The Affordable Care Act (ACA) requires health plans to cover certain preventive health care services with no cost to the patient, but this ACA benefit is limited. Physicians detail educational tools, insurance plan designs, and advocacy initiatives that can help.
A joint report from the AMA Council on Medical Service and the AMA Council on Science and Public Health issued at the 2018 AMA Interim Meeting addresses the confusion among provider, patient and payer communities in paying for preventive services and strives to further a common goal of improving affordable access to high-value health care services.
The AMA House of Delegates (HOD) adopted the report’s recommendations on how to align the clinical and financial incentives for high-value care.
“The ACA requirement for coverage of select preventive services without cost-sharing has been a popular and successful step in promoting access to preventive care, but more could and should be done to facilitate and incentivize high-value care,” said AMA Secretary Russell W.H. Kridel, MD.
“The AMA can play a critical leadership role in building needed common understanding, coding tools and education resources to protect and improve access to zero-dollar preventive care,” Dr. Kridel said.
When incentives conflict
The report highlights key challenges that persist alongside the ACA preventive services benefit, including how patients face conflicting incentives when it comes to high-value health care.
That is, even when evidence indicates that a certain health care service could save patients’ health and finances in the future, that service may be unaffordable. In such cases, patients are weighing science and their doctors’ recommendations against their immediate financial well-being.
VBID is a potential partial solution to this problem that is consistent with longstanding AMA policy. Plans designed according to VBID and its principles of “clinical nuance” recognize that the same medical service can produce different amounts of health.
VBID plans have the potential to better align clinical and financial incentives to encourage patients to pursue the care that is high value for them. In addition, advocacy by the AMA and national medical specialty societies can help policy-makers better identify and incentivize high-value care.
To protect and improve access to zero-dollar preventive care and create incentives for the use of high-value care, the HOD adopted policies to:
- Support VBID plans designed with “clinical nuance,” recognizing that medical services may differ in the amount of health produced, and that the clinical benefit derived from a specific service depends on the person receiving it—as well as when, where, and by whom the service is provided.
- Support initiatives that align provider-facing financial incentives created through payment reform and patient-facing financial incentives created through benefit-design reform, to ensure that patient, provider, and payer incentives all promote the same quality care. Such initiatives may include reducing patient cost-sharing for the items and services that are tied to provider quality metrics.
- Support requiring private health plans to provide coverage for evidence-based preventive services without imposing cost-sharing on patients.
- Support implementing innovative VBID programs in Medicare Advantage plans.
- Support legislative and regulatory flexibility to accommodate VBID that preserves coverage without patient cost-sharing for evidence-based preventive services and allows innovations that expand access to affordable care, including changes needed to allow high-deductible health plans paired with health savings accounts to provide pre-deductible coverage for preventive and chronic care management services.
- Encourage national medical specialty societies to identify services that they consider to be high-value and collaborate with payers to experiment with benefit plan designs that align patient financial incentives with utilization of high-value services.
Delegates also directed on the AMA to develop:
- Coding guidance tools to help providers appropriately bill for zero-dollar preventive interventions and promote common understanding among health care providers, payers, patients and health care information technology vendors regarding what will be covered at given cost-sharing levels.
- Educational tools that prepare physicians for conversations with their patients about the scope of preventive services provided without cost-sharing and instances where and when preventive services may result in financial obligations for the patients.
“As plans continue to innovate around VBID, organized medicine and physicians will have a critical role in helping plans understand the highest value care they want to encourage,” the AMA joint-council report says.
“The exact same service may be highly valuable for some patients, but constitute overtreatment for other patients, and the physician community can lead the way in shaping policies that recognize and embrace this approach to payment reform and benefit design.”
