Covid-19 and the Mandate to Redefine Preventive Care | NEJM - nejm.org

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As the U.S. health care system defines the new normal for ambulatory care in the Covid-19 era, it needs a new approach to providing routine preventive care for adults. Concerns about contagion, competing demands, and shortages of personal protective equipment may limit preventive care visits — most commonly the “routine annual exam” and the Medicare Annual Wellness Visit. But given that routine physical examinations have been shown to have limited clinical value, we believe health care organizations should take this opportunity to advance alternative systems for promoting evidence-based prevention.^1,2 Failure to do so will sustain or worsen the long-standing disparities in health that have been underscored by the pandemic.

Before Covid-19, many primary care clinicians believed that annual exams did not optimally make use of their skills. The visit often became an exercise in checking off regulatory boxes, performing a head-to-toe physical exam for which there is no evidence of benefit, and ordering “routine” lab tests, many of which also lack supporting evidence. Yet many clinicians value these exams as a time for establishing or maintaining relationships with patients and reviewing the results of and rationale for key preventive screening tests recommended (with a grade A or B) by the U.S. Preventive Services Task Force (USPSTF) — a list that is 25 items long and growing.

There are troubling disparities, however, in use of these evidence-based preventive services according to race, ethnicity, and socioeconomic status.³ Since use of annual exams is more common among White people than Black people and increases with household income, such exams won’t help address disparities in the delivery of preventive services.⁴ So we are faced with a long and growing list of evidence-based preventive services to deliver to a broad population but a low-efficiency, low-efficacy mechanism for doing so. And the pandemic has revealed the clear and pressing need for a revamped approach.

We believe the U.S. health care system should embrace this moment as an opportunity to shift the locus of preventive care from face-to-face annual exams to a strategy that focuses on population health: clinical registries that readily identify all preventive services for which a patient is due; annual prevention kits for patients that facilitate widespread deployment of home-based testing, shared decision making, and self-scheduling of preventive screening tests and procedures in more convenient and approachable community settings; and robust community-based strategies involving navigators to overcome health disparities in underserved populations.

The first step in this strategy is developing a robust, real-time clinical preventive care registry that allows tracking of care needs asynchronously from visits. At our institution, we have deployed a comprehensive registry that tracks all USPSTF grade A and B preventive services and their completion status for our approximately 250,000 primary care patients in eastern Massachusetts, including people who receive care at three community health centers in low-income neighborhoods. The registry is fully integrated into our electronic health records (EHRs) and has robust communication tools for patient outreach. Although many health systems and EHR vendors have established registry functionality, there is a pressing need for “smarter” registries that are interoperable across diverse health care settings, regardless of EHR vendor, and that can analyze utilization patterns, health conditions, and demographics to help link patients to the best prevention approach for them. These registries could also become shared, interactive tools for use by both clinicians and patients to facilitate preventive care.

The second step is to build the infrastructure for an annual “prevention kit” received by every patient. The kit should consist of a language-appropriate, culturally sensitive package that addresses all indicated USPSTF grade A and B preventive services as indicated by the clinical prevention registry. Point-of-care tests should be included to allow preventive care to happen from patients’ homes; these could include fecal immunochemical testing, glycated hemoglobin and lipid testing, and perhaps soon, self-sampling of human papilloma virus for cervical cancer screening. QR code links to standardized electronic questionnaires should be included for depression screening, tobacco and alcohol use, and personalized risk assessment for common conditions such as breast cancer and cardiovascular disease. Shared-decision-making materials for lung cancer screening, breast cancer screening intervals, and highly controversial topics such as prostate cancer screening are well studied and easily deployed.⁵ Self-scheduling instructions for all recommended procedures and imaging studies should be provided.

After receiving the prevention kit, patients could be invited to schedule a virtual encounter with their primary care provider to review recommendations, engage in shared decision making on nuanced topics such as when to start or stop each type of screening, discuss any findings that may be of concern, and plan necessary interventions. Immunizations and other high-value preventive care that cannot be delivered at home could be addressed during in-person patient visits or at dedicated immunization clinics, rather than during dedicated annual exams.

The third step is to create specific programs to address the known disparities in preventive care within a given population. There is a rich body of literature supporting the effectiveness of community-based patient navigators in closing gaps in cancer-screening rates affecting underserved patients.³ These navigators facilitate patients’ preventive care by using proactive outreach and motivational interviewing and by accompanying patients to procedures such as colonoscopies. Navigators are also well suited to systematically screening for and facilitating access to community-based resources for addressing social determinants of health. In addition, they can connect patients with community-based campaigns to promote prevention, such as screening vans. Though navigation programs cannot eliminate key social determinants of poor health, such as poverty, educational barriers, food insecurity, and racism, they can help make access to evidence-based preventive services more equitable.

The primary hurdles for implementation of our plan are payment reform and provider and patient acceptance. For a population-based prevention strategy to succeed, the health system needs to offer prospective payment for primary care with accountability for overall completion of evidence-based preventive care throughout a population and a demonstrable commitment to addressing disparities in preventive care. Services provided by patient navigators are not billable on any payer’s fee schedule and will not generate substantial fee-for-service revenue, since navigators may interact with only a small proportion of a health system’s patients. There is no reimbursable Current Procedural Terminology (CPT) code for a preventive care kit or shared-decision-making materials.

Health care centers that disproportionately provide care for disadvantaged populations may face additional barriers to implementing a population-based approach to prevention, since they may have more limited infrastructure and resources, particularly now that the dramatic drop in visit volume during the pandemic has left many safety-net providers in financial crisis. Payment reform should be prioritized to allow these sites to move away from visit-based payments and facilitate innovative community-based prevention programs. Perhaps the Centers for Medicare and Medicaid Services could offer such centers one-time incentive payments to facilitate investment in population health technology.

Gaining clinician and patient acceptance of a new model is a second hurdle. But a potential positive outcome of the current pandemic is that patients may demand a care system that is more comprehensive and accessible, promotes equity, and facilitates their engagement in preventive care from the comfort of their home or community. Providers will face a backlog of patients in need of management of acute and chronic health conditions and will realize that care has to be provided more efficiently and effectively. Both patients and clinicians will have discovered virtual visits’ potential for discussion and counseling. If we move to more sophisticated systems that can deliver convenient, personalized home-based testing strategies to patients, engage patients in their own care, and deploy evidence-based programs to ensure equitable access to preventive services, we believe our population’s health will be improved.

A large-scale shift to a population-based prevention strategy is long overdue. The Covid-19 pandemic is delaying life-saving preventive screening for millions of patients, and our health system will struggle to catch up. Perhaps this crisis will be the impetus for change.

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