Medicare
Beneficiary Use of Clinical Preventive Services Gao ID: GAO-02-422 April 10, 2002Preventive medicine, including immunizations for many diseases and screening for some types of cancer, holds the promise to extend and improve the quality of life for millions of Americans. Medicare now covers three preventive services for immunizations and three for screenings, and the Centers for Medicare and Medicaid Services (CMS) sponsors "interventions" to increase the use of preventive services. GAO found that the use of preventive services varies widely by service, state, ethnic group, income, and education. The greatest differences among ethnic groups were for immunization rates. Cancer screening rates tended to differ according to income and education level. CMS pays for interventions that promote breast cancer screenings and pneumonia and flu shots. Most of the techniques being used, such as reminder systems that medical offices can use to alert doctors and patients to needed cancer screenings, have been effective. CMS is evaluating what its current efforts have accomplished and expects the results later this year.
GAO-02-422, Medicare: Beneficiary Use of Clinical Preventive Services
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United States General Accounting Office:
GAO:
Report to the Chairman, Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce, House of Representatives:
April 2002:
Medicare:
Beneficiary Use of Clinical Preventive Services:
GAO-02-422:
Contents:
Letter:
Results in Brief:
Background:
Use of Preventive Services Is Growing but Varies Widely:
Efforts Under Way to Increase Use of Some Preventive Services:
Agency Comments and Our Evaluation:
Appendix I: Comments from the Centers for Medicare and Medicaid
Services:
Appendix II: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Preventive Services Covered by the Medicare Program as of
January 2002:
Table 2: Percentage of Medicare Beneficiaries Age 65 and Older Using
Preventive Services in 1995, 1997, and 1999:
Table 3: Variation in State Usage Rates for Preventive Services by
Medicare Beneficiaries 65 and Older, 1999:
Table 4: Percentages of Medicare Beneficiaries 65 and Older Using
Preventive Services by Income and Education, 1999:
Abbreviations:
BRFSS: Behavior Risk Factor Surveillance Survey:
CDC: Centers for Disease Control and Prevention:
CMS: Centers for Medicare and Medicaid Services:
NCI: National Cancer Institute:
PRO: Peer Review Organization:
[End of section]
United States General Accounting Office:
Washington, DC 20548:
April 12, 2002:
The Honorable Jim Greenwood:
Chairman:
Subcommittee on Oversight and Investigations:
Committee on Energy and Commerce:
House of Representatives:
Dear Mr. Chairman:
Preventive health care services can extend lives and promote well-
being among our nation's seniors. For example, immunizations against
the flu can prevent thousands of hospitalizations and deaths each year
among those age 65 and older. Screening for some types of cancer may
extend and improve the quality of life through early detection and
treatment. Such preventive services are a growing part of Medicare,
the federal government's health insurance program for some 34 million
Americans age 65 and older, as well as 6 million younger disabled
persons. Medicare, administered by the Centers for Medicare and
Medicaid Services (CMS), now covers 10 preventive services-3 types of
immunizations and 7 types of screening.[Footnote 1]
Although Medicare provides coverage for these preventive services,
some beneficiaries do not receive them. These beneficiaries may, for
example, face barriers in obtaining the services or simply choose not
to use them. To help ensure that preventive services are being
delivered to those beneficiaries who need them, CMS sponsors efforts-”
called "interventions"-”aimed at increasing preventive service usage
rates.
You asked us to examine two questions regarding preventive services
for older Americans:
* To what extent are Medicare beneficiaries using covered preventive
services?
* What action has CMS taken to increase use of preventive services
among the Medicare population?
To answer these questions, we estimated Medicare beneficiaries' use of
services from a nationwide, state-based survey conducted by the
Centers for Disease Control and Prevention (CDC).[Footnote 2] We
obtained information about effective techniques to increase use of
preventive services from published reports and discussions with
program officials at the federal and state levels[Footnote 3] who are
responsible for implementing projects intended to increase the use of
preventive services. For both questions, we conducted interviews with
officials from the Department of Health and Human Services, CDC, the
National Institutes of Health, CMS, and the Agency for Health Care
Research and Quality. We also spoke with representatives from the
Partnership for Prevention, a nonprofit association involved in the
research and promotion of preventive services. We conducted our work
from August through February 2002 in accordance with generally
accepted government auditing standards.
While the use of preventive services offered under Medicare has
increased over time, use of these services varies widely by service
and state. It also varies by ethnic group, income, and education. From
1995 through 1999, the proportion of all Medicare beneficiaries
immunized against flu and pneumonia, as well as the proportion of
women who received screens for cervical and breast cancer, increased
steadily. Nevertheless, in 1999, usage rates varied considerably among
individual services. For example, the 75 percent usage rate for breast
cancer screening was considerably higher than the 55 percent rate for
pneumonia immunizations. However, even for widely used preventive
services such as breast cancer screening, state-by-state usage rates
ranged from 66 to 86 percent. Among ethnic groups, differences were
greatest for immunizations. About 70 percent of whites reported
receiving flu shots within the past year compared to 49 percent of
African Americans. The disparities between income and educational
groups were greatest for cancer screening. While most Medicare
beneficiaries received at least one covered preventive service, a much
smaller number received additional preventive services covered under
Medicare. For example, 1999 data showed that while 91 percent of
female Medicare beneficiaries received at least one preventive
service, only 10 percent of these beneficiaries were screened for
cervical, breast, and colon cancer, as well as immunized against flu
and pneumonia.
CMS pays for interventions aimed at increasing the use of three
services”breast cancer screening and immunizations against flu and
pneumonia”in each state. CMS also pays for interventions that focus on
increasing use of services by ethnic groups and income groups with low
usage rates. The majority of techniques being used in these
interventions, such as developing reminder systems medical offices can
use to alert providers and patients when breast cancer screenings are
needed, have been found effective in the past. CMS is evaluating what
the current efforts are accomplishing and expects the results later in
2002.
In commenting on a draft of this report, CMS stated that the report
did not consider many of CMS's publication and education campaigns
that were either completed or underway to increase use of Medicare
covered preventive services. We chose to focus mainly on those types
of interventions that studies showed to be the most effective in
ensuring that patients obtain services.
Background:
When the Medicare program was established in 1965, it only covered
health care services for the diagnosis or treatment of illness or
injury. Preventive services did not fall into either of these
categories and, consequently, were not covered. Since 1980, the
Congress has amended Medicare law several times to add coverage for
certain preventive services for different age and risk groups within
the Medicare population. (See table 1.) For most of these services,
Medicare requires some degree of cost-sharing by beneficiaries,
although most beneficiaries have additional insurance, which may cover
most, if not all, of these cost-sharing requirements.[Footnote 4] Some
services, such as pneumonia and flu shots and the fecal-occult blood
test for colorectal cancer, have no cost-sharing requirements.
Table 1: Preventive Services Covered by the Medicare Program as of
January 2002:
Service: Immunizations: Pneumococcal;
Year first covered: 1981;
Groups covered: All beneficiaries;
Frequency of service: As needed (probably once per lifetime);
Cost-sharing service requirements[A]: None.
Service: Immunizations: Hepatitis B;
Year first covered: 1984;
Groups covered: Beneficiaries at intermediate or high risk of
contracting hepatitis B;
Frequency of service: As needed (probably once per lifetime);
Cost-sharing service requirements[A]: Copayment after deductible.
Service: Immunizations: Influenza;
Year first covered: 1993;
Groups covered: All beneficiaries;
Frequency of service: Every year;
Cost-sharing service requirements[A]: None.
Service: Screening services: Cervical cancer”pap smear;
Year first covered: 1990;
Groups covered: All female beneficiaries;
Frequency of service: Every 2 years;
Cost-sharing service requirements[A]: Copayment with no deductible[B].
Service: Screening services: Breast cancer”mammography;
Year first covered: 1991;
Groups covered: Female beneficiaries 35 to 39;
Frequency of service: One baseline mammogram for this period;
Cost-sharing service requirements[A]: Copayment with no deductible.
Service: Screening services: Breast cancer”mammography;
Year first covered: 1991;
Groups covered: Female beneficiaries 40 and older;
Frequency of service: Every year;
Cost-sharing service requirements[A]: Copayment with no deductible.
Service: Screening services: Vaginal cancer”pelvic exam;
Year first covered: 1998;
Groups covered: All female beneficiaries;
Frequency of service: Every 2 years[C];
Cost-sharing service requirements[A]: Copayment with no deductible[B].
Service: Screening services: Colorectal cancer”fecal-occult blood test;
Year first covered: 1998;
Groups covered: Beneficiaries 50 and older;
Frequency of service: Every year;
Cost-sharing service requirements[A]: No copayment or deductible.
Service: Screening services: Colorectal cancer”sigmoidoscopy[D];
Year first covered: 1998;
Groups covered: Beneficiaries 50 and older;
Frequency of service: Every 4 years;
Cost-sharing service requirements[A]: Copayment after deductible[E].
Service: Screening services: Colorectal cancer”colonoscopy[D];
Year first covered: 1998;
Groups covered: All beneficiaries;
Frequency of service: Every 10 years[F];
Cost-sharing service requirements[A]: Copayment after deductible.
Service: Screening services: Osteoporosis”bone mass measurement;
Year first covered: 1998;
Groups covered: Estrogen-deficient female beneficiaries at clinical
risk for osteoporosis as well as other qualified individuals[G];
Frequency of service: Every 2 years[H];
Cost-sharing service requirements[A]: Copayment after deductible.
Service: Screening services: Prostate cancer”prostate-specific antigen
test and/or digital rectal examination;
Year first covered: 2000;
Groups covered: Men 50 and older;
Frequency of service: Every year;
Cost-sharing service requirements[A]: Copayment after deductible.
Service: Screening services: Glaucoma;
Year first covered: 2002;
Groups covered: Beneficiaries medically determined to be at high risk
for glaucoma;
Frequency of service: Every year;
Cost-sharing service requirements[A]: Copayment after deductible.
[A] Applicable Medicare cost-sharing requirements generally include a
20 percent copayment after a $100 per year deductible. Each year,
beneficiaries are responsible for 100 percent of the payment amount
until those payments equal a specified deductible amount, $100 in
2002. Thereafter, beneficiaries are responsible for a copayment that
is usually 20 percent of the Medicare approved amount. For certain
tests, the copayment may be higher. See 42 U.S.C. § 1395(a)(1).
[B] The costs of the laboratory test portion of these services are not
subject to copayment or deductible. The beneficiary is subject to a
deductible and/or copayment for physician services only.
[C] The exam is covered once every 12 months if the beneficiary has
had an abnormality within the prior 3 years or is otherwise determined
to be a high-risk candidate for cervical cancer.
[D] The doctor can decide to use a barium enema instead of a
sigmoidoscopy or colonoscopy for beneficiaries 50 and older. The
frequency of service is the same as the sigmoidoscopy or colonoscopy
it substitutes for.
[E] The copayment is increased from 20 to 25 percent for services
rendered in an ambulatory surgical center.
[F] Beneficiaries medically determined to be at high risk may receive
a colonoscopy every 2 years.
[G] The statute defines "other qualified individuals" as those who
have vertebral abnormalities or primary hyperparathyroidism, or who
are receiving long-term glucocorticoid steroid or osteoporosis drug
therapy. See 42 U.S.C. § 1395x(rr)(2).
[H] CMS permits coverage of a bone mass measurement at any time”sooner
than 2 years”if the service is medically necessary. See 42 CFR §
410.31(c).
[End of table]
Many other preventive services exist besides those specifically
covered as preventive services under Medicare, such as blood pressure
screening and cholesterol screening. Although Medicare does not
explicitly provide coverage for these other services, Medicare
beneficiaries may receive some of them during office visits for other
medical problems. Data from surveys of Medicare beneficiaries indicate
that the receipt of such services is common.[Footnote 5] For example,
in 1999, nearly 98 percent of seniors reported that they had had their
blood pressure checked within the last 2 years, and more than 88
percent of seniors reported having their cholesterol checked within
the prior 5 years. At least a portion of these services were likely
ordered by physicians in order to diagnose the causes of medical
problems, and were paid for by Medicare as such.
To identify how best to increase use of preventive services needed by
the Medicare population, CMS sponsors reviews of studies that examine
various kinds of interventions that have been used in the past for
populations age 65 and older. CMS also takes action to implement
interventions in each state through its Peer Review Organization (PRO)
program.[Footnote 6] Under this program, CMS contracts with 37
organizations responsible for each state, U.S. territory, and the
District of Columbia. The PRO program, which is designed to monitor
and improve quality of care for Medicare beneficiaries, currently
includes the goal of increasing the use of flu and pneumonia
immunizations, as well as breast cancer screening, in each state.
These organizations collaborate with hospitals and health care
professionals, suggesting systemic changes to improve how preventive
services are provided. CMS also conducts a variety of health promotion
activities to educate beneficiaries about the benefits of preventive
services and to encourage their use. These include the publication of
brochures on certain covered services and media campaigns.
Use of Preventive Services Is Growing but Varies Widely:
Use of preventive services offered under Medicare has increased over
time. Some services are used more extensively than others, and use of
individual services varies by state and, to a lesser extent, by
demographic characteristics such as ethnicity, income, and education.
Although opportunities remain to increase the use of preventive
services within Medicare, there are limits to the extent some
beneficiaries would be expected to use certain services.
The Use of Individual Preventive Services Has Increased over Time but
a Minority Receive Multiple Services:
Information on usage for 4 of the 10 preventive services covered under
Medicare is available in the data we used[Footnote 7]-”immunizations
against pneumonia and flu and screening for cervical and breast
cancer.[Footnote 8] This information shows that beneficiaries age 65
and older are increasing their use of all 4 services. (See table 2.)
For example, 68 percent of beneficiaries received flu shots in 1999,
compared with 60 percent in 1995.
Table 2: Percentage of Medicare Beneficiaries Age 65 and Older Using
Preventive Services in 1995, 1997, and 1999:
Service and frequency: Immunizations: Pneumococcal”ever;
Year first covered under Medicare: 1981;
National usage rate, 1995[A]: 38%;
National usage rate, 1997: 46%;
National usage rate, 1999: 55%.
Service and frequency: Immunizations: Influenza”within previous year;
Year first covered under Medicare: 1993;
National usage rate, 1995[A]: 60%;
National usage rate, 1997: 66%;
National usage rate, 1999: 68%.
Service and frequency: Screening services: Cervical cancer”pap smear
within previous 3 years;
Year first covered under Medicare: 1990;
National usage rate, 1995[A]: 70%;
National usage rate, 1997: 71%;
National usage rate, 1999: 72%.
Service and frequency: Screening services: Breast cancer”mammogram
within previous 2 years;
Year first covered under Medicare: 1991;
National usage rate, 1995[A]: 66%;
National usage rate, 1997: 72%;
National usage rate, 1999: 75%.
[A] For 1995 only, values obtained from CDC's BRFSS web site data.
These 1995 data includes Puerto Rico, and may include some survey
respondents not enrolled in Medicare.
Source: CDC's BRFSS for 50 states and the District of Columbia.
[End of table]
In 1999, although each preventive service was used by the majority of
Medicare beneficiaries, fewer receive multiple preventive services.
For example, 1999 data show that while 91 percent of female Medicare
beneficiaries received at least 1 preventive service, only 10 percent
of these beneficiaries were screened for cervical,[Footnote 9] breast,
and colon cancer,[Footnote 10] as well as immunized against flu and
pneumonia. These data also show that 44 percent of male beneficiaries
were immunized against both flu and pneumonia. When colorectal
screening is included in this set of services, the proportion of men
who had received all 3 services falls to less than 27 percent.
Use of Services Varies by State and Other Demographic Characteristics:
While national rates provide an overall picture of current use, they
mask substantial differences in how seniors living in different states
use some services. For example, the national breast cancer screening
rate for Medicare beneficiaries was 75 percent in 1999, but rates for
individual states ranged from a low of 66 percent to a high of 86
percent. In table 3, we show the range over which state estimates of
preventive service usage rates vary from lowest to highest for
selected states.[Footnote 11]
Table 3: Variation in State Usage Rates for Preventive Services by
Medicare Beneficiaries 65 and Older, 1999:
Preventive service[A]: Immunizations: Pneumococcal”ever;
National usage rate percentage[B]: 55%;
Usage rate range among states percentage: 51 to 62%;
Number of states included in range[C]: 24.
Preventive service[A]: Immunizations: Influenza”within previous year;
National usage rate percentage[B]: 68%;
Usage rate range among states percentage: 63 to 77%;
Number of states included in range[C]: 30.
Preventive service[A]: Screening services: Breast cancer”mammogram
within previous 2 years;
National usage rate percentage[B]: 75%;
Usage rate range among states percentage: 66 to 86%;
Number of states included in range[C]: 21.
Preventive service[A]: Screening services: Colorectal cancer”fecal-
occult blood test in past year;
National usage rate percentage[B]: 25%;
Usage rate range among states percentage: 14 to 37%;
Number of states included in range[C]: 34.
Preventive service[A]: Screening services: Colorectal cancer”colonoscopy
or sigmoidoscopy within previous 5 years;
National usage rate percentage[B]: 40%;
Usage rate range among states percentage: 27 to 46%;
Number of states included in range[C]: 24.
[A] Data were unavailable for Medicare population use of hepatitis B
immunization and screening services for osteoporosis.
[B] National usage rate includes all states and the District of
Columbia.
[C] This includes the number of states whose 95 percent confidence
intervals for the respective preventive services were narrower than 10
percentage points. State specific data were not included for cervical
cancer screening because none met this level of precision.
Source: CDC's BRFSS for 50 states and the District of Columbia.
[End of table]
While usage rates for each service varied from state to state, the
services with the highest rates in each state were generally the same.
For example, in most states, screening rates for breast and cervical
cancer were higher than rates for colorectal screens.
Usage rates for Medicare beneficiaries also varied based on ethnicity,
and on socioeconomic status, as defined by income and education. By
ethnicity, the biggest differences occurred in use of immunization
services. For example, 1999 data show that about 57 percent of whites
and 54 percent of "other"[Footnote 12] ethnic groups were immunized
against pneumonia, compared to about 37 percent of African Americans
and Hispanics. Similarly, about 70 percent of whites and "other"
ethnic groups received flu shots during the year compared to 49
percent of African Americans. The only other statistically significant
difference between ethnic groups was for the fecal-occult blood test
for colon cancer, for which 26 percent of whites received screenings
within the past year compared to 16 percent of Hispanics and "other"
ethnic groups.[Footnote 13] For income and education, in general, as
income and education rose, the rates at which individuals used
preventive services also increased. (See table 4.)
Table 4: Percentages of Medicare Beneficiaries 65 and Older Using
Preventive Services by Income and Education, 1999:
Screening service[A]: Immunizations: Pneumococcal-ever;
Income: Less than $25,000: 53.7%;
Income: $25,000 and over: 57.5%;
Education: Less than high school: 47.9%;
Education: High school and some college: 56.4%;
Education: College graduate and postgraduate: 60.1%.
Screening service[A]: Immunizations: Influenza-within previous year;
Income: Less than $25,000: 65.2%;
Income: $25,000 and over: 71.0%;
Education: Less than high school: 61.7%;
Education: High school and some college: 68.6%;
Education: College graduate and postgraduate: 72.6%.
Screening service[A]: Preventive services: Cervical cancer-pap smear
within previous 3 years;
Income: Less than $25,000: 66.1%;
Income: $25,000 and over: 81.5%;
Education: Less than high school: 62.0%;
Education: High school and some college: 74.8[B]%;
Education: College graduate and postgraduate: 78.6[B]%.
Screening service[A]: Preventive services: Breast cancer-mammogram
within previous 2 years;
Income: Less than $25,000: 69.7%;
Income: $25,000 and over: 84.2%;
Education: Less than high school: 65.3%;
Education: High school and some college: 76.9%;
Education: College graduate and postgraduate: 84.0%.
Screening service[A]: Preventive services: Colorectal cancer-fecal-
occult blood test in previous year;
Income: Less than $25,000: 21.3%;
Income: $25,000 and over: 28.1%;
Education: Less than high school: 19.7%;
Education: High school and some college: 25.3%;
Education: College graduate and postgraduate: 29.7%.
Screening service[A]: Preventive services: Colorectal cancer-
colonoscopy or sigmoidoscopy within previous 5 years;
Income: Less than $25,000: 36.8%;
Income: $25,000 and over: 46.1%;
Education: Less than high school: 33.3%;
Education: High school and some college: 40.2%;
Education: College graduate and postgraduate: 48.3%.
[A] Data were unavailable for Medicare population utilization of
Hepatitis B immunization and screening services for osteoporosis.
[B] All differences between income and education groups are
statistically significant except for cervical cancer screening
services for high school graduates and above.
Source: CDC's BRFSS for 50 states and the District of Columbia.
[End of table]
Opportunities and Limitations Exist to Increase the Use of Preventive
Services:
Various studies have identified a variety of factors affecting
beneficiary decisions to seek preventive care, including low patient
awareness of the benefits of the services as well as the need for
service. Some factors, such as those involving patient awareness of
the benefits, may represent opportunities to increase the use of
preventive services. For example, see the following.
* In a 1997 report, the Agency for Healthcare Research and Quality
found that, although patients may be unaware of the risks or symptoms
of colorectal cancer, they are more likely to participate in screening
once they understand the nature and risks of the disease.
* Data from CMS's 1999 Medicare Current Beneficiary Survey show that,
while about one-fourth of beneficiaries who did not receive flu shots
were unaware of the benefits of obtaining this immunization, about
half of the people who were not immunized avoided getting the shot for
reasons such as concerns about side effects and whether doing so would
effectively prevent illness.
On the other hand, usage rates alone may not provide a clear picture
of success, and may mask inherent limitations to increasing usage
rates. For example, survey data show that 44 percent of women age 65
and over have had hysterectomies[Footnote 14]-”an operation that
usually includes removing the cervix. For these women, researchers
state that cervical cancer screening may not be necessary unless they
have a prior history of cervical cancer.[Footnote 15] Also, according
to officials in charge of research on preventive services at the
National Institutes of Health, it is reasonable for beneficiaries,
their families, or their providers to decide to forgo services because
of the limited benefits they would offer patients with terminal
illnesses or of advanced age. These officials explained that research
has shown, for example, that the benefits of cancer screening
services, such as for prostate, breast, and colon cancer, can take 10
years or more to materialize, a time frame that could exceed the life
expectancy of as much as half of the Medicare population.[Footnote 16]
CMS officials also pointed out that the controversy over the
effectiveness of some services, such as mammography and prostate
cancer screening, may add to the difficulty in further improving
screening rates for these services. The benefit of mammography has
recently been challenged by two Danish researchers and an independent
group of experts on the National Cancer Institute's (NCI) advisory
panel citing serious flaws in 6 of the 8 clinical trials that showed
benefits. However, subsequent to the Danish report and the NCI panel's
statement, both the NCI and the U.S. Preventive Services Task Force
[Footnote 17] reiterated their recommendation for regular mammography
screening. While acknowledging the methodological limitations in these
trials, the U.S. Preventive Services Task Force concluded that the
flaws in these studies were unlikely to negate the reasonable,
consistent, and significant mortality reductions observed in these
trials. Routine screening for prostate cancer is also a matter of
controversy. For example, the American Cancer Society and the American
Urological Association support routine prostate cancer screening,
while the U.S. Preventive Services Task Force and others[Footnote 18]
state that there is insufficient evidence to support it.
Efforts Under Way to Increase Use of Some Preventive Services:
CMS has studied various types of interventions to increase the use of
preventive services among seniors. These studies show that many types
of interventions can potentially be effective, but also that
interventions must be tailored to the circumstances of specific
situations. CMS is funding efforts in every state to implement
interventions for three preventive services that Medicare covers. CMS
also has efforts under way aimed at increasing the use of preventive
services among minority and low-income seniors.
Studies Identify Effective Methods to Increase Use of Services:
CMS has sponsored reviews of studies looking at the effectiveness of
interventions to increase use of preventive services among people age
65 and older. One of these reviews evaluated the effectiveness of
interventions targeting people over age 65 for five services covered by
Medicare”immunizations for flu and pneumonia and screenings for
breast, cervical, and colon cancer.[Footnote 19] The report evaluated
218 separate studies on interventions designed to increase use of
preventive services. The studies were performed in both academic and
nonacademic settings in various geographic areas, and in a mixture of
reimbursement systems. Most of the interventions studied that involved
pneumococcal and influenza immunizations were targeted toward persons
over 65 years of age, while cancer screening interventions were
targeted at adults, but not necessarily those 65 years of age.
This evaluation concluded that no specific intervention was
consistently most effective for all services and settings, and that
success depended on how closely the intervention addressed the unique
circumstances in each state and for different populations within each
state, while also taking into account the cost and difficulty of
implementation. Obstacles to improved screening rates can differ
across states thus requiring different approaches. For example,
officials responsible for improving the use of preventive services in
Idaho and Washington explained that while a significant barrier in
Idaho was beneficiary access to Medicare providers, this was not a
barrier in Washington. The CMS evaluation also showed that using
multiple interventions generally provided greater success than using a
single approach.
The types of interventions evaluated in the CMS-sponsored review
[Footnote 20] included a variety of efforts targeting health delivery
systems, providers, and patients. The key conclusion the report drew
from the literature was that organizational and system change, such as
the use of standing orders[Footnote 21] and the use of financial
incentives, were the most consistent at producing the largest increase
in the use of preventive services. These and other interventions found
to be effective follow.
* System Change. These interventions change the way a health system
operates so that patients are more likely to receive services. For
example, medical or administrative staff may be given responsibility
to ensure that patients receive services, or standing orders may be
implemented in nursing homes to allow nonphysician personnel to
administer immunizations without a physician's order.
* Incentives. These interventions include gifts or vouchers to
patients for free services. Medicare allows this type of approach only
in limited circumstances.[Footnote 22]
* Reminders. These interventions include computer-generated or other
approaches by which medical offices (1) reminded physicians to provide
the preventive service as part of services performed during a medical
visit or (2) generated notices to patients that it was time to make an
appointment for the service. Studies show that reminders to either
patients or physicians can effectively improve rates for cancer
screening. However, a computerized provider reminder is consistently
more cost effective than notifying the patient directly when a
computerized information system is already available in a physician's
medical office. Patient reminders that are personalized or signed by
the patient's physician are more effective than generic reminders.
* Education. These interventions include pamphlets, classes, or public
events providing information for physicians or beneficiaries on
coverage, benefits, and time frames for services. The study found that
while the effect of patient education is significant, it is
consistently less effective than system change, incentives, or
reminders.
CMS Is Sponsoring Interventions to Increase Use of Three Services:
CMS is implementing interventions in all states through its PRO
program. Under this program, CMS contracts with 37 PROs, each
responsible for monitoring and improving the quality of care for
Medicare beneficiaries in one or more states, in U.S. territories, or
in the District of Columbia. These efforts are currently aimed at
three preventive services offered under Medicare”immunizations against
flu and pneumonia and screening for breast cancer. CMS chose these
topics based on their public health importance and other factors. CMS
also contracts with select PROs to provide support and assistance to
all PROs for each area of focus. For example, CMS has contracted with
two of the existing PROs, one for flu and pneumonia immunizations and
one for breast cancer screening, to provide support and share
information among the PROs regarding their efforts to improve usage
rates for these services. Our discussions with the officials from
these two PROs indicate that, for immunizations, most PROs are
focusing on ways to better educate patients and providers on the
importance of getting flu and pneumonia shots. For breast cancer
screening, efforts are focusing on developing integrated reminder
systems, such as chart stickers or computer-based alerts that
physicians' offices can use to contact patients on a timely basis.
Officials for the two PROs providing support indicated that most PROs
were implementing multiple interventions. For example, in a newsletter
intended to help PROs share information, officials at one PRO reported
that they have developed concurrent breast cancer screening
interventions for their state, which are targeted at physicians and
their staffs, nurses, and beneficiaries. Officials for this PRO report
the following.
* For physicians and their staffs, they (1) host seminars to teach
them about reminder and billing systems, (2) provide toolkits that
include reminder systems, checklists, and other materials, and (3)
conduct on-site consultations to encourage providers to implement
system changes.
* For nurses, they are conducting a campaign intended to increase
awareness and encourage nurses and student nurses to identify female
friends and family members who are overdue for mammograms. The
campaign includes information packets, a newsletter, and information
booths at nursing organization meetings.
* For beneficiaries, the PRO publishes a periodic newsletter on the
subject of preventive medicine. This newsletter includes articles on
the importance of mammography for early detection of breast cancer.
CMS has taken steps to evaluate the success of PRO efforts. CMS
officials explained that the contracts with the PRO organizations are
"performance based" and provide financial incentives as a reward for
superior outcomes. The contracts include a methodology in which the
performance of the PRO for each state, U.S. territory, and the
District of Columbia is scored based on 22 indicators, including flu
and pneumonia vaccination rates and mammography rates. The performance
of the PRO in each state will then be ranked against all other states
in order to identify the higher and lower performing PROs. CMS intends
to automatically renew the contracts with the top 75 percent of the
PROs for the next contract cycle, which begins in 2002. The PRO
contracts also contain financial performance incentives allowing each
PRO to receive up to an additional 2 percent payment based on the
positive outcomes of their interventions. CMS officials expect
information on the results by the summer of 2002. Consequently, we
have not assessed the outcome of PRO efforts or CMS's methodology for
measuring PRO performance.
While the current efforts include 3 of the 10 preventive services
covered by Medicare, CMS is also developing indicators and performance
measures necessary for interventions to increase use of screening
services for osteoporosis and colorectal and prostate cancer. CMS
officials stated that such interventions would be implemented in
future contracts with PROs. CMS is not currently developing indicators
for the remaining preventive services covered by Medicare”hepatitis B
immunizations or screenings for glaucoma and vaginal cancer.
CMS Is Also Sponsoring Interventions to Increase Use of Services among
Minorities and Low-Income Seniors:
CMS is also sponsoring PRO interventions and projects in each state to
increase use of preventive services by minorities and low-income
Medicare beneficiaries. CMS-funded research on successful
interventions for the general Medicare population 65 and older
concluded that evidence was insufficient to determine how best to
increase use of services by minorities and low-income seniors across
various geographic settings. Differences in how populations use
preventive services are sometimes found even when the populations have
similar geographic settings or delivery systems. For example, a study
showed that although use of flu shots among white and African American
seniors is higher under managed care than fee-for-service, the
significant disparities in levels of use between these ethnic groups
persist in both these environments.[Footnote 23]
To begin addressing these information gaps, CMS requires that each PRO
conduct a project focusing on one of several specified Medicare
populations. This population can be low-income seniors enrolled in
both Medicare and Medicaid or one of several minority groups: American
Indians, Alaska Natives, Asian Americans and Pacific Islanders,
African Americans, or Hispanics. For the population chosen, the PRO is
to target interventions for one service. The projects in most states
are focusing on increasing breast cancer screening or flu and
pneumonia immunization among African American or low-income seniors.
PROs are required to identify the barriers that exist for the selected
population and service, and to implement interventions specifically
designed to address these barriers for patients and providers. A
summary of PRO efforts to increase services for minorities and low-
income seniors is expected to be published sometime after the spring
of 2002.
Other studies or projects under way by CMS also aim to identify
barriers and increase use of services by certain Medicare populations.
For example, the Congress directed CMS to conduct a demonstration
project to, among other things, develop and evaluate methods to
eliminate disparities in cancer prevention screening measures.
[Footnote 24] The law specifies a total of nine demonstration projects
to include two state-level demonstrations for each of four minority
groups (American Indians, including Alaska Natives, Eskimos, and
Aleuts; Asian Americans and Pacific Islanders; African Americans; and
Hispanics) and one project in the Pacific Islands. In addition, one of
the projects must have a rural focus and one must have an urban focus
for each group. CMS expects to produce a report by December 2002,
after the project's first phase is completed, identifying best
practices and models to be tested in demonstration projects. The
second phase, which is to start around December 2002, is to test these
models by implementing them in actual demonstration projects intended
to determine which methods are most effective in reducing the
incidence of cancer and improving minority health by overcoming
barriers to the use of preventive services in the target populations.
A report evaluating the cost effectiveness of the demonstration
projects, the quality of preventive services provided, and beneficiary
and health care provider satisfaction is due to the Congress in 2004.
Agency Comments and Our Evaluation:
We obtained comments on our draft report from CMS. CMS commented that
the draft report focused on the activities of its PROs and did not
consider all of CMS's health promotion activities. CMS provided
details on its publication and educational campaigns to inform
Medicare beneficiaries about preventive service benefits and to
encourage their use. CMS's comments are reproduced in appendix I.
We acknowledge that our report does not describe all of CMS's health
promotion/education activities underway that relate to increasing the
use of preventive services among the Medicare population. While
beneficiary education activities are worthwhile, CMS studies have
shown that other interventions, such as those that are directed at
changing the way a health delivery system operates so that patients
are more likely to receive services, are more effective. Because PROs
and CMS demonstration projects are accountable for facilitating the
implementation of these types of interventions, we focused our efforts
in describing these activities and the status of their evaluations. We
have revised the report to make it clear that PRO activities are in
addition to other CMS beneficiary education efforts.
CMS also provided technical comments that we considered and
incorporated where appropriate.
As arranged with your office, unless you release its contents earlier,
we plan no further distribution of this report until 30 days after its
issuance date. At that time we will send copies of this report to the
secretary of health and human services, the administrator of the
Centers for Medicare and Medicaid Services, the director of the
Centers for Disease Control and Prevention, and others who are
interested. We will also make copies available to others on request.
If you or your staff have any questions, please contact me at (202)
512-7119, or Frank Pasquier at (206) 2874861. Other major contributors
are included in appendix II.
Sincerely yours,
Signed by:
Janet Heinrich:
Director, Health Care”Public Health Issues:
[End of section]
Appendix I: Comments from the Centers for Medicare and Medicaid
Services:
Department Of Health & Human Services:
Centers for Medicare & Medicaid Service:
Administrator:
Washington, DC 20201:
Date: March 29, 2002:
To: Janet Heinrich:
Director:
Health Care”Public Health Issues:
From: [Signed by} Thomas A. Scully:
Administrator:
Subjects: General Accounting Office (GAO) Draft Report, Medicare
Beneficiary Use of Clinical Preventive Services: Utilization Under
Medicare (GAO-02-422):
Thank you for sending the above-referenced report for comments. We
appreciate GAO's examination of the utilization of preventive services
under the Medicare program.
At the Centers for Medicare & Medicaid Services (CMS), we strive to
use efficient and cost-effective approaches by partnering with other
agencies and organizations, utilizing Medicare contractors to educate
people with Medicare about covered preventive services, and
encouraging beneficiaries to use these services. We include health
promotion information as a part of other education campaigns that
address different aspects of the Medicare program or Medicare+Choice
options. We also incorporate health promotion messages with
information that is communicated to beneficiaries on an everyday basis
(e.g., services such as the 1-800-MEDICARE help-line, Medicare.gov.,
Medicare summary notices, and the Medicare & You handbook).
It is in this context that we are commenting on the draft report. We
note at the outset that the draft focuses only on activities conducted
by Quality Improvement Organizations (formerly referred to as Peer
Review Organizations or PROs) and does not consider other CMS efforts
to increase the use of Medicare-covered preventive services. We
suggest that GAO expand the report to cover many significant CMS
activities that have not been addressed.
The following list of activities highlights some of the measures CMS
has undertaken in the areas of health promotion, quality measurement,
and health assessment activities:
Health Promotion Activities:
Our goal is to inform Medicare beneficiaries about the preventive
service benefits and to encourage their use, and we educate
beneficiaries in a variety of ways:
The CMS has established partnerships with other Department of Health
and Human Services' agencies such as the Centers for Disease Control
and Prevention (CDC) and the National Cancer Institute (NCI) to carry
out health promotion initiatives ranging from a limited distribution
of outreach kits to full-blown national multi-media, multi-year
campaigns involving numerous partners at the local and national level.
In addition, we integrate communications about preventive services
with other Medicare educational initiatives. For instance:
* The Medicare & You handbook includes information on preventive
services, and CMS publishes and distributes a brochure entitled,
Medicare Preventive Services. To Help Keep You Healthy. Medicare and
You is distributed to all beneficiary households.
* Medicare carriers and intermediaries include messages on preventive
services when sending out Medicare Summary Notices (MSNs) during
certain months of the year to correspond with health themes (e.g.,
March is Colorectal Cancer Awareness Month). They also discuss these
services and give out materials when giving talks on other Medicare
issues, and include articles on preventive services in their
newsletters and on their Websites.
* The CMS regional offices disseminate information on preventive
services during other information campaigns (e.g., during Regional
Education About Choices in Health (REACH) campaigns).
* The 1-800-MEDICARE help line and Medicare.gov Internet site include
information on preventive services that corresponds with particular
calendar health themes.
We use opportunities such as these whenever possible to promote the
use of preventive services covered by Medicare.
Our educational campaigns vary in their level of intensity and
duration and use of resources, depending on factors such as
opportunities to partner with other agencies, priorities established
for Medicare contractors, available funding, and agreement within the
medical community on appropriate screening practices. Campaigns may
utilize radio and television public service announcements, Video News
Release (VNRs), print materials and media kits, Websites, and articles
in journals, newsletters, and other means. In addition, the campaigns
target high-risk populations, which are generally minorities. They
also target health care practitioners since they are some of the
greatest influences on patient behavior.
The CMS has entered into numerous Intra-Agency agreements to carry out
health promotion campaigns and other initiatives. The following
activities are being carried out to educate Medicare beneficiaries
about covered preventive services:
Covered Service: Bone Mass Measurement:
Mission:
Raise awareness concerning the disease, osteoporosis and the available
interventions, including Bone Mass Density (BMD) testing, as well as
Medicare coverage of BMD tests.
Background:
Focus testing of Medicare beneficiaries indicates a need to raise
public awareness about the disease and pertinent tests. In an effort
to raise public awareness, we conducted formative research to
determine Medicare beneficiaries' and providers' attitudes about the
disease, as well as their knowledge of the disease and bone density
tests. The CMS partners with CDC and the Agency for HealthCare
Research and Quality (AHRQ) with whom CMS has an intra-agency
agreement.
We have provided coverage and payment information on BMD tests in the
publications, Medicare Preventive Services and Medicare and You
handbook.
Covered Services: Diabetes Self-Management Benefits/Medical Nutrition
Therapy:
National Campaign (The Power to Control Diabetes):
Mission:
Help older adults understand the importance of routine self-monitoring
of blood sugar levels to delay or prevent the complications of
diabetes. Increase awareness of older adults about comprehensive
diabetes care and Medicare benefits.
Background:
The CMS has partnered with the National Diabetes Education Program
(NDEP) since 1998. We chose to partner with this organization because
NDEP is jointly sponsored by the National Institute of Diabetes and
Digestive and Kidney Diseases and the Centers for Disease Control and
Prevention. The goal of the NDEP is to reduce the morbidity and
mortality associated with diabetes and its complications.
The beneficiary education campaign in 2001 encouraged beneficiaries to
control their blood sugar and publicized the expanded Medicare benefit
for blood sugar management. Over 3.2 million people were reached via
print media and 2.2. million people via television campaigns. We will
distribute The Power to Control Diabetes health care practitioner kits
in spring 2002.
In order to strengthen grassroots efforts to increase awareness of
older adults about comprehensive diabetes care and Medicare benefits,
we plan to build a dissemination network of community-based
organizations, community service organizations, ethnic minority
organizations, and other NDEP partners. We also will establish a
synchronized approach to increase awareness of older adults by
educating NDEP work groups and partners that target their outreach
efforts to audiences such as health care providers, African Americans,
Native Americans, Asian-Americans, Alaskan and Pacific Islanders,
Hispanics, business and labor organizations, interfaith communities,
and others.
The new campaign message will be: "Be Smart About Your Heart: Know the
ABC's of Diabetes--Al C, Blood Pressure and Cholesterol." The campaign
target audience will be caregivers, health care providers, community
organizations, adults age 65 and older who have diabetes, and family
members of adults age 65 and older who have diabetes. The campaign
message will be "Comprehensive care of diabetes is essential, and
Medicare helps individuals ages 65 and older to manage their illness
through comprehensive self-management and nutritional benefits that
can help them stay healthier and be more independent."
An upcoming campaign in conjunction with the National Institutes of
Health (NIB) National Eye Institute will promote the new Medicare
benefit for glaucoma detection. The benefit provides coverage for an
annual dilated eye examination for Medicare beneficiaries at high risk
for glaucoma (including those with diabetes). See below for more
details.
Covered Service: Glaucoma Screening:
Mission:
To promote the new Medicare benefit for glaucoma detection. Prevent
vision loss from glaucoma through early detection and treatment.
Empower older adults to take charge of their visual health.
Background:
We have formed a partnership with NIH's National Eye Institute to
promote the new Medicare benefit for glaucoma detection, which was
effective January 1, 2002.
Activities include a media campaign (January-February 2002),
development of a community outreach kit including materials and
strategies for local promotion, and a kit for health care
professionals. A press release was issued on January 14, 2002,
announcing that Medicare now covers glaucoma detection eye
examinations. The target audience includes eligible Medicare
beneficiaries who are defined as people with diabetes, people at high
risk for developing the disease, and African-Americans over age 50.
The secondary audience will be aging networks, primary care physicians
and other health care providers.
Covered Service: Colorectal Cancer Screening:
National Colorectal Cancer (CRC) Action Campaign (Screen for Life):
Mission:
Increase utilization of the Medicare benefit.
Background:
After enactment of the Balanced Budget Act of 1997, CMS began working
in partnership with the CDC to develop the Screen for Life (SFL)
campaign, which began in March 1999. The NCI has provided technical
support to the campaign. The SFL campaign--a multiyear, multimedia,
national CRC education campaign--informs men and women age 50 and
older (the age at greatest risk of developing CRC) about the
importance of regular CRC screening tests. The campaign's
communication objectives are to: inform the public about the benefits
of CRC screening; motivate the target audience to talk with their
health care providers to establish a CRC screening program, and
promote Medicare's CRC screening benefits.
Materials continue to be developed and distributed each year. Press
releases and new materials are issued during March, National CRC
Awareness Month. Materials target people aged 50 and older and people
with Medicare. Many of the materials target African-Americans.
Examples of materials include: four versions of a Medicare oriented
"Good News" poster targeting African-American, Caucasian, Hispanic,
and Asian-American populations; brochures (English and Spanish); print
slicks; fact sheets; and articles.
The CRC information and materials are widely distributed via the
following channels: annual press releases and media kits; VNRs;
televised public service announcements (PSAs); Internet articles;
messages on beneficiary MSNs; the 1-800 MEDICARE help line;
Medicare.gov; distribution of materials at meetings, health fairs, and
presentations; newsletters; slicks in magazines; and radio play. The
following organizations participate in distributing materials:
Medicare contractors (carriers, intermediaries, Quality Improvement
Organizations); State Health Departments; partners participating in
the National CRC Awareness Month campaign; and CMS Central Office and
Regional Office staff.
Covered Service: Flu and Pneumonia Vaccinations:
National Flu/Pneumonia Campaign (Get the Flu Shot Not the Flu):
Mission:
Increase the utilization of Medicare's influenza and pneumococcal
vaccination benefits.
Background:
As discussed in the GAO report, CMS's 53 Quality Improvement
Organizations are contractually obligated to address increasing flu
and pneumococcal vaccinations as one of their six clinical priority
areas and are actively involved in the campaign.
During the past year, we worked with providers to realize their
significant roles in motivating patients to get vaccinated, and to
discuss and promote influenza and pneumococcal vaccinations with their
patients. We encouraged physicians and their office personnel to
promote influenza and pneumococcal vaccinations by hanging posters on
their office or clinic walls to function as reminders for both
providers and their patients, and by using wall charts to track
immunizations. These activities will continue.
Postcards were produced with the key message to "Get the Flu Shot, Not
the Flu." Messages were included on MSNs and Explanation of Medicare
Benefits (EOMBs), advising beneficiaries that shots given in January
were just as effective as those given during October. In addition, we
added a message in the yearly provider enrollment package, encouraging
providers to vaccinate their high-risk patients before mass
vaccinations. We also prepared an article in the CMS Health Watch.
Covered Service: Mammograms:
National Mammography Campaign (Not Just Once, But For a Lifetime):
Mission:
Increase utilization of the Medicare benefit of annual screening
mammograms.
Background:
This national campaign which spreads the word about the importance of
regularly-scheduled screening mammograms for early detection of breast
cancer. The campaign also works to increase beneficiaries' and
providers' awareness of the annual screening mammography benefit. As
discussed in GAO's report, we also work with CMS's 53 Quality
Improvement Organizations (QIOs) to increase screening mammograms, as
breast cancer is one of the QIOs' six clinical priority areas.
Covered Service: Pap Tests/Pelvic Exams:
Pap Tests/Cervical Cancer Awareness (A Healthy Habit for Life):
Mission:
Raise awareness of women with Medicare about Medicare's preventive
screening Pap test benefit as an effective means to screen for
cervical cancer and to remind health care providers that Pap tests may
be appropriate for their older patients.
Background:
Via an interagency agreement, we partner with the National Cancer
Institute (NCI) to educate Medicare-aged women and their health care
practitioners about the continued benefit of Pap tests and the
Medicare benefit. We are working to correct myths about cervical
cancer that serve as barriers to providers recommending Pap tests and
Medicare-aged women getting them.
To coincide with Cervical Health Month, information has been placed on
our provider Websites along with statistics about the impact of
cervical cancer across age/race/ethnic groups. In addition, messages
about cervical health have been printed on Medicare Summary Notices
and Explanations of Medicare Benefits sent to beneficiaries. Also,
information was included on Medicare.gov and cms.gov, and articles
were placed in newsletters.
As specified in the intra-agency agreement with NCI, we developed and
printed a brochure entitled "Pap Tests for Older Women: A Healthy
Habit for Life." We also developed and distributed a provider kit that
includes screening recommendations, a Pap test tear off-sheet with
cervical health information for a general population, and screening
recommendations for health care providers that discuss ethnic/racial
disparities. The CMS and NCI's contractor have conducted surveys to
learn the extent to which the materials were used and to garner
information about preferred distribution channels. The contractor will
provide CMS and NCI with a report of findings and recommendations for
future development and distribution of materials.
Covered Service: Prostate Cancer Screening:
Mission:
Raise awareness about the coverage of Prostate Cancer Screening.
Background:
In an effort to develop appropriate messages targeted at this group of
Medicare beneficiaries, we entered into an intra-agency agreement with
AHRQ to obtain appropriate promotional and awareness messages, based
on its evidence report and the U.S. Preventive Services Task Force
recommendations.
The CDC is developing various materials to address prostate cancer
concerns and to raise awareness about screening. These materials will
be distributed nationally and will be tailored for the Medicare
beneficiary.
[End of section]
Appendix II: GAO Contact and Staff Acknowledgments:
GAO Contact:
Frank Pasquier (206) 287-4861:
Acknowledgments:
Other major contributors to this report include Lacinda Ayers, Matthew
Byer, Jennifer Cohen, Jennifer Major, Behn Miller, and Stan Stenersen.
[End of section]
Footnotes:
[1] A recent bill proposes adding visual acuity, hearing impairment,
cholesterol, and hypertension screenings as well as expanding the
eligibility of individuals for bone density screenings. See H.R. 2058,
107th Cong. § 203 (2001).
[2]The Behavioral Risk Factor Surveillance System (BRFSS), the survey
we used, is an ongoing, state-based, random-digit-dialed telephone
survey of U.S. civilian, noninstitutionalized adults 18 years or
older. We used data from 1995, 1997, and 1999. Data from this survey
are self-reported.
[3] These included peer review organizations (PROs) under CMS contract
to improve quality of Medicare services. We talked to the two lead
PROs responsible for supporting PRO efforts to increase flu and
pneumococcal immunizations and breast cancer screening services, as
well as to the PRO leading efforts to reduce disparities in the use of
preventive services among disadvantaged populations. We also talked to
three PROs responsible for increasing use of services in states with
the lowest, median, and highest utilization rates. These six PROs were
geographically dispersed across the nation.
[4] U.S. General Accounting Office, Medigap Insurance: Plans Are
Widely Available but Have Limited Benefits and May Have High Costs,
[hyperlink, http://www.gao.gov/products/GAO-01-941] (Washington, D.C.:
July 31, 2001).
[5] Survey data are from the CDC's BRFSS 1999.
[6] During the course of our review CMS began referring to these
entities as Quality Improvement Organizations. CMS officials told us
that CMS plans to formalize the name change in a future Federal
Register notice.
[7] The data were from the CDC's BRFSS for 50 states and the District
of Columbia. BRFSS does not contain data for colorectal cancer
screening for 1995 and 1997.
[8] Although Medicare has covered immunizations for hepatitis B since
1984, usage data are not available.
[9] We excluded women who reported having had hysterectomies before
calculating the usage rate for the cervical cancer screen.
[10] Sigmoidoscopy or colonoscopy in past 5 years or fecal-occult
blood test in past year.
[11] We excluded states whose 95 percent confidence intervals for that
service were wider than 10 percentage points.
[12] "Other" ethnic groups include survey respondents who reported an
ethnicity other than African American, Hispanic, or white.
[13] There was no statistically significant difference between the
rate at which the ethnic groups used cervical and breast cancer
screening or the sigmoidoscopy/colonoscopy colorectal cancer
screenings. Likewise, there was no statistically significant
difference between the rates that African Americans and Hispanics were
immunized against pneumonia or that whites and "other" ethnic groups
were immunized for either pneumonia or the flu.
[14] Data are from the CDC's BRFSS, 2000.
[15] CDC researchers report that among the general population, over 80
percent of hysterectomies are performed for noncancerous conditions
such as fibroids and endometriosis.
[16] One half of the Medicare population is age 75 and older, and in
1997, the life expectancy for 75 year olds was about 86.2 years.
[17] The U.S. Preventive Services Task Force is a committee of medical
experts convened by the Department of Health and Human Services to
evaluate evidence and make recommendations for clinical preventive
services such as mammography and prostate cancer screening.
[18] These organizations include the American College of Physicians,
the National Cancer Institute, and the American College of Preventive
Medicine.
[19] Health Care Financing Administration, Evidence Report and
Evidence-Based Recommendations: Interventions that Increase the
Utilization of Medicare-Funded Preventive Services for Persons Age 65
and Older, Publication No. HCFA-02151 (Prepared by Southern California
Evidence-based Practice Center/RAND, 1999).
[20] Health Care Financing Administration, Evidence Report and
Evidence-Based Recommendations: Interventions that Increase the
Utilization of Medicare-Funded Preventive Services for Persons Age 65
and Older.
[21] CMS is conducting a standing orders pilot through its PRO program
in nine states (using five additional states as control states) to
test organizational and system change in nursing homes.
[22] Under certain circumstances, Medicare providers may offer
incentives for preventive services. Specifically, under regulations
which became effective April 26, 2000, providers may forgo some
compensation by waiving coinsurance and deductible payments for
medical services, including Medicare preventive services. In addition,
other types of incentives”such as free transportation or gift
certificates”are also allowed so long as the incentive is not
disproportionately large in relationship to the value of the
preventive service. Under no circumstances may cash or instruments
convertible to cash be used. See 42 CFR § 1003.101.
[23] E.C. Schneider, MD, MSc, et al, "Racial Disparity in Influenza
Vaccination: Does Managed Care Narrow the Gap Between African
Americans and Whites?" JAMA, Volume 286, Number 12, (September 26,
2001).
[24] See the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000, Public Law 106-554, Appendix F, § 122, 114
Stat. 2763, 2763A-476 classified to 42 U.S.C. § 1395b-1 nt.
[End of section]
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