Clinical Preventive Services for Women: Closing the Gaps
Testimony provided by the Institute of Medicine
Committee on Preventive Services for Women
Linda Rosenstock, MD, MPH
Dean, School of Public Health
University of California at Los Angeles
Chair, Committee on Preventive Services for Women
Board on Population Health and Public Health Practice
Institute of Medicine
The National Academies
Committee on the Judiciary
U.S. House of Representatives
February 28, 2012
My name is Dr. Linda Rosenstock. I am the Dean of the School of Public Health at the University of California, Los Angeles. I also served as chair of the Institute of Medicine’s Committee on Preventive Services for Women. The Institute of Medicine, or IOM, is the health arm of the National Academy of Sciences, an independent, nonprofit organization that provides unbiased and authoritative advice to decision makers and the public.
At the request of the U.S. Department of Health and Human Services' Assistant Secretary for Planning and Evaluation, the IOM assembled a diverse, expert committee to identify critical gaps in preventive services for women as well as recommend measures that will further ensure women's health and well-being.
The committee gathered evidence, deliberated on its findings and recommendations, and met five times in a six-month time period in order to write its report, Clinical Preventive Services for Women: Closing the Gaps. This report underwent a rigorous, independent external review prior to its release in July of last year. The Committee recommended that eight preventive health services for women be added to the services that health plans cover at no cost to patients under the Patient Protection and Affordable Care Act of 2010, commonly known as the ACA. The ACA requires plans to cover the services listed in the comprehensive list of preventive services at www.healthcare.gov.
The committee defined preventive health services as measures— including medications, procedures, devices, tests, education and counseling— shown to improve well-being, and/or decrease the likelihood or delay the onset of a targeted disease or condition. To guide its deliberations in determining gaps in preventive services not included in existing guidelines, the committee developed four overarching questions:
- Are high-quality systematic evidence reviews available which indicate that the service is effective in women?
- Are quality peer-reviewed studies available demonstrating effectiveness of the service in women?
- Has the measure been identified as a federal priority to address in women’s preventive services?
- Are there existing federal, state, or international practices, professional guidelines, or federal reimbursement policies that support the use of the measure?
Preventive measures recommended by the IOM committee for preventive coverage consideration met the following criteria:
- The condition to be prevented affects a broad population;
- The condition to be prevented has a large potential impact on health and well-being; and
- The quality and strength of the evidence is supportive.
The committee took seriously its task of focusing on women’s unique health needs. Women are consistently more likely than men to report a wide range of cost-related barriers to receiving or delaying medical tests and treatments and to filling prescriptions for themselves and their families. Studies have also shown that even moderate copayments for preventive services such as mammograms and Pap smears deter patients from receiving those services.
Throughout the study process, the committee repeatedly questioned whether the disease or condition was significant to women and, especially, whether it was more common or more serious in women than in men or whether women experienced different outcomes or benefited from different interventions than men.
The report suggested the following additional services:
- screening for gestational diabetes
- human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
- counseling on sexually transmitted infections
- counseling and screening for HIV
- contraceptive methods and counseling to prevent unintended pregnancies
- lactation counseling and equipment to promote breast-feeding
- screening and counseling to detect and prevent interpersonal and domestic violence
- yearly well-woman preventive care visits to obtain recommended preventive services
Examples of why these services are crucial in supporting women's optimal health and well-being are listed below.
Deaths from cervical cancer could be reduced by adding DNA testing for HPV, the virus that can cause this form of cancer, to the Pap smears that are part of the current guidelines for women's preventive services. Cervical cancer can be prevented through vaccination, screening, and treatment of precancerous lesions and HPV testing increases the chances of identifying women at risk.
Although lactation counseling is already part of the HHS guidelines, the report recommended comprehensive support that includes coverage of breast pump rental fees as well as counseling by trained providers to help women initiate and continue breast-feeding. Evidence links breast-feeding to lower risk for breast and ovarian cancers; it also reduces children's risk for sudden infant death syndrome, asthma, gastrointestinal infections, respiratory diseases, leukemia, ear infections, obesity, and Type 2 diabetes.
The report recommended that HHS consider screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes. The United States has the highest rates of gestational diabetes in the world; it complicates as many as 10 percent of U.S. pregnancies each year. Women with gestational diabetes face a 7.5-fold increased risk for the development of Type 2 diabetes after delivery and are more likely to have infants that require delivery by cesarean section and have health problems after birth.
To reduce the rate of unintended pregnancies, which accounted for almost half of pregnancies in the U.S. in 2001, the report urged HHS to consider adding the full range of Food and Drug Administration-approved contraceptive methods as well as patient education and counseling for all women with reproductive capacity.
Unintended pregnancy is linked to a host of health problems. Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy. Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which increase their chances of health and developmental problems.
Family planning services are preventive services that enable women and couples to avoid an unwanted pregnancy and to space their pregnancies to promote optimal birth outcomes. Pregnancy spacing is a priority for women’s health because of the increased risk of adverse pregnancy outcomes for pregnancies that are too closely spaced (within 18 months of a prior pregnancy). A wide array of safe and highly effective FDA-approved methods of contraception is available. This range of methods provides options for women depending upon their life stage, sexual practices, and health status.
The committee noted that contraceptive coverage has become routine for most private insurance and federally funded insurance programs. Additionally, federal goals included in Healthy People 2010 and later in Healthy People 2020 strive to reduce the number of unintended pregnancies.
The report addressed concerns that the current guidelines on preventive services contain gaps when it comes to women's needs. Women suffer disproportionate rates of chronic disease and disability from some conditions. Because they need to use more preventive care than men on average due to reproductive and gender-specific conditions, women face higher out-of-pocket costs.
Positioning preventive care as the foundation of the U.S. healthcare system is critical to ensuring Americans’ health and well-being. This is a shift from an historically reactive system that primarily responds to acute problems and urgent needs to one that helps foster optimal health and well-being.
Thank you very much for the opportunity to submit this testimony.