The Affordable Care Act requires that high-value preventive services recommended by the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP) and the Health Resources Services Agency (HRSA) are available to health plan members with no cost sharing. This includes general preventive services (USPSTF), vaccinations (ACIP) and services for women’s health (HRSA). This is a core precept of value-based insurance design, where member cost share should be lower for high-value services, and higher for low-value services.
But we all know that many with insurance still end up paying for preventive care in many cases! For example, women getting oral contraceptives might find that their pharmacy benefit manager imposes a fee for not using mail-order pharmacies. Cost sharing is sometimes improperly applied to screening tests that should be fully covered.
Research published in JAMA Network Open showed that those who had lower income, lower educational level, or were part of minoritized groups were statistically significantly more likely to face denials of claims for preventive services. The researchers reviewed four years of data from about 1.5 million people who received 4.2 million preventive services, including contraception, breast and colon cancer screening, diabetes and cholesterol screening and wellness visits. Their database used self-identified race and ethnicity obtained from medical records, voter registration and other publicly available sources. They followed each denial through any appeals and resubmissions.
They found that about 1.34% of total preventive services were denied overall. The three most commonly denied services were diabetes screening (3.1%), depression screening (2.8%) and contraceptive care (1.1%). Benefit denials and billing errors represented most of the denials for all services and all subgroups.
This analysis didn’t include some procedures that are unequivocally preventive, but where billing rules mean that insurers aren’t required to provide coverage without out-of-pocket costs. The researchers removed these services based on billing codes. This includes colonoscopies, which are considered “diagnostic” for those with previous colon polyps or colon cancer, and mammograms, which are considered diagnostic in women with a history of breast cancer. Therefore, this analysis understates the portion of those with insurance who face out-of-pocket costs for preventive services.
The Centers for Disease Control and Prevention reported that overdose deaths have declined about 10% between April, 2023 and April, 2024. Overdose deaths are still about at the 2021 rate and remain over 40% higher than the rate of deaths in 2019. This study is adjusted for delayed reporting.
Higher death rates from opioid use disorder in the early 2020s were driven almost entirely by synthetic opioids, mostly fentanyl. While these opioids are very useful for severe pain in a medical setting, they can be deadly, even in tiny doses. The illicit drug supply has been contaminated with fentanyl, and some people have died of respiratory depression while having no idea that the drug they were using contained fentanyl.
This decrease could be due to more effective enforcement of laws preventing the importation of fentanyl. The Drug Enforcement Administration reports that fentanyl seizures increased by a factor of three from 2021 to 2023. This decrease is likely because more people can get naloxone (Narcan) through a nasal spray. Most first responders now carry this spray and some workplace first aid kits have it. California just passed a bill that will require naloxone in workplace first aid kits by 2028. I carry naloxone in my backpack in case I meet someone who’s unexpectedly unresponsive and not breathing; I got it for free at our local library. People who have health plans from their employers can usually get naloxone covered by their insurance. The drug costs less than $50 for two packs without a prescription.
The pancreas controls blood glucose (sugar) levels carefully. People with diabetes need to watch their blood glucose and change their insulin dose to keep their blood sugar in a healthy range. Recently, people with diabetes have been able to automate insulin delivery by using a combination of a continuous glucose monitor and an algorithm that instructs a connected pump to deliver just the right dose of insulin to keep blood glucose under good control. This is especially helpful for young people with Type 1 diabetes and decreases their need to draw blood from their fingers and administer insulin injections.
Researchers published a report in New England Journal Evidence showing just how much better diabetes control was for patients between ages seven and 25. HbA1C results and average blood sugar readings were vastly improved. Those with automated insulin delivery, on average, had eight hours more each day of their blood sugar in the target range. Better blood sugar control is associated with lower future risk of cardiovascular disease, kidney disease, eye disease, disability and death.
This was a randomized trial, although the size was relatively small (80 patients), 37 of whom got the intervention. The control group had three serious diabetes-related complications (two cases of ketoacidosis where blood sugar was too high, and one case of hypoglycemia where the blood sugar was too low). There were no severe adverse outcomes in the intervention group.
Two recent studies in JAMA Internal Medicine show that GLP-1 medications such as Ozempic, Monjouro, Wegovy and Zepbound aren’t likely to lead to increased depression or suicidality. These add to a large observational study reported in January that showed those on these drugs for obesity had lower rates of suicidal ideation and suicide than those on other obesity medications. However, these new studies are stronger because one was a randomized clinical trial and the other included full national registries of medication use, medical care and death.
The first study followed over 2,000 patients treated with the highest recommended dose of Wegovy for between 17 and 24 months, and found that their PHQ-9 scores, a standard way to assess depression, were statistically significantly better than those of patients treated with placebo.
The second study retrospectively reviewed 72,420 patients with no history of psychiatric disease who were started on GLP-1 medications for diabetes between 2013 and 2021 in Sweden and Denmark. The researchers found that suicide rates and incidents of self-harm weren’t higher than the general population. About half of the patients in this study were on liraglutide (Saxenda or Victoza), an earlier daily GLP-1 medication which leads to less weight loss than semaglutide and tirzepatide, which are now much more commonly used for obesity.
In both cases, patients with preexisting mental illness were excluded, so these studies can’t rule out worsening of existing mental health problems from this class of drugs.
Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.
Plan redesign outweighs cost-shifting to reduce the cost of care, WTW survey finds
