The Institute of Medicine’s suggestion that contraceptives be covered by insurers raised hackles this summer. However, Repertoire readers were paying more attention to the other details of the IOM’s report, many of which could signal more sales of diagnostic and therapeutic products to their OB/GYN customers.


In mid-July, the IOM 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, that is, the healthcare reform law. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine is responsible for providing independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. 


IOM’s report followed by three months an updated schedule of the American Congress of Obstetricians and Gynecologists’ recommended routine screenings, lab tests, and immunizations for non-pregnant adolescents and women


‘Critical gaps’ cited


Last year, the federal government issued interim final regulations regarding preventive services that new insurance plans and issuers must cover without cost-sharing by enrollees when delivered by in-network providers. (See September 2010 Repertoire.) It’s a long list, but some of the services are targeted specifically at women. They include screening for breast cancer (mammography) every one to two years for women aged 40 and older; screening for osteoporosis among women aged 60 and older who are at increased risk for osteoporotic fractures; screening for cholesterol abnormalities in women who are at increased risk for coronary heart disease; screening for chlamydial infection in sexually active, non-pregnant women aged 24 and younger, and for older non-pregnant women who are at increased risk; and screening for gonorrhea among sexually active women, if they are at increased risk of infection.


But this summer, following a request from the Department of Health and Human Services, the IOM identified what it called “critical gaps in preventive services for women as well as measures that will further ensure women’s health and well-being.” In addition to the contraceptive methods and counseling, they include:

  • Yearly well-woman preventive care visits to obtain recommended preventive 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.
  • Lactation counseling and equipment to promote breast-feeding.
  • Screening and counseling to detect and prevent interpersonal and domestic violence.


The IOM committee justified its recommendations because of its members’ concerns that gaps exist in the current guidelines on preventive services. “Women suffer disproportionate rates of chronic disease and disability from some conditions,” it said in its recommendations. “Because they need to use more preventive care than men on average due to reproductive and gender-specific conditions, they face higher out-of-pocket costs.”


For sexually active women, the committee found that current recommendations of screening for cervical cancer, counseling for sexually transmitted infections, and HIV counseling and screening were too limited in scope and should be expanded


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, the IOM concluded. 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 IOM report recommends 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, according to the IOM. 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 United States has the highest rate of gestational diabetes in the world, according to IOM. 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 who require delivery by cesarean section and have health problems after birth. Hence the IOM’s recommendation that screening for gestational diabetes be performed among 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. 


Guidelines on preventive health services for women need to be updated routinely in light of new science, according to the IOM. As part of this process, IOM called for HHS to establish a commission to recommend which services health plans should cover. 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, the IOM concluded.


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