Weighing the value of prevention: the Bay Area Business Group wants to encourage employees to select health plans based on their prevention efforts - Bay Area Business Group on Health - Coalition Report - Column

Business & Health, April, 1994 by Dan Wise

A survey by the Bay Area Group on Health, of 19 employers an Francisco, shows overall screening rates for preventive services were higher than some employers expected, and higher than the health plans themselves have reported in the past, says Tracy Rodriguez, associate director of the BBGH. The bad news, however, is that there was a wide variation in the results among different health plans.

BBGH has completed a survey of 20,820 employees in nine California companies, asking them what preventive services or health counseling they have received from their health plans. The survey covered II managed care plans and three fee-for-service plans.

The BBGH will use the data to push health care plans to improve their approach to preventive screening. The data may also be used in employee communications to encourage workers to consider how different health plans approach screening. The goal is to encourage workers to select plans with the best performance.

The survey had a 48% response rate, and was based on prevention guidelines drawn up by the Health Services Advisory Committee, a task force of BBGH member employers and health care plans. (See "Measuring Quality of Preventive Services," April 1993).

In general, the survey found that HMOs provide more preventive care than fee-for-service plans, even when the fee-for-service plans cover preventive services. In one fee-for-service plan, for example, only 32% of women over 49 years of age reported that they had a mammogram in the last two years that was covered by their health plan. But at an HMO, 88% of women in that age group had been tested.

The study's results also suggest there is a substantial overlap in the screening and wellness education efforts conducted individually by employers and their health plans, says Rodriguez.

Overall, the average screening rate for the respondents was 80%, with different plans providing an average of 55% to 88% of the screenings within the intervals specified by the guidelines. The percentages refer to the average compliance rate of the plans in providing the total number of recommended screenings to individuals within a specified period of time.

In the past, health plans focused their efforts on individuals who sought services and measured quality of care by the number of services performed. The BBGH survey is a departure from that methodology. BBGH's approach is to look at the utilization of services over a number of years and among individuals who seek preventive care and those who do not. Measuring care in this way encourages plans to reach out to all members and doesn't allow duplication of services to increase screening rates, she says.

The screening rates in the BBGH's survey were consistently higher than rates independently reported by some plans, Rodriguez says. The survey's questions were worded to determine not just whether individuals had received a test within the past year, but whether they had the screening within the interval of time recommended by the guidelines.

Most other surveys on preventive services focus on whether respondents have been screened within the past year because that length of time is thought to be more accurately recalled, Rodriguez says. However, since many recommended screening intervals are more than a year, such surveys fail to give a fair account of appropriate screening practices. For example, individuals were asked whether they had their cholesterol tested in the last five years. If the respondent was a woman over 50, the questionnaire asked whether she had had a mammogram within the last two years.

Statistics released by the health plans on preventive screening rates also may underestimate the extent of preventive care because they do not include care that may have been received in another plan or paid for out of pocket by the individual. The BBGH survey counted all incidents and attributed them to the employee's current health plan regardless of whether all of those tests were furnished by the current plan.

"Right now health care plans provide the majority of screenings," Rodriguez says. According to survey figures, 92% of respondents reported having their blood pressure measured in the last two years, and of that figure 88% had their blood pressure measured by their health plan.

BBGH is encouraged that most health plans can screen 90% of plan enrollees but is concerned about the other 10% of enrollees who typically do not seek screening. Illustrating the size of the problem, Rodriguez says the 12% of women who have not had a recent pap smear, applied to the 500,000 women employed by the companies represented by the BBGH, amounts to 60,000 women who have not been screened. To capture the attention of workers who do not screen, employers in the coalition may now target the difficult to reach population and educate them about the value of preventive care.

Health education is an important issue and the BBGH survey measured whether individuals have discussed specific health education issues with health professionals over the past three years. Counseling rates varied considerably by topic. Between 40% and 50% of individuals had discussed exercise and nutrition with a health professional but only 9% to 15% had been counseled on sexually transmitted diseases, alcohol use, or injury prevention. Smoking cessation was discussed with only 44% of smokers or ex-smokers during the three-year study period. Overall, 44% of individuals surveyed reported that they received no counseling from their health plans.