Rethinking Automatic Insurance Coverage For Preventive Health Care

Oct 10, 2016

Three doctors who have led a task force that evaluates preventive medical services say the group's recommendations shouldn't be tied by law to insurance coverage.

The former chairmen of the U.S. Preventive Services Task Force say the link between medical recommendations and insurance coverage leads to financial incentives that can corrupt the process and distort people's health care decisions.

Under the Affordable Care Act, any preventive service that receives one of the USPSTF's top two ratings must be covered by insurance without any out-of-pocket cost for the patient. The doctors advice to decouple the task force ratings from insurance coverage would require a change in the health law.

The authors of the commentary, which appears Monday in the Annals of Internal Medicine, point to heavy lobbying by the pharmaceutical company Mylan N.V. to get its anti-allergy device EpiPen deemed a preventive service. They say such lobbying can interfere with the task force's mission to evaluate medical services to improve the health of the overall population.

"When people try to twist that mission for their own purposes, essentially what they're doing is violating the integrity of the task force process, and it's distracting from the mission," says Dr. Virginia Moyer, the lead author of the commentary. Moyer, a former chairman of the task force, is now a vice president of the American Board of Pediatrics.

The USPSTF is an independent group of volunteer physicians who review the research on preventive medical services, such as vaccines and screenings tests, and recommend who should get them and how often.

Mylan has been lobbying the task force to have the EpiPen listed as a preventive device, even though it is used by people with diagnosed allergies. The EpiPen is an automatic injector that delivers a dose of epinephrine to stop dangerous allergic reactions. A two-pack costs more than $633, according to GoodRx.

The company has been under fire in recent months because it has raised the price of the device more than fivefold since 2007, even though the product has been on the market for decades. Mylan CEO Heather Bresch has blamed the uproar on trends in insurance coverage that leave patients responsible for a larger share of their medical costs.

If EpiPens were covered as preventive medications, patients could get them at no cost. The price increases Mylan has put in place would be invisible to consumers but would have to be borne by insurers.

"What Mylan has done, or what they're attempting to do with this effort, is use a provision in law, which is intended to give people access to preventive services, and use it to their advantage for something that just plain is not a preventive service," Moyer says.

That effort by Mylan, which was detailed in a story by The New York Times, spurred Moyer and her two colleagues, Dr. Michael LeFevre and Dr. Ned Calonge, who were also task force leaders, to write the opinion piece that questions the overall idea that insurance coverage should be tied by statute to the recommendations of the volunteer medical group.

The authors say the issues with the link go beyond the problem of lobbying. By putting prevention ahead of treatment of illness by making it free of cost, the system created by the ACA may be making treatment of illness more expensive and putting it out of reach of some patients.

"If such financial access comes at the cost of increased deductibles or copays for equally important services that are not preventive, then we must question whether the link inadvertently discourages other important care," they write.

"Perhaps it is time for the USPSTF to inform, but not determine, coverage," they conclude.

A recent survey by the Kaiser Family Foundation shows that more than half of people with insurance through their employer have policies with deductibles of more than $1,000.

Many advocates and economists agree that preventive services can cost more but also can improve the quality of health care. When the Affordable Care Act was being debated, advocates on both sides argued whether or not preventive services would save money in the long run.

"Preventive health services have become quite expensive over time," says Joe Antos, a resident scholar at the American Enterprise Institute.

He says some preventive services such as vaccines are inexpensive and undoubtedly valuable. Others, such as mammograms, are also medically important but don't necessarily save money.

When those services are provided free, the costs are spread across all policy holders through premiums and deductibles.

But Antos cautions against blaming rising deductibles and premiums only on preventive care.

"To what extent have preventive services been responsible for the big increase in deductibles and co-payments over the last decade or so?" he asks. "I would argue that they've contributed. But we're really talking about rising health care costs, not just preventive services."

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There's a panel of volunteer doctors whose decisions affect nearly everyone who has health insurance. They review scientific literature and pass judgment on preventive medical services. The panel is called the Preventive Services Task Force.

Since the Affordable Care Act took effect in 2010, the panel's judgments have carried added weight. Insurance companies must now pay for the preventive tests or drugs the group recommends. That's why some former members are now calling for a change. NPR's Alison Kodjak reports.

ALISON KODJAK, BYLINE: The task force has been controversial almost since it was created back in 1984, but before the new Obamacare rules, its advice was just that - advice. Now if task force members recommend something like, say, a mammogram every X number of years, insurance companies must pay 100 percent of the cost, and that's raise the stakes for doctors and drug companies.

VIRGINIA MOYER: The task force is lobbied all the time.

KODJAK: Virginia Moyer was chair of the task force for three years. She's the lead author of an article in the current Annals of Internal Medicine where three former task force leaders argue that tying its medical recommendations to insurance coverage can corrupt the process.

As one example, she points to efforts by the maker of EpiPens, Mylan, to get the task force to deem the drug a preventive medication so it's covered at a hundred percent.

MOYER: What Mylan has done or what they're attempting to do with this effort is to use a provision in law which is intended to give people access to preventive services and use it to their advantage for something that just plain is not a preventive service.

KODJAK: Mylan has been criticized by consumers and members of Congress for raising the price of EpiPens more than 500 percent in recent years. Having the device fully covered would mask the high cost.

Douglas Kamerow is a former assistant surgeon general who worked on the task force staff in the 1980s. He says lobbying like Mylan's has become a real problem for the task force.

DOUGLAS KAMEROW: They're constantly being barraged with all kinds of specialist societies who want their particular procedure covered or drug companies who want their preventive drug coverage. And so that's something that they shouldn't need to worry about.

KODJAK: But Kamerow doesn't agree with the second argument made by the article's authors that money being spent on preventive care because of the Affordable Care Act raises the cost of health care for people who are sick. He says in the past, many checkups and screenings weren't even covered by insurance.

KAMEROW: And so now we have an incentive to deliver the appropriate evidence based on preventive services by having no co-pay and no deductible. That's a good thing.

KODJAK: And economists like Joe Antos at the American Enterprise Institute say it's unlikely that preventive services are a major driver of health care inflation.

JOE ANTOS: I would argue that they've contributed, but we're talking generally about rising health care costs. It's not just preventive services.

KODJAK: Antos and Kamerow say most health care spending comes not from preventive care but from hospital stays and end-of-life care. So de-linking the task force from the ACA is unlikely to cut the cost to consumers. But it may cut back on lobbying by companies like Mylan, who want the task force to bless their products. Alison Kodjak, NPR News, Washington. Transcript provided by NPR, Copyright NPR.