Meningococcal Vaccine: Protection, Risk, Schedule

The Supreme Court Will Determine The Future Of Free Preventative Care

Convincing patients to get mammograms, reproductive care and colonoscopies is a huge part of Allison Ruff's job as a primary care doctor at the University of Michigan. 

"I spent three years probably convincing this one male patient in his 60s to get his colonoscopy," she said.

He finally got the procedure and told Ruff that doctors found and removed a precancerous growth.

"He was totally overwhelmed. He was like, 'Thank you, doc. They were able to remove it completely. I don't have cancer,'" she said. "But if we'd waited another year, it would have been a very different conversation."

There are few guaranteed free parts of American health care. But for the last 15 years, we've all become accustomed to getting screenings for cancer, diabetes and infectious diseases, knowing our insurance will pick up the whole tab. That could all go away if the Supreme Court sides with two Texas businesses.

This is the fourth time the justices are hearing a challenge to the law, and a decision is likely coming this summer.

Since 2010, screening rates for colon cancer, chronic diseases and vaccinations have increased. That's when the Affordable Care Act required insurers to pay for these kinds of important preventive care.

"High-value things should be cheap, and low-value things should be expensive," said Dr. Mark Fendrick. This idea that Fendrick and a colleague came up with is called value-based insurance design. He now runs a center with that name at the University of Michigan.

Fendrick's idea made it into the ACA. Now, every year, an independent panel of doctors and medical experts update which preventive care should be free for patients. 

"And one of the great things about it is it's a gift that keeps on giving," he said.

But in 2020, two Texas businesses disagreed. They say in court filings filings that the requirement to pay for HIV prevention meds, contraception and STD testing through company insurance violates their religious beliefs. They argue the medical experts who decide which preventive care should be free were illegally hired and are too independent. 

When Fendrick heard about the case he said it felt like a "punch in the gut," he said. "This is something that I advocated for for many years and — most importantly — actually saw the impressive impact on patient behavior."

He worries if the justices overturn this guaranteed free care, it could reverse more than a decade of public health progress.

This case threatens a return to the days before standardized coverage, noted Zach Baron, director of the Center for Health Policy and the Law at Georgetown.

"At the end of the day, this case is about whether [insurers and employers] can sort of go back to the Wild West that we had before the Affordable Care Act was signed into law," he said.

Even if the mandate does go away, most businesses say they plan to keep paying for this care, in part because it saves money long-term. 

Health Systems Rethink Primary Care For Older Adults

As the older adult population grows, health systems are expanding community care, virtual visits and home-based models to better meet their evolving needs. 

By 2050, there will be 82 million adults aged 65 and older in the U.S. — a 47% increase from 58 million in 2022, according to projections. This age group is also predicted to account for 22% of the U.S. Population within the next 25 years. 

In anticipation of this patient population's growth, three health system leaders told Becker's how their organizations are working to increase primary and preventive care for older adults. 

Note: Responses have been lightly edited for length and clarity.

George Hennawi, MD. Physician Executive Director of Geriatrics and Senior Services at MedStar Health (Columbia, Md.): Older adults are individuals that are also unique personally. Not every older person is the same, and that is extremely important. When you want to design primary or preventive services, you have to understand the unique differences between older adults that dictate what type of primary care are we planning to offer and what type of preventive health they should or should not be getting. 

A 75-year-old that is functional and cognitively intact, they're doing everything for themselves, has different primary and preventive care needs than a 75-year-old that has cognitive impairment, functional impairment, and is not able to do things for themselves. That dictates the strategy for primary and preventive care. 

Because older adults will have unique needs as they age, we follow a framework created by the Institute for Healthcare Improvement. It's called the 4Ms framework. This framework dictates the ability to assess what matters to them. That's the first M, matters. The second is mentation. How are they doing cognitively, and how are they doing from the mental health perspective? The third is an assessment of their medications, and the fourth is addressing their mobility. Part of our approach for primary care and preventive care is focused on implementing this framework.

Our decision to enhance the primary care and preventative care services for older adults started with the idea that we need to meet them where they are. We created the Centers for Successful Aging, which are designed for older adults with significant needs. These centers go beyond colonoscopies and mammograms to offer cognitive support, psychosocial support, mobility support, community support, that type of stuff. 

For the folks who are not able to come to see us at our primary care practices, we created home-based primary care services. We deploy physicians, nurse practitioners, social workers and nurses to the homes, and we play the role of their primary care physicians in their homes. 

But then we realized that there was a broad population of folks that we're not touching. We decided to implement a two-pronged community strategy:

Deploying providers to community and aging centers to give education about primary care and preventive care. 

Embedding providers into senior housings in Baltimore and Washington, D.C., where they work with the patients and residents on education about primary care and preventive health, as well as doing blood pressure screening, encouraging cholesterol checks, delivering vaccines and guiding them to the proper primary care.

We also embedded providers into nursing and retirement communities' wellness centers, where our providers become the primary care providers. It's all embedded into the wellness approach, and for the folks who are complicated and need more services beyond just the plain preventive health, we have our providers see them at nursing facilities or assisted living and deliver the same type of care.

Mark Sannes, MD. Chief Medical Officer of HealthPartners Care Group (Bloomington, Minn.): 

Our virtualist program in primary care creates more opportunities for patients to seek care by allowing them to be seen beyond an in-office setting. Our patients have options outside of an office setting, whether it's a real-time virtual visit with a clinician or sending messages to set up preventive screening recommendations. 

Our care team members identify preventive services and other risk factors through annual Medicare wellness exams, routine care and registry outreach. We offer same-day access for in-person and virtual visits.

Primary care virtualist programs provide direct, same-day access for patients and home care nurses, reducing the need for in-person visits and emergency department usage. 

Nurse practitioners and physicians in home-visit programs provide ongoing care for patients unable to go to a clinic. They also can support patients transitioning out of hospitals or transitional care units until they can go back to a clinic. 

E-consults give patients access to a specialty opinion without requiring an in-person visit. Video visits with a primary care clinician or virtualist save patients on travel time.

Patsy McNeil, MD. Executive Vice President and System Chief Medical Officer of Adventist HealthCare (Gaithersburg, Md.): Caring for older adults is an essential part of Adventist HealthCare's population health strategy and comprehensive system of care. Older adults have many factors that make it harder for them to access care and manage their health, including multiple chronic conditions and medications, transportation limitations, nutrition needs, insurance challenges and limited funds. A robust primary care and population health strategy are critical for this population. 

We participate in the Maryland Primary Care Program and a Medicare-based ACO Shared Savings Program, which center around older adults and form the core of our population health work. 

Within Adventist HealthCare's clinically integrated network, we also participate in other shared savings programs that focus on preventive care and chronic condition management. A team that includes nurse care navigators follows high-risk patients across different healthcare specialties and providers. The team is embedded in community-based primary care practices to coordinate care, provide education, manage multiple health conditions, and identify and mitigate risk factors that could lead to hospitalization or poor health management. These programs provide support to help vulnerable patients actively engage in their care.

Adventist HealthCare also offers a diabetes education program across its primary care practices, clinically integrated network and hospitals. Older adults can access diabetes nurse educators onsite and virtually, improving access to support and education to better manage diabetes. 

The health system is also piloting an advanced care planning platform to ensure patients' and families' end-of-life wishes are known by providers. 

In addition, Adventist HealthCare's robust Home Care and Home Assistance services ensure older adults have a safe environment, support to transition home from hospital care, help managing their conditions and assistance with daily tasks to maintain their quality of life.

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