Preventive Womens Health Services &Health Care Reform: Closing the GapsKey Considerations in ImplementationAlina Salganicoff, Ph.D.Vice President and Director of Women’s Health PolicyKaiser Family FoundationMarch 18, 2012Womens Health 2012 CongressWashington, DC
Health care affordability is a barrier to care for many women Percentage of men and women who say they or a family member have done each of the following in the past year because of COST: Put off or postponed getting 29% needed health care 26% Skipped a recommended medical 25% test or treatment 18%* Women 28% Didn’t fill a prescription 22% Men * 20% Cut pills or skipped doses of medicine 14% * 33% Skipped dental care or checkups 29%Source:Kaiser Health Tracking Poll: (August 2011).*Indicates statistical significance at the 95% level.
Costs often a problem even for insured women: How will ACA change this for women?*Significantly different from Private, p<.05.Source: Ranji and Salganicoff, Kaiser Women’s Health Survey, 2008.
The Affordable Care Act makes improvements to insurance that affect affordability for women• Will make getting health coverage more affordable and accessible• Will ban “Gender Rating”• Will ban exclusions for pre-existing conditions• Will require review of rate hikes• Requires NEW plans to cover preventive services without cost sharing
Adult Preventive Services to be Covered w/o Cost Sharing Cancer Chronic Conditions Immunizations Healthy Behaviors Pregnancy-Related** Reproductive Health Breast Cancer Cardiovascular health Td booster, Tdap Alcohol misuse Tobacco and cessation STI and HIV counseling – Mammography for ⁻ Hypertension screening and interventions (adults at high risk; all women 40+* screening MMR counseling (all adults) sexually-active Alcohol misuse – Genetic (BRCA) ⁻ Lipid disorders screening/counseling women♀) Meningococcal Intensive healthy diet screening and screenings counseling (adults Rh incompatibility screening Screenings: counseling ⁻ Aspirin Hepatitis A, B – Preventive medication w/high cholesterol, Gestational diabetes ⁻ Chlamydia (sexually counseling Type 2 Diabetes Pneumococcal CVD risk factors, diet- screenings♀ active women <24y/o, screening (adults w/ related chronic ⁻ 24-28 weeks gestation older women at high Cervical Cancer elevated blood Zoster disease) ⁻ First prenatal visit (women risk) ‒ Pap testing (women pressure) at high risk for diabetes) ⁻ Gonorrhea (sexually Influenza, Tobacco counseling active women at high 18+, Screenings and cessation risk) ‒ High-risk HPV DNA Depression screening Varicella ⁻ Hepatitis B interventions (all ⁻ Syphilis (adults at high testing ♀ (adults, when follow ⁻ Chlamydia (<24, hi risk) adults) risk) up supports available) HPV (women 19- ⁻ Gonorrhea Colorectal Cancer 26) ⁻ HIV (adults at high risk; Interpersonal and ⁻ Syphilis ⁻ One of following: fecal Osteoporosis all sexually active domestic violence ⁻ Bacteriurea occult blood testing, screening (all women women♀) screening and colonoscopy, 65+, women 60+ at Folic acid supplements Contraception (women counseling (women sigmoidoscopy high risk) (women w/repro capacity) w/repro capacity) ♀ 18-64)♀ ⁻ All FDA approved Iron deficiency anemia Obesity Well-woman visits methods as prescribed, screening Screening (all adults) (women 18-64) ♀ ⁻ Sterilization procedures Breastfeeding Supports ⁻ Patient education and Counseling and ⁻ Counseling counseling behavioral ⁻ Consultations with trained interventions (obese provider♀ adults) ⁻ Equipment rental♀Sources:U.S. DHHS, “Recommended Preventive Services.” Available at http://www.healthcare.gov/center/regulations/prevention/recommendations.html.More information about each of the services in this table, including details on periodicity, risk factors, and specific test and procedures are available at the following websites:USPSTF: http://www.uspreventiveservicestaskforce.org/recommendations.htmACIP: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm#compHRSA Women’s Preventive Services: http://www.hrsa.gov/womensguidelines/
What types of plans are affected?• All NEW private plans – employer-sponsored – individually purchased – self insured• “Grandfathered” plans exempted, but plans losing their grandfather status (i.e. change benefits or cost-sharing) must now cover ACA preventive services• State Exchanges will include preventive services as Essential Health Benefits• Rules do not apply to Medicare, Medicaid, VA, IHS, and Military health.
When do these new preventive coverage rules take effect?• TODAY: All NEW private insurance plans must cover without cost-sharing, all services recommended by USPSTF, ACIP, and Bright Futures (effective 9/2010)• In August 2012: All NEW private insurance plans must also cover the HRSA recommended services for women
What about religious exemptions?• All “houses of worship” may be exempt from ONLY the contraceptive coverage requirement if they wish• An HHS accommodation provided a one year delay for religiously affiliated organizations that object. In those cases, the insurer will be required to cover the contraceptive services and supplies -- NOT the employer• Many details will be worked out over the coming year
Any Other Caveats…?• If service is performed by an out-of-network provider, insurers may charge patients for the office visit and the preventive service.• If office visit and the preventive service billed separately, insurer may impose cost-sharing for the office visit.• If primary reason for visit is not preventive screening, patients may have to pay for office visit. What happens when a women wants a sterilization post-partum?• Insurers can use reasonable judgment based on established medical practices to make coverage decisions, if frequency not specified
Considerations for Clinical Practice• Well woman visit? What should be included?• How do we adequately train providers to deliver services? Is the current supply adequate?• Contraceptive services: What happens to OTC contraceptives? What about OCs and tiering? Reasonable medical management rules apply…• New opportunities to get coverage for counseling for a wide range of issues, but is there enough time in the visit?
Resources on Prevention, Women’s Health and Health Reform • IOM – Clinical Preventive Services for Women: Closing the Gaps http://www.iom.edu/Reports/2011/Clinical-Preventive-Services-for- Women-Closing-the-Gaps/Press-Release-MR.aspx • HHS – HHS ACA website http://www.healthcare.gov – HRSA Guidelines http://www.hrsa.gov/womensguidelines/ • Kaiser Family Foundation – The Impact of Health Reform on Women’s Access to Coverage and Care http://www.kff.org/womenshealth/7987.cfm – Preventive Services Covered by Private Health Plans under the Affordable Care Act http://www.kff.org/healthreform/8219.cfm – Health Reform Source: http://healthreform.kff.org/
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