Judge rules against preventive services, maternal quality and safety, COVID update
September 9, 2022
Today, I’ll talk about first dollar coverage for preventive care, review a recent report from the Leapfrog Group on maternal quality and safety, and review recent pandemic developments.
1. Federal judge rules against Affordable Care Act preventive care requirements.
Federal judge Reed O’Connor has ruled in favor of a small Texas employer which sued to avoid being required to provide first dollar coverage for drugs to prevent HIV infection and HPV vaccination on religious grounds. The judge found that the requirement for this coverage violated the Religious Freedom Restoration Act. His ruling also calls into question the Affordable Care Act’s (ACA’s) requirement that employers cover preventive care recommended by the US Preventive Services Task Force (USPSTF) without member cost sharing.
As of this writing, the judge has not laid out the “remedy” for his ruling or determined how broadly it would apply. Therefore, the requirement to provide first dollar coverage for preventive care as recommended by the USPSTF remains in effect. His ruling about the constitutionality of the USPSTF does not apply to preventive care coverage recommended by the Health Resources Services Administration (HRSA) and the Advisory Committee on Immunization Practices. This ruling is also likely to be appealed.
The requirement that employer sponsored health insurance cover evidence-based preventive care is an excellent example of “value-based insurance design,” where the amount of out-of-pocket cost in a health plan is inversely proportional to the value of the care. We know that out-of-pocket costs decrease utilization, so making exceptionally valuable care cost less (or nothing) increases the amount of high-value care delivered.
Some employers have gone further than the ACA requires, for instance offering diabetes medicines and supplies without out-of-pocket cost.
Here are a few things that employers should keep in mind as they monitor implications of this ruling over the coming weeks:
- The ACA’s preventive services list includes vaccinations, screenings for cancer, infectious disease, diabetes and some types of vascular disease, contraception, and breast pumps.
- A full list of USPSTF recommendations is here. A list of HRSA recommendations is here, and a list of ACIP recommendations is here.
- The total cost of these preventive services is relatively low. The Health Care Cost Institute estimates these costs at $100-200 per member per year.
- About 152 million Americans received first dollar coverage for preventive care mandated by the ACA in 2020.
- First dollar coverage for preventive care is supported by a majority of Americans.
- The US has seen a dramatic decline in screening and vaccination through the pandemic, and adding cost sharing at this point to these preventive services could mean fewer preventive services and more preventable illness and death.
- Coverage of contraceptives helps increase workforce participation, important to many employers given the current labor shortages.
- Pre-exposure prophylaxis (PrEP) is 99% effective at preventing HIV infection. PrEP is now available generically, which has substantially lowered its cost. The ruling noted that PrEP can cost $22,000 a year, and much of the press has reported this number. I can find the generic PrEP drug for under $17 a month - so cost should not be a reason to require cost-sharing or to not cover this valuable drug.
2. Maternal quality in the US: Poor, but at least some evidence of improvement
The quality and safety of maternity care in the US remains poor. The US has the highest rate of maternal mortality of developing countries and is alone among developed countries to have an increase in mortality from childbirth over the last decade.
Source: Gates Foundation, 2021, LINK
Racial disparities in the risk of childbirth are also large. For Black women, the risk of dying of pregnancy in the US (41 per 100,000) is higher than the risk of dying of pregnancy in at least two African countries (Egypt and Tunisia).
The Leapfrog Group, a nonprofit organized to monitor and improve the health care purchased by employers, issued its most recent report on the quality of maternal health care in the US. This report reflects data from hospitals that report to Leapfrog. This reports shows at least a glimmer of hope.
For instance, the rate of low-risk Cesarean Sections has declined from 26.4% (2015) to 24.5% (2020), although it remains higher than the Healthy Persons 2020 goal of 23.9%.
Source: The Leapfrog Group, September, 2022 LINK
Perhaps the most impressive success is the dramatic decline in early elective deliveries (before 39 weeks), which are associated with preventable prematurity and increased risk of cesarean section.
Source: The Leapfrog Group, September, 2022 LINK
Implications for employers:
- Too many women in the US have avoidable complications of pregnancy, and our maternal mortality rate is far too high. Racial disparities remain awful, with Black women three times as likely to die of pregnancy-related complications as White people.
- Employers can focus attention on the problem of maternal quality and safety by requiring that health plans report on maternal quality of care. Measures that should be reported on include low risk cesarean section (CS) rates, early elective deliveries, trials of labor after CS, vaginal birth after CS, breastfeeding at hospital discharge, and complications like episiotomy, infection, high blood pressure and blood clots.
- Employers can also pressure health plans to tie provider payment to improvement in the quality of care.
- Employers can identify pregnant individuals earlier and target resources to these women in order to foster healthier pregnancies and deliveries.
3. COVID-19 Update
- Bivalent COVID-19 boosters, which provide protection against the original strain as well as Omicron BA.4 and BA.5, became available over the last week. I’m looking forward to getting mine. The White House also announced that they expect to recommend one booster shot each fall. Ashish Jha, the White House Coronavirus Response Task Force Coordinator, said “I really believe this is why God gave us two arms — one for the flu shot and the other one for the COVID shot”
I think the White House is being optimistic, as immunity from previous vaccinations has waned more quickly, and we don’t know what coronavirus mutations will pose threats over the coming year. But we could see substantial advances in vaccine technology, too. For instance, China just approved the first inhaled vaccine, and it’s possible that such a vaccine could be better at “sterilizing immunity,” where protection is high against even mild infections. This could diminish the risk for everyone. A combined flu/COVID-19 vaccination next fall would likely increase vaccination rates, too.
A Commonwealth Fund study this summer found that if COVID-19 booster rates were similar to influenza vaccination rates, a fall booster campaign could prevent 101,000 deaths, a million hospitalizations, 25 million infections, and $63 billion in direct medical costs.
- Most projections suggest that COVID-19 infections, hospitalizations and deaths will decline in the next month
The pandemic has thrown us many curves - so that combining many different data models likely has higher predictive ability than following a single model. The CDC offers four week projections from a “national ensemble model” which combines the outputs from 16 independent mathematical models. It shows a likely decline in deaths and hospitalizations through the end of this month.
Source: Centers for Disease Control and Prevention (CDC) September, 2022 LINK
- CVS pharmacists will prescribe Paxlovid.
CVS is rolling out a national program where its retail pharmacists prescribe and dispense Paxlovid, within strict clinical parameters. This service should be available in all CVS locations by end of October. This is great news – as the drug is most effective when given promptly, which is easier with access to “test and treat” at local pharmacies.