aspects of well-child care are immunization and health supervision. Immunizations are standardized and required by State laws. Health supervision includes periodic health examinations, health education and parental counseling.

DATA ON UTILIZATION OF PREVENTIVE SERVICES 1

There is a limited number of studies on the extent to which preventive services are offered by clinicians or received by patients. The studies that do exist do not investigate the use of preventive services in general, but are limited to specific procedures such as mammograms, or to specific illnesses or risk factors such as coronary heart disease or smoking. This leaves a lack of data on utilization of periodic examinations. Studies may be further limited by small sample sizes, non-random samples or confined geographic areas. This section reviews available utilization data from national studies or surveys. Some of the studies relied on in this section compare utilization to standards or recommendations that are discussed in greater detail later in this memorandum.

Children

There is very little information on children's utilization of health supervision or other preventive services. The one service category for which adequate data exist is immunization. The Centers for Disease Control estimates immunization levels for children entering school at 98 percent in 1989.2 Among children under age 2, it is estimated that 75 to 80 percent have received the basic immunization series.3 Levels of immunization are 10 to 16 percent lower for non-white children and for children living in central city areas.1 Many parents delay having their children immunized until school entry age. As a result, because it is often the pre-schoolers who succumb to childhood diseases, control of vaccine-preventable diseases is weakened.

1 In this section, data from the Louis Harris and Associates survey and from the 1982 National Health Interview Survey are from: U.S. Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion, Disease Prevention/Health Promotion, THE FACTS (Palo Alto, Calif.: 1988).

2 U.S. Department of Health and Human Services, Fiscal Year 1990 Justification of Appropriation Estimates for Committee on Appropriations, vol. 2 (Washington, D.C.: 1989), 61.

3 U.S. Department of Health and Human Services, Public Health Service, Draft of Promoting Health/Preventing Disease: Year 2000 Objectives for the Nation (Washington, D.C.: 1989). (Hereafter cited as U.S. Department of Health and Human Services, Draft of Promoting Health/Preventing Disease.)

U.S. Congress, Office of Technology Assessment, Healthy Children: Investing in the Future (Washington, D.C.: Government Printing Office, February 1988), 143. (Hereafter cited as Office of Technology Assessment, Healthy Children.)

Adult Immunizations

Information on adult immunization status is fragmented. The Public Health Service (PHS) has estimated that in 1985 10 percent of the non-institutionalized high risk population had received pneumococcal vaccine and 20 percent had received influenza vaccine; the goal of the PHS for the year 2000 is immunization of 60 percent of this population.5 Studies show use of influenza vaccine about 60 percent of the time it is indicated. With no baseline data available, the goal of the PHS for the year 2000 is 80 percent immunization against pneumococcal pneumonia and influenza among institutionalized chronically ill and elderly.7

Adult Screening

Data from the 1982 National Health Interview Survey (NHIS) suggests that use of screening services increases with education and income. About 90 percent of the women reported ever having a Pap smear or breast examination. Women with less than 12 years of education and household incomes under $10,000 were more likely never to have had either examination.

A national survey conducted by Louis Harris and Associates in 1985 supported findings from the NHIS. For example, while 78 percent of the women reported having a Pap smear every 1 or 2 years, this was most likely among women with some college education and household incomes of $25,000 or more. Similarly, as 48 percent of the respondents claimed to have annual cholesterol testing, those most likely to have been tested were over 40 years old and in a $50,000 income bracket.

Both the Louis Harris survey and the NHIS found that over 85 percent of the population received annual blood pressure readings with no differences in income, occupation or education. The Louis Harris survey found that blacks were most likely to have a blood pressure reading more often than once a year.

Makuc, et al., comparing data from the 1973 and 1974 National Health Interview Surveys to data from the 1985 National Health Interview Surveys con

U.S. Department of Health and Human Services, Draft of Promoting Health/Preventing Disease, 12-14.

• Charles E. Lewis, "Disease Prevention and Health Promotion Practices of Primary Care Physicians in the United States,” in Implementing Preventive Services, eds. Renaldo N. Battista and Robert S. Lawrence (New York: 1988), 9-15. (Hereafter cited as Lewis, Implementing Preventive Services.)

'U.S. Department of Health and Human Services, Draft of Promoting Health/Preventing Disease, 2-14.

firmed that black women are most likely to be tested, not only for hypertension but, in 1985, for cervical and breast cancers as well. The researchers found that while poor women continued to be least likely to be screened, they had made substantial gains in the use of tests over the period. In 1985, the percent of women with a recent Pap test or breast exam was 10 to 13 percentage points lower among poor women than among the non-poor with two exceptions: among black women 60 to 79 years of age, the difference was only 4 percentage points lower for Pap smears and 5 percentage points lower for breast examinations. Between 1973 and 1985, the percent of women with recent breast examinations increased more for the poor of both races than for the non-poor. Also, the percentage of women who had never had a Pap smear or a breast examination was highest among

older poor women (18%) than among other subgroups. However, it was older poor women and black women who accounted for substantial gains in the use of tests between 1973 and 1985.8

Prenatal Care

Although 93 percent of the mothers responding to the Louis Harris survey mentioned above reported having sought prenatal care during the first 3 months of pregnancy, other sources indicate the national number is closer to 75 percent.9 The 25 percent who do not receive early prenatal care are the poor, the uninsured and racial minorities. Women in these groups are also likely to make fewer than the recommended number of visits for prenatal care. 10, 11

Health Education and Counseling

There are more data on counseling for smoking than for other risk factors. Audits of patient charts show about 63 percent of smokers advised by physicians to stop smoking. 12 With regard to other lifestyle factors, surveys of family physicians indicate dietary counseling is provided to about 58 percent of those at risk, and exercise counseling for sedentary individuals to about 25 percent. 13

Diane M. Makuc, Virginia M. Freid and Joel C. Kleinman, "National Trends in the Use of Preventive Health Care by Women," American Journal of Public Health, 79 (1) (January 1989): 21-26. (Hereafter cited as Makuc, American Journal.)

General Accounting Office, Prenatal Care Medicaid Recipients and Uninsured Women Obtain Insufficient Care (September 1987).

10 General Accounting Office, Human Resources Division, PRENATAL CARE Medicaid Recipients and Uninsured Women Obtain Insufficient Care (Washington, D.C.: 1987), chap. 2.

11 The Alan Guttmacher Institute, The Financing of Maternity Care in the United States (New York: 1987), 30-32.

12 Lewis, Implementing Preventive Services, 9-15.

13 Lewis, Implementing Preventive Services, 9-15.

FACTORS IN UTILIZATION

As the utilization data suggest, income, education and minority status are often correlated with failure to receive health care, including preventive services. Financial access, in particular, has been cited as critical. Two studies analyze receipt of preventive services with particular attention to costs and availability of third-party payment for services.

Woolhandler and Himmelstein examined data from the 1982 National Health Interview Survey to explore the relationships between insurance coverage and receipt of blood pressure check-ups, clinical breast examinations, and Pap smears by middle-aged women. Screening was deemed inadequate if it did not meet published guidelines for optimal frequency. Eightyeight percent of the sample were adequately screened for hypertension, and 62 percent for breast cancer. For 73 percent of the women, Pap tests were adequate. The investigators found that the poor and the uneducated were least likely to be screened and black women were more likely to be screened. However, in all subgroups, lack of insurance was the strongest predictor of receipt of preventive services. The authors concluded that because the socioeconomically disadvantaged who make up most of the uninsured are at particularly high risk for preventable illness, inadequate insurance coverage leads to reverse targeting of preventive care. That is, those who would benefit most are least likely to receive it. 14

The second study, by Nicole Lurie et al., looked at whether insurance coverage was an important determinant of the amount of preventive care received by enrollees during a 3-year period in the Rand Health Insurance Experiment (HIE). The HIE was a trial of cost sharing on the demand for health services; participants were assigned to either free care or one of several levels of cost sharing. The participant population was considered to be a representative sample of the U.S. population under age 65. The population was broad enough to enable the investigators to look at how different age groups used a range of recommended preventive services.

This study showed that enrollees in the HIE received far fewer preventive services than recommended. Only 45 to 60 percent of young children received timely immunizations. Seven percent of the children received no well child care in their first 18 months of life. Only 2 percent of the women aged 45 to 64 received mammography. One percent of the

14 Steffie Woolhandler and David U. Himmelstein, "Reverse Targeting of Preventive Care Due to Lack of Health Insurance," Journal of the American Medical Association, 259 (19) (May 20, 1988): 2872-2874.

adults received preventive sigmoidoscopy. The most frequently performed screening procedure was Pap smears, provided to 57 percent of the middle-aged women and to 66 percent of younger women.

Cost sharing was associated with reduced use of preventive services. Fifty-nine percent of the children in the free plans received some immunization compared to 49 percent of the children in the cost sharing plans. Sixty-five percent of the middle-aged women in the free plan received Pap smears compared to 52 percent of the women in the cost sharing plans. Although cost sharing affected utilization, even enrollees in the free plan did not receive all recommended services. Therefore, the researchers concluded that cost sharing is not the only obstacle to receipt of preventive care. 15

Non-financial obstacles to preventive care may rest with the attitudes and knowledge of either the physician or the patient or with the health care delivery system that affects them both.

A variety of explanations have been offered for physicians' failure to offer preventive services. Some physicians who see themselves primarily as healers may offer less preventive care, concentrating on the greater challenge of managing disease rather than maintaining health. Also, curative treatment may be felt more satisfying because it yields visible short term results rather than the uncertain outcomes of preventive care. These views may be reinforced by a lack of emphasis on prevention in medical training. Attitudes toward patients may also play a part, with physicians less likely to offer service if there is skepticism about the patient's interest, willingness to pay for the service, or willingness to comply with advice. 16

tainties regarding the efficacy, frequency and side effects of preventive services. The argument states, if experts do not agree, then a practicing physician cannot be expected to have either the knowledge or the commitment necessary to providing a service. Tests have not supported this argument. In a study of the factors related to vaccinating elderly patients against influenza, McKinney and Barnas found no relationships between physicians' knowledge of the vaccine's efficacy or side effects and the decision to offer vaccine. In this study, only 41 percent of the patients eligible to receive the vaccine actually received it. Offers of vaccine were made most often to patients who had been vaccinated in the previous year. The authors also cited a report of a nursing home population in which only 33 percent of the residents were immunized even though the attending physicians expressed strong convictions in favor of immunization. 18

Patients may not be inclined to seek preventive care that entails behavioral changes related to smoking, diet or exercise. Preventive care may be avoided because of the discomfort, inconvenience or fear of side effects. Failure to actively seek prenatal care or immunization for children may result from lack of awareness of the potential benefits. Similarly, patients may be unaware of standards for care that require that some procedures be done on a regular basis.

Systemic barriers that affect both providers and patients include lack of third-party reimbursement for preventive services, especially counseling, and a lack of system-generated cues for timely action.

COVERAGE OF PREVENTIVE SERVICES

Insurance coverage of preventive services has historically been very limited. Private health insurance plans and Medicare have generally denied payment for services not medically necessary for the diagnosis and treatment of illness or injury. Medicaid, the Federal-State program for low-income individuals, has been an exception in offering substantial benefits for preventive services. More recently, some private health benefit plans have begun to add such benefits, and a few preventive services are now eligible for Medicare reimbursement. This section reviews the current preventive service provisions of public and private health insurance programs, as well as other

18 W. Paul McKinney and Gary P. Barnas, “Influenza Immunization in the Elderly: Knowledge and Attitudes Do Not Explain Physician Behavior," American Journal of Public Health, 79 (10) (October 1989): 1422–1424.

sources of funding for preventive services, such as Federal grant programs.

It should be noted that some preventive services may be reimbursed under health plans even when the plans exclude such services. Many screening procedures may also be used as diagnostic techniques. The line between use of a given test for screening and use of the same test to diagnose illness may be an imprecise one. Pap tests performed for screening purposes may be reimbursed if the provider reports cervicitis as a diagnosis when claiming payment; screening mammography may be reimbursed under the reported diagnosis of chronic cystic mastitis. The extent to which preventive services are being covered in such circumstances cannot be determined.

Private Health Insurance

Preventive services have historically been excluded from private health insurance policies because the use of such services does not meet the traditional definition of an "insurable event." Insurance is based on pooling risk. Subscribers pay a premium to insure against liability for a large portion of the cost of a low-probability high cost event that will occur to only a few in the risk pool. Insurance coverage is attractive because covered events are unpredictable on an individual basis. The amount of the premium is much less than the total payment for the event but the aggregate premiums cover the costs of occurrences. Preventive services, however, are predictable along age/sex lines and can be used in some form by everyone. Consequently, the premium has to be set high enough to cover services to all subscribers, and cover profit and administrative costs to the insurer. From the insurers' perspective, then, coverage of preventive services is really prepayment and not insurance.

The general failure to cover preventive services might seem short-sighted if the provision of such services could reduce claims for more costly services in the future. The extent to which preventive care can actually produce long-term savings is discussed later in this memorandum. Given the current structure of the health insurance system, however, long-term savings may not be a consideration for insurers or employers in designing a benefit package. Insurers attempting to measure the cost-effectiveness of prevention must think in terms of costs and savings in a single policy year, because purchasers may shift from one insurer to another. If, as will be suggested below, the benefits of preventive services are not realized immediately, the insurer has no incentive to offer them. Employers' incentives may be somewhat different. If an employer has relatively low turnover of workers,

and can thus expect to be providing health benefits to the same pool of workers for many years, the employer might have a greater interest in potential longterm savings. Even in the absence of this incentive, employees may press for coverage of preventive care through collective bargaining or other means.

Thus, despite the traditional insurance treatment of preventive services, some employer health benefit plans have begun to add coverage of these services. A 1988 Bureau of Labor Statistics (BLS) survey of medium and large firms found that 28 percent of health plan enrollees were covered for routine physicals, compared to 18 percent in 1986.19 Other recent surveys also suggest that coverage of preventive services may be increasing. The Foster Higgins Health Care Benefits Survey found that 41 percent of surveyed firms offered physicals to some or all employees in 1987, compared to 24 percent in 1986.20 The BLS survey also found growing coverage of other preventive services. In 1988, 31 percent of plan participants were covered for well-baby care and 29 percent for immunizations. Some plans exempt preventive services from the cost-sharing requirements applicable to other types of care. IBM, for example, will reportedly reimburse up to $200 per year in preventive services with no deductible.21 Statistics on the prevalence of this practice are not available.

Health maintenance organizations (HMOs)-health insurers that provide or arrange covered services through affiliated providers instead of merely paying claims for services from any provider-have traditionally been more likely than other insurance plans to offer preventive services. The term "health maintenance organization" was coined in the early 1970s to reflect the view of HMO proponents that these plans were less costly than conventional plans because of their emphasis on preventive care. More recent evidence suggests that most HMO savings are achieved through other means, such as control of inpatient hospital services. However, coverage of preventive services remains a major distinction between HMOs and conventional plans. Federally qualified HMOs must provide as basic benefits periodic health assessments, well baby care, and immunizations. 22 As of June

19 U.S. Department of Labor, Bureau of Labor Statistics, Employee Benefits in Medium and Large Firms, 1986 (Washington, D.C.: June 1987).

20 A. Foster Higgins & Co., Foster Higgins Health Care Benefits Survey, 1987 (New York: 1987). The difference between the BLS and Foster Higgins figures stems from the fact that the BLS survey considers only plans offered to all full-time workers, while Foster Higgins takes into account special plans offered to executives.

21 Jonathan E. Fielding, "Economic and Social Determinants of Prevention in Health Care Provision in the United States," Implementing Preventive Services, 1988.

22 A Federally qualified HMO is one determined by the Department of Health and Human Services to meet minimum standards set forth in the HMO Act (Title XIII of the Public Health Service Act). Certain employers

1988, 76 percent of the 31 million HMO enrollees were in federally qualified plans subject to these requirements. 23 HMOs that are not federally qualified may be subject to State licensure laws that impose similar minimum benefits or may offer preventive benefits on their own (possibly because they are in competition with federally qualified plans).

The BLS survey cited earlier found that 99 percent of participants in HMOs were covered for physicals and immunizations and 98 percent for well-baby care. Coverage of these services for participants in nonHMO plans ranged from 11 percent for physicals to 15 percent for well-baby care. These figures suggest that much of the recent growth in preventive services coverage may stem from growth in the market share of HMOs, rather than from changes in conventional coverage options. Still, even non-HMO plans are beginning to offer these services to a greater extent than before.

Plans that do not generally cover preventive services may offer them for a special class of employees, such as executives. The 1989 Hay/Huggins survey of medium and large employers found that 43 percent of plans covered physical examinations only for executives, and another 6 percent had different policies for executives and other salaried employees. Only 15 percent offered coverage of physicals uniformly to all salaried employees. 24 (The Tax Reform Act of 1986 added a new section 89 to the Internal Revenue Code, which would have denied tax preferences to plans that discriminated in favor of highly compensated employees. This provision was repealed in 1989, but there remain some restrictions on discriminatory plans offered by self-insured employers.)

Supplemental preventive benefits may also be offered as part of a flexible benefits or "cafeteria plan," under which employees may choose among such fringe benefits as child care, legal assistance, or enhanced health benefits. A Wyatt Company survey found that 19 percent of firms offered flexible benefits in 1988. Of these, 71 percent offered as one of the optional benefits "medical care reimbursement accounts." 25 In these arrangements, the employer contributes a specified sum to the account, and the employee can then draw on the account to cover services not otherwise available under the employer's standard health benefit plan, such as preventive care.

that offer health benefits may be required to offer an HMO option to their employees if there is a Federally qualified HMO in the area that seeks to be offered.

23 InterStudy, The InterStudy Edge (Excelsior, Minn.: Fall 1988).

24 Hay Management Consultants, Hay/Huggins Benefits Report (Philadelphia: 1989).

25 Wyatt Company, 1988 Group Benefits Survey Report (Washington, D.C.: 1988).

A number of States have mandated that insurers cover preventive services. Fifteen States require coverage of mammograms; seven mandate preventive services for children and infants. Diabetic education is required in four States and Pap smears in two. One State mandates coverage of prenatal care. However, these mandates apply to employer health benefit plans only if the employer purchases a policy from a Statelicensed insurer. An employer that self-insures, covers employees' health costs directly instead of through an insurance policy, is exempt from State mandates under the Employee Retirement Income Security Act of 1974 (ERISA). As of 1984, more than 50 percent of all employees with health insurance were in self-insured plans that were exempt from State mandates. 26

Federal Health Programs

Medicare-Medicare law specifically excludes coverage of preventive services, with a few exceptions. Influenza vaccine and pneumococcal vaccine are covered; vaccine for hepatitis B is covered for persons at high or intermediate risk of contracting the disease. The Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239) added coverage of Pap smears, effective July 1990. Beneficiaries may receive a Pap smear every 3 years, or more often for persons determined to be at high risk for cervical cancer. Coverage of screening mammography was included in the Medicare Catastrophic Coverage Act of 1988 (P.L. 100360), but was subsequently repealed.

As in the case of private insurance, beneficiaries who choose to enroll in HMOs may receive broader preventive service coverage. Of the 131 HMOs and competitive medical plans (CMPs) with Medicare risk contracts in December 1989, 82 percent offered routine physicals, 76 percent covered immunizations beyond those covered under Medicare, and 62 percent provided health education. 27

The Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99-272) required the Secretary to conduct at least five 4-year demonstration projects to determine the costs and effectiveness of providing preventive health services to Medicare beneficiaries. Six such projects are currently under way in RaleighDurham, Seattle, San Diego, Los Angeles, Baltimore, and Pittsburgh. Randomly selected patients are placed into either experimental or control groups. The control group patients receive their usual care, while

26 Patricia McDonnell, et al., "Self-Insured Health Plans," Health Care Financing Review, 8 (2) (Winter 1986): 1-16.

27 Health Care Financing Administration, Office of Prepaid Health Care, Monthly Report: Medicare Prepaid Health Plans (December 1989).