IOM Recommends Full Coverage of Contraceptives, Other Reproductive Health Care Under Health Reform

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IOM Recommends Full Coverage of Contraceptives, Other Reproductive Health Care Under Health Reform

Jodi Jacobson

In a new--and much-anticipated--report, the Institute of Medicine recommends that health reform guidelines for preventive care to be developed by the HHS include no-copay for contraception and a wide range of preventive services.

All articles included in Rewire’s coverage of the IOM Report can be found here.

In a new–and much-anticipated–report, the Institute of Medicine (IOM) is recommending that health reform guidelines for preventive care to be developed by the U.S. Department of Health and Human Services (HHS) include a full range of reproductive health services, including all methods of contraception approved by the Food and Drug Administration (FDA) without a co-pay.  In developing these and other recommendations for women’s preventive health care, the IOM took into account the recommendations of medical bodies and of peer-reviewed studies demonstrating important health needs and outcomes.

Apart from coverage of contraceptive supplies, the IOM also breaks new ground with recommendations on inclusion of screening for gender-based and domestic violence, education, testing, and counseling for sexually transmitted infections, and inclusion of other essentials to a broader package of “well-woman” care as part of basic insurance coverage.

In total, the IOM report recommends inclusion of eight preventive health services for women at no cost under the Patient Protection and Affordable Care Act of 2010 (ACA). The ACA requires plans to cover the services listed in HHS’s comprehensive list of preventive services.  At the agency’s request, an IOM committee identified critical gaps in preventive services for women as well as measures that will further ensure women’s health and well-being.

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HHS has set its own self-imposed deadline of August 2nd for release of these final guidelines.

The IOM recommends that HHS including the following as part of standard preventive care guidelines for women:

  • 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 addition of high-risk human papillomavirus DNA testing in addition to conventional cytology testing in women with normal cytology results. Screening should begin at 30 years of age and should occur no more frequently than every 3 years.
  • Annual counseling on sexually transmitted infections for all sexually active women.
  • Counseling and screening for human immunodeficiency virus infection on an annual basis for sexually active women.
  • The full range of Food and Drug Administration-approved contraceptive methods,
    sterilization procedures, and patient education and counseling for all women with reproductive capacity.
  • Comprehensive lactation support and counseling and costs of renting breastfeeding equipment. A trained provider should provide counseling services to all pregnant women and to those in the postpartum period to ensure the successful initiation and duration of breastfeeding. (The ACA ensures that
    breastfeeding counseling is covered; however, the committee recognizes that interpretation of this varies.)
  • Screening and counseling for interpersonal and domestic violence. Screening and
    counseling involve elicitation of information from women and adolescents about current and past violence and abuse in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems.
  • At least one well-woman preventive care visit annually for adult women to obtain
    the recommended preventive services, including preconception and prenatal care. The committee also recognizes that several visits may be needed to obtain
    all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors.

The report asks HHS to strengthen some already-existing practices for women’s health care.  For example, it notes that while lactation counseling is already part of the HHS guidelines, the report recommends 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.

Likewise, the IOM notes that 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. 

And in regard to contraceptive coverage, the IOM report states:

To reduce the rate of unintended pregnancies, which accounted for almost half of pregnancies in the U.S. in 2001, the report urges that HHS 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.  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 raise their chances of health and developmental problems.

 The IOM also recommend that HHS should 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,” states the report. “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.”

The conclusions for the final report were drawn after a review by IOM of evidence and testimony from experts on the most critical public health problems particular to women.

The recommendations are based on a review of existing guidelines and an assessment of the evidence on the effectiveness of different preventive services.  The committee identified diseases and conditions that are more common or more serious in women than in men or for which women experience different outcomes or benefit from different interventions.

To develop the recommendations, the IOM convened a committee of experts to identify critical gaps in the preventive services already identified in the ACA, which are based on recommendations developed by three independent bodies: the United States Preventive Services Task Force, the American Academy of Pediatrics’ Bright Futures recommendations for adolescents, and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

As the report notes, “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, 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.

To put it all simply, the IOM did what medical professionals are supposed to do.  They looked at the hard evidence on what women need to be healthy and to make healthy choices for themselves, and for their families.  And they recommended health care guidelines be developed based on what would be the greatest good for the greatest number.

Moreover, IOM sees this as an ongoing process of promoting excellence in women’s health care, recommending regular review of the guidelines as new evidence is developed.

HHS’s guidelines on preventive health services for women will need to be updated routinely in light of new science.  As part of this process, HHS should establish a commission to recommend which services health plans should cover, the report says.  The commission should be separate from the groups that assess evidence of health services’ effectiveness, and it should consider cost-effectiveness analyses, evidence reviews, and other information to make coverage recommendations.

“This report provides a road map for improving the health and well-being of women,” said committee chair Linda Rosenstock, dean, School of Public Health, University of California, Los Angeles.  “The eight services we identified are necessary to support women’s optimal health and well-being.  Each recommendation stands on a foundation of evidence supporting its effectiveness.”

Based on previous positions on reproductive health care services in the health reform bill, reaction to the report’s recommendations, particularly on birth control and ongoing sexual health education and counseling for from groups like the United States Council on Catholic Bishops, the Family Research Council and other vehemently anti-choice groups is expected to be fiercely negative.  For these and other reasons, health and rights groups will likely be working hard between now and August 2nd to ensure that HHS includes these scientifically and medically sound recommendations in its policies for no-cost health care.

Tomorrow: Analysis of the reports recommendations for changing women’s health care.