HealthMay 28, 2024

Aligning health policies with clinical evidence to support preventative care

As preventative care recommendations like hepatitis B screenings are updated, health plans need tools to help them design policies that are current, support members, and reduce provider friction.

For payers grappling with a rapidly changing healthcare landscape, policy design adjustments need to keep pace, all while building in administrative efficiencies to reduce costs and support members, clients, and provider networks. This is a challenging proposition, but one that can be managed with the right focus and partners.

One area of particular interest in payer medical management is designing policies that promote preventative care. When payers encourage members to take advantage of preventative care services, they can see improved health status for their members as health issues are caught and treated earlier, often leading to more appropriate utilization rates and costs.

Barriers to preventative care and screenings

One challenge is that members may not actively take steps for preventative care. A study estimates that only 8% of Americans undergo routine preventative screenings, and only 15 states have above-average preventative healthcare metrics. Among females, nearly half skip preventative care services for routine check-ups, vaccines, and screenings. Without these screenings and services, potential health risks go undetected, leading to more urgent and costly procedures later on.

In some cases, the lack of preventative care is due to social or economic barriers, especially among populations that are low-income, diverse, mobility-challenged, or rurally located. These barriers can include:

  • Family or work responsibilities
  • Childcare availability
  • Perceived discrimination
  • Transportation barriers

Additionally, some barriers are specific to members’ health coverage:

  • Coverage barriers - not understanding what their plan covers or if they will maintain their plan.
  • Financial barriers - worrying that their health insurance won’t cover care or they will have to pay more than they expect or can afford.

During care, providers inevitably bring up routine or newer recommendations like vaccines, screenings, and other services, and this can lead members to wonder about coverage and finances. Health plans can help reassure members by clearly incorporating preventative care into policies, benefit-at-a-glance materials, and member portals. 

Staying current with hepatitis B testing recommendations

As new clinical information is produced and regulations on preventative care requirements are updated, it can also be challenging to stay current with the latest recommendations. 

One example is a recent change in recommendations for hepatitis B virus (HBV) testing. In March 2023, the Center for Disease Control and Prevention (CDC) updated its recommendations for HBV screening, adding a one-time screening for those over 18 years of age without risk factors to catch any possible fringe cases. The following month, the UpToDate® editorial team expanded clinical recommendations for hepatitis B virus screening in adults to align with the CDC recommendations and included their own graded care recommendations. 

Having the latest available evidence for preventative care can help medical management teams design more effective health policies to ensure members are covered during clinic visits.

Aligning leading clinical evidence with policy design

One of the biggest challenges between payers and providers is friction between treatments and coverage. A 2022 survey by the American Hospital Association found that 78% of hospitals and health systems reported their experience with commercial insurers is getting worse. One area that can reduce friction and costly policy compliance processes is through plan alignment with the same evidence the clinicians themselves are referencing to ensure the latest recommendations are accounted for, enabling updated policy coverage for members.

This includes preventative care, like Hepatitis B testing. Having all of the latest updates in one location can support plan design and timely modifications. Within UpToDate clinical decision support, the Practice Changing UpDates section clearly highlights the latest updates to any clinical issue and provides clear graded recommendations to indicate how providers should proceed.

When medical management is referencing the same leading evidence-based content as the provider teams caring for a member, policy plans can be more aligned, reduce friction with providers, and better support member populations. Ensuring the latest preventative care is covered in policies is a key step to improving member outcomes and reducing costs.

Learn more about how solutions from UpToDate can equip payers with the latest evidence-based information.

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