By John Palmer
A new study shows that only a small percentage of the mainstream population in the United States receives proper preventive care and recommends that the U.S. healthcare system revamp itself to increase use of preventive services.
The paper, published in the June issue of Health Affairs, asserts that preventive services can help patients maintain their good health, and that the entire healthcare delivery system must adopt a proactive approach to care.
“Commonly known reasons for not getting appropriate preventive services include lack of health insurance; lack of a usual source of care; and gaps in provider capacity, including wait times,” the authors wrote.
Researchers from the Agency for Healthcare Research and Quality (AHRQ) developed a composite measure and a survey to capture the use of all recommended high-priority, appropriate clinical preventive services. They found that just 8% of adults age 35 and older had received all their recommended services. Women were overall more likely than men to receive their recommended preventive services at all ages, with the exception of women ages 50–64.
The investigators included Amanda Borsky, DrPH, MPP, a dissemination and implementation advisor in the Center for Evidence and Practice Improvement at the AHRQ, located in Rockville, Maryland. “People expect and deserve to receive all of the evidence-based clinical preventive services that are appropriate for them,” the authors wrote.
The researchers used data from the Preventive Services Self-Administered Questionnaire (PSAQ) with responses from 2,186 adults. PSAQ asks about the receipt of 15 high-priority preventive services. Based on the person’s age, sex, and medical history, respondents should have received between seven and 13 services.
The survey results found that only 8% received all their recommended high-priority preventive services, while just 22.4% received at least 76% of their recommended services. Only 16.3% received 25% or fewer, and just under 5% received none at all. Men were more likely than women to have received no recommended services at all (7.3% of men vs. 2.4% of women).
There were significant differences between men and women for routine services such as blood pressure screening (84.7% of men vs. 89.6% of women), cholesterol screening (79.3% vs. 85%), obesity screening and counseling (59.2% vs. 63.7%), and depression screening (36.5% vs. 45.1%).
“Health systems and individual practices can use the PSAQ survey and composite measure to assess the receipt of clinical preventive services among the people they serve,” the authors wrote. “They can drill down and target quality improvement efforts based on observed disparities in care and on which services are most commonly not being received.”
What can be done to improve preventive care in the U.S.? Dave Chase, author of The Opioid Crisis Wake-Up Call and co-founder of Health Rosetta, a health benefits provider that promotes reform for what he calls the dysfunctional U.S. healthcare system of fee-for-service care, says the industry isn’t addressing the real problem.
“Our healthcare system is designed to address medical ‘fires’ versus ‘fire’ prevention,” he says. “The clearest manifestation of this is how we underinvest in primary care and public health. A key consequence is the U.S. doesn’t have a well-functioning primary care system. Since there’s no well-functioning healthcare system in the world that doesn’t have proper primary care, the result is predictable: We spend far more to get far less.”
To fix this, Chase says, the healthcare system needs to stop putting bandages on the undermined primary care model through ineffective “solutions” such as urgent care clinics, ERs delivering what should be addressed in primary care, carrier nurse care coordinators, and telehealth.
“None of these are necessary when there’s a proper primary care model,” he says. “There are no shortcuts to rebuilding primary care. Places ranging from Seattle to Tyler, Texas, are rebuilding primary care brick by brick, leaving behind fee-for-service primary care in favor of primary care that mixes the best of old and new.”
For instance, he says that for adults and older, the annual cost of four vaccine-preventable diseases—influenza, pneumococcal disease (both invasive disease and pneumonia), herpes zoster (shingles), and pertussis—is a staggering $26.5 billion.
“The cost is high due to two major factors,” Chase notes. “First, we didn’t prevent it via vaccines. Second, due to poor access to primary care, patients are far worse off than if the issue had been addressed earlier in a primary care setting versus a hospital ER. Generally, insurance does cover these preventive vaccines, but that doesn’t change the fact that primary care is difficult to access.”
Chase says the best alternative is for the U.S. healthcare system to shift to value-based primary care (VBPC), a more proactive care model that prioritizes preventive and chronic care.
“Employers are fed up with the financial and human cost of a badly undermined primary care system,” he says. “The forward-looking among them realize that VBPC is foundational to any long-term solution to the healthcare problem. Not only is VBPC effective at prevention and dealing with acute episodes (in well-functioning VBPC, they can handle >90% of the issues people come into the healthcare system for), it’s vital for expensive and complex medical conditions. They serve as a seasoned sea captain helping patients navigate treacherous medical seas. Without that, we see patients receiving uncoordinated care that puts patients in jeopardy of conflicting prescriptions and care plans.”
One of the most pressing problems in healthcare—and one that has spilled into our society in general—is the overprescribing of opioids for pain management. Chase says all too often, providers turn to opioids instead of focusing on alternative therapies.
“While there’s no silver bullet on a multifactorial problem like the opioid crisis, undermined primary care has been one of the enablers,” he says.
In VBPC, Chase says, many issues such as lower back pain can be addressed without non-evidence-based opioid prescriptions. They either include physical therapy in the VBPC clinic itself, or they closely coordinate with physical therapy. Non-evidence-based musculoskeletal treatments, such as many spinal procedures, are one of the major onramps to opioid prescriptions, which in turn are all too likely to lead to misuse.
“Evidence shows that after seven days of opioid use, one in six will become addicted,” he says. “Even with all of the awareness around opioid overuse, 30% of all people in large employer plans receive an opioid prescription every year. That is a rate that far exceeds what evidence-based medicine would suggest is appropriate.”
In fact, a March 2017 CDC report studied the relationship between the number of days of a patient’s first opioid prescription and the patient’s likelihood of long-term use. It found that patients face an increased risk of opioid dependency in as few as four days of taking the drugs. Opioid prescriptions longer than five days in length significantly increased the likelihood of continued opioid use both one and three years later.
“Awareness among prescribers, pharmacists, and persons managing pharmacy benefits that authorization of a second opioid prescription doubles the risk for opioid use one year later might deter overprescribing of opioids,” the CDC report said. “Knowledge that the risks for chronic opioid use increase with each additional day supplied might help clinicians evaluate their initial opioid prescribing decisions and potentially reduce the risk for long-term opioid use. Discussions with patients about the long-term use of opioids to manage pain should occur early in the opioid prescribing process.”
The study analyzed 1.3 million non-cancer patients and found that only 6% of patients prescribed a one-day supply of opioids were still taking the drugs a year later, but that number doubled to 12% if patients were prescribed a six-day supply and quadrupled to 24% if patients were given a 12-day supply.
“I’m not aware of hospitals using VBPC in their anti-opioid programs,” Chase says. “Virtually all anti-opioid programs are dealing with those already enslaved by opioid overuse disorders. VBPC is helpful when they offer medication-assisted treatment inside a primary care setting. However, VBPC is most effective at stopping addiction before it starts by avoiding non-evidence-based opioid prescriptions for musculoskeletal issues.”
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.