May 09, 2023
Screening and prevention play an essential role in early detection of serious diseases and achieving overall long-term health outcomes. About a quarter of employees reported that preventive care is one of the most important services health plans should cover, but utilization and guideline compliance continues to be a problem, often disproportionately present within patient populations that experience other barriers to care due to Social Determinants of Health (SDOH).1 Changing rules and guidelines require employers to remain vigilant about preventive service coverage provisions within their plan design.
Preventive screenings refer to procedures like colonoscopies, mammograms and other tests that detect health problems before symptoms develop. More broadly, preventive care includes all measures used to avoid disease such as screenings, vaccinations, annual checkups and wellness visits. Emerging innovative screening technologies and new data indicating earlier occurrence of certain cancers, like colorectal and breast cancers, coupled with higher incidence of late-stage diagnosis, are a call to action for some employers to assess their coverage, programs and communications.2 Their partners, including health plans and primary care providers, also play a role in promoting the use of preventive screenings and educating members about the importance of adhering to preventive care guidelines.
While in general consumers may be aware that their health insurance plans are required to cover 100% of the costs for preventive care, determining what qualifies as ”preventive care” is complex and can be confusing for employees. This often leads to misunderstandings about the preventive care cost-sharing rules and difficulties estimating out-of-pocket costs. In a health care landscape where many have forgone accessing health care services due to COVID-19- related concerns and may now be subject to delays in care due to backlog and shortage of providers, it is more important than ever for employers to promote appropriate adherence to evidence-based preventive care, identify those most at risk from missed screenings and facilitate access to such services.
As employers are thinking about how to design their plans to maximize member engagement in disease prevention, they need to decide what to include in the list of preventive screenings that do not require cost sharing, how the age- based screening eligibility criteria should be adjusted and how to implement patient support services and design communications that adhere to evidence-based preventive guidelines and empower members to access preventive services in a timely and cost-effective way.
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