As the health care industry moves toward value-based reimbursement, the use of preventive services seems obvious. It’s become obvious, at least, to a number of health plans who are incentivizing the use of well visits, screenings, and other preventive programs to keep patients healthy.
In January 2013, states that offered preventive programs at low or no cost to Medicaid populations began receiving additional funding. And the Affordable Care Act (ACA) set up a $15 billion Prevention and Public Health Fund to help keep beneficiaries healthy.
But most Americans aren’t taking advantage of this new emphasis on prevention. According to the Centers for Disease Control and Prevention (CDC), only 25 percent of adults 50-64, and less than 50 percent of adults older than 65 are up to date on using preventive services. What is even more sobering is data from 2006 that suggests if 20 preventive services had been used as recommended, 2 million people would still be alive without an increase in cost.
Where’s the gap? It’s quite simple: health care organizations often lack the population data and analytics to know which patients need preventive services. And this lack of data and technology is impacting patient health as well as costing providers millions of dollars in potential reimbursements. Optum conducted a review of 451,076 patients and found that 42.3 percent – or 190,805 people – had not had an adult preventive service visit in the last 24 months. Further culling of the data showed about 103,000 of the roughly 190,000 patients did not have an insurer on their record.
Go a bit deeper and the impact of the numbers above hit home. Not only are these patients missing out on health benefits of early disease detection, we estimated that, for the 85,317 patients for whom the data showed a health insurer, providers left nearly $7.8 million in potential reimbursements on the table. Taking a conservative approach and doubling that amount for the 103,000 for whom insurance coverage wasn’t recording, the value of preventive services reaches more than $15 million.
Realistically, a provider likely would not recoup all that money by bringing in all of its patients for a preventive visit. But what if an organization could convince a third of that population to come in? The impact to both patient health and the providers’ bottom lines would be tremendous. Fee-for-value structures can lead to such savings, but it won’t happen overnight.
Before provider organizations truly realize the benefits from preventive services, they must embrace more powerful and robust data analytics systems. It comes down to understanding who within their patient populations have – or have not – received preventive services.
In my next blog post, I’ll discuss what tools health care organizations need to identify populations in need of preventive services, and prioritize delivery of those services.
For more on the subject, please download our full white paper: Why prevention matters.
–Carl Johnson, MD, EdM, MSc.
 Data from Optum statistically de-identified common data repository (dCDR).
About the Author:
Carl Johnson, MD, EdM, MSc. is a pediatrician trained at Boston Children’s Hospital. He completed a Medical Education fellowship at Harvard Medical School and was a faculty health services researcher at The Mount Sinai School of Medicine.
Before joining Optum Analytics he worked as a physician executive at Cerner Corporation. He is a graduate of the Mount Sinai School of Medicine in New York City and has held faculty positions at Harvard Medical School, University of California at San Francisco, The Ohio State University, and The Mount Sinai School of Medicine.
Dr. Johnson believes that healthcare can be transformed with the help of the right data. When he is not helping to transform healthcare, he can be found playing tennis, cooking, perfecting his French, taking photographs, reading historical fiction, listening to music, and watching Ohio State Football.