Preventive Care Guide

By taking a fresh look at some of the updated screening guidelines and evolving test methods, this guide will assist employers in evaluating ways to improve their members' compliance with preventive screening and remove cost barriers to accessing preventive care.

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In contrast to annual preventive visits or biometric exams, an annual wellness visit (AWV) is focused on conversations between the patient and physician about their mental health, home situation and other social determinants of health.⁵ Increasingly, research has shown that AWVs in some cases may be more effective than  annual preventive exams, which may not be necessary for individuals without chronic conditions. A March 2019 study of Medicare patients estimates that reaching out to patients to conduct AWVs led to 5.7% downstream savings. Such downstream savings may be achieved by addressing gaps in care, mitigating issues in the home that may present health risks and deepening the patient’s bond with their PCPs. This facilitates more appropriate utilization of primary care and emergency room visit avoidance.³

Keeping up with preventive screening guidelines has been a challenge for consumers and plan sponsors alike. For consumers, issues include determining when and how often to go in for certain procedures and understanding what their health plan will cover. Timing may become an issue as well: Employees often lose track of the last time they completed a screening, particularly when guidelines change and less frequent services are required. This can lead to unintentional overutilization as employees switch to a new provider or underutilization as they delay preventive services beyond the recommended frequency. Simple reminders based on claim data generated by either the health plan or the provider’s office and improved data interoperability,  as well as the ability for personal health records to be transferred effectively when an individual changes health plans, can alleviate these challenges.

Another challenge is differentiating between diagnostic versus preventive services. While preventive services can be covered without cost sharing, any follow-up tests or screenings administered due to the presence of symptoms, higher risk level or inability to determine health status based on initial screenings are deemed diagnostic and therefore may lead to out-of-pocket costs. The most common examples of such a surprise cost are sonograms performed after a mammography. Because these services may serve different purposes (diagnostic versus preventive) in certain scenarios, communication and education are important to preventing employees from receiving bills for services they may have thought would be 100% covered by their plan.

It is important for patients to understand why a test or service is ordered: the same test can be preventive, diagnostic or routine chronic care depending on the reason it was ordered.⁶ There are several tests and services that are not recommended as appropriate screening for individuals with low risk for a specific condition; for example, both the USPSTF and American Academy of Family Physicians cautions providers against ordering electrocardiography (EKG) on an annual basis for low-risk patients without symptoms.⁷ For this population, health plans  may not cover the screening as a preventive service, potentially leading to unexpected out-of-pocket costs to the member.

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Articles & Guides Plan Design & Administration Preventive Services Primary Care