VI. Conclusion

The experiences captured in this report depict the usage and integration of the USPSTF recommendations at the health plan level. Health plans consulted for this study have adopted, integrated, and delivered the USPSTF recommendations for clinical preventive services. They have also demonstrated substantial progress in the use of health IT tools, and quality improvement techniques to integrate recommendations for clinical preventive services. The unique perspectives of the respondents have highlighted the challenges and barriers to the integration and delivery of the Task Force recommendations and identified new ways to improve the utility and dissemination of the recommendations.

To assess our findings, we present our lessons learned. We then conclude by presenting specific ways for AHRQ to move forward given these findings and also suggest key areas for future study.

Lessons Learned

From the health plans' experiences, we compiled our key findings and lessons learned to inform the AHRQ Prevention Team; the USPSTF; researchers and policymakers; and health plan administrators, clinicians, and other implementers of clinical preventive health services recommendations. Our lessons learned are in four key areas. The first key area is the impact of health plan structures on the integration of the USPSTF recommendations. The remaining three areas focus on our study findings in relation to our three evaluation research questions, which have guided the development and direction of the study.

1. Health plan structures impact the integration and delivery of the USPSTF recommendations

Different health plan models were selected to explore whether health plan structure has an impact on the integration and delivery of the USPSTF recommendations. We found that health plan structure clearly impacts variables related to recommendation integration and delivery, including health information technology, quality improvement, adoption, and provider incentives.

• Health plan system structures are largely characterized by two key factors: 1) the health plan- provider relationship (e.g., are providers employees or contractors?); and 2) the centralization of the decision-making at the plan (e.g., does the plan have local/regional autonomy to make decisions or are decisions made at a centralized headquarters?). While not a structural issue, it is clear that a plan's corporate culture, values, and mission also affect its focus on prevention activities making it difficult to disentangle the influences on decisions related to integration of USPSTF recommendations in some instances.
• Highly centralized plans that also have direct control over providers, such as the closed-panel plan, have a strong ability to integrate the USPSTF recommendations via health information technology, whereas the opposite is true for more decentralized plans such as the open-panel plan.
• Plans with mixed-model structures like the hybrid plan are unique because they have features of both open and closed-panel health plans. Approximately half of the hybrid plan's members seek services from plan-affiliated, system-system employed providers; the remainder seeks services from contracted providers. The impact of this mixed-model structure on health IT is quite interesting as patient records and information are inconsistent and incomplete, making it difficult to integrate, deliver, and track the delivery of the USPSTF recommendations. Contracted providers, who provide services to members of multiple health plans, are provided access to, but often do not use, the EMR. The hybrid plan must employ aggressive patient outreach efforts which include phone calls and mass mailings.

2. Clinical preventive services, and specifically the USPSTF recommendations, are integrated into each of the health care plans

The USPSTF recommendations for clinical preventive services are being integrated into each of the four health plans, though the degree of integration varies across plans. While it is more difficult to ascertain the level of delivery at each of the plans, our conversations with respondents indicated that the perception is that many of the "A" and "B" recommendations are being delivered. The USPSTF recommendations play an important role in the process that health plans use to develop and adopt their own recommendations or policies for clinical preventive services; each health plan has its own unique process for adopting clinical preventive services recommendations from the USPSTF and other sources, which largely depends on the health plan's system structure.

• The majority of respondents were familiar with the USPSTF recommendations, although this familiarity ranged from having heard of the recommendations to actually working with the recommendations. Many of the respondents were unfamiliar with which clinical preventive services recommendations are "A" and "B" recommendations. Others did not recognize the USPSTF grading scheme at all.
• Health plans integrate the USPSTF recommendations into their plans in a number of ways. The USPSTF recommendations are: integrated in health plan provider manuals on clinical preventive services, performance measures, or other publications; integrated electronically using health information technology tools such as electronic medical records, clinical reminders, and order sets for clinicians; and incorporated into the plan's patient health education materials that are distributed to the member population. Health plans also engage in quality improvement activities to increase the appropriate delivery of the recommendations, and the majority of plans utilize their reimbursement structure to reward the delivery of clinical preventive services.

3. Health plans face common challenges with respect to the delivery of clinical preventive services

Health plans face a number of common challenges and barriers with regard to adopting, integrating, and delivering the USPSTF recommendations, and recommendations for clinical preventive services, more generally.

• Identified barriers include: time constraints; patient resistance; staff availability; availability of clinical preventive services in some practice settings; geographic barriers to care; IT barriers; process-related barriers; and difficulties associated with adopting and integrating counseling recommendations. These challenges are not due to fundamental issues with the Task Force recommendations, but rather the result of larger systems-level challenges that health plans face with respect to adopting and integrating clinical preventive services recommendations.
• Respondents indicated that certain types of recommendations are easier to adopt and integrate than others. Recommendations that are not associated with specific measures are more difficult to integrate and monitor in the plan's EMR.

4. AHRQ can contribute to the increased implementation of USPSTF recommendations within health plans

AHRQ could play a key role in improving the dissemination of the Task Force recommendations and methodology in a few key ways. First, AHRQ should focus on disseminating the Task Force recommendations to health plan staff. Second, AHRQ should disseminate more information about the Task Force's methodology for selecting and grading recommendations to health plan staff. While Clinical Advisors have a strong knowledge of the methodology used by the Task Force, Quality Improvement Staff across plans do not. Third, AHRQ could improve the dissemination of its line of tools and products that incorporate the USPSTF recommendations, such as the Put Prevention into Practice materials, the Electronic Preventive Services Selector, the pocket manual of recommendations, and email updates.

• Respondents requested that AHRQ provide health plans with new ways to improve integration of the USPSTF recommendations such as: clinical decision support tools for nurses administering Task Force counseling recommendations; patient level prevention tools; cost information about preventive services and programs recommended by the Task Force; and procedure codes or performance measures that coincide with Task Force recommendations.
• There was some agreement that the Task Force's prevention priorities are aligned with payer expectations and quality indicators. However, responses varied on the degree of alignment with these variables. Respondents across plans described that the prevention priorities are aligned moderately well HEDIS measures.
• Many respondents believe that the USPSTF's prevention priorities are not aligned well with consumer demand. Several reasons were cited, including that prevention and wellness are the last priorities for large purchasers of health care, and that consumers do not have adequate knowledge and tools to request the appropriate screenings from providers. Consumer education was highlighted as an important priority for AHRQ in the future.

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Next Steps for AHRQ

Given our key findings and lessons learned, NORC has prepared several recommendations for AHRQ, which are intended to help guide future endeavors with regard to the USPSTF recommendations. These recommendations are targeted to reduce barriers to the adoption, delivery, integration, and dissemination of the USPSTF recommendations in health plans. Our suggestions reflect the perspectives, ideas, and experiences of health plan respondents at the four participating plans:

Enhance the visibility of USPSTF and its recommendations.

In order to improve the adoption and integration of the USPSTF recommendations, AHRQ should take strides towards improving the visibility of both the USPSTF and its recommendations for clinical preventive services. We propose this recommendation for a variety of reasons. In response to the question, "How can AHRQ improve its dissemination of the Task Force recommendations to improve adoption rates at the systems-level," a number of respondents indicated that the USPSTF needs to improve its public visibility. Many respondents have heard of the USPSTF, but are not familiar with the recommendations. Others were not familiar with the USPSTF or its recommendations for clinical preventive services. A Director of Quality Improvement reinforced the importance of visibility: "The one thing I would say is I don't know anybody who's involved with [the USPSTF recommendations]. They're not a visible organization, and I think they ought to create dialogue and become more visible."

Improving the visibility of the USPSTF is particularly important for drawing the attention of physicians. We found that the health plans, with the exception of the open-panel plan, do not provide their physicians with the USPSTF recommendations. However, even in the case of the open-panel plan, it is unclear whether providers are consulting the USPSTF recommendations on their own. According to a Director of Health IT for the open-panel plan: "The health policy group does make reference to the Task Force for policy issues for preventive services. All the information is online, but it's passive. It isn't sent out to providers—it's there for their reference." One Clinical Advisor indicated that providers do not typically consult the USPSTF recommendations unless a recommendation becomes highly controversial. Several respondents also discussed the importance of "selling the USPSTF recommendations to clinicians."

Given these findings, we recommend that AHRQ take steps towards increasing the visibility of the USPSTF and its recommendations. One way to improve visibility is for AHRQ or the USPSTF members to participate on behalf of the USPSTF in professional conferences for providers. Clinical Advisors suggested that the USPSTF should consider participating in conferences that address clinical preventive services in order to improve the visibility of the recommendations amongst the larger audience of primary care physicians. USPSTF representation at conferences should not necessarily be limited to primary care focused conferences, as specialty care clinicians would also benefit from information about the USPSTF. Although the USPSTF currently participates in a limited number of professional conferences, such as the American College of Preventive Medicine and the American Academy of Family Physicians, the Task Force should consider participating in a larger, more diverse set of professional conferences to increase its visibility amongst providers. Some prime examples include the American College of Preventive Medicine national meeting and the Association of Teachers of Preventive Medicine annual meeting.

AHRQ should also consider presenting about the role of the USPSTF recommendations in promoting preventive health services at professional health research and policy conferences that yield a broader health care audience. Ideal venues would include the National Health Policy Conference, sponsored by AcademyHealth and Health Affairs, and the American Public Health Association's Annual Conference.

Another way to improve the USPSTF's visibility and also improve the dissemination of the recommendations was suggested by a Director of Quality Improvement at the hybrid plan. Namely, AHRQ could sponsor a membership organization for USPSTF users. Such a group would consist of health plan professionals across the country (e.g. Directors of Quality Improvement or other clinical preventive service staff) that utilize the USPSTF recommendations. A membership organization would foster a unique and productive opportunity for dialogue about the USPSTF recommendations. In addition to the membership organization, AHRQ could sponsor a USPSTF users conference to foster dialogue on important and timely issues related to clinical preventive services recommendations.

Next Steps for AHRQ

Create new USPSTF products and publicize existing ones.

Given respondents' desire to learn more about the methodology that the USPSTF uses to select and prioritize its recommendations, we propose that AHRQ develop a small brochure on methodology for distribution across health plans. As suggested by a Director of Quality Improvement, we recommend that AHRQ develop a pocket-sized brochure that presents a matrix of the "A" and "B" recommendations for certain subgroups of the populations, also taking into account other patient characteristics (e.g., recommendations for a male smoker within a certain age range).

Second, given that respondents were unfamiliar with the Put Prevention into Practice materials, such as the Electronic Interactive Preventive Services Selector, we propose that AHRQ further disseminate and publicize the availability of these tools and the opportunity to join the USPSTF listserv online.

Work more closely with health plan leadership.

Respondents recommended that AHRQ work more closely with their health plan leadership, such as the Medical Directors and Directors of Quality Improvement at the plans. Specifically, respondents suggested that AHRQ and the USPSTF develop collaborative relationships with their health plans, similar to the existing partnerships that plans form with other organizations that issue recommendations. For example, Quality Improvement Staff indicated that the hybrid plan partners with a state chapter of the American Academy of Pediatrics (AAP), consulting AAP when developing new prevention materials and education programs on practice change for immunizations. The hybrid plan also works closely with the American Cancer Society, partnering with the organization on an initiative to improve screening rates for colorectal cancer. Respondents suggested that it would be beneficial for AHRQ and the USPSTF to reach out to health plans about preventive health in similar ways. Clinical Advisors have stressed that clinical preventive services recommendations are integrated at the health plan leadership level. As a result, close collaboration with health plan leadership would improve the potential for the USPSTF recommendations to be consulted and potentially adopted into the health plan.

Educate consumers about the USPSTF recommendations and prevention.

Several respondents indicated the importance of educating consumers about the USPSTF recommendations. Our interviews demonstrated that health plan leadership is not aware of different strategies that AHRQ uses to disseminate its USPSTF tools and products to consumers. One Quality Improvement Director suggested that the USPSTF recommendations should be "marketed" to consumers - perhaps even though the television media. Clinical Advisors also indicated that a key goal should be to reach consumers about the USPSTF recommendations, similar to pharmaceutical campaigns. Another respondent suggested that USPSTF include its recommendations on popular web news services such as WebMD, which provides timely health information and tools for health management.

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Key Issues for Future Study

While the current study has elucidated important findings and lessons learned, we identify four key areas that merit further investigation to assist AHRQ in moving forward.

• The integration of the USPSTF recommendations in hybrid plans. The issue of integrating USPSTF recommendations into hybrid plans is particularly interesting given their unique characteristics and prevalence in today's health care market. Few plans today can be characterized as purely open-model or closed-model, making the issues and concerns faced by these plans an important area of study. The mixed-model nature of hybrid plans makes them an ideal study environment to learn more about the integration of the USPSTF recommendations. Future studies should explore whether the mixed-model structure underlying hybrid health plans offers unique incentives for providers to integrate and deliver the USPSTF recommendations for clinical preventive services.
• Use of hybrid plans as ideal study sites to investigate the impact of plan structure on the USPSTF recommendations. Hybrid plans function as a natural learning laboratory through which to study open and closed-model plan characteristics. Their mixed-model nature presents a unique opportunity to compare key health plan variables of open and closed-panel health plans while also controlling for systems-level differences. Therefore, hybrid plans are the ideal study sites to investigate the impact of plan structure on the USPSTF recommendations. Future research in hybrid plans has the potential to identify new directions and interventions to increase the integration and delivery of USPSTF recommendations across all types of health plans. Studies could compare the implementation and integration of the USPSTF recommendations in hybrid plans between plan-affiliated and contracted providers. Longitudinal studies that explore these research areas and others have the potential to unlock the impact of plan structure on the USPSTF recommendations. More broadly, as health plan structures continue to evolve, research focused on hybrid plans offers an opportunity to explore preventive service delivery within both traditional and emerging health plan structures.
• Health plan use of the USPSTF recommendations during times of change and controversy. Our findings suggest that health plans strategically consult the USPSTF recommendations during times of change (e.g. clinical preventive services recommendations are evolving for new diseases and conditions such as obesity) and controversy (e.g. new science merits the USPSTF and other organizations to abruptly revisit current recommendations for clinical preventive services). Given the small sample of this study, further research should explore whether health plans do, in fact, consult the USPSTF recommendations in a strategic manner. Furthermore, if this is the case on a larger scale, it would be beneficial for AHRQ to increase its dissemination and visibility of the USPSTF recommendations during climates of change and controversy to improve their potential for adoption and delivery in health plans.
• Competing recommendations for clinical preventive services. The USPSTF recommendations represent an important resource for health plans that develop their own clinical preventive services recommendations. However, the USPSTF recommendations are clearly only one of many resources consulted by the plans. The question is why? Our study only begins to explore why some health plans are partial to the recommendations of other professional organizations and societies for certain clinical conditions. Additional work may be required to understand, for example, why the hybrid plan utilizes recommendations from the American Cancer Society rather than the USPSTF for its clinical preventive services related to cancer. Or, alternatively, why other health plans reference a handful of specialty societies or professional organizations for certain clinical preventive services recommendations rather than simply utilizing the USPSTF recommendations. Is it because health plans believe that recommendations from specialty organizations and professional societies are easier to "sell" to providers? Further research will be necessary to understand why competing recommendations from specialty organizations are referenced for certain types of clinical services, and whether there are trends across different types of health plans.
• Why are certain "A" and "B" USPSTF recommendations consulted more than others? Our research suggests that while some of the "A" and "B" recommendations are referenced by health plans, there are a variety of others that are not (e.g., screenings for visual impairment in children younger than age 5 years, lipid disorders, obesity in adults, Rh (D) incompatibility, gonorrhea, hepatitis B virus infection, and HIV). Why are these "A" and "B" USPSTF recommendations rarely consulted? We propose the development of a detailed matrix of the four health plans' clinical preventive services recommendations. By obtaining complete listings of all of the clinical preventive services recommendations for the open-panel plan, closed-panel plan, hybrid plan, and governmental plan, and identifying the roots of the recommendations (e.g., the USPSTF, American Cancer Society, etc.), we will be able to uncover important trends across plans. Additionally, conducting a small number of followup interviews with the plans to discuss the trends will help AHRQ to better understand why the "A" and "B" USPSTF recommendations are being implemented for certain clinical conditions and not others. This research will assist AHRQ in improving the dissemination of USPSTF tools, information, and products to health plans.
• The functions of a USPSTF membership organization for health plans. This study confirmed the importance of increasing the visibility of the USPSTF and its recommendations. One respondent suggested that AHRQ could sponsor a USPSTF "user group," consisting of health plan professionals across the country (e.g., Directors of Quality Improvement or other clinical preventive service staff) that utilize the USPSTF recommendations. While our study identifies the importance of establishing a membership organization that would foster a regular dialogue about the USPSTF recommendations amongst health plan staff, it is crucial to consider a few questions: (1) how would the user group be structured?; (2) who would participate from health plans?; (3) would AHRQ be the appropriate administrator of the user group, or would such an endeavor be better operated by an outside organization?; (4) what types of issues would the group discuss?; and (5) will a user group facilitate improvements in the dissemination and delivery of the USPSTF recommendations in health plans? Further study would explore these questions in order to better guide the development of a membership organization for the USPSTF recommendations.

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