Q&A: HRSA updates preventive care guidelines for women, kids

Updates to the Affordable Care Act preventive health care guidelines will require coverage of certain screening and preventive measures for women and children, HHS said.

The new guidelines for women will require coverage without cost-sharing for specific breast pumps and obesity prevention in certain women.

In addition, the ACA’s preventive care and screenings for children includes updates regarding universal screening for suicide risk among those aged 12 to 21 years and new guidance for behavioral, social and emotional screening for children of all ages.

The guidelines, which are developed by an expert committee, become official when accepted by HHS’s Health Resources & Services Administration, or HRSA, according to an HHS press release. Starting in 2023, the ACA stipulates that certain group health plans and insurance issuers cover these services with no out-of-pocket cost for the recipient.

Michael D. Warren, MD, MPH, FAAP, the associate administrator of the maternal and child health bureau within HRSA, said the guidelines offer “an important opportunity to think about prevention.”

“We often think about taking care of people once they are sick or once they have a chronic disease and trying to mitigate the consequences of that chronic disease,” he told Healio. “But there is real value in prevention, and in particular, preventing those bad outcomes from ever occurring in the first place.”

The complete updated guidelines for women will be published in several journals this year, and the complete updated guidelines for children will be posted on the AAP’s website in the spring, an HRSA spokesperson said.

In the meantime, Healio asked Warren to discuss more pivotal updates from each guideline.

Healio: What are the most important guideline updates that primary care physicians should be aware of regarding the ACA’s preventive health care guidelines for women?

Warren: There are a few updates that I think are particularly noteworthy in this year's updates to the women's preventive services. In the area of breastfeeding, the recommendation, for the first time, includes coverage for a double-electric breast pump. Importantly, the provision of that pump cannot be conditioned on having failed with a manual pump prior to that. The breastfeeding recommendation also specifies that clinicians as well as peer support service providers can provide breastfeeding education.

The recommendation also removes the term “female-controlled contraceptives” that was previously in the recommendation. This was done to remove barriers for accessing both male- and female-controlled condoms, because both of those are preventive contraception methods that impact women’s health.

There is also an update that recommends HIV infection counseling and screening begin in those aged 15 years and older. This recommendation now aligns with other recommendations like the U.S. Preventive Services Task Force and the American Academy of Pediatrics and will reduce confusion about different ages and different sets of recommendations.

The last thing I would add is that there is a new recommendation for obesity counseling, saying that primary care providers should provide counseling to women aged 40 to 60 who are either at a normal weight or overweight when you look at BMI. The counseling would be to maintain weight or to limit weight gain in order to prevent obesity.

Healio: Once the guidelines are implemented, how will eligible patients obtain breastfeeding equipment without paying out‐of‐pocket costs?

Warren: Within the Affordable Care Act, there are provisions that require certain health insurance coverage plans to provide these recommended preventive services without cost sharing. So, at no cost to the patient, beginning 1 year after these recommendations are issued, the requirements for coverage will be in place for the breastfeeding equipment.

Patients who desire, for example, a double electric breast pump, will be able to request that equipment through their insurance company. Patients can work with that insurance provider to receive that pump without cost sharing.

Healio: Why is the guideline on obesity prevention limited to middle‐aged women? When should physicians provide obesity prevention counseling to women who do not fall into this age category?

Warren: The committee that reviews the guidelines identified middle-aged women and obesity prevention counseling as an area where there was a recommendation gap, and that there was an opportunity to address risk factors for obesity in this age population. We know that weight gain during this age range is not uncommon. But prior to this guideline being created, there were no guidelines, specifically for women of this age range who were at normal weight or who were overweight. This fills in a gap and increases support for individuals during this particular age range.

There is an online product developed by the Women’s Preventive Service Initiative called a “well woman chart,” which is an outline for various aspects of well woman care, including the obesity screening and counseling that crosses all age groups.

Healio: The guideline now states that “these services may be completed at a single or as part of a series of visits that take place over time to obtain all necessary services.” Why was this added?

Warren: We realize that every patient is different, every encounter with the clinician is different, and depending on a woman’s health history and her risk factors, it may not be possible or feasible to complete all of the necessary screenings in a single visit. So, this language really creates the space to make sure that the preventive services that are being provided makes sense in the context of that individual patient and their clinician, and indicates to the insurance providers that those services should be covered without cost sharing.

Healio: Is there anything you wish to add about the women’s preventive service guidelines?

Warren: There is so much interest in improving maternal health outcomes and we hear a lot about maternal mortality and morbidity. Our work towards improving those outcomes really starts with preventing chronic disease before it ever happens. And these guidelines ensure that women have access to those needed preventive services without cost sharing.

Healio: Moving onto the ACA preventive health care guidelines for children, why was universal suicide screening for children aged 12 to 21 years added to the current depression screening category?

Warren: We know that that suicide is the second leading cause of death for adolescents 15 to 19 years old. We know that suicide rates in that population group have been increasing over the last couple of decades, and that suicide affects young people from all races and socioeconomic groups. Like many other health outcomes, there are disparities. For example, American Indian and Alaska Native males have the highest suicide rate.

In many cases, pediatricians and primary care providers may already be screening for suicide, but this really underscores the need that we need to ask, given the increasing rates.

Healio: What does the new guidance say about behavioral, social and emotional screening? Why was this guidance added to the Bright Futures recommendations?

Warren: There was already a category in the guidelines that was called psychosocial and behavioral assessments that are supposed to happen at every well visit. The new guidance broadens the name of the category, and really emphasizes that it is important to think about social and emotional factors as providers have conversations with patients.

Right now, we think anywhere from 11% to 20% of all children in the United States have either a behavioral or an emotional disorder at any given time. So, as things go, these are pretty common. We also know that many times, school-aged children who have mental health diagnoses do not get the care that they need. Doing these screenings and making sure that they are a part of routine care is a way to make sure that we are picking up on them when they exist. Then once a disorder is identified, it gives us an opportunity to make a referral for additional clinical services.

Healio: What prompted the two new categories: the assessment for cardiac arrest or death risks in children aged 11 to 21 years and the assessment for hepatitis B virus infection in newborns to 21‐year‐olds?

Warren: Cardiac death is another example of looking at things that occur with some frequency and, where there is an opportunity, to think about building it into the preventive care schedule. Sudden cardiac death occurs in about 2,000 patients every year in the United States, so it is important to think about where we have opportunities to identify any risk factors for that. For example, it is very common in pediatric practice when kids, adolescents or young adults come in for a sports physical, providers ask about risk factors because they think about sudden cardiac death in athletes. But we know that this risk is there beyond kids who are athletes. We really want to think about how this screening is universal. Adding it to the guideline will prompt providers to ask those questions to see if there are any signs or symptoms, or any elements of a person's family history, for example, that might warrant further screening or investigation.

The hepatitis B recommendation is a reminder to think about this disease across the age range of childhood and about the various ways that an individual might acquire hepatitis B. And so, thinking about, for example, very young children at birth, their parents’ hepatitis status. Or if there is a child who is new to a practice and has moved here from another country, thinking about the prevalence of hepatitis in that country and whether screening needs to occur. Or for older children, thinking about hepatitis B in injection drug use, or a child who has HIV, thinking about risk for hepatitis B in that age group. It really is a prompt for providers to think across the age ranges about the potential exposure sources or risk factors for hepatitis B, and to screen for that. We know that’s important because if we can detect hepatitis B virus early and treat that, we can significantly reduce the risk of liver disease and liver cancer later on.

Healio: What needed clarification on dental fluoride varnish and fluoride supplementation?

Warren: While the clinical recommendations in this area have not changed, the reference to the clinical policy statement did. We wanted to make sure that the schedule of preventive services links to the most current document.

Healio: Anything else to add regarding the children’s preventive services guidelines?

Warren: In the case of the pediatric guidelines, these really give us an opportunity to focus on prevention and preventing bad outcomes before they ever happen.

References:

HRSA. Bright Futures. https://mchb.hrsa.gov/programs-impact/programs/bright-futures. Accessed Jan. 21, 2022.

HRSA updates the Affordable Care Act Preventive Health Care Guidelines to improve care for women and children. Published Jan. 11, 2022. Accessed Jan. 21, 2022.

HRSA. Women’s Preventive Services Guidelines. https://www.hrsa.gov/womens-guidelines. Accessed Jan. 21, 2022.