Cancer Prevention and Early Detection: An Employer Perspective March 1, 2007 Center for Prevention and Health Services National Business Group on Health • Founded in 1974, formerly the Washington Business Group on Health • Non-profit membership organization of large public and private employers • 264 members; half of Fortune 500 • Members also include health plans, healthcare consultants, and healthcare industry companies Background • The Business Group develops information, education, and policy guidance for large employers on a wide range of healthcare topics • Products designed for corporate medical directors, benefit managers, employee assistance personnel, and wellness directors • Partner with federal agencies (AHRQ, CDC, MCHB, SAMHSA, etc) Employers as Purchasers • Employers provide coverage for 160 million Americans.1 • Employers play a unique role in shaping healthcare • Purchase healthcare services (e.g., health plan) • Develop healthcare programs (e.g. health promotion / EAP) • Implement health-related policies (e.g., smoking ban) Employers as Drivers of Healthcare • Benefit structures drive utilization – – – – Included versus excluded services Administrative hoops Network providers Other barriers • Cost-sharing can enhance or limit access – 100% coverage for preventive care – Tiered formularies Economic Burden of Cancer • Economic burden is substantial – Direct medical costs are high – Lost productivity is substantial – Disability is common and of long duration • In 2005, the overall cost for all types of cancer was estimated to be $210 billion.2 • Cancer patients = 1.6% of the commercially insured population but account for 10% of employers’ medical claims costs.3 Indirect Costs Disability • Cancer is the second leading cause of long-term disability and the sixth leading cause of short-term disability claims in the U.S.4 • In a recall study, patients with cancer reported 10.9 days of impairment (during one month of illness) –nearly double the days of impairment reported for any other chronic condition.5 Lost Productivity and Absenteeism • Cancer is responsible for $136 billion in lost productivity annually.6 • Smoking costs an estimated $92 billion per year in lost productivity.7 – Lost productivity due to smoking and smoking related illnesses cost employers $1,897 per smoking employee per year (2002 dollars). Overlooking Prevention • Purchasers have been ―treatment-oriented‖ in the past – Limited access to prevention – Higher out-of-pocket costs (proportionally) for preventive services – Excessive restrictions Coverage of Preventive Services • Cancer screening coverage rates among large employers are relatively high in comparison to other preventive services8: – – – – Breast: 95% Cervical: 92% Colorectal: 79% Any type of tobacco cessation service: 31% / Comprehensive coverage: 4% • Unknowns – How many employers cover ―new‖ cancer prevention/control services such as tamoxifen therapy or genetic testing – How many employers provide comprehensive coverage based on evidence Economic Benefit of Cancer Prevention / Early Detection • • • • • • Improves beneficiary health Averts direct medical costs Reduces lost productivity Reduces disability Reduces employee turnover Reduces excess medical costs from related conditions, complications, or sequelae The Purchaser’s Guide Purchaser’s Guide • Developed collaboratively by the Business Group and CDC (TA: AHRQ) – Multi-disciplinary group of scientists, physicians, and program experts • Released Nov 2006 • Purpose: – Promote preventive medical benefits that are based on evidence – Provide information needed to select, define, prioritize, and implement preventive medical benefits Components • 7 part reference book • Overview of prevention and preventive services • Specific and detailed summary plan description (SPD) language to guide benefit design, negotiation, and implementation • Recommendations on what clinical preventive services employers should cover and how to prioritize expansion in a strategic implementation plan • Information on leveraging benefits through communitybased services and education • Benchmarking data Summary Plan Description (SPD) Language Breast Cancer: Normal Risk • Screening – Mammography and CBE for average risk women aged 40 to 80 once per calendar year. Younger women may qualify for screening if medically indicated. Breast Cancer: High-Risk • • • • Counseling on Testing & Preventive Medication and Preventive Treatment – Counseling provided as medically indicated and at least once before and once after a BRCA mutation test BRCA Mutation Testing – Once per lifetime Preventive Treatment – Surgical removal of the breast(s) with or without reconstructive surgery – Surgical removal of the ovaries Preventive Medication – All FDA-approved breast cancer preventive medications (e.g., tamoxifen) for 5 years - may be extended if medically necessary Current Procedural Terminology (CPT) Codes Forms of Evidence Used in the Purchaser’s Guide • U.S. Preventive Service Task Force (USPSTF) recommendations • CDC • Other U.S. Department of Health and Human Services – U.S. Public Health Service – U.S. Surgeon General – National Heart, Lung, and Blood Institute (NHLBI) • Professional organizations – American Academy of Pediatrics (AAP) – American Academy of Family Physicians (AAFP) – Many others • Respected associations Evidence-Statements for Recommended Clinical Preventive Service Benefits • Provides screening, counseling, testing, immunization, preventive medication, preventive treatment recommendations – 72 clinical preventive services in 46 topic areas; 10 specific to cancer prevention / early detection and tobacco cessation • Recommendation statement • Condition / disease specific information – Epidemiology – Risk factors Evidence-Statements for Recommended Clinical Preventive Service Benefits • Value of prevention – – – – Economic burden Workplace burden Economic benefit of preventive intervention Estimated cost of preventive intervention • 2004 paid claims average from the Medstat Marketscan database (commercially insured population) – Cost-effectiveness / cost-benefit Specific Example: Breast Cancer • Breast cancer accounts for ¼ of all cancer-related healthcare costs which totaled $190 billion in 2004. • Working age women (40-64) accounted for 61% of in situ and 54% of invasive breast cancer cases and 40% of breast cancer deaths in 2005. • Screening may reduce costs by identifying tumors in their earliest stages went treatment is more successful and less expensive. • 2002 terminal care cost for breast cancer (Medicare) = $63,455 • 2004 average private-sector prevention costs: – – – – Screening mammography = $51 BRCA mutation testing =$53 Genetic counseling = $39 per session AWP of a 1-month supply of tamoxifen ranged from $58 (generic to $128 (brand) Evidence-Statements for Recommended Clinical Preventive Service Benefits • Preventive intervention information – – – – – Purpose Process Benefits and risks of intervention Population, initiation/cessation, frequency of benefit Treatment information Value of the Purchaser’s Guide • Closes the gap between knowledge and practice • ―Plug and Play‖ ease of use – Appropriate for different organizations, workforces, priorities, and resources – Precise SPD language and codes – Up-to-date cost, cost-effectiveness, and ROI estimates • Trustworthy: – Authoritative sources – Evidence based: What works and what doesn’t work • Will have a dramatic benefit for employees and their families Other Strategies • Cancer prevention at the worksite – Mobile mammography units – Health education – Time off for ―check-ups‖ • 100% first-dollar coverage for preventive services – 62% of large employers offer HDHPs- approx 80% of who reduce/eliminate fees for preventive care • Premium credits/fees for smokers – Non-discrimination laws Free Access PDFs and preventive services search engine: www.businessgrouphealth.org/prevention/purchasers For more information, contact: Kathryn Phillips Campbell, MPH Phone (direct): 202-585-1800 E-mail: PhillipsCampbell@businessgrouphealth.org References 1 Kaiser Family Foundation. Health Education Research Trust. Employer health benefit study 2005. Summary of results. Menlo, CA: Kaiser Family Foundation; 2006. 2 National Heart. Lung, and Blood Institute. Fact Book 2004. Washington, DC: National Health, Lung, and Blood Institute; 2004. 3 Pyenson B, Zenner PA. Milliman, INC. Cancer Screening: Payer Cost / Benefit thru Employee Benefits Programs. Commissioned by C-Change and the American Cancer Society; 2005. 4 Leopold RS. A Year in the Life of A Million American Workers. New York, New York; Moore Wallace, Met Life Group Disability: 2003. 5 Kessler RC, Greenberg PE, Mickelson LM, Wang PS. The effects of chronic medical conditions on work loss and work cutback. Journal of Occupational and Environmental Medicine 2004 43(3):218-225. 6 American Cancer Society. Cancer Facts & Figures. American Cancer Society; 2005. 7 Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1997–2001. MMWR 2005; 54(25); 625-628. 8 Bondi MA, Harris JR, Atkins D, French ME, Umland B. Employer coverage of clinical preventive services in the United States. American Journal of Health Promotion 2006; 20(3): 214-222.