IOM list of preventive services expected to boost women's health

If accepted by federal officials, these routine services would carry none of the cost-sharing that leads some women to delay care.

By Doug Trapp — Posted Aug. 1, 2011

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Health insurance plans should cover HIV screening and counseling, contraceptives, domestic abuse care and other preventive services for women without any patient cost-sharing, according to independent advice given to the Dept. of Health and Human Services.

The Institute of Medicine recommendations, if accepted by HHS, would expand the list of services health plans must provide without co-pays, co-insurance or deductibles. Federal officials have said they will rely heavily on commissioned expert advice when finalizing the list.

Physicians applauded the easing of cost-related barriers to women's preventive care that would result. "Removing any hurdle is good," said James N. Martin Jr., MD, president of the American Congress of Obstetricians and Gynecologists.

Terry L. Mills, MD, a family physician in Newton, Kan., said, "If a co-pay is in place, we have patients [who] make tough decisions with limited resources."

The health system reform law requires health plans to cover a variety of evidence-based preventive care without imposing patient cost-sharing. The mandated list already includes dozens of screenings, tests and other care recommended by federal scientific panels that examine the value of certain care to patients. Health plans with about 41 million enrollees began providing this existing list without cost-sharing in 2011, according to HHS. The full list is expected to take effect in 2013 for about 78 million insured.

Most of the mandatory preventive care list had been finalized last year, except for preventive services for women. HHS asked the IOM, an independent nonprofit organization, to review evidence and suggest core services for women.

The IOM Committee on Preventive Services for Women selected measures based on a review of quality evidence, peer-reviewed studies and professional guidelines. The panel chose services that could improve well-being or decrease the likelihood of a disease or condition in a broad population of women. The committee released its recommendations July 19.

"The eight services we identified are necessary to support women's optimal health and well-being," said IOM committee Chair Linda Rosenstock, MD, MPH, dean of the School of Public Health at the University of California, Los Angeles. "Each recommendation stands on a foundation of evidence supporting its effectiveness." For example, up to 50% of pregnancies are unintended, she said, which justifies the need to include contraception in the list.

The IOM-recommended services include all contraceptives approved by the Food and Drug Administration -- such as the "morning-after pill" -- lactation support and counseling, HIV counseling and screening for sexually active women, and screening and counseling for interpersonal and domestic violence.

Dr. Rosenstock said the panel recommended expanded HIV screening because many HIV-positive women are not aware that they have been infected. The committee also found strong evidence that increased access to domestic violence care can help reduce the rates of such violence, said IOM committee member Paula A. Johnson, MD, MPH, chief of the division of women's health at Brigham and Women's Hospital in Boston.

The IOM recommended that HHS establish an independent commission to support updating the preventive care list as more information on care effectiveness becomes available.

HHS could determine by Aug. 1 which services will make the final list. Fifteen of the 16 IOM panel members approved the recommendations.

Private health plans with tens of millions of enrollees will remain exempt from the cost-sharing ban at first. Many health plans that existed when health reform was enacted in 2010 are grandfathered in when it comes to certain provisions of the law as long as the plans do not significantly change their cost or benefit structures. HHS estimated in July 2010 that 98 million people -- mostly in group health plans -- would remain exempt from the law in 2013.

Cost concerns on both sides

Women often face co-pays of $20 to $40 for many of the IOM-recommended preventive services, said Dr. Mills, the Kansas family physician. Women also often face deductibles and coinsurance that could require them to pay hundreds of dollars out of pocket for an annual checkup with a routine mammogram and Pap smear, he said.

Women in financially difficult situations tend to delay these well visits and routine screenings if they feel they are healthy enough to get by, Dr. Mills said. "That works out until suddenly it doesn't work. And then we've all got a problem."

Health plans and employers have warned the government against making the list of services they must cover too long and prescriptive. The increased costs associated with such a policy might end up being passed onto consumers and the government through higher premiums.

Improved access to preventive care will help keep people healthier and live longer, but it probably won't reduce overall, long-term health spending, said Gene Rudd, MD, an ob-gyn and senior vice president of the Christian Medical & Dental Assns.

For example, better access to smoking cessation could reduce the prevalence of lung cancer, he said. "We'll then live long enough to die from some other disease than lung cancer."

The IOM committee did not consider the cost of its recommended services because that was not part of its work. But someone must address health care cost-drivers, Dr. Rudd said. "We have to have some form of rationing, because there's not enough money to do everything we want to do. What rationing is acceptable?"

Asking about domestic abuse

The IOM committee's recommendations for improved access to domestic violence counseling should be a reminder that such abuse is more common than many physicians realize, said Leigh Vinocur, MD, a clinical assistant professor of medicine at the University of Maryland School of Medicine in Baltimore. As many as one in four women will be an abuse victim, she said.

Doctors should ask patients nonjudgmental questions about injuries, offer assistance and let patients know that domestic abuse is common, said Dr. Vinocur, a board member of the Maryland Network Against Domestic Violence, which lobbies for laws against domestic violence. (See correction)

Dr. Vinocur asks every person entering the emergency department -- except those in car crashes -- how they were hurt. Sometimes a domestic abuse victim will ask for help; other times, not. An abuse victim may not be ready to talk or could fear the repercussions of speaking up, she said.

Doctors should realize that not all domestic abuse victims present with obvious physical trauma, she added. Some batterers target hidden body areas, and some abuse isn't physical.

"It can be emotional abuse, too," Dr. Vinocur said. "I've had some victims tell me they can take the hitting more than the emotional abuse."

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The elite eight

The Institute of Medicine recommends the inclusion of eight preventive services for women in a larger list of care that insured Americans will receive without co-pays or other cost-sharing under a health system reform mandate. The Dept. of Health and Human Services will approve the final list. The IOM-recommended services are:

  • Gestational diabetes screenings for high-risk pregnant women. The screenings should occur at the first prenatal visit and between 24 and 28 weeks of gestation.
  • Human papillomavirus DNA testing for high-risk women with normal cytology test results. DNA testing should begin at age 30 and repeat no more often than every three years.
  • Annual counseling on sexually transmitted infections for sexually active women.
  • Annual HIV counseling and screening for sexually active women.
  • All Food and Drug Administration-approved contraceptives and sterilization procedures, plus counseling and patient education for all women with reproductive capacity.
  • Lactation support and counseling and the cost of renting breastfeeding equipment for all pregnant and postpartum women.
  • Screening and counseling for interpersonal and domestic violence. The services should involve eliciting information from women about current and past abuse to address health safety concerns.
  • At least one well-care visit each year for women to obtain the recommended preventive services, including preconception and prenatal care. Multiple visits should be covered if needed.

Source: "Clinical Preventive Services for Women: Closing the Gaps," Institute of Medicine, July (link)

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External links

"Clinical Preventive Services for Women: Closing the Gaps," Institute of Medicine, July (link)

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This story originally misstated a former affiliation for Dr. Vinocur. She was a board member of the Maryland Network Against Domestic Violence. American Medical News regrets the error.

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