who smoke.
Syphilis screening: non-pregnant persons The USPSTF strongly recommends that clinicians screen persons at increased risk for syphilis infection.
Syphilis screening: pregnant women The USPSTF recommends that clinicians screen all pregnant women for syphilis infection.

Because the healthcare needs of adults change with age, the USPSTF has developed additional evidence-based recommendations for preventive services in adults aged 65 and older, as follows[8]:

  1. Abdominal aortic aneurysm screening
  2. Breast cancer screening
  3. Carotid artery stenosis screening
  4. Cervical cancer screening
  5. Colorectal cancer screening
  6. Coronary heart disease screening
  7. Dementia screening
  8. Hormone replacement therapy
  9. Immunizations, adult
  10. Osteoporosis screening
  11. Ovarian cancer screening
  12. Peripheral arterial disease screening
  13. Prostate cancer screening
  14. Thyroid disease screening
  15. Vision screening in older adults

In addition, enrollees in non-grandfathered plans are eligible to receive vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) without cost-sharing requirements.[9]

Figure 1

Increasing Patient Access to Services

Because patients may be unaware of recent changes by private insurers and employment-based plans to their preventive service coverage, clinicians should encourage patients to take advantage of preventive health services to improve health outcomes, avoid preventable hospitalizations, and reduce complications of preventable diseases.

There are several ways that clinicians can review the potential need for preventive services during patient visits. First, electronic health records (EHRs) can track the need for and administration of preventive services, send electronic reminders to patients, and alert medical staff of the current status at each visit. Data from patient encounters also enables practices to demonstrate meaningful use for EHR incentive payment.[11]

"With meaningful-use EHR incentives, sites are encouraged to incorporate decision and treatment support tools and reminder systems whenever a patient comes in," explains Dr Derksen. "In our clinic, patients come in for a specific problem, and that may be your chance to provide preventive services. If a child is brought in by a parent for otitis media, for example, then we take advantage of that by checking to see if the child is up to date on his or her immunizations."

However, clinicians in practices without an EHR can still incorporate checklists into their patient encounter process so that screenings and preventive services won't be missed. Dr Derksen, who works between 2 clinical settings, one with an EHR and the other with a paper-based system, points out that the decision support tools -- such as a list of preventive services to check against -- are much the same." In both the manual and electronic system, the list is a tool that makes it easier for a nurse practitioner, physician assistant, or family physician to make sure patients are being screened," says Dr Derksen. "For example, when we have a patient with diabetes in our clinic, there is a checklist of services that should be considered. Has the patient had a yearly foot exam or an ophthalmology check? Has the hemoglobin A1c been tested in the last 6 months? Incorporating checklists has helped make considerations like these routine."

Understanding the Details of How Plans Cover Preventive Services

While non-grandfathered coverage must include USPSTF grade A and B recommendations and the ACIP-recommended vaccines, it is important to recognize some of the nuances associated with this requirement to ensure that patients do not inadvertently face cost-sharing for these services. For example, private insurers and employment-based plans are allowed to use reasonable medical management techniques when providing access to this coverage and can require enrollees to obtain these services in-network in order to avoid cost-sharing. In addition, enrollees may be charged cost-sharing if a preventive service is billed separately from the office visit or if the preventive service is not billed separately and the preventive service was not the primary purpose of the visit. Since the preventive service recommendations change periodically, insurers and plans do not have to cover them until the plan or policy year that starts on or after the date that is 1 year after a new recommendation is announced.

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