Medicare
Use of Preventive Services is Growing but Varies Widely Gao ID: GAO-02-777T May 23, 2002Preventive health care services can extend lives and promote the well being of the nation's seniors. Medicare now covers 10 preventive services--three types of immunizations and seven types of screenings--and legislation has been introduced to cover additional services. However, not all beneficiaries avail themselves of Medicare's preventive services. Some may simply choose not to use them, but others may be unaware that these services are covered by Medicare. Although the use of Medicare preventive service is growing, it varies from service to service and by state, ethnic group, income, and level of education. To ensure that preventive services are delivered to those who need them, the Centers for Medicare and Medicaid Services (CMS) sponsors activities to increase their use. CMS now funds interventions to increase the use of three services--breast cancer screening and immunizations against the flu and pneumonia--in each state. CMS also pays for interventions to increase use of services by minorities and low-income beneficiaries with low usage rates. CMS is evaluating the effectiveness of current efforts and expects to have the evaluation results later in 2002.
GAO-02-777T, Medicare: Use of Preventive Services is Growing but Varies Widely
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United States General Accounting Office:
GAO:
Testimony:
Before the Subcommittee on Oversight and Investigations, Committee on
Energy and Commerce, House of Representatives:
For Release on Delivery:
Expected at 10:00 a.m.
Thursday, May 23, 2002:
Medicare:
Use of Preventive Services is Growing but Varies Widely:
Statement of Janet Heinrich:
Director, Health Care”Public Health Issues:
GAO-02-777T:
Mr. Chairman and Members of the Subcommittee:
We are pleased to be here today as you review existing preventive
health care services offered in the Medicare program and consider
proposals for expanding these benefits. At your Subcommittee's
request, we have been examining several issues related to preventive
services and have prepared a report that is being released today.
[Footnote 1] My statement today highlights some of the key aspects of
that report.
Preventive health care services, such as flu shots and cancer
screenings, can extend lives and promote the well-being of our
nation's seniors. Medicare now covers 10 preventive services-3 types
of immunizations and 7 types of screening”and legislation has been
introduced to cover additional services.[Footnote 2] However, not all
beneficiaries avail themselves of Medicare's preventive services. Some
beneficiaries may simply choose not to use them, but others may be
unaware that these services are available or covered by Medicare.
You asked us to examine two questions regarding preventive services
for older Americans:
* To what extent are Medicare beneficiaries using covered preventive
services?
* What actions have the Centers for Medicare and Medicaid services
(CMS), which administers Medicare, taken to increase beneficiaries'
use of preventive services?
Our data on the extent to which beneficiaries are using covered
services are taken primarily from a survey conducted by the Centers
for Disease Control and Prevention (CDC), another agency that like CMS
is within the Department of Health and Human Services. The survey
collects information on the use of several preventive services covered
under Medicare, including immunizations for influenza and pneumococcal
disease, and screening for breast, cervical, and colon cancer.
In summary, although use of Medicare covered preventive services is
growing, it varies from service to service and by state, ethnic group,
income, and level of education. For example, in 1999, 75 percent of
women had been screened within the previous 2 years for breast cancer,
compared with 55 percent of beneficiaries who had ever been immunized
against pneumonia. However, even for a widely used preventive service
such as breast cancer screening, state-by-state usage rates ranged
from 66 to 86 percent. Among ethnic groups, differences were greatest
for immunizations. For example, 1999 data show that about 57 percent
of whites and 54 percent of "other" ethnic groups had been immunized
against pneumonia, compared to about 37 percent of African Americans
and Hispanics.[Footnote 3] Among income and educational groups,
variation was greatest for cancer screening.
To help ensure that preventive services are being delivered to those
beneficiaries who need them, CMS sponsors activities”called
"interventions"”aimed at increasing use. CMS currently funds
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 minorities and low-income beneficiaries who have low usage
rates. The techniques being used in some of these interventions, such
as allowing nurses or other nonphysician medical personnel to
administer vaccinations with a physician's standing order, have been
found effective in the past. CMS is evaluating the effectiveness of
current efforts and expects to have the evaluation results later in
2002.
Types of Services Covered:
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 the Medicare law several times to add coverage
for certain preventive services for different age and risk groups
within the Medicare population. These services include three types of
immunizationspneumococcal disease, hepatitis B, and influenza.
Screening for five types of cancer”cervical, vaginal, breast,
colorectal, and prostate”are also covered, as well as screening for
osteoporosis and glaucoma. Except for flu and pneumonia immunizations,
and laboratory tests, Medicare requires some cost-sharing by
beneficiaries. Most beneficiaries have additional insurance, which may
cover most, if not all, of these cost-sharing requirements.[Footnote 4]
For a number of reasons, not all Medicare beneficiaries are likely to
use these services. For some beneficiaries, certain services may not
be warranted or may be of limited value. Screening women for cervical
cancer is an example. Survey data show that 44 percent of women age 65
and over have had hysterectomies”an operation that usually includes
removing the cervix.[Footnote 5] For these women, researchers state
that cervical cancer screening may not be necessary unless they have a
prior history of cervical cancer.[Footnote 6] Also, patients with
terminal illnesses or of advanced age may decide to forgo services
because of the limited benefits preventive services would offer.
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 Finally, 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.
To help determine which preventive services are beneficial among
various patient populations, the U.S. Department of Health and Human
Services established a panel of experts in 1984, called the U.S.
Preventive Services Task Force. The task force identifies and
systematically evaluates the available evidence to determine the
effectiveness of preventive services for different age and risk
groups, and then makes recommendations as to their use. Task force
recommendations were first published in the Guide to Clinical
Preventive Services in 1989, and are periodically updated as new
evidence becomes available. These recommendations are for screening,
immunizations, and counseling services that are specific for each age
group, including people 65 and older. See table 1 for the task force
recommendations for various preventive services including those
currently covered by Medicare.
Table 1: Preventive Services Covered by Medicare or Recommended by the
Task Force:
Service: Immunizations: Pneumococcal;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: 1981;
Medicare cost-sharing requirements[A]: None.
Service: Immunizations: Hepatitis B;
Task force recommendation for age 65+: No recommendation;
Year first covered by Medicare as preventive service: 1984;
Medicare cost-sharing requirements[A]: Copayment after deductible.
Service: Immunizations: Influenza;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: 1993;
Medicare cost-sharing requirements[A]: None.
Service: Immunizations: Tetanus-diphtheria (Td) boosters;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Cervical cancer”pap smear;
Task force recommendation for age 65+: Recommended[B];
Year first covered by Medicare as preventive service: 1990;
Medicare cost-sharing requirements[A]: Copayment with no deductible[C].
Service: Screening: Breast cancer”mammography;
Task force recommendation for age 65+: Recommended[D];
Year first covered by Medicare as preventive service: 1991;
Medicare cost-sharing requirements[A]: Copayment with no deductible.
Service: Screening: Vaginal cancer”pelvic exam;
Task force recommendation for age 65+: No recommendation;
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: Copayment with no deductible[C].
Service: Screening: Colorectal cancer”fecal-occult blood test;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: No copayment or deductible.
Service: Screening: Colorectal cancer”sigmoidoscopy;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: Copayment after deductible[E].
Service: Screening: Colorectal cancer”colonoscopy;
Task force recommendation for age 65+: No recommendation;
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: Copayment after deductible[E].
Service: Screening: Osteoporosis”bone mass measurement;
Task force recommendation for age 65+: No recommendation;
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: Copayment after deductible.
Service: Screening: Prostate cancer”prostate-specific antigen test
and/or digital rectal examination;
Task force recommendation for age 65+: Not recommended;
Year first covered by Medicare as preventive service: 2000;
Medicare cost-sharing requirements[A]: Copayment after deductible[C].
Service: Screening: Glaucoma;
Task force recommendation for age 65+: No recommendation;
Year first covered by Medicare as preventive service: 2002;
Medicare cost-sharing requirements[A]: Copayment after deductible.
Service: Screening: Vision impairment;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Hearing impairment;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Height, weight, and blood pressure;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Cholesterol measurement;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Problem drinking;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Counseling: Diet and exercise, smoking cessation, injury
prevention, and dental health;
Task force recommendation for age 65+: Recommended[F];
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Counseling: Postmenopausal hormone prophylaxis;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Counseling: Aspirin for primary prevention of cardiovascular
events;
Task force recommendation for age 65+: Recommended;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
[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 task force found insufficient evidence to recommend for or
against an upper age limit for pap testing, but recommendations can be
made on other grounds to discontinue regular testing after age 65 in
women who have had regular previous screenings in which the smears
have been consistently normal.
[C] 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.
[D] The task force recommends routine screening for breast cancer
every 1 to 2 years, with mammography alone or along with an annual
clinical breast examination, for women aged 50 to 69. The task force
found insufficient evidence to recommend for or against routine
mammography or clinical breast examination for women aged 40 to 49 or
aged 70 and older.
[E] The copayment is increased from 20 to 25 percent for services
rendered in an ambulatory surgical center.
[F] The task force recommends these counseling services on the basis
of the proven benefits of modifying harmful or risky behaviors.
However, the effectiveness of clinician counseling to change these
behaviors has not been adequately evaluated.
Source: U.S. General Accounting Office, Medicare: Beneficiary Use of
Clinical Preventive Services, GAO-02-422 (Washington, D.C.: Apr. 12,
2002) and U.S. Preventive Services Task Force, Guide to Clinical
Preventive Services, 2nd ed. (Washington, DC, 1996) and related
updates.
[End of table]
As table 1 shows, Medicare explicitly covers many, but not all, of the
preventive services recommended by the task force. However,
beneficiaries may receive some of the preventive services not
explicitly covered by Medicare. For example, even though blood
pressure and cholesterol screening are not explicitly covered under
Medicare, 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.[Footnote 7] Other task force recommended
services”such as counseling intended to change a patient's unhealthy
or risky behaviors”may also be occurring during office visits.
[Footnote 8] Determining the extent to which these preventive
counseling services occur is difficult, in part, because the content
of such services is not well defined. It is also interesting to note
that the task force recommends these counseling services on the basis
of the proven benefits of a good diet, daily physical activity,
smoking cessation, avoiding household injuries such as falls, and
avoiding dental caries (tooth decay) and periodontal (gum and bone)
disease. However, the effectiveness of clinician counseling to
actually change these patient behaviors has not been established.
Use of Preventive Services is Growing but Varies Widely:
Use of preventive services offered under Medicare has increased over
time. For example, in 1995, 38 percent of beneficiaries had been
immunized against pneumonia, compared with 55 percent in 1999.
Similarly, the use of mammograms at recommended intervals had
increased from 66 percent in 1995 to 75 percent in 1999. While these
examples show that use of preventive services generally is increasing,
they also show variation in use by service. Beneficiaries received
screenings for breast and cervical cancer at higher rates than they
did immunizations against flu and pneumococcal disease. Of the
services for which data are available, colorectal screening rates were
the lowest, with 25 percent of the beneficiaries receiving a
recommended fecal occult blood test within the past year, and 40
percent receiving a recommended colonoscopy or sigmoidoscopy procedure
within the last 5 years.
Relatively few beneficiaries receive multiple services. While 1999
utilization data show progress in improving receipt of preventive
services, and in some cases relatively high rates of use for
individual services, a small number of beneficiaries access most of
the services. For example, although 91 percent of female Medicare
beneficiaries received at least 1 preventive service, only 10 percent
of female beneficiaries were screened for cervical, breast, and colon
cancer, and immunized against both flu and pneumonia.
Although 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. Individual states also ranged from 27 percent to 46
percent in the extent to which beneficiaries receiving a colonoscopy
or sigmoidoscopy for cancer screening.
Usage rates also varied based by beneficiary, income, and education.
Among ethnicity groups, 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" 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. Beneficiaries with higher incomes and
levels of education tend to use preventive services more than those at
lower levels.
Efforts Under Way to Increase Use of Some Preventive Services:
CMS has conducted a variety of efforts to increase the use of
preventive services. These include identifying which approaches work
best and sponsoring specific initiatives to apply these approaches in
every state.
Studies Identify Effective Methods to Increase Use of Services
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 used in the past.[Footnote 9] Among the
CMS-sponsored reviews was one that examined the effectiveness of
various interventions for flu and pneumonia immunizations and
screenings for breast, cervical, and colon cancer.[Footnote 10] This
evaluation, which consolidated evidence from more than 200 prior
studies, concluded that no specific intervention was consistently most
effective for all services and settings.
While no one approach appears to work in all situations, the CMS
evaluation concluded that system changes and financial incentives were
the most consistent at producing the largest increase in the use of
preventive services.
* System changes. These interventions change the way a health system
operates so that patients are more likely to receive services. For
example, standing orders may be implemented in nursing homes to allow
nurses or other nonphysician medical personnel to administer
immunizations.
* Incentives. These interventions include gifts or vouchers to
patients for free services. Medicare allows providers to use this type
of approach only in limited circumstances.[Footnote 11] For example,
in order to encourage the use of preventive services, providers may
forgo some compensation by waiving coinsurance and deductible payments
for 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.
Other interventions found to be effective”though to a lesser degree
than the categories above”are reminder systems and education programs.
* Reminders. These interventions include approaches to (1) remind
physicians to provide the preventive service as part of services
performed during a medical visit or (2) generate notices to patients
that it is time to make an appointment for the service. Studies show
that reminders to either physicians or patients can effectively
improve rates for cancer screening. However, if a computerized
information system is present in a medical office, computerized
provider reminders are consistently more cost-effective than notifying
the patient directly. 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 review found
that while the effect of patient education is significant, it has the
least effect of any of these types of interventions.
CMS Is Sponsoring Efforts to Increase Use of Services:
CMS contracts with 37 Quality Improvement Organizations (QIOs), each
responsible for monitoring and improving the quality of care for
Medicare beneficiaries in one or more states, in the District of
Columbia, or in U.S. territories.[Footnote 12] QIO activities
currently aim to increase use of three Medicare preventive services”
immunizations against flu and pneumonia and screening for breast
cancer.
QIOs are using various methods of increasing the use of these
preventive services. For example, they are developing reminder
systems, such as chart stickers or computer-based alerts, that remind
physicians to contact patients on a timely basis for breast cancer
screening. QIOs are also conducting activities to educate patients and
providers on the importance of flu and pneumonia shots. CMS has taken
steps to evaluate the success of these efforts. CMS officials
explained that the contracts with the QIO organizations are
"performance based" and provide financial incentives as a reward for
superior outcomes. CMS officials expect information on the results by
the summer of 2002.
CMS plans to expand these efforts by QIOs. While the current efforts
include only 3 of the preventive services covered by Medicare, CMS is
also planning to include requirements for the QIOs to increase the use
of screening services for osteoporosis, colorectal, and prostate
cancer in future QIO contracts. CMS is not currently planning to
include QIO contract requirements for the remaining preventive
services covered by Medicare”hepatitis B immunizations or screenings
for glaucoma and vaginal cancer.
Other specific efforts have been started to increase use of preventive
services by minorities and low-income Medicare beneficiaries in each
state. 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
minority and low-income seniors. To address this lack of information,
CMS has tasked each QIO to undertake a project aimed at increasing the
use of a preventive service in a given population. For example, the
QIO may work with community organizations, such as African American
churches, in order to convince more women to receive mammograms. CMS
expects to publish a summary of QIO efforts to increase services for
minorities and low-income seniors after the spring of 2002.
Finally, other studies or projects that CMS has under way 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 13] These demonstration projects are in the
planning stages. 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.
Concluding Observations:
Medicare beneficiaries are making more use of preventive services than
ever before, but there is still room for improvement. While most
preventive services are used by a majority of beneficiaries, few
beneficiaries receive multiple services. Also, disparities exist in
the rates that beneficiaries of different ethnic groups, income and
education levels use Medicare covered preventive services. CMS has
activities underway that have the potential to increase usage of
preventive services. However, the full effect of these activities will
not be known for quite some time.
As the Subcommittee and Congress consider broadening Medicare's
coverage of preventive services, it is important to recognize the
difficulty of translating some preventive service recommendations into
covered benefits. For example, inclusion of behavioral counseling
services may be beneficial, but reaching consensus on common
definitions of these services remains a major challenge. Establishing
Medicare coverage for some screening activities such as blood pressure
and cholesterol screening may not be necessary since most
beneficiaries already receive these services. Nevertheless, we believe
that it is important to regularly review Medicare's coverage of
preventive services as information on the effectiveness of such
services becomes available. It is also important to continue to
explore new approaches to encourage beneficiaries to avail themselves
of the preventive services Medicare covers.
This concludes my prepared statement, Mr. Chairman. I will be happy to
respond to any questions that you or Members of the Subcommittee may
have.
Contacts and Acknowledgments:
For future contacts regarding this testimony, please call Janet
Heinrich, Director, Health Care”Public Health Issues, at (202) 512-
7119, or Frank Pasquier at (206) 287-4861. Other individuals who made
key contributions include Matthew Byer, Behn Miller, and Stan
Stenersen.
[End of section]
Footnotes:
[1] U.S. General Accounting Office, Medicare: Beneficiary Use of
Clinical Preventive Services, [hyperlink,
http://www.gao.gov/products/GAO-02-422] (Washington, D.C.: April 12,
2002).
[2] A bill introduced last year 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).
[3] "Other" ethnic groups include survey respondents who reported an
ethnicity other than African American, Hispanic, or white.
[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] Data are from the CDC's Behavioral Risk Factor Surveillance System
(BRFSS), 2000.
[6] CDC researchers report that among the general population, over 80
percent of hysterectomies are performed for noncancerous conditions
such as fibroids and endometriosis.
[7] Survey data are from the CDC's BRFSS 1999.
[8] Counseling women regarding hormone replacement therapy, and all
beneficiaries regarding the use of aspirin for the prevention of
cardiovascular events is not necessarily intended to change behavior.
Rather, it is intended to provide the patient current information on
both the potential benefits and risks of these therapies. The task
force recommends that the decision to undertake these therapies should
be based on patient risk factors for disease and a clear understanding
of the probable benefits and risks of these therapies.
[9] 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.
[10] 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).
[11] Under regulations that became effective on April 26, 2000,
Medicare providers may offer certain incentives for preventive
services. Under no circumstances may cash or instruments convertible
to cash be used. See 42 CFR § 1003.101.
[12] CMS formerly referred to this program as the Peer Review
Organization program. 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.
[13] See the Medicare, Medicaid, and SCRIP 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]
