Background

Overview
A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage
How Services Were Selected
Explanation of the Evidence
Acknowledgments
Funder and Partner Information

Overview

This website is based on a A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage (Purchaser's Guide). The Purchaser's Guide is an information source for employers on clinical preventive service benefit design.

Developed in collaboration with the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ), the Purchaser's Guide:

• Provides guidance for the selection of clinical preventive services shown to be effective by the U.S. Preventive Services Task Force (USPSTF), CDC and other authoritative organizations;
• Translates clinical guidelines and medical evidence into lay terms; and
• Provides large employers with the information they need to select, define and implement comprehensive and structured preventive service benefits.

---

A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage

In August 2009, the Purchaser?s Guide moved to a web-based format to accommodate the changing and updating of recommendations and information for clinical preventive services. While most of the Purchaser?s Guide has been moved to this website and updated, we preserved the following chapters from the original document.

• The Role of Clinical Preventive Services in Disease Prevention and Detection — provides information for employers on comprehensive clinical preventive services benefits.
  
  
• Summary Plan Description (SPD) Language Statements for Recommended Clinical Preventive Service Benefits — includes summary plan description (SPD) language, federal regulation, and the role of high-deductible plans in promoting prevention.
  
  
• The Prioritization of Clinical Preventive Services in a Strategic Implementation Plan — provides practical advice about the strategic implementation of benefits.
  
  
• Leveraging Benefits: Opportunities to Promote the Delivery and Use of Preventive Services — presents actions for employers to strengthen prevention efforts by supporting or implementing public health interventions.
  

---

Selection of Included Preventive Services

The clinical preventive services recommended for coverage in the Purchaser's Guide were selected by the National Business Group on Health with technical assistance from the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ).

The Purchaser's Guide recommendations are based mainly on AHRQ's U.S. Preventive Services Task Force (USPSTF) recommendations for clinical preventive services (an A - D, I scale). The Business Group recommends and provides detail for all of the USPSTF "A" and "B"-rated recommendations. For more information on preventive services that have insufficient evidence (I), have no recommendation for or against (C), or are not recommended (D), see I Statements and C and D Recommendations of the US Preventive Services Task Force.

In order to be included in the Purchaser's Guide, clinical preventive service recommendations were required to meet the following criteria:

1. Be based on medical evidence or recommended guidance.
2. Address a serious health threat in terms of morbidity (illness), mortality (death), or quality of life (including risk of disability)
3. Address a condition that results in substantial direct (e.g., treatment costs) or indirect costs (e.g., absenteeism, lost productivity) for payers.

Recommendations from sources other than the USPSTF were inserted in place of a USPSTF recommendation, when:

• No current USPSTF recommendation was available; or
• When a newer recommendation superseded the existing USPSTF recommendation

The evidence for clinical preventive services is growing. Purchasers are encouraged to sign up for email alerts of new recommendations and updates and periodically check the U.S. Preventive Services Task Force (USPSTF) website for up-to-date recommendations on clinical preventive services.

---

Explanation of the Evidence

Each recommendation for the USPSTF is given a letter grade (A-D, I) based on the strength of evidence available to support the particular clinical preventive service and the magnitude of net benefit for that service.

RECOMMENDATION GRADE	RECOMMENDATION LANGUAGE Please note that recommendations prior to May 2007 have slightly different interpretations than those after May 2007. These differences are outlined below.	EMPLOYER ACTION
A	PRIOR TO MAY 2007 Strongly Recommended The USPSTF strongly recommends that clinicians provide the service to eligible patients. The USPSTF found good evidence that the service improves important health outcomes and concludes that the benefits substantially outweigh harms. AFTER MAY 2007 Recommended The USPSTF recommends the service. There is high certainty that the net benefit is substantial.	Employers should cover A recommendations based on good evidence that such services improve health outcomes and benefits outweigh risks.
B	PRIOR TO MAY 2007 Recommended The USPSTF recommends that clinicians provide the service to eligible patients. The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that the benefits outweigh harms. AFTER MAY 2007 Recommended 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.	Employers should cover B recommendations based on good to fair evidence that such services improve health outcomes and benefits outweigh risks.
C	PRIOR TO MAY 2007 No Recommendation Either For or Against The USPSTF makes no recommendation either for or against routine provision of the service. The USPSTF found at least fair evidence that the service can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation. AFTER MAY 2007 Recommends Against Routinely Providing The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in specific employee population. There is at least moderate certainty that the net benefit is small.	Employers should only cover this service if other considerations support the offering or providing the service in their employee population. Therefore, the provision of coverage for C-rated services should be secondary to the provision of coverage for all recommended services featured in the Purchaser's Guide.
D	PRIOR TO MAY 2007 Recommend Against The USPSTF recommends against routinely providing the service to asymptomatic patients. The USPSTF found at least fair evidence that the service is ineffective or that the harms associated with the service outweigh benefits. AFTER MAY 2007 Recommends Against 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.	Employers are discouraged from providing coverage for clinical preventive services that received a D rating from the USPSTF, as these services have been found to be ineffective or to have more harms than benefits.* * IMPORTANT NOTE: "D"-rated services are not recommended for the general asymptomatic population and therefore should not be covered as preventive services within a medical benefit plan. However, these services may play an important role in the treatment or management of existing conditions and should be covered for all populations under the health plan's treatment benefit.
I	PRIOR TO MAY 2007 Insufficient Evidence in Order to Make a Recommendation The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. Insufficient evidence means the evidence is not currently adequate for evidence-based decisions. Evidence that the service is effective is lacking, of poor quality, or the balance of benefits and harms cannot be determined. AFTER MAY 2007 Insufficient Evidence in Order to Make a Recommendation The USPSTF concludes that the current evidence is insufficient (low certainty) to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.	Employers have discretion as to whether to provide coverage for services with anI rating (limited or conflicting evidence). If employers cover this service, they should understand the uncertainty about the balance of benefits and harms. The I rated services coverage should be secondary to the provision of coverage for all recommended services featured in the Purchaser's Guide. Employers may need to resort to the informed opinions of unbiased experts about such interventions.

---

Level of Certainty	Description
High	The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate	The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: The number, size, or quality of individual studies. Inconsistency of findings across individual studies. Limited generalizability of findings to routine primary care practice. Lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low	The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies. Important flaws in study design or methods. Inconsistency of findings across individual studies. Gaps in the chain of evidence. Findings not generalizable to routine primary care practice. Lack of information on important health outcomes. More information may allow estimation of effects on health outcomes

* The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

---

American Academy of Family Physicians: Strength of Evidence Scale

SR	Strongly Recommended Good quality evidence exists which demonstrates substantial net benefit over harm; the intervention is perceived to be cost-effective and acceptable to nearly all patients.
R	Recommended Although evidence exists which demonstrates net benefit, either the benefit is only moderate in magnitude or the evidence supporting a substantial benefit is only fair. The intervention is perceived to be cost-effective and acceptable to most patients.
NR	No Recommendation Either For or Against Either good or fair evidence exist of at least a small net benefit. Cost-effectiveness may not be known or patients may be divided about acceptability of the intervention.
I	Insufficient Evidence to Recommend Either For or Against No evidence of even fair quality exists or the existing evidence is conflicting.
IHB	Healthy behavior is identified as desirable, but the effectiveness of physician's advice and counseling is uncertain.

---

Acknowledgments

Advisory Board:
The Business Group would like to thank the following individuals for their participation at the 2008 advisory group meeting.

Michael S. Barr, M.D., MBA, FACP Vice President Practice Advocacy and Improvement American College of Physicians Wendy Heaps, MPH, CHES Senior Health Communications Specialist Division of Partnerships and Strategic Alliances Centers for Disease Control and Prevention Jeff Burtaine, M.D. Corporate Medical Director, North America Volvo/Mack Trucks, Inc. Darryl L. Landis, M.D., MBA, CPE, FAAFP, FACPE Senior Health & Productivity Consultant Watson Wyatt Worldwide John Clymer President Partnership for Prevention Michael LeFevre, M.D., MSPH Medical Director Department of Family & Community Medicine University of Missouri-Columbia Thomas G. DeWitt, M.D. The Carl Weihl Professor of Pediatrics Director, Division of General and Community Pediatrics Department of Pediatrics of Cincinnati College of Medicine Associate Chair for Education Cincinnati Children's Hospital Medical Center Ronald Loeppke, M.D., MPH, FACOEM, FACPM EVP, Health & Productivity Strategy Alere Co-Chairman, Health & Productivity Section American College of Occupational and Environmental Medicine

Richard E. Dixon, M.D., FACP (Co-Chair) Distinguished Consultant CCHIS, NCHM Centers for Disease Control and Prevention J. Brent Pawlecki, M.D., MMM Corporate Medical Director Pitney Bowes, Inc. Randy W. Elder, PhD, MEd Scientific Director for Systematic Reviews, Community Guide Branch Division of Health Communication and Marketing National Center for Health Marketing Centers for Disease Control and Prevention Tricia L. Trinité, MSPH, APRN (Co-Chair) Director, Prevention Implementation Agency for Healthcare Research and Quality William Fried, M.D. Medical Director Aetna, Inc. Ed Weisbart, M.D., CPE, FAAFP Chief Medical Officer, Medical Affairs Express Scripts Georgette V. Hampton Manager, Benefits Policy and Strategy The Boeing Company Tracy Wolff, M.D., MPH Medical Officer U.S. Preventive Services Task Force Program Center for Primary Care, Prevention, and Clinical Partnerships Agency for Healthcare Research and Quality Razia Hashmi, M.D., MPH Vice President, Medical Director National Accounts Anthem Insurance Companies, Inc.

Agency for Healthcare Research and Quality

Tricia Trinite, MSPH, ANP-BC CAPT, USPHS
Director, Prevention Dissemination & Implementation

Claire Kendrick, MSEd, CHES
Center for Primary Care, Prevention, and Clinical Partnerships

Centers for Disease Control and Prevention

Richard E. Dixon, M.D., FACP, FIDSA
Distinguished Consultant
Office of the Chief Science Officer

Wendy Heaps, MPH, CHES
Senior Health Communications Specialist
Division of Partnerships and Strategic Alliances
Centers for Disease Control and Prevention

Andrew Lanza, MPH, MSW
Formerly of The Division of Partnerships and Strategic Alliances
National Center for Health Marketing
Centers for Disease Control and Prevention

The National Business Group on Health

Georgette Flood
Former Program Associate, Center for Prevention and Health Services

Krissy Kraczkowsky, MPH, MBA
Program Analyst, Center for Prevention and Health Services

Kathryn Phillips, MPH
Former Manager, Center for Prevention and Health Services

Dannielle Sherrets, MPH, CHES
Manager, Center for Prevention and Health Services

Cynthia Reeves Tuttle, Ph.D, MPH
Vice-President, Center for Prevention and Health Services

Elisabeth A. Meinert
Program Assistant, Center for Prevention and Health Services

Over 100 individuals were involved in the development, authorship, and review of the original Purchaser's Guide. Without the commitment and effort of these individuals, the Purchaser's Guide would not have been possible. To see the full list of contributors to the original Purchaser's Guide, please see Acknowledgments.

---

Funder & Partner Information

Centers for Disease Control and Prevention
The Purchaser's Guide and the development of this website are a result of a partnership between the Center for Prevention and Health Services at the National Business Group on Health and the Division of Partnerships and Strategic Alliances within the National Center for Health Marketing (NCHM) at the Centers for Disease Control and Prevention (CDC). Via a cooperative agreement structure, the Business Group and the CDC work collaboratively to better educate large employers about health-related issues.

The U.S. Preventive Services Task Force (USPSTF)
Most of the recommendations featured in the Purchaser's Guide were adapted from the U.S. Preventive Services Task Force (USPSTF). The USPSTF, sponsored by the Agency for Healthcare Research and Quality (AHRQ) (part of the U.S. Department of Health and Human Services), is recognized as the gold-standard in clinical preventive service recommendation.

The USPSTF is an independent panel of experts in primary care and prevention that makes recommendations regarding clinical preventive services after a careful review of the scientific literature.¹

The USPSTF is mandated by Congress to evaluate preventive services and publishes recommendations and evidence synthesis, which are the culmination of an extensive literature review, debate and analysis of critical comments from expert reviewers. USPSTF recommendations are based on an objective process that weighs the benefits and the harms of a preventive service.

---

Citations:

¹ U.S. Preventive Services Task Force. Questions and answers. Background: What is the USPSTF? Agency for Healthcare Research and Quality. Available: http://www.ahrq.gov/clinic/uspstfix.htm. Accessed May 13, 2009.