Medicare
Most Beneficiaries Receive Some but Not All Recommended Preventive Services Gao ID: GAO-03-958 September 8, 2003Medicare, the federal health program insuring almost 35 million beneficiaries age 65 and older, covers certain preventive services, such as flu shots and mammograms. Most beneficiaries receive care through Medicare's fee-for-service program, under which they generally receive these services as part of visits to the doctor for specific illnesses or conditions. Other beneficiaries receive services under Medicare's managed care program, called Medicare + Choice. GAO was asked to determine (1) the extent to which beneficiaries received recommended preventive services through existing visits, (2) whether approaches used by Medicare + Choice plans provide insight for improving delivery of preventive care services for fee-for-service beneficiaries, and (3) what the Centers for Medicare & Medicaid Services (CMS) is doing to explore suggested options for delivering preventive care to fee-for-service beneficiaries. GAO's work included analyzing data from four national health surveys and reviewing five Medicare + Choice plans considered to have innovative approaches to delivering preventive services. GAO also interviewed Department of Health and Human Services (HHS) and CMS officials and reviewed documents on CMS demonstrations related to preventive services.
Most Medicare beneficiaries receive some preventive services through their visits to physicians, but relatively few receive the full range of preventive services available. Survey data showed, for example, that in 2000 about 30 percent of beneficiaries did not receive a flu shot, and 37 percent had never been vaccinated against pneumonia. Moreover, many Medicare beneficiaries are apparently unaware that they may have conditions that preventive services are meant to detect. For example, in a 1999-2000 nationally representative survey during which people received physical examinations, nearly one-third of those age 65 and older who were found to have high cholesterol measurements said they had not previously been told by a physician or other health professional that they had high cholesterol. Projected nationally, this percentage could represent 2.1 million people. No clear "best practice" approach to delivering preventive care stands out among the innovative Medicare + Choice plans GAO studied. All five plans identify health risks, provide feedback on risks to patients or their physicians, and follow up to reduce those risks. But their follow-up programs, approaches, and priorities differ, and little is known about the effectiveness of these efforts for the Medicare-age population. CMS has begun the development work to design a project evaluating the use of individual assessments of health risks, followed by counseling and other services, as a way to improve preventive care delivery. Another suggested approach--adding a routine physical examination benefit to Medicare's fee-for-service program--could provide more opportunities, but at increased cost and without guarantee that preventive services would actually be provided to Medicare beneficiaries.
GAO-03-958, Medicare: Most Beneficiaries Receive Some but Not All Recommended Preventive Services
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Report to the Chairman, Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce, House of Representatives:
United States General Accounting Office:
GAO:
September 2003:
MEDICARE:
Most Beneficiaries Receive Some but Not All Recommended Preventive
Services:
Medicare:
GAO-03-958:
GAO Highlights:
Highlights of GAO-03-958, a report to the Chairman, Subcommittee on
Oversight and Investigations, Committee on Energy and Commerce, House
of Representatives
Why GAO Did This Study:
Medicare, the federal health program insuring almost 35 million
beneficiaries age 65 and older, covers certain preventive services,
such as flu shots and mammograms. Most beneficiaries receive care
through Medicare‘s fee-for-service program, under which they generally
receive these services as part of visits to the doctor for specific
illnesses or conditions. Other beneficiaries receive services under
Medicare‘s managed care program, called Medicare + Choice. GAO was
asked to determine (1) the extent to which beneficiaries received
recommended preventive services through existing visits, (2) whether
approaches used by Medicare + Choice plans provide insight for
improving delivery of preventive care services for fee-for-service
beneficiaries, and (3) what the Centers for Medicare & Medicaid
Services (CMS) is doing to explore suggested options for delivering
preventive care to fee-for-service beneficiaries.
GAO‘s work included analyzing data from four national health surveys
and reviewing five Medicare + Choice plans considered to have
innovative approaches to delivering preventive services. GAO also
interviewed Department of Health and Human Services (HHS) and CMS
officials and reviewed documents on CMS demonstrations related to
preventive services.
What GAO Found:
Most Medicare beneficiaries receive some preventive services through
their visits to physicians, but relatively few receive the full range
of preventive services available. Survey data showed, for example,
that in 2000 about 30 percent of beneficiaries did not receive a flu
shot, and 37 percent had never been vaccinated against pneumonia.
Moreover, many Medicare beneficiaries are apparently unaware that they
may have conditions that preventive services are meant to detect. For
example, in a 1999–2000 nationally representative survey during which
people received physical examinations, nearly one-third of those age
65 and older who were found to have high cholesterol measurements said
they had not previously been told by a physician or other health
professional that they had high cholesterol. Projected nationally,
this percentage could represent 2.1 million people.
No clear ’best practice“ approach to delivering preventive care stands
out among the innovative Medicare + Choice plans GAO studied. All five
plans identify health risks, provide feedback on risks to patients or
their physicians, and follow up to reduce those risks. But their
follow-up programs, approaches, and priorities differ, and little is
known about the effectiveness of these efforts for the Medicare-age
population.
CMS has begun the development work to design a project evaluating the
use of individual assessments of health risks, followed by counseling
and other services, as a way to improve preventive care delivery.
Another suggested approach”adding a routine physical examination
benefit to Medicare‘s fee-for-service program”could provide more
opportunities, but at increased cost and without guarantee that
preventive services would actually be provided to Medicare
beneficiaries.
HHS generally concurred with the findings of this report.
www.gao.gov/cgi-bin/getrpt?GAO-03-958.
To view the full report, including the scope and methodology, click on
the link above. For more information, contact Janet Heinrich on
202-512-7250.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Most Beneficiaries Receive Some Preventive Services, but Not All That
Are Recommended:
Medicare + Choice Plans Reviewed Assess Health Risks Using Varying
Approaches:
New Ways to Improve the Provision of Preventive Services within
Medicare's Fee-for-Service Program Are Promising but Untested:
Concluding Observations:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Preventive Services Recommended by the U.S. Preventive
Services Task Force or Covered by Medicare:
Appendix III: National Health and Nutrition Examination Survey
Methodology and Results:
Appendix IV: Comments from the Department of Health and Human Services:
Tables:
Table 1. Feedback Processes Described by Medicare + Choice Plans:
Table 2: Four National Health Surveys with Preventive Services Data,
1999-2000:
Table 3: Estimated Proportion of Fee-for-Service Physician Visits Made
by People Age 65 and Older, by Major Reason for the Visits, 2000:
Table 4: Estimated Proportion of Fee-for-Service Physician Visits in
Which Diet Counseling Services Were Provided or Ordered, by Major
Reason for the Visits, 2000:
Table 5: Estimated Proportion of Fee-for-Service Physician Visits in
Which Blood Pressure Measurements Were Provided or Ordered, by Major
Reason for the Visits, 2000:
Table 6: Medicare + Choice Plans Included in GAO's Study:
Table 7: NHANES Data GAO Used to Determine if Participants Had Measures
of Specific Health Conditions:
Table 8: People Age 65 and Older in the United States Found to Have
Measures of Specific Health Conditions, NHANES 1999-2000:
Table 9: People Age 65 and Older in the United States Found to Have
Measures of Specific Health Conditions and Who Reported They Had Not
Previously Been Told They Might Have the Condition, NHANES 1999-2000:
Figures:
Figure 1: Major Reasons for Physician Visits by Medicare Beneficiaries
in the Fee-for-Service Program, 2000:
Figure 2: Estimated Number of Medicare Beneficiaries Age 65 and Older
Who Were Aware and Unaware That They Might Have High Blood Pressure or
High Cholesterol, 1999-2000:
Abbreviations:
AMA: American Medical Association:
ACE Inhibitor: Angiotensin-converting enzyme inhibitor:
BRFSS: Behavior Risk Factor Surveillance Survey:
CDC: Centers for Disease Control and Prevention:
CMS: Centers for Medicare & Medicaid Services:
HHS: Department of Health and Human Services:
NHANES: National Health and Nutrition Examination Survey:
Td: Tetanus-diphtheria:
United States General Accounting Office:
Washington, DC 20548:
September 8, 2003:
The Honorable Jim Greenwood
Chairman
Subcommittee on Oversight and Investigations
Committee on Energy and Commerce
House of Representatives:
Dear Mr. Chairman:
Medicare, the federal government's health insurance program that covers
almost 35 million people age 65 and older, was created largely to help
pay beneficiaries' health care costs once they become ill or
injured.[Footnote 1] For the most part, the federal government pays
physicians and other health care providers to treat Medicare
beneficiaries for illnesses and health conditions. In addition, the
Congress has broadened Medicare coverage to include specific preventive
services, aimed at either (1) keeping an illness or condition from
developing or (2) keeping it from becoming more serious through early
detection and subsequent management. Immunization against influenza (a
"flu shot") is an example of the first type of preventive service; a
mammogram to detect breast cancer is an example of the second. Overall
preventive care depends heavily on identifying health risks associated
with the onset or progression of disease and taking steps to reduce or
mitigate these risks.
We previously reported to you that Medicare beneficiaries' use of
covered preventive services has increased over time but varies widely
from service to service.[Footnote 2] In response, you asked us to
follow up on several issues. One issue is the success of providing
preventive services through a Medicare service delivery system based
primarily on treating existing illnesses and health conditions. Under
Medicare's fee-for-service program, which enrolls about 84 percent of
Medicare beneficiaries, no specific provision exists for a routine
annual physical or checkup that could be a vehicle for delivering
preventive services.[Footnote 3] Unless beneficiaries in the fee-for-
service program have supplemental insurance that covers such a checkup,
they may have to depend on receiving preventive services during their
visits for specific illnesses or conditions, or during other visits for
those specific preventive services that Medicare does cover. A second
issue is what can be learned about the effectiveness of preventive
service approaches put in place by plans that contract with Medicare to
offer health care on a managed care basis.[Footnote 4] These plans,
which enroll about 14 percent of all Medicare beneficiaries under an
option known as Medicare + Choice, generally offer a benefit for
periodic checkups.[Footnote 5] Some of these Medicare + Choice plans
are regarded as particularly innovative in assessing risk, providing
screening services, and conducting prevention programs. This report
addresses the following questions:
* Do Medicare beneficiaries receive recommended preventive services
through existing physician visits?
* What approaches for preventive care have been taken by selected
Medicare + Choice plans, and what is known about their effectiveness
for the Medicare beneficiaries they serve?
* What delivery options for identifying and reducing health risks have
been suggested for Medicare fee-for-service beneficiaries, and are any
of these options being explored by the Centers for Medicare & Medicaid
Services (CMS), the agency administering the program?
Because no single source contained all the information we needed to
assess the extent to which Medicare beneficiaries receive preventive
services through existing physician visits, we analyzed data from four
nationally representative health surveys. The Centers for Disease
Control and Prevention's (CDC) Behavioral Risk Factor Surveillance
System asks a range of health questions over the telephone, including
if respondents received a "routine checkup" within the past year. CMS's
Medicare Current Beneficiary Survey collects self-reported data,
including whether respondents have received influenza or pneumonia
immunizations. CDC's National Health and Nutrition Examination Survey
(NHANES) collects data on health conditions by means of both
comprehensive health examinations and interviews, where patients self-
report information, including whether a physician or other health
professional has ever told them that they have a given health
condition. Unlike the other surveys, which take a sample of the
population, CDC's National Ambulatory Medical Care Survey samples
physician practices, collecting detailed information about office
visits, including the major reason for the visit and which preventive
services were ordered or provided. In addition, this survey captured
information that allowed us to assess whether visits by Medicare
beneficiaries were on a fee-for-service basis. Unless otherwise noted,
however, the data we report generally included beneficiaries from both
systems.
To describe the approaches of selected Medicare + Choice plans in
delivering preventive services, we assessed literature and interviewed
national experts to identify plans that were considered innovative in
preventive care. We then obtained information from five such plans:
AvMed Health Plans, Group Health Cooperative, Highmark Blue Cross and
Blue Shield, Kaiser Permanente, and Oxford Health Plans. Collectively,
an estimated 1.2 million Medicare beneficiaries in 15 states plus the
District of Columbia receive their health care under these plans. To
determine suggested options for identifying and reducing health risks
and what CMS is doing to assess them, we reviewed the results of past
related research demonstrations and congressionally mandated studies
and interviewed Department of Health and Human Services (HHS) and CMS
officials and other experts. (App. I further describes our scope and
methodology.) We conducted our work from October 2002 through August
2003 in accordance with generally accepted government auditing
standards.
Results in Brief:
Most Medicare beneficiaries receive some but not all recommended
preventive services, although they typically visit a physician several
times during a year. Our analysis of year 2000 data shows that nearly 9
in 10 Medicare beneficiaries visited a physician at least once that
year, with a beneficiary making an average of six visits or more within
the year. Preventive services are delivered during all types of visits-
-whether for illnesses, health conditions, or nonillness care.
Regardless of the reason for a visit, however, many beneficiaries did
not receive recommended preventive services. In 2000, for example,
about 30 percent of Medicare beneficiaries did not receive an influenza
vaccination and 37 percent had never had a pneumonia vaccination, as
recommended under current guidelines for people age 65 and older.
Moreover, many Medicare beneficiaries may have conditions of potential
concern that they are unaware of. For example, among the Medicare
beneficiaries who participated in a nationally representative survey
and were found through physical examinations to have high cholesterol,
about one-third said they had not previously been told by a physician
or other health professional that they might have this condition.
Projected nationally, this percentage translates into about 2.1 million
people age 65 and older.
Although they differ from one another in approach and emphasis, the
preventive care approaches of the Medicare + Choice plans we reviewed
share common elements. In particular, their approaches screen enrollees
to identify health risks and then provide a number of follow-up
activities designed to reduce those risks. The plans generally use
combinations of methods to ascertain needed preventive services,
including periodic preventive visits, health risk questionnaires, and
periodic assessments of medical claims and pharmacy data. All plans
also have follow-up strategies to help beneficiaries obtain needed
preventive services, although their strategies and priorities vary.
Follow-up interventions include counseling programs to encourage
behavioral change, cancer screening for early detection of disease, and
programs to coordinate and manage chronic conditions such as diabetes
and cardiovascular disease. Although some plans furnished us with data
suggesting that their approaches hold promise, few had conducted a
systematic evaluation of whether the approaches improved health
outcomes or lowered health care costs. Those studies that do show a
relationship between greater use of preventive services and improved
health outcomes or cost savings are limited in terms of how their
findings might be generalized to Medicare beneficiaries.
Several options have been suggested for improving the provision of
preventive services under Medicare's fee-for-service program, each with
its own advantages and disadvantages. Two options center on adding a
new benefit for a nonillness-related examination, specifically either
(1) a one-time "welcome-to-Medicare" examination for new beneficiaries
or (2) a periodic examination benefit for all beneficiaries. Coverage
of a one-time or periodic wellness examination could be easily
administered, and the examination could provide an opportunity for
beneficiaries to receive some preventive services. Adding such a
benefit, however, could increase Medicare costs and still not guarantee
that beneficiaries receive the preventive services they need. The
results of a past CMS demonstration indicate that offering Medicare
beneficiaries packages of broad-based preventive services has not
consistently improved health or lowered hospital and other costs. As a
result, CMS has recently considered an alternative option that would
essentially create a different structure using nonphysician providers
to assess health risks and ensure the delivery of preventive services
within the fee-for-service program. The agency has started the
development work to design a project to examine whether assessments of
individual health risks, combined with continued counseling and follow-
up services provided by nonphysicians, will improve delivery of
preventive services and beneficiary health. CMS also has under way
several other demonstration projects related to preventive care in the
fee-for-service program, such as a smoking cessation program tailored
to Medicare beneficiaries. Results from these demonstration efforts are
not expected for several years.
HHS reviewed a draft of this report and generally concurred with the
findings.
Background:
Many of the health conditions that people age 65 and older experience
are preventable and linked to specific health risks. Some health risks
are difficult to change, and some, such as a hereditary predisposition
for a given disease, cannot be changed. For these, preventive services
such as cancer screens can help identify disease in its early stages so
that people can be referred to other services that can help manage or
treat the disease. Other health risks, such as complications from
influenza, can be successfully reduced by targeted preventive services.
For example, studies show that immunizations against influenza can
prevent thousands of hospitalizations and deaths each year among those
age 65 and older. Health risks such as high blood pressure and high
cholesterol are also considered health conditions because, if left
alone, they can develop into potentially more significant conditions,
such as cardiovascular disease, or lead to stroke.
The term preventive care covers a wide spectrum of actions aimed at
reducing risks for deteriorating health and improving the detection and
management of disease. Generally, preventive care is intended for three
purposes:
* To prevent a health condition from occurring at all. Vaccinations and
physical activity to reduce the risk of heart disease, for example,
qualify as this first type of preventive care (termed primary
prevention).
* To prevent or slow a condition's progression to more significant
health conditions by detecting a disease in its early stages.
Mammograms to detect breast cancer and other screens to detect disease
early are examples of this second type of preventive care (termed
secondary prevention).
* To prevent or slow a condition's progression to more significant
health conditions by minimizing the consequences of a disease. Care
coordination and self-management of an existing disease, such as
diabetes or asthma, are examples of this third type of preventive care
(termed tertiary prevention).
Many people associate the idea of preventive care with annual physical
examinations, or "routine checkups," by a family doctor, a practice
first proposed by the American Medical Association (AMA) in the early
twentieth century. In the early 1980s, however, the AMA determined that
appropriate preventive care depends on an individual's age and
particular health risks, not simply on the results of a standard
battery of tests.[Footnote 6] To evaluate preventive care for different
age and risk groups, HHS in 1984 established a panel of experts called
the U.S. Preventive Services Task Force. At present, the task force
recommends certain screening, immunization, and counseling services for
people age 65 and older (see app. II).
Medicare covers some, but not all, of the task force-recommended
preventive services (see comparison in app. II). Medicare's fee-for-
service program--which comprises approximately 84 percent of Medicare
beneficiaries--does not cover periodic checkups, where clinicians might
assess an individual's health risk and provide needed preventive
services. These Medicare beneficiaries may, however, receive some of
these services during office visits for other health problems. Under
Medicare + Choice, which covers about 14 percent of Medicare
beneficiaries, a benefit for periodic checkups generally does exist.
Most Beneficiaries Receive Some Preventive Services, but Not All That
Are Recommended:
Medicare beneficiaries typically visit a physician several times during
a year and most receive some preventive services, but most do not
receive the full range of recommended services. Based on 2000 survey
data and U.S. Bureau of the Census estimates of people age 65 and
older, we estimate that beneficiaries visit a physician at least six
times a year, on average, mainly for illnesses or medical
conditions.[Footnote 7] About 1 in 10 visits occurred when
beneficiaries were well, and most Medicare beneficiaries reported
having what they considered to be a "routine checkup" in the previous
year. The purposes of these routine checkups and the specific services
that are delivered during these visits, however, remain unknown. Many
Medicare beneficiaries did not receive recommended preventive services,
such as influenza and pneumonia immunizations. Moreover, another
national survey indicated that a substantial share of Medicare
beneficiaries who were at risk for a condition that preventive services
are meant to identify said that they had not been told by a health
professional that they might have that condition.
Medicare Beneficiaries Visit Physicians Often, and Most Report
Receiving Routine Checkups:
In 2000, 88 percent of Medicare beneficiaries reported that they
visited a physician at least once that year.[Footnote 8] On the basis
of data from CDC's National Ambulatory Medical Care Survey, we estimate
that, on average, beneficiaries visit physicians at least six times a
year.[Footnote 9] Almost 9 in 10 visits made by beneficiaries in the
fee-for-service program were to treat illnesses or health conditions:
more than half the visits targeted preexisting (chronic) problems, more
than one-fourth targeted illnesses of sudden or recent onset (acute),
and about 10 percent of visits took place pre-or postsurgery or to
follow up after injuries. Only about 10 percent of visits dealt with
nonillness care when the patient was considered healthy (see fig.
1).[Footnote 10]
Figure 1: Major Reasons for Physician Visits by Medicare Beneficiaries
in the Fee-for-Service Program, 2000:
[See PDF for image]
Note: Numbers do not add to 100 percent due to rounding. The survey
defined an "acute problem" as a condition or illness of sudden or
recent onset, a "chronic problem" as a preexisting long-term or
recurring condition or illness, and "nonillness care" as a general
health maintenance examination or routine periodic examination of a
presumably healthy person. For chronic problems, the survey reported
results separately for "routine chronic problems" and for "chronic
problem flare-ups." We combined these results in this figure. The
separate results are found in app. I.
[End of figure]
Even though the majority of visits to physicians are for treating
illness or health conditions, most Medicare beneficiaries reported
receiving routine checkups. In CDC's 2000 Behavioral Risk Factor
Surveillance System Survey, for example, 93 percent of respondents age
65 and older reported that they had received a "routine checkup" within
the previous 2 years. This survey did not, however, provide information
on which specific services were delivered during those checkups.
Indeed, as the following section shows, few beneficiaries receive all
recommended services, although they receive some preventive services
during visits when they are healthy as well as during visits to treat
illnesses or health conditions.
Despite Frequency of Visits, Many Medicare Beneficiaries Do Not Receive
the Full Range of Recommended Preventive Services:
Despite how often Medicare beneficiaries visit physicians, many of them
do not receive a full complement of recommended preventive services,
including some recommended by the U.S. Preventive Services Task Force
and currently covered by Medicare. As we reported earlier, use of
specific preventive services varies widely by service.[Footnote 11]
Although each preventive service we reviewed was delivered to a
majority of Medicare beneficiaries, relatively few beneficiaries
received the full range of preventive services. For example, 91 percent
of female Medicare beneficiaries received at least one preventive
service, but only 10 percent were screened for cervical, breast, and
colon cancer and also immunized against influenza and
pneumonia.[Footnote 12] Our analysis of additional data since our
previous report shows that many Medicare beneficiaries still do not
receive certain recommended preventive services. The task force
recommends, for example, that all people age 65 and older receive an
annual influenza vaccination and at least one pneumonia vaccination. In
CMS's Medicare Current Beneficiary Survey of 2000, however, about 30
percent of Medicare beneficiaries did not receive an influenza
vaccination, and 37 percent had never had a pneumonia vaccination.
Survey data showing the services provided during office visits indicate
that Medicare beneficiaries do receive some preventive services during
visits when they are ill or being treated for a health condition, and
services are delivered at comparable rates during all types of visits,
whether for nonillness care or for treating acute or chronic
conditions. Beneficiaries in the fee-for-service program receive
preventive services, such as cholesterol and blood tests, during visits
when they are healthy and during visits to treat acute or chronic
health conditions. Some tests are typically provided or ordered
slightly more often during visits for nonillness care. In 2000, for
example, blood tests for anemia[Footnote 13] were provided in about 16
percent of visits for nonillness care, compared with 7 percent of
visits for chronic problems and 5 percent of visits for acute
conditions. Other preventive services were provided at similar rates
during the different types of visits. For example, we estimate that
blood pressure measurement, a clinical screen for conditions such as
hypertension, was done during 56 to 62 percent of visits, depending on
the type of visit. Diet counseling services were provided during 13 to
20 percent of visits, depending on the type of visit.[Footnote 14]
Many Beneficiaries May Be Unaware of Their Risk for Health Conditions
That Preventive Care Is Meant to Detect:
Many Medicare beneficiaries may not know that they are at risk for
health conditions that preventive care could detect--strong evidence
that they may not be receiving the full range of recommended preventive
services.[Footnote 15] For example, data from CDC's NHANES for 1999-
2000 show that, of beneficiaries participating in this nationally
representative survey who had a physical examination and were found to
have elevated blood pressure readings at the time of the examination,
32 percent reported that no physician or other health professional had
ever told them about the condition. On the basis of this survey, we
estimate that, during the period when the survey was conducted, 21
million Medicare beneficiaries may have been at risk for high blood
pressure, and an estimated 6.6 million of them may have been unaware of
this risk. Similarly, 32 percent of those found in the 1999-2000 survey
to have a high cholesterol level reported that no one had told them
that they had high cholesterol. Projected nationally, this percentage
translates into 2.1 million Medicare beneficiaries (see fig. 2).
Figure 2: Estimated Number of Medicare Beneficiaries Age 65 and Older
Who Were Aware and Unaware That They Might Have High Blood Pressure or
High Cholesterol, 1999-2000:
[See PDF for image]
Note: CDC's NHANES measured blood pressure three or four times during
its 1-day physical examination. For our analysis, we calculated the
average of the blood pressure measurements and applied CDC's definition
of high blood pressure: that is, a patient's having an average systolic
blood pressure equal to or greater than 140, or an average diastolic
blood pressure equal to or greater than 90, or a patient who reported
taking hypertension medication. CDC defined high cholesterol as a total
cholesterol level equal to or greater than 240.
[End of figure]
Medicare + Choice Plans Reviewed Assess Health Risks Using Varying
Approaches:
The Medicare + Choice plans we reviewed vary in their specific
strategies for delivering preventive services, but several common
themes emerge from their efforts. First, nearly all identify members'
health risks and inform them or their providers about specific services
that might be needed. For example, some plans mail questionnaires to
members, seeking information, such as when certain screening tests were
last performed; other plans review claims and prescription data to
identify at-risk members who might need a screening test or other
preventive service. Second, all plans have follow-up strategies to help
beneficiaries obtain needed preventive services, although their
strategies and priorities vary. Third, while limited data provided by
some plans suggest promising results, most plans have not evaluated the
degree to which their strategies improve health outcomes or affect
health care costs for Medicare beneficiaries.
Plans Use a Combination of Ways to Identify Health Risks:
Although all the Medicare + Choice plans we reviewed use questionnaires
to meet the requirement that they conduct health assessments for newly
enrolled Medicare beneficiaries,[Footnote 16] they use a combination of
approaches to identify health risks. The particular risks that plans
seek to identify vary from plan to plan. Risks include those associated
with depression or lack of physical activity; risks from not obtaining
recommended immunizations or screenings, such as mammography; and more
general risk of short-term hospitalization or illness.[Footnote 17] For
example, Group Health Cooperative, Highmark Blue Cross and Blue Shield,
and Kaiser Permanente use questionnaire information to calculate a risk
score meant to represent each enrollee's probability of using health
services heavily in the future. From its questionnaire, Kaiser
Permanente also calculates the probability of 3-year survival for
enrollees who have an existing advanced illness, as well as the
probability that they will become dependent on others for daily care or
need nursing home services during the next year (a condition Kaiser
Permanente officials refer to as frailty). Oxford Health Plan, on the
other hand, analyzes questionnaire data to assign enrollees a risk
classification of high, moderate, or low and assigns patients to health
management teams or programs appropriate for each risk level.
For existing members, plans use slightly different approaches to
identify health risks, including information from claims and pharmacy
data, annual risk assessment questionnaires, physician visits, and
computer systems (called registries) that indicate when patients
require specific preventive services. The specific approaches vary from
plan to plan. For instance, Group Health Cooperative officials reported
that they review the health risks, such as the immunization status, of
their existing members through health maintenance visits, which they
encourage Medicare beneficiaries to have every 2 years. During this
visit, the provider reviews responses to a completed questionnaire that
each patient is asked to bring to the visit and updates computer
registry data, compiled from previous risk assessment questionnaires
and physician visits. AvMed conducts a health risk assessment for each
of its Medicare members and also uses claims and pharmacy data to
identify members with specific diseases, so as to target preventive
services. For example, using pharmacy and claims data to identify
people with diabetes, AvMed invites these members to a health fair
featuring services to prevent further progression of the disease.
Paying a single copayment to attend the health fair, members can
receive a number of services, such as a blood draw for laboratory work
and vision and glaucoma screening.
Finally, some plans report that they have increased the use of specific
preventive services through their participation in CMS-required
national performance improvement projects.[Footnote 18] For example,
Highmark reported that in 2002 the plan used medical claims data to
identify female Medicare beneficiaries who had not received a mammogram
within the past 2 years and notified the beneficiaries and their
physicians. As a result, the officials reported that 60 percent of
contacted beneficiaries went on to receive mammograms.
Plans Use a Variety of Follow-up Means to Reduce Identified Risks:
After identifying the health risks of Medicare beneficiaries--whether
new enrollees or existing members--plans we contacted reported that
they also make efforts to follow up on that information by providing
feedback to enrollees about risks and referring them to specific, risk-
related preventive services. For example, all plans have approaches to
prevent disease progression for individuals identified as having
chronic health conditions. The plans sometimes differ in their types of
follow-up and in their emphasis on different types of preventive
services. Some plans we reviewed, for example, stress primary
prevention activities, such as exercise programs for all members, to a
greater degree than others.
To provide feedback, many plans contact members directly through
letters or phone calls, encourage contact with primary care physicians,
or combine written or oral feedback with follow-up physician
examinations (see table 1).
Table 1: Feedback Processes Described by Medicare + Choice Plans:
Health plan: Group Health Cooperative; Feedback process: Using data
available on computer registry, health professionals can review
specific health risks with members. Health professionals also monitor
the computer registry to track services members use.
Health plan: Kaiser Permanente; Feedback process: For new enrollees,
physicians review a summary report and provide feedback during an
initial office visit. In San Diego, existing members who visit health
assessment centers receive a letter, based on a completed questionnaire
and tests estimating "health age," that discusses ways of decreasing
specific health risks, and they receive a second visit for a complete
exam.
Health plan: Oxford Health Plans; Feedback process: Various departments
receive health risk reports based on risk assessment questionnaires.
Reports for high-risk members go to teams of registered nurses, who
contact the members and their primary care physicians to coordinate
care.
Health plan: Highmark Blue Cross and Blue Shield; Feedback process:
Plan sends results of health risk assessment to physicians to
facilitate discussion with patients. Members with risks related to
smoking, heart disease, or osteoporosis receive letters. New members
identified as at risk for being frail are referred to case managers,
and members identified with chronic disease are referred to a condition
management program for targeted interventions.
Health plan: AvMed Health Plans; Feedback process: Physicians receive
health risk information from risk assessment questionnaires and
pharmacy and claims data. Members identified as having specific risks
are contacted directly by the plan if health promotion or disease
management programs are available for them.
Source: Plan officials and plan documents.
[End of table]
In addition to educating members about their health risks, some plans
also link members to specific preventive services to reduce or mitigate
these risks. For example, plans may send targeted health promotion
materials; offer 24-hour telephone access to a nurse to discuss health
concerns; or offer access to fitness programs, nutrition courses,
immunizations, exams, and disease management or care coordination
programs. These care coordination programs resolve health care issues
through various means, such as in-depth telephone evaluations,
communication with primary care physicians, in-home visits, or
connections with community resources like Meals on Wheels.
To refer Medicare members to preventive services, one plan we contacted
emphasized directing them to primary prevention services, such as
physical activity programs, while another plan emphasized connecting
members to tertiary prevention services, such as disease management
programs. For example, identifying physical activity and social
isolation as two important predictors of overall health outcomes for
seniors, Group Health Cooperative refers Medicare members to physical
activity benefits and other primary prevention services. In contrast,
acknowledging that most individuals age 65 or older have more than one
chronic health condition, AvMed focuses more on identifying members
with existing conditions and referring them to preventive services that
can mitigate the condition. AvMed has created eight disease management
programs covering conditions such as congestive heart failure, asthma,
and diabetes. The goal is to provide members having these conditions
with a series of condition-specific care interventions. For example,
interventions for AvMed enrollees in the congestive heart failure
program include prescribing specific drugs (such as ACE[Footnote 19]
inhibitors, diuretics, and beta-blockers), providing self-directed
care plans, and monitoring weight.
Some plans described how they track the success of their efforts to
provide people with specific preventive care interventions. Highmark,
for example, offers financial incentives to physicians who follow
specific clinical guidelines for a given condition. The plan also gives
physicians quarterly report cards, generated by a computer registry,
that indicate whether their patients have received all the care
recommended by the management programs in which the patients are
enrolled. AvMed, on the other hand, tracks the number of members
identified as eligible for specific disease management programs,
whether the program was offered to all eligible members, and the number
who enrolled. AvMed also reported setting, monitoring, and reporting on
performance goals for the percentage of members receiving specific care
interventions. For example, for enrollees in the congestive heart
failure management program, AvMed tracks the percentage receiving an
ACE inhibitor drug.
Assessments of Health Outcomes or Cost Savings for Medicare
Beneficiaries Are Limited:
Few of the health plans we contacted had specifically evaluated whether
their approaches to risk identification and reduction lead either to
improved health outcomes for Medicare beneficiaries or to cost savings
for the plan. From those plans that have such information, the
available data suggest that offering disease management programs to
people who have existing health conditions may hold promise, but most
plans lacked evidence from controlled studies of a specific benefit to
their Medicare members.
AvMed and Oxford are among the plans that have evaluated whether their
approach improves health outcomes and saves money. For example, AvMed
plan officials observed that, in all AvMed plans, including its
Medicare + Choice plan, AvMed members with existing chronic conditions
spent fewer days in the hospital during the same period when more of
their members with existing conditions were enrolled in disease
management programs. According to AvMed officials, between 2001 and
2002, shorter hospital stays of Medicare congestive heart failure
patients led to total savings of $1 million, and shorter hospital stays
of asthma patients from all plans (not limited to Medicare
beneficiaries) led to savings of $400,000. Similarly, Oxford has
estimated savings attributed to various interventions, such as a mean
savings of $219 per member per month from Medicare beneficiaries who
voluntarily participated in a self-management workshop for diabetes, as
compared with a random group of diabetic members who did not attend the
workshop. Although these findings show potential to improve health and
decrease costs, it is unclear from this information whether the
decreased length of hospitalization and cost savings resulted from
disease management or from other factors. It is also not clear what the
long-term effects may be on Medicare beneficiaries and whether these
observations would also apply to beneficiaries in a fee-for-service
environment.
Some plans are evaluating specific aspects of their approaches as a
first step in determining which approaches are effective. For example,
Kaiser Permanente officials provided data demonstrating their ability
to identify a certain type of health risk among Medicare beneficiaries,
but they did not provide data demonstrating that their overall
approaches to risk identification or risk reduction resulted in
improved health outcomes or cost savings.[Footnote 20] Specifically,
they found that three questions on the risk assessment questionnaire,
along with the patient's age, predicted with a high degree of accuracy
whether a person would need daily assistance from another person during
the following year. Kaiser identified these people as at risk for
frailty and through additional study found that, over the next decade,
frail people spent more days in nursing homes than individuals who were
not frail.[Footnote 21] Kaiser Permanente officials told us that they
have not identified interventions that decrease or prevent frailty from
developing but were instead focusing on identifying interventions to
improve outcomes for those people once they were identified as
frail.[Footnote 22]
In addition to reviewing the efforts of contacted Medicare + Choice
plans, we reviewed several studies that evaluated the effectiveness of
employer-sponsored approaches to providing preventive services, such as
health risk assessment and feedback, to both employees and retirees.
Although these studies conclude that employer-sponsored approaches hold
promise in terms of increasing preventive services, improving health
outcomes, and lowering cost, we found the results limited in how they
might be generalized to all Medicare beneficiaries. For example,
General Motors evaluated its companywide prevention program, which
offered health risk assessments, individualized health profiles, a
quarterly newsletter, a self-care book, and a toll-free health
information line. The company reported that providing risk assessment
and feedback helped participants lower their health risk status and
that nearly half of this benefit was realized within the first of 5
years. Although General Motors provides a similar risk appraisal
program to retirees, this study did not include them, so the study's
finding cannot be generalized to the Medicare population.
New Ways to Improve the Provision of Preventive Services within
Medicare's Fee-for-Service Program Are Promising but Untested:
Several options have been suggested for improving the provision of
preventive services within Medicare's fee-for-service program. They
include adding a new benefit for a nonillness-related examination,
either a one-time "welcome-to-Medicare" examination for new
beneficiaries or an examination available to all beneficiaries on a
periodic basis. Although covering a one-time or periodic nonillness
examination could be easily administered and could increase the receipt
of some preventive services, doing so could also increase Medicare
costs without necessarily ensuring that beneficiaries receive the full
range of preventive services. CMS has tested similar options in the
past and found that they produced mixed results. It is now examining an
alternative that would essentially create a different structure using
nonphysician providers to assess health risks and connect individuals
with preventive services. The design work will be completed at the end
of 2003, and if the decision is made to conduct a demonstration,
results would not be available for several years after that. Additional
demonstrations also under way--such as one exploring effective smoking
cessation approaches and one giving physicians incentives to coordinate
and manage the overall health care needs of beneficiaries--may provide
additional insights into coordinating and delivering appropriate
preventive services within the Medicare fee-for-service program.
Two Proposed Options Center on Adding a Preventive Examination to the
Medicare Fee-for-Service Program:
A one-time "welcome-to-Medicare" examination for new beneficiaries has
been proposed as a means to better ensure that health care providers
have enough time to identify individual Medicare beneficiaries' health
risks and provide preventive services appropriate for their
risks.[Footnote 23] Proponents assert that a one-time benefit could
combine a health evaluation with screenings and immunizations, along
with counseling about health promotion and disease prevention. It could
also orient new beneficiaries to Medicare and encourage them to make
informed choices about providers and plans. Health risk assessment and
behavior counseling could be provided by a range of nonphysician
professionals, including nurses, counselors, and dietitians.
A similar option would have Medicare cover an annual or periodic
preventive visit available to all fee-for-service beneficiaries. In
theory, many of the advantages of a one-time preventive visit would
also apply to periodic examinations. For instance, dedicated preventive
visits might provide greater opportunities for health care providers to
assess and address health risks. Some evidence also suggests that a
periodic health examination may increase use of preventive cancer
screening and counseling services. For example, a National Cancer
Institute-supported study surveyed general internists and family
physician practices and their patients in 1992 and found that patients
who had received a periodic health examination within the previous year
were substantially more likely to have received appropriate cancer
screening and counseling.[Footnote 24]
While these options have benefits, they also have potential drawbacks.
Adding a benefit for a one-time or periodic examination to the Medicare
fee-for-service package could increase the program's costs without
necessarily ensuring that beneficiaries receive the full range of
preventive services. The Congressional Budget Office in June 2002
estimated that a one-time physical examination benefit for new
enrollees could cost as much as $1.6 billion over the 2003-2012
period.[Footnote 25] According to a Congressional Budget Office
official, the agency has not recently estimated the potential costs of
a Medicare benefit for examinations provided on a periodic basis. This
cost, however, would likely be substantially higher than that of a one-
time visit for new beneficiaries. At the same time, establishing such a
benefit would not necessarily ensure delivery of the full range of
preventive services. In addition, primary care physicians typically
cannot provide services such as mammography screenings for breast
cancer and colonoscopies for colon cancer, because these services
usually require specialists.
It also remains uncertain whether covering a one-time or periodic
examination would be an effective means of improving beneficiary health
outcomes. A previous CMS initiative that included preventive health
care visits ended with mixed results. In the late 1980s and early
1990s, the agency conducted a congressionally mandated demonstration to
test varied health promotion and disease prevention services, such as
free preventive visits, health risk assessment, and behavior
counseling, to see if they would increase use of preventive services,
improve health outcomes, and lower health care expenditures for
Medicare beneficiaries.[Footnote 26] The agency's final report,
published in 1998, concluded that the demonstration services were
marginally effective in raising the use of some simple disease
prevention measures, such as immunizations and cancer screenings, but
did not consistently improve beneficiary health outcomes or reduce the
use of hospital and skilled nursing services.[Footnote 27]
CMS Is Exploring an Alternative for Assessing Health Risks and
Delivering Preventive Services:
CMS is exploring one alternative for Medicare preventive care that
would provide systematic health risk assessments to fee-for-service
beneficiaries through a means other than physician visits. In the late
1990s, the agency commissioned the RAND Corporation to evaluate the
potential effectiveness of health risk assessment programs. Similar to
the approaches taken by the Medicare + Choice plans we reviewed, such
programs collect information from individuals; identify their risk
factors; and refer the individuals to at least one intervention to
promote health, sustain function, or prevent disease.[Footnote 28] The
study concluded that health risk assessment programs have increased
beneficial behavior (particularly exercise) and improved physiological
variables (particularly diastolic blood pressure and weight) and
general health status. It also concluded that more research would help
clarify the programs' effects on preventive services such as clinical
screening.[Footnote 29] In addition, the study stated that to be
effective, risk assessment questionnaires must be coupled with follow-
up interventions such as referrals to appropriate services. The study
found limited but encouraging evidence on the effectiveness of health
risk assessment programs but concluded that the evidence was
insufficient to accurately estimate the programs' cost-effectiveness.
The study recommended that CMS conduct a demonstration to test cost-
effectiveness and other aspects of the health risk assessment approach
for Medicare beneficiaries.
Following up on the study's findings, CMS has begun designing a fee-
for-service-focused demonstration project, called the Medicare Senior
Risk Reduction Program, to identify health risks and follow up with
preventive services provided by means other than physician visits. The
program will use a beneficiary-focused health risk assessment
questionnaire to assess health risks, such as lifestyle behaviors, and
use of clinical preventive and screening services. Because the
demonstration is still in its design phase, the particular set of risk
factors to be included is not yet final. Risk factors that might be
addressed include preventable accidents such as falls, lack of
exercise, high blood pressure, obesity, and use of preventive services.
The Medicare Senior Risk Reduction Program will test different
approaches to administering health risk assessments, creating feedback
reports, and providing follow-up services, such as referring
beneficiaries to health-promoting community services including
physical activity and social support groups. According to project
researchers, the program will tailor preventive interventions to
individual risks; track patient risks and health over time; and provide
beneficiaries with self-management tools and information, health
behavior advice, and end-of-life counseling where appropriate. The
design phase is scheduled for completion in late 2003, when CMS will
decide whether to conduct a full demonstration.[Footnote 30] According
to CMS officials, the potential demonstration's final cost was
uncertain at the time our report was completed. CMS is spending
approximately $1 million on the developmental work.
Unlike some health risk assessment programs, CMS's program will be
limited to questionnaires and follow-up contacts; it will not directly
provide clinical screening such as blood pressure or cholesterol
measurements. Instead, the program will concentrate on identifying,
through information provided by the beneficiary, any modifiable
lifestyle and behavioral risk factors and on referring beneficiaries to
services for reducing those risks. CMS officials and researchers did
indicate, however, that the program's risk assessment tools will
collect information on needed immunizations and cancer screenings and
alert beneficiaries and their physicians to any needed services.
CMS Is Also Exploring Ways to Improve Care for Those with Identified
Health Risks and Conditions:
CMS has other initiatives under way that may help improve the delivery
of preventive services within the fee-for-service program. The first is
the Medicare Stop Smoking Program, a smoking cessation demonstration
project for fee-for-service beneficiaries. Recognizing that smoking is
the single most preventable cause of disease and death in the United
States, posing a significant health risk to the aged, CMS launched the
demonstration to identify the most effective service to help
beneficiaries stop smoking. The demonstration will evaluate the
effectiveness of different smoking cessation services. The four
services being tested are: (1) reimbursement for provider counseling,
(2) reimbursement for provider counseling and for smoking cessation
drugs or nicotine replacement therapy, (3) access to a telephone
counseling quit-line plus reimbursement for nicotine replacement
therapy, and (4) provision of written information on smoking cessation.
Seven states are participating in the demonstration: Alabama, Florida,
Missouri, Ohio, Oklahoma, Nebraska, and Wyoming. The study will be
completed in 2004, with the results published in 2005. CMS has budgeted
approximately $14 million for this project.
CMS is also developing a physician group-practice demonstration that
was required by the Medicare, Medicaid, and SCHIP Benefits Improvement
and Protection Act of 2000.[Footnote 31] The aim of this demonstration
is to provide incentives for physicians to coordinate and manage the
overall health care needs of Medicare fee-for-service beneficiaries,
especially those with chronic health conditions. Under the 3-year
demonstration, physician groups will be paid on a fee-for-service basis
and may, in some circumstances, earn a bonus from savings achieved if
the average Medicare expenditure for beneficiaries in their group of
patients is below an established target.[Footnote 32] Up to six
physician group practices will be selected to participate in the
demonstration, which is expected to start during 2003. Under the
mandate, the aggregate expenditures for this demonstration must be
budget neutral. Any bonus payments made to physician groups must
therefore be taken from savings produced by the participating
organizations.
Finally, a 4-year coordinated-care demonstration is currently under way
at 16 sites. Authorized by the Balanced Budget Act of 1997, this
demonstration examines private-sector best practices for coordinating
the care of patients with complex chronic conditions.[Footnote 33]
These conditions include congestive heart failure, other heart and lung
diseases, liver diseases, diabetes, psychiatric disorders, Alzheimer's
disease or other dementia, and cancer. CMS is testing whether care
coordination programs--such as those that develop a plan of care after
a complete assessment of patient needs and offer patient education,
health care service arrangements, and coordination with providers--can,
without increasing program costs, improve the quality of care and
reduce avoidable hospital admissions among Medicare beneficiaries with
chronic diseases. The selected sites mix case management and disease
management models in their practices;[Footnote 34] operate in urban and
rural settings around the country; and include hospitals, retirement
communities, and academic medical centers. CMS is required to formally
evaluate the projects every 2 years after implementation and report to
the Congress on its findings. HHS officially announced the selected
sites in January 2001, and as of May 2003, the 16 sites had enrolled
approximately 10,000 Medicare beneficiaries in the demonstration. CMS
officials stated that the demonstration could eventually enroll more
than 36,000 beneficiaries, although half of these will serve as a
control group who will not receive coordinated care. CMS officials told
us that they expect this demonstration to also be budget neutral. That
is, they anticipate that overall costs to Medicare for providing the
services will be offset by savings achieved from providing the care
coordination services.
Concluding Observations:
Most Medicare beneficiaries receive some preventive services, but many
do not receive services that can help prevent and manage their health
risks and conditions early, before significant health problems occur.
Services recommended for all people in this age group are not delivered
consistently. Perhaps of most concern, nearly one-third of
beneficiaries who were screened and identified as having elevated blood
pressure or high cholesterol measures in a nationally representative
survey had not previously been told by their physicians or other health
providers that they had these conditions. Projected nationally, the
survey results translate into millions of people who could be unaware
that they have a health condition whose treatment could prevent or
delay much more significant health concerns.
The solutions to ensure that beneficiaries receive needed services are
not obvious. The experience of selected Medicare + Choice plans shows
that no single approach stands out. All plans we contacted had a means
to identify health risks, to provide feedback on risks to patients or
their physicians, and to follow up with interventions to reduce those
risks. But the follow-up programs, approaches, and priorities differed
among the plans we contacted, and few had evaluated their approaches in
a manner that would indicate whether these programs could, without
significantly increasing costs, improve health outcomes for Medicare
beneficiaries. Nevertheless, some current research shows promise for
improving the delivery of preventive services--particularly when there
are follow-up interventions, such as referrals to appropriate services.
Agency Comments:
We obtained comments on our draft from HHS as well as from the health
plans we contacted. HHS generally concurred with our findings and
provided examples of CMS's successes in promoting existing preventive
services and in identifying strategies that might be used in future
health promotion efforts. HHS also clarified the status of its program
evaluating the use of individual health risk assessments, which is in
development, and clarified its Medicare Stop Smoking Program, which
will assess options for a new benefit for smoking cessation but not
necessarily lead to CMS coverage for these benefits. HHS emphasized
that only the Congress can decide which preventive services or benefits
Medicare covers. HHS also updated its estimate of this program's
budget. We incorporated these clarifications in the draft.
HHS also commented that without sufficient evidence, the report links
beneficiaries' lack of knowledge that they may have certain conditions,
such as high blood pressure, with evidence that they are not receiving
the full range of preventive services. We did not intend to link these
statements, but we have independent evidence for each of them and have
added information to our summary of results to help clarify this
evidence. HHS's comments are reproduced in appendix IV.
HHS and the health plans 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
issue date. We are sending copies of this report to the Secretary of
HHS, the Administrator of CMS, the Director of CDC, and others who are
interested. We will make copies available to others on request. In
addition, the report will be available at no charge on the GAO Web site
at http://www.gao.gov.
If you or your staff have any questions, please contact me at (202)
512-7119 or Katherine Iritani, Assistant Director, at (206) 287-4820.
Other individuals who made contributions to this report include Matthew
Byer, Sophia Ku, and Tina Schwien.
Sincerely yours,
Janet Heinrich
Director, Health Care--Public Health Issues:
[End of section]
Appendix I: Scope and Methodology:
Because no single source contained all the information we needed to
assess the extent to which Medicare beneficiaries receive preventive
services through existing physician visits, we used data from four
national health surveys: three conducted by the Centers for Disease
Control and Prevention (CDC) and one conducted by the Centers for
Medicare & Medicaid Services (CMS) (see table 2). For example, CMS's
Medicare Current Beneficiary Survey samples Medicare beneficiaries,
asking them for detailed information on their demographic
characteristics, insurance coverage, and health status but asking only
a few questions about specific preventive services received during
physician visits. In contrast, CDC's National Ambulatory Medical Care
Survey samples physicians about office visits, rather than the people
who made those visits. The survey contains information about reasons
for office visits and about diagnostic and preventive services provided
during visits, but it cannot be used to determine the extent to which
Medicare beneficiaries received these services.[Footnote 35]
Table 2: Four National Health Surveys with Preventive Services Data,
1999-2000:
Survey: Behavioral Risk Factor Surveillance System, CDC; Data year:
2000; Sample size: Annual target of 189,450 adults; Description: A
state-based random telephone survey of U.S. adults covering a wide
range of behaviors affecting health. The largest continuing telephone
survey in the United States, it provides national as well as state-
specific estimates.
Survey: National Ambulatory Medical Care Survey, CDC; Data year: 2000;
Sample size: 27,369 office visits, of which 7,381 were made by people
age 65 and older; Description: A national sample survey of visits to
office-based physicians in the United States. Detailed information
about each visit, such as major reason for the visit and diagnostic and
preventive services ordered or provided, is collected through a patient
record form completed by the physicians' offices.
Survey: National Health and Nutrition Examination Survey, CDC; Data
year: 1999-2000; Sample size: 9,965 people, of which 1,392 were age 65
and older; Description: This survey gathers nationally representative
data on the health and nutrition of the U.S. population through direct
physical examinations and interviews.
Survey: Medicare Current Beneficiary Survey, CMS; Data year: 2000;
Sample size: About 16,000 Medicare beneficiaries; Description: A
continuous survey of a representative national sample of the Medicare
population that collects detailed data on beneficiaries' insurance
coverage, health status and functioning, and health care use and
expenditures.
Source: CDC and CMS.
[End of table]
For our analyses of these surveys, we extracted data for people age 65
and older to represent Medicare beneficiaries, because almost 95
percent of the population in this age group was enrolled in Medicare in
2000.[Footnote 36] Also, because the National Ambulatory Medical Care
Survey samples office visits to physicians, not the people who made the
visits, to estimate the average number of physician visits made by
Medicare beneficiaries, we first estimated the number of visits made by
patients age 65 and older using this database, and then divided this
number by the U.S. Bureau of the Census estimates of the civilian
noninstitutionalized population age 65 and older. To determine the
major reasons for physician visits and the specific types of preventive
services provided to Medicare beneficiaries in the fee-for-service
program, we used visit data in this survey for patients age 65 and
older who did not belong to a health maintenance organization and whose
visits were not paid on a capitated basis.[Footnote 37] Tables 3 to 5
show the estimates and standard errors in data from the National
Ambulatory Medical Care Survey 2000 on major reasons for physician
visits and on the preventive diet counseling services provided during
those visits. We also tested at the 95 percent confidence level the
statistical significance of differences we observed between nonillness
and other types of visits in the proportion of visits where preventive
screening tests (e.g., cholesterol and blood tests) were provided.
Table 3: Estimated Proportion of Fee-for-Service Physician Visits Made
by People Age 65 and Older, by Major Reason for the Visits, 2000:
Major reason: Acute problem; Sample size: 1,155; Estimated number (in
thousands): 32,843; Estimated percentage: 25.8; Standard error of
percentage: 1.7.
Major reason: Chronic problem, routine; Sample size: 2,081; Estimated
number (in thousands): 53,701; Estimated percentage: 42.2; Standard
error of percentage: 1.7.
Major reason: Chronic problem, flare-up; Sample size: 532; Estimated
number (in thousands): 13,254; Estimated percentage: 10.4; Standard
error of percentage: 0.8.
Major reason: Pre-or postsurgery, injury follow-up; Sample size: 577;
Estimated number (in thousands): 12,533; Estimated percentage: 9.8;
Standard error of percentage: 1.1.
Major reason: Nonillness care; Sample size: 395; Estimated number (in
thousands): 12,479; Estimated percentage: 9.8; Standard error of
percentage: 1.1.
Major reason: Blank or unknown; Sample size: 84; Estimated number (in
thousands): 2495; Estimated percentage: 2.0; Standard error of
percentage: 0.4.
Source: GAO analysis of the National Ambulatory Medical Care Survey,
CDC.
[End of table]
Table 4: Estimated Proportion of Fee-for-Service Physician Visits in
Which Diet Counseling Services Were Provided or Ordered, by Major
Reason for the Visits, 2000:
Major reason: Acute problem; Sample size: 1,155; Estimated number (in
thousands): 4,138; Estimated percentage[A]: 12.6; Standard error of
percentage: 3.0.
Major reason: Chronic problem, routine; Sample size: 2,081; Estimated
number (in thousands): 11,785; Estimated percentage[A]: 22.0; Standard
error of percentage: 3.0.
Major reason: Chronic problem, flare-up; Sample size: 532; Estimated
number (in thousands): 1,673; Estimated percentage[A]: 12.6; Standard
error of percentage: 2.5.
Major reason: Nonillness care; Sample size: 395; Estimated number (in
thousands): 2,295; Estimated percentage[A]: 18.4; Standard error of
percentage: 3.6.
Source: GAO analysis of the National Ambulatory Medical Care Survey,
CDC.
[A] The differences in rates of services provided among the different
types of visits were not statistically significant. According to CDC,
diet counseling services could be underreported because the survey
captured this information only if it was contained in the medical
record. If the physician provided counseling but did not write it in
the chart, counseling would not have been captured in the survey.
[End of table]
Table 5: Estimated Proportion of Fee-for-Service Physician Visits in
Which Blood Pressure Measurements Were Provided or Ordered, by Major
Reason for the Visits, 2000:
Major reason: Acute problem; Sample size: 1,155; Estimated number (in
thousands): 18,491; Estimated percentage[A]: 56.3; Standard error of
percentage: 3.2.
Major reason: Chronic problem, routine; Sample size: 2,081; Estimated
number (in thousands): 31,706; Estimated percentage[A]: 59.0; Standard
error of percentage: 2.9.
Major reason: Chronic problem, flare-up; Sample size: 532; Estimated
number (in thousands): 7,870; Estimated percentage[A]: 59.4; Standard
error of percentage: 4.8.
Major reason: Nonillness care; Sample size: 395; Estimated number (in
thousands): 7,762; Estimated percentage[A]: 62.2; Standard error of
percentage: 4.8.
Source: GAO analysis of the National Ambulatory Medical Care Survey,
CDC.
[A] The differences in rates of services provided among the different
types of visits were not statistically significant.
[End of table]
To estimate the proportion of Medicare beneficiaries who had health
conditions that they were not previously aware of--specifically, high
blood pressure or high cholesterol--we used data from both the
interview and the physical examination portions of CDC's National
Health and Nutrition Examination Survey (see app. III for methodology
and results from this analysis).
To describe the preventive care approaches of Medicare + Choice plans,
we consulted with national experts and officials from the American
Association of Health Plans and chose five plans considered to have
innovative preventive care programs. Together, these five plans serve
more than 1.2 million Medicare beneficiaries in 15 states and the
District of Columbia (see table 6). We interviewed officials from each
plan and reviewed documents, including plan-provided studies or
evaluations of their preventive services programs. We reviewed the
scope and methodology of the studies done by some of the plans, but we
did not independently verify the accuracy of the data.
Table 6: Medicare + Choice Plans Included in GAO's Study:
Medicare + Choice plans: AvMed Health Plans; Geographic areas served:
Florida; Beneficiaries served: 24,400.
Medicare + Choice plans: Group Health Cooperative; Geographic areas
served: Washington; Beneficiaries served: 59,300.
Medicare + Choice plans: Highmark Blue Cross & Blue Shield; Geographic
areas served: Pennsylvania; Beneficiaries served: 182,000.
Medicare + Choice plans: Kaiser Permanente; Geographic areas served:
California, Colorado, District of Columbia, Georgia, Hawaii, Maryland,
Ohio, Oregon, Virginia, Washington; Beneficiaries served: 880,000.
Medicare + Choice plans: Oxford Health Plans; Geographic areas served:
Connecticut, New Jersey, New York; Beneficiaries served: 72,000.
Source: Plan officials and plan Web sites.
[End of table]
To examine the alternatives for identifying and reducing health risks
and CMS's efforts in exploring them, we reviewed available literature,
including results of past demonstrations and congressionally mandated
studies, and interviewed experts in the field, including those
conducting studies and developing position papers for the Partnership
for Prevention, a nonprofit organization funded by the Robert Wood
Johnson Foundation. We also interviewed Department of Health and Human
Services and CMS officials and reviewed documents on planned and
present CMS demonstrations related to preventive services.
[End of section]
Appendix II Preventive Services Recommended by the U.S. Preventive
Services Task Force or Covered by Medicare:
Service: Immunization:
Service: Pneumococcal; Task force recommendation for age 65+:
Recommends; Year first covered by Medicare as preventive service: 1981;
Medicare cost-sharing requirements[A]: None.
Service: 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: Influenza; Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: 1993; Medicare
cost-sharing requirements[A]: None.
Service: Tetanus-diphtheria (Td) boosters; Task force recommendation
for age 65+: Recommends; Year first covered by Medicare as preventive
service: Not covered[B]; Medicare cost-sharing requirements[A]: N/A.
Service: Varicella; Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered[B];
Medicare cost-sharing requirements[A]: N/A.
Service: Screening:
Service: Cervical cancer: pap smear; Task force recommendation for age
65+: Recommends against[C]; Year first covered by Medicare as
preventive service: 1990; Medicare cost-sharing requirements[A]:
Copayment with no deductible[D].
Service: Breast cancer: mammography; Task force recommendation for age
65+: Recommends[E]; Year first covered by Medicare as preventive
service: 1991; Medicare cost-sharing requirements[A]: Copayment with no
deductible.
Service: Vaginal cancer: pelvic exam; Task force recommendation for age
65+: Not evaluated; Year first covered by Medicare as preventive
service: 1998; Medicare cost-sharing requirements[A]: Copayment with no
deductible[D].
Service: Colorectal cancer: fecal-occult blood test[F]; Task force
recommendation for age 65+: Strongly recommends; Year first covered by
Medicare as preventive service: 1998; Medicare cost-sharing
requirements[A]: No copayment or deductible.
Service: Colorectal cancer: flexible sigmoidoscopy or colonoscopy[F];
Task force recommendation for age 65+: Strongly recommends; Year first
covered by Medicare as preventive service: 1998; Medicare cost-sharing
requirements[A]: Copayment after deductible[G].
Service: Osteoporosis: bone mass measurement; Task force recommendation
for age 65+: Recommends (women only); Year first covered by Medicare as
preventive service: 1998; Medicare cost-sharing requirements[A]:
Copayment after deductible.
Service: Prostate cancer: prostate-specific antigen test and/or digital
rectal examination; Task force recommendation for age 65+: Insufficient
evidence to recommend for or against; Year first covered by Medicare as
preventive service: 2000; Medicare cost-sharing requirements[A]:
Copayment after deductible[D].
Service: Glaucoma; Task force recommendation for age 65+: Insufficient
evidence to recommend for or against; Year first covered by Medicare as
preventive service: 2002; Medicare cost-sharing requirements[A]:
Copayment after deductible.
Service: Vision impairment; Task force recommendation for age 65+:
Recommends; Year first covered by Medicare as preventive service: Not
covered; Medicare cost-sharing requirements[A]: N/A.
Service: Hearing impairment; Task force recommendation for age 65+:
Recommends; Year first covered by Medicare as preventive service: Not
covered; Medicare cost-sharing requirements[A]: N/A.
Service: Height, weight, and blood pressure; Task force recommendation
for age 65+: Recommends; Year first covered by Medicare as preventive
service: Not covered; Medicare cost-sharing requirements[A]: N/A.
Service: Cholesterol measurement; Task force recommendation for age
65+: Strongly recommends; Year first covered by Medicare as preventive
service: Not covered; Medicare cost-sharing requirements[A]: N/A.
Service: Problem drinking; Task force recommendation for age 65+:
Recommends; Year first covered by Medicare as preventive service: Not
covered; Medicare cost-sharing requirements[A]: N/A.
Service: Depression; Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Counseling:
Service: Smoking cessation, injury prevention, dental health; Task
force recommendation for age 65+: Recommends; Year first covered by
Medicare as preventive service: Not covered; Medicare cost-sharing
requirements[A]: N/A.
Service: Aspirin for primary prevention of cardiovascular events; Task
force recommendation for age 65+: Strongly recommends; Year first
covered by Medicare as preventive service: Not covered; Medicare cost-
sharing requirements[A]: N/A.
Source: U.S. General Accounting Office, Medicare: Use of Preventive
Services Is Growing but Varies Widely, GAO-02-777T (Washington, D.C.:
April 12, 2002), and U.S. Preventive Services Task Force, Guide to
Clinical Preventive Services, 2nd ed. (Washington, D.C.: 1996) and
related updates.
[A] Applicable Medicare cost-sharing requirements generally include a
20 percent copayment after a $100 per year deductible. Specifically,
each year, beneficiaries are responsible for 100 percent of the payment
amount until those payments equal a specified deductible amount, $100
in 2003. 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. 42 U.S.C. § 1395(a)(1) (2000).
[B] Although the tetanus-diphtheria (Td) and varicella (chickenpox)
booster vaccinations are not now covered under Medicare as a
"preventive" service, these treatments might be covered under Medicare
if necessary to a beneficiary's medical treatment. Medicare provides
coverage for medical treatment and services that are "reasonable and
necessary for the diagnosis or treatment of an illness or injury,"
provided that the services or products used are "safe and effective"
and not merely "experimental." 42 U.S.C. § 1395(a)(1)(A) (2000).
[C] The task force recommends against routinely screening women older
than 65 for cervical cancer if they have had adequate recent screening
with normal Pap smears and are not otherwise at high risk for cervical
cancer.
[D] The costs of the laboratory test portion of these services are not
subject to copayment or deductible. The beneficiary is subject to a
deductible, copayment, or both for physician services only.
[E] The task force recommends screening mammography, with or without a
clinical breast examination, every 1-2 years for women age 40 and
older.
[F] Data are insufficient to determine which strategy is best to
balance benefits against potential harms or cost-effectiveness. Barium
enemas are covered as an alternative if a physician determines that
their screening value is equal to or greater than sigmoidoscopy or
colonoscopy.
[G] The copayment has increased from 20 to 25 percent for services
rendered in an ambulatory surgical center.
[End of table]
[End of section]
Appendix III: National Health and Nutrition Examination Survey
Methodology and Results:
Background:
Conducted by the Centers for Disease Control and Prevention's (CDC)
National Center for Health Statistics, the National Health and
Nutrition Examination Survey (NHANES) is a nationwide population-based
survey designed to estimate the health and nutrition of the
noninstitutionalized U.S. civilian population. Our analysis was based
on data gathered during NHANES 1999-2000, which represent the most
recent information available. This survey comprises two parts: an in-
home interview and a health examination. During the in-home interview,
participants are asked about their health status, disease history, and
diet; during the health examination, participants receive a number of
tests, including blood pressure readings and a blood test to determine
total serum cholesterol.[Footnote 38] Details of the survey design,
questionnaires, and examination components are available at http://
www.cdc.gov/nchs/nhanes.htm.
Scope, Methodology, and Results:
For our analysis, we used the NHANES data described in table 7 to
determine if participants age 65 and older[Footnote 39] had high blood
pressure or high total serum cholesterol. We used the same criteria for
these conditions as CDC and the National Heart Blood and Lung Institute
use to estimate the conditions' prevalence.
Table 7: NHANES Data GAO Used to Determine if Participants Had Measures
of Specific Health Conditions:
Health condition: High blood pressure[A]; NHANES data: Average[B]
systolic blood pressure Š 140 during NHANES exam; or; Average[B]
diastolic blood pressure Š 90 during NHANES exam; or; Participant
reported during NHANES interview that he or she took hypertension
medication.
Health condition: High total cholesterol[A]; NHANES data: Total
cholesterol level Š 240 at NHANES examination.
Source: CDC criteria and GAO methodology.
[A] CDC's definitions of high blood pressure and high total
cholesterol.
[B] Participants' blood pressure was measured three or four times
during the 1-day physical examination. For our analysis, we determined
the average of these blood pressure measurements and applied CDC's
definition of high blood pressure.
[End of table]
To determine whether the participants age 65 and older found by
examination to have elevated measures of these health conditions were
previously unaware of having them, we used patients' responses from the
NHANES interview. During the interview, participants were asked if they
had ever been told by a physician or health professional that they had
certain conditions, including high blood pressure and high cholesterol.
Tables 8 and 9 show the estimates and standard errors from 1999-2000
NHANES data for specific health conditions and level of awareness among
participants age 65 and older.
Table 8: People Age 65 and Older in the United States Found to Have
Measures of Specific Health Conditions, NHANES 1999-2000:
Health condition: High blood pressure; Sample size: 835; Estimated
number in the U.S. population: 21,000,000; Estimated proportion: 71.6%;
Standard error of proportion: 2.07.
Health condition: High total cholesterol; Sample size: 250; Estimated
number in the U.S. population: 7,100,000; Estimated proportion: 25.6%;
Standard error of proportion: 1.76.
Source: GAO analysis of NHANES.
[End of table]
Table 9: People Age 65 and Older in the United States Found to Have
Measures of Specific Health Conditions and Who Reported They Had Not
Previously Been Told They Might Have the Condition, NHANES 1999-2000:
Not previously told of the health condition: High blood pressure;
Sample size: 254; Estimated number in the U.S. population: 6,600,000;
Estimated proportion: 31.6%; Standard error of proportion: 2.02.
Not previously told of the health condition: High total serum
cholesterol; Sample size: 87; Estimated number in the U.S. population:
2,100,000; Estimated proportion: 32.1%; Standard error of proportion:
4.65.
Source: GAO analysis of NHANES.
[End of table]
Estimated numbers, proportions, and standard errors were obtained using
SUDAAN, a computer program for analyzing data from complex sample
surveys, as suggested in the NHANES Analytic Guidelines.
[End of section]
Appendix IV: Comments from the Department of Health and Human Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES Office of Inspector General:
AUG 20 2003:
Ms. Janet Heinrich:
Director, Health Care - Public Health Issues United States General
Accounting Office Washington, D.C. 20548:
Dear Ms. Heinrich:
Enclosed are the Department's comments on your draft report entitled,
"Medicare: Most Beneficiaries Receive Some But Not All Recommended
Preventive Services." The comments represent the tentative position of
the Department and are subject to reevaluation when the final version
of this report is received.
The Department also provided several technical comments directly to
your staff.
The Department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Dara Corrigan
Acting Principal Deputy Inspector General:
Signed by Dara Corrigan:
Enclosure:
The Office of Inspector General (OIG) is transmitting the Department's
response to this draft report in our capacity as the Department's
designated focal point and coordinator for General Accounting Office
reports. OIG has not conducted an independent assessment of these
comments and therefore expresses no opinion on them.
Comments of the Department of Health and Human Services on the General
Accounting Office's Draft Report, "Medicare: Most Beneficiaries Receive
Some But Not All Recommended Preventive Services" (GAO-03-958):
The Department of Health and Human Services (Department) appreciates
the opportunity to review and comment on the above-referenced draft
report. The General Accounting Office (GAO) report focuses on the
preventive services Medicare beneficiaries receive through fee-for-
service or the managed care program.
Generally, we concur with the findings of the draft report and would
note that prevention is a key goal for the Secretary. To support the
Secretary's goal, the Centers for Medicare & Medicaid Services (CMS)
have taken a number of steps to improve the delivery of preventive
services for Medicare beneficiaries. The following are examples of CMS
successes in promoting existing preventive services and in identifying
strategies that might be used in future health promotion efforts:
* The Healthy Aging Project produced evidence reports on how to better
promote existing Medicare preventive benefits, and explore other
strategies for healthy aging. These include smoking cessation, health
risk appraisal programs, falls prevention, chronic disease self-
management, and physical activity. These reports have allowed CMS to
think prospectively about strategies to help older adults stay healthy.
* The requirement was removed from the providers' Conditions of
Participation that a physician must write an individual order for each
influenza and pneumococcal vaccination given in hospital and long term
care settings and by home health agencies. Where allowed by State law,
appropriate non-physician personnel can now provide these vaccinations
under a facility-approved standing order protocol. This change to the
Conditions of Participation was based on evidence generated by the
Healthy Aging Project indicating that standing orders are effective for
increasing immunization rates, and a CMS-Centers for Disease Control
and Prevention pilot study, which implemented standing orders in
nursing homes in 14 States.
CMS also increased Medicare payment rates for influenza / pneumococcal
/ hepatitis B vaccine administration. Medicare's 2003 vaccine
administration rate allowances average $7.72 for 2003, a 94% increase
over 2002. The rates range from $5.34 to $10.98 depending on geographic
location.
Recognizing that smoking is the single most preventable cause of
disease and death in the United States, posing a significant health
risk to the aged, CMS launched the Medicare Stop Smoking Program, a
demonstration to identify the most effective strategy for helping older
smokers help themselves to quit smoking. The evidence suggests that
counseling by clinicians and by telephone, with and without smoking
cessation medications have been effective in helping adults quit
smoking. This demonstration tests these
strategies in older adults to identify which strategies are most
effective for helping older smokers help themselves to quit smoking. To
date, this demonstration has enrolled 3,328 seniors, and according to
experts, could possibly be the largest smoking cessation study to
address the needs of older smokers.
* CMS is designing the Benefits Improvement and Protection Act (BIPA)
mandated "Cancer Prevention and Treatment Demonstration for Ethnic and
Racial Minorities." The purpose of this demonstration is to evaluate
best practices; and design, implement and evaluate projects involving
new and innovative intervention models that improve health, clinical
outcomes, satisfaction, quality of life, and appropriate use of
Medicare-covered services; and reduce disparities in cancer prevention
and treatment for African American, Latino, Asian American/Pacific
Islander, and American Indian/Alaskan Native beneficiary populations
living in both urban and rural communities. The information gathered
from this demonstration will inform efforts to reduce healthcare
disparities.
* Colon cancer screening rates are low, with less than 50 percent of
people age 50 and older receiving any screening test for colon cancer.
CMS has funded Medical Review of North Carolina (MRNC), a Quality
Improvement Organization, to analyze colon cancer screening rates. MRNC
has an interactive website which displays State and county rates for
the various Medicare-covered colon cancer screening tests, allowing
organizations to target their efforts to increase rates. These data are
currently being updated to include 2000-2002 data, and are the only
comprehensive resource for both State and county data.
* There is collaboration between CMS and other agencies in the
Department on public awareness campaigns to promote Medicare preventive
and screening services, specifically colon cancer screening,
mammography, and adult immunization.
CMS has initiated developmental work to design a study to evaluate the
use of individual health risk assessments and tailored follow-up
interventions to reduce health risks and promote the appropriate use of
preventive services.
In the report, the linkage is drawn between the lack of knowledge of
risk for health conditions with evidence that beneficiaries are not
receiving the full range of preventive services. This linkage is
presented specifically relating to high blood pressure. While we can
see the correlation between the "lack of knowledge of health risk for
that condition, additional evidence should be presented before
extending this conclusion to the full range of preventive services.":
Two CMS initiatives are mischaracterized-the Medicare Stop Smoking
Program and the design of a study to evaluate the use of health risk
assessments and tailored follow-up interventions.
Several references are made to a study using health risk assessment and
follow-up interventions to improve the delivery of preventive services.
CMS has not yet decided whether it will conduct this study. If CMS
decides to conduct this study, it will need to be approved by the
Office of Management and Budget. The references to this study in this
report imply that this study is underway when in fact no decision has
been made about its conduct.
The description of the Medicare Stop Smoking Program implies that CMS
will identify and cover a new benefit for smoking cessation. Congress,
not CMS, makes coverage decisions regarding preventive services. In
addition, the estimate of the project's budget is inaccurate.
We look forward to working with GAO on this and future issues.
FOOTNOTES
[1] We focused our work on the people covered by Medicare who are 65
and older--about 86 percent of the entire Medicare population. Besides
this age group, Medicare also covers about 5.8 million disabled persons
younger than age 65. Throughout this report, except where otherwise
noted, we use the term "Medicare beneficiaries" to refer only to those
beneficiaries age 65 and older.
[2] U.S. General Accounting Office, Medicare: Beneficiary Use of
Clinical Preventive Services, GAO-02-422 (Washington, D.C.: April
2002).
[3] "Fee-for-service" is the Medicare arrangement sometimes referred to
as the original Medicare plan. Under this option, Medicare pays a
health care practitioner for each visit or procedure received by a
patient, and a beneficiary can visit any hospital, physician, or health
care provider who accepts Medicare patients. Medicare pays a set
percentage of the expenses, and the beneficiary is responsible for
certain deductibles and coinsurance payments--the portion of the bill
that Medicare does not pay.
[4] These are health care options (like health maintenance
organizations) in some areas of the country. In most programs, the
beneficiary can go only to doctors, specialists, or hospitals on the
program's list. Programs must cover all Medicare part A and part B
health care but can also cover extras, like prescription drugs and
periodic checkups.
[5] Besides the 84 percent of Medicare beneficiaries in fee-for-service
and the 14 percent in Medicare + Choice (2002 data), a small percentage
of Medicare beneficiaries receive services through such arrangements as
prepaid group practice plans or Medicare demonstrations.
[6] The annual physical examination of healthy persons, in which a
standard set of tests and procedures is performed, was first proposed
by the AMA in 1922. For many years afterward, health professionals
recommended routine physicals and comprehensive laboratory testing as
effective preventive medicine. But in 1983, the AMA withdrew its
support for a standard annual examination. Instead, the organization
supported periodic visits in which patients receive preventive services
depending upon the individual's unique combination of age, sex, and
health risk.
[7] The surveys and other data sources from which we developed our
information generally did not disaggregate the information into
beneficiaries receiving care through fee-for-service and beneficiaries
receiving care through Medicare + Choice programs. As a result, unless
otherwise noted, the data reported include beneficiaries from both
groups.
[8] CMS's Medicare Current Beneficiary Survey, 2000.
[9] To estimate the average number of physician visits, we used data
from the National Ambulatory Medical Care Survey and the U.S. Bureau of
the Census. See app. I for a description of our methodology. We believe
that the result is a conservative estimate of the average number of
physician visits, since the segment of the survey that we analyzed
excluded visits made in hospital outpatient and emergency departments
or other institutional settings and also excluded physicians in the
specialties of anesthesiology, pathology, and radiology.
[10] Because Medicare's fee-for-service program does not cover routine
physical examinations but does cover some preventive services, such as
immunizations and certain cancer screening tests, it is possible that
some of the nonillness visits in 2000 were to obtain such services. In
addition, some fee-for-service beneficiaries may be paying for
nonillness examinations through other means, such as employer-provided
or other supplemental insurance. According to CMS's Medicare Current
Beneficiary Survey, in the year 2000 about 41 percent of Medicare fee-
for-service beneficiaries had insurance from former employers to
supplement their basic Medicare benefit.
[11] GAO-02-422.
[12] In January 2003, the U.S. Preventive Services Task Force released
new recommendations for the use of pap smears to screen for cervical
cancer. The task force now "recommends against screening women 65 and
older who have had adequate recent screenings with normal Pap smears
and are not otherwise at increased risk for cervical cancer."
[13] Anemia is a condition in which the blood is deficient in red blood
cells, hemoglobin, or total volume. The hematocrit/hemoglobin test is
used to test for anemia and to measure the concentration of packed red
blood cells and hemoglobin in the blood. Hemoglobin is an iron-
containing respiratory pigment in red blood cells that helps transport
oxygen from the lungs to the body tissues.
[14] Specifically, blood pressure measurements were provided at 56
percent of visits for acute problems, 59 percent of visits for chronic
problems, and 62 percent of nonillness visits. Diet counseling services
were provided at 13 percent of visits for acute problems, 20 percent of
visits for chronic problems, and 18 percent of nonillness visits. For
both blood pressure measurement and diet counseling service estimates,
the differences in these percentages were not statistically significant
at the 95 percent confidence level. See app. I for a discussion of the
methodology and specific results. Source: CDC's National Ambulatory
Medical Care Survey, 2000.
[15] The source of data for this statement was CDC's National Health
and Nutrition Examination Survey of 1999-2000. This survey oversampled-
-that is, included a larger number of persons age 60 and older in the
sample, providing for a sample size that enabled us to focus our
analysis specifically on the Medicare-age population for selected
conditions. App. III contains a description of this survey and the
specific results of our analyses.
[16] Medicare + Choice plans are required to make a "best effort
attempt" to assess newly enrolled Medicare beneficiaries. 42 C.F.R. §
422.122(b)(4)(i) (2002).
[17] The risk assessment questionnaires for some plans are as brief as
a one-page form, while others are as long as eight pages. A number of
questions focus on identifying functional status, such as the ability
to bathe independently; immunization status; current use of
prescription medications; the history of screening tests, such as
mammography; past health care use, such as the number of times
enrollees saw their primary care physician in the preceding 6 months;
behavior risks, such as smoking; and past illnesses or existing health
conditions.
[18] CMS generally requires each Medicare + Choice plan to undertake
one national quality assessment and performance improvement project per
year to measure and improve its own performance in a CMS-defined
national focus area. Past national focus areas include improving
diabetes care and increasing vaccination rates for influenza and
pneumonia.
[19] Angiotensin-converting enzyme.
[20] Specifically, over the next decade, people designated as "frail"
spent 800 percent more days in nursing homes than individuals who were
not frail. K.K. Brody, R.E. Johnson, and L.D. Ried, "Evaluation of a
Self-Report Screening Instrument to Predict Frailty Outcomes in Aging
Populations," The Gerontologist, 37 (1997): 182-191.
[21] K.K. Brody et al., "A Comparison of Two Methods for Identifying
Frail Medicare-Aged Persons," Journal of American Geriatrics Society,
50 (2002): 562-569.
[22] Once frail people are identified, for example, Kaiser encourages
medical providers to follow guidelines intended to detect conditions
such as depression and to prevent outcomes such as injuries from falls.
[23] Partnership for Prevention, A Better Medicare for Healthier
Seniors: Recommendations to Modernize Medicare's Prevention Policies
(Washington, D.C.: Partnership for Prevention, 2003), and Gilbert S.
Omenn, "Historical and Current Policy Issues in Establishing Coverage
for Clinical Preventive Services under Medicare," cited in the
Partnership for Prevention's report.
[24] C.H. Sox et al., "Periodic Health Examinations and the Provision
of Cancer Prevention Services," Archives of Family Medicine, 6 (1997):
223-230. This study reviewed a random selection of community general
internists and family physician practices in New Hampshire and Vermont.
Care was assessed for those who were patients of the study physicians
for at least 1 year, were age 42 or older, had no life-threatening
illness, and had recently visited the physician.
[25] See Congressional Budget Office cost estimate, H. R. Rep. 107-539,
pt. 1, at 238. Beginning in 2004, the bill would have required Medicare
to pay for a routine physical examination and associated services when
furnished within 6 months of a beneficiary's enrollment in part B.
Beneficiaries already enrolled would not have been eligible for this
benefit. H.R. 4954, 107th Cong. (2d Sess. 2002).
[26] A 4-year demonstration was mandated in the Consolidated Omnibus
Budget Reconciliation Act of 1985, Pub. L. No. 99-272, § 9314, 100
Stat. 82, 194 (1986), and extended for 1 year by the Omnibus Budget
Reconciliation Act of 1990, Pub. L. No. 101-508, § 4164, 104 Stat.
1388, 1388-100. At the time, CMS was known as the Health Care Financing
Administration.
[27] Donna E. Shalala, Medicare Prevention Demonstration: Final Report,
RC 87-172 (Washington, D.C.: Department of Health and Human Services,
1998). The report tempered these results by pointing out that the
relatively brief period during which the services were provided
(roughly 2 years) and the limited number of provider contacts and
follow-ups (one to two) may have been inadequate to achieve measurable
outcomes. In addition, the grouping of the health risk assessment and
preventive services into a preventive package may have obscured the
relative effects of individual components of the package.
[28] A typical health risk assessment obtains information on
demographic characteristics (e.g., sex, age), lifestyle (e.g., smoking,
exercise, alcohol consumption, diet), personal health history, and
family health history. In some cases, physiological data (e.g., height,
weight, blood pressure, cholesterol levels) are also obtained, as well
as a patient's status regarding cancer screens and immunizations.
[29] Southern California Evidence-Based Practice Center/RAND, Health
Risk Appraisals and Medicare (Baltimore: Centers for Medicare &
Medicaid Services, 2001). RAND identified 267 articles, unpublished
reports, and conference presentations, of which 27 contained data that
project staff deemed necessary to be included as evidence of the
effectiveness of health risk assessments.
[30] According to CMS, the demonstration would also require approval
from the Office of Management and Budget.
[31] Pub. L. No. 106-554, app. F, § 412, 114 Stat. 2763, 2763a-509.
[32] Annual performance targets will be established for each
participating physician group, equal to the average Medicare
expenditures of beneficiaries assigned to that group during the base
period and adjusted for health status and expenditure growth.
[33] Pub. L. No. 105-33, § 4016, 111 Stat. 343, 345.
[34] Case management services would be provided to help manage general
health, and disease management services would be provided to help
manage a specific disease.
[35] The National Ambulatory Medical Care Survey is conducted by CDC's
National Center for Health Statistics. See the Web site http://
www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm for details on the survey
design.
[36] According to data from CDC's Behavioral Risk Factor Surveillance
System, in 2000, almost 95 percent of adults age 65 and older reported
having Medicare coverage.
[37] "Capitated" refers to a method of payment for health services in
which an individual or institutional provider is paid a fixed amount
for each person served, without regard to the actual number or nature
of services provided to each person in a set period of time.
[38] Which examinations and blood tests a participant had depended on
that participant's age and sex.
[39] Of the 9,282 individuals participating in both the NHANES
interview and examination components, 1,196 were age 65 and older.
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TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director, NelliganJ@gao.gov (202) 512-4800 U.S.
General Accounting Office, 441 G Street NW, Room 7149 Washington, D.C.
20548:
