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Medicare: Use of Preventive Services is Growing but Varies Widely
(23-MAY-02, GAO-02-777T).					 
                                                                 
Preventive health care services can extend lives and promote the 
well being of the nation's seniors. Medicare now covers 10	 
preventive services--three types of immunizations and seven types
of screenings--and legislation has been introduced to cover	 
additional services. However, not all beneficiaries avail	 
themselves of Medicare's preventive services. Some may simply	 
choose not to use them, but others may be unaware that these	 
services are available or covered by Medicare. Although the use  
of Medicare preventive service is growing, it varies from service
to service and by state, ethnic group, income, and level of	 
education. To ensure that preventive services are delivered to	 
those who need them, the Centers for Medicare and Medicaid	 
Services (CMS) sponsors activities to increase their use. CMS now
funds interventions to increase the use of three services--breast
cancer screening and immunizations against the flu and		 
pneumonia--in each state. CMS also pays for interventions to	 
increase use of services by minorities and low-income		 
beneficiaries with low usage rates. CMS is evaluating the	 
effectiveness of current efforts and expects to have the	 
evaluation results later in 2002.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-777T					        
    ACCNO:   A03418						        
  TITLE:     Medicare: Use of Preventive Services is Growing but      
Varies Widely							 
     DATE:   05/23/2002 
  SUBJECT:   Beneficiaries					 
	     Health care programs				 
	     Health care services				 
	     Managed health care				 
	     Immunization services				 
	     Disease detection or diagnosis			 
	     Medicare Program					 

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GAO-02-777T
     
Testimony Before the Subcommittee on Oversight and Investigations, Committee
on Energy and Commerce, House of Representatives

United States General Accounting Office GAO For Release on Delivery Expected
at 10: 00 a. m. Thursday, May 23, 2002 MEDICARE

Use of Preventive Services is Growing but Varies Widely

Statement of Janet Heinrich Director, Health Care- Public Health Issues GAO-
02- 777T

Page 1 GAO- 02- 777T Mr. Chairman and Members of the Subcommittee: We are
pleased to be here today as you review existing preventive health care

services offered in the Medicare program and consider proposals for
expanding these benefits. At your Subcommittee?s request, we have been
examining several issues related to preventive services and have prepared a
report that is being released today. 1 My statement today highlights some of
the key aspects of that report.

Preventive health care services, such as flu shots and cancer screenings,
can extend lives and promote the well- being of our nation?s seniors.
Medicare now covers 10 preventive services- 3 types of immunizations and 7
types of screening- and legislation has been introduced to cover additional
services. 2 However, not all beneficiaries avail themselves of Medicare?s
preventive

services. Some beneficiaries may simply choose not to use them, but others
may be unaware that these services are available or covered by Medicare. You
asked us to examine two questions regarding preventive services for older
Americans:

To what extent are Medicare beneficiaries using covered preventive services?

What actions have the Centers for Medicare and Medicaid services (CMS),
which administers Medicare, taken to increase beneficiaries? use of
preventive services?

Our data on the extent to which beneficiaries are using covered services are
taken primarily from a survey conducted by the Centers for Disease Control
and Prevention (CDC), another agency that like CMS is within the Department
of Health and Human Services. The survey collects information on the use of
several preventive services covered under Medicare, including immunizations
for

influenza and pneumococcal disease, and screening for breast, cervical, and
colon cancer.

In summary, although use of Medicare covered preventive services is growing,
it varies from service to service and by state, ethnic group, income, and
level of 1 U. S. General Accounting Office, Medicare: Beneficiary Use of
Clinical Preventive Services,

GAO- 02- 422 (Washington, D. C.: April 12, 2002). 2 A bill introduced last
year proposes adding visual acuity, hearing impairment, cholesterol, and
hypertension screenings as well as expanding the eligibility of individuals
for bone density screenings. See H. R. 2058, 107th Cong. sect. 203 (2001).

Page 2 GAO- 02- 777T education. For example, in 1999, 75 percent of women
had been screened within the previous 2 years for breast cancer, compared
with 55 percent of beneficiaries

who had ever been immunized against pneumonia. However, even for a widely
used preventive service such as breast cancer screening, state- by- state
usage rates ranged from 66 to 86 percent. Among ethnic groups, differences
were greatest for immunizations. For example, 1999 data show that about 57
percent of whites and 54 percent of ?other? ethnic groups had been immunized
against pneumonia,

compared to about 37 percent of African Americans and Hispanics. 3 Among
income and educational groups, variation was greatest for cancer screening.
To help ensure that preventive services are being delivered to those
beneficiaries who need them, CMS sponsors activities- called
?interventions?- aimed at increasing use. CMS currently funds interventions
aimed at increasing the use of three services- breast cancer screening and
immunizations against flu and pneumonia- in each state. CMS also pays for
interventions that focus on increasing use of services by minorities and
low- income beneficiaries who have low usage rates. The techniques being
used in some of these interventions, such

as allowing nurses or other nonphysician medical personnel to administer
vaccinations with a physician?s standing order, have been found effective in
the past. CMS is evaluating the effectiveness of current efforts and expects
to have the evaluation results later in 2002.

When the Medicare program was established in 1965, it only covered health
care services for the diagnosis or treatment of illness or injury.
Preventive services did not fall into either of these categories and,
consequently, were not covered. Since 1980, the Congress has amended the
Medicare law several times to add coverage for certain preventive services
for different age and risk groups within the

Medicare population. These services include three types of immunizations-
pneumococcal disease, hepatitis B, and influenza. Screening for five types
of cancer- cervical, vaginal, breast, colorectal, and prostate- are also
covered, as well as screening for osteoporosis and glaucoma. Except for flu
and pneumonia

immunizations, and laboratory tests, Medicare requires some cost- sharing by
beneficiaries. Most beneficiaries have additional insurance, which may cover
most, if not all, of these cost- sharing requirements. 4 3 ?Other? ethnic
groups include survey respondents who reported an ethnicity other than
African American, Hispanic, or white. 4 U. S. General Accounting Office,
Medigap Insurance: Plans Are Widely Available but Have Limited Benefits and
May Have High Costs, GAO- 01- 941 (Washington, D. C.: July 31, 2001). Types
of Services Covered

Page 3 GAO- 02- 777T For a number of reasons, not all Medicare beneficiaries
are likely to use these services. For some beneficiaries, certain services
may not be warranted or may be

of limited value. Screening women for cervical cancer is an example. Survey
data show that 44 percent of women age 65 and over have had hysterectomies-
an operation that usually includes removing the cervix. 5 For these women,
researchers state that cervical cancer screening may not be necessary unless
they have a prior history of cervical cancer. 6 Also, patients with terminal
illnesses or

of advanced age may decide to forgo services because of the limited benefits
preventive services would offer. Research has shown, for example, that the
benefits of cancer screening services, such as for prostate, breast, and
colon

cancer, can take 10 years or more to materialize. Finally, the controversy
over the effectiveness of some services, such as mammography and prostate
cancer screening, may add to the difficulty in further improving screening
rates for these services.

To help determine which preventive services are beneficial among various
patient populations, the U. S. Department of Health and Human Services
established a panel of experts in 1984, called the U. S. Preventive Services
Task Force. The task force identifies and systematically evaluates the
available

evidence to determine the effectiveness of preventive services for different
age and risk groups, and then makes recommendations as to their use. Task
force recommendations were first published in the Guide to Clinical
Preventive Services in 1989, and are periodically updated as new evidence
becomes available. These recommendations are for screening, immunizations,
and counseling services that are specific for each age group, including
people 65 and older. See table 1 for the task force recommendations for
various preventive services including those currently covered by Medicare.

5 Data are from the CDC?s Behavioral Risk Factor Surveillance System
(BRFSS), 2000. 6 CDC researchers report that among the general population,
over 80 percent of hysterectomies are performed for noncancerous conditions
such as fibroids and endometriosis.

Page 4 GAO- 02- 777T Table 1: Preventive Services Covered by Medicare or
Recommended by the Task Force Service

Task force recommendation for age 65+

Year first covered by Medicare as preventive service Medicare cost- sharing

requirements a Immunizations Pneumococcal Recommended 1981 None Hepatitis B
No recommendation 1984 Copayment after deductible Influenza Recommended 1993
None Tetanus- diphtheria (Td) boosters Recommended Not covered N/ A

Screening Cervical cancer- pap smear Recommended b 1990 Copayment with no
deductible c Breast cancer- mammography Recommended d 1991 Copayment with no
deductible Vaginal cancer- pelvic exam No recommendation 1998 Copayment with
no deductible c Colorectal cancer- fecal- occult blood test Recommended 1998
No copayment or deductible Colorectal cancer- sigmoidoscopy Recommended 1998
Copayment after deductible e Colorectal cancer- colonoscopy No
recommendation 1998 Copayment after deductible e Osteoporosis- bone mass

measurement No recommendation 1998 Copayment after deductible Prostate
cancer- prostate- specific antigen test and/ or digital rectal examination

Not recommended 2000 Copayment after deductible c Glaucoma No recommendation
2002 Copayment after deductible Vision impairment Recommended Not covered N/
A Hearing impairment Recommended Not covered N/ A Height, weight, and blood
pressure Recommended Not covered N/ A Cholesterol measurement Recommended
Not covered N/ A Problem drinking Recommended Not covered N/ A

Counseling Diet and exercise, smoking cessation, injury prevention, and
dental health Recommended f Not covered N/ A Postmenopausal hormone
prophylaxis Recommended Not covered N/ A Aspirin for primary prevention of
cardiovascular events Recommended Not covered N/ A

a Applicable Medicare cost- sharing requirements generally include a 20
percent copayment after a $100 per year deductible. Each year, beneficiaries
are responsible for 100 percent of the payment amount until those payments
equal a specified deductible amount, $100 in 2002. Thereafter, beneficiaries
are responsible for a copayment that is usually 20 percent of the Medicare
approved

amount. For certain tests, the copayment may be higher. See 42 U. S. C. sect.
1395( a)( 1). b The task force found insufficient evidence to recommend for
or against an upper age limit for pap testing, but recommendations can be
made on other grounds to discontinue regular testing after age 65 in women
who have had regular previous screenings in which the smears have been
consistently normal. c The costs of the laboratory test portion of these
services are not subject to copayment or deductible. The beneficiary is
subject to a deductible and/ or copayment for physician services only.

Page 5 GAO- 02- 777T d The task force recommends routine screening for
breast cancer every 1 to 2 years, with mammography alone or along with an
annual clinical breast examination, for women aged 50 to 69. The task force
found insufficient evidence to recommend for or against routine mammography
or clinical breast examination for women aged 40 to 49 or aged 70 and older.
e The copayment is increased from 20 to 25 percent for services rendered in
an ambulatory surgical center. f The task force recommends these counseling
services on the basis of the proven benefits of modifying harmful or risky
behaviors. However, the effectiveness of clinician counseling to change

these behaviors has not been adequately evaluated. Source: U. S. General
Accounting Office, Medicare: Beneficiary Use of Clinical Preventive
Services, GAO- 02- 422 (Washington, D. C.: Apr. 12, 2002) and U. S.
Preventive Services Task Force, Guide to Clinical Preventive Services, 2nd
ed. (Washington, DC, 1996) and related updates. As table 1 shows, Medicare
explicitly covers many, but not all, of the preventive services recommended
by the task force. However, beneficiaries may receive some of the preventive
services not explicitly covered by Medicare. For example, even though blood
pressure and cholesterol screening are not explicitly covered under
Medicare, in 1999, nearly 98 percent of seniors reported that they had had
their blood pressure checked within the last 2 years, and more than 88
percent of seniors reported having their cholesterol checked within the
prior 5 years. 7 Other task force recommended services- such as counseling
intended to change a

patient?s unhealthy or risky behaviors- may also be occurring during office
visits. 8 Determining the extent to which these preventive counseling
services occur is difficult, in part, because the content of such services
is not well defined. It is also interesting to note that the task force
recommends these counseling services on the basis of the proven benefits of
a good diet, daily physical activity,

smoking cessation, avoiding household injuries such as falls, and avoiding
dental caries (tooth decay) and periodontal (gum and bone) disease. However,
the effectiveness of clinician counseling to actually change these patient
behaviors has not been established.

7 Survey data are from the CDC?s BRFSS 1999. 8 Counseling women regarding
hormone replacement therapy, and all beneficiaries regarding the use of
aspirin for the prevention of cardiovascular events is not necessarily
intended to change behavior. Rather, it is intended to provide the patient
current information on both the potential benefits and risks of these
therapies. The task force recommends that the decision to undertake these
therapies should be based on patient risk factors for disease and a clear
understanding of the probable benefits and risks of these therapies.

Page 6 GAO- 02- 777T Use of preventive services offered under Medicare has
increased over time. For example, in 1995, 38 percent of beneficiaries had
been immunized against

pneumonia, compared with 55 percent in 1999. Similarly, the use of
mammograms at recommended intervals had increased from 66 percent in 1995 to
75 percent in 1999. While these examples show that use of preventive
services generally is increasing, they also show variation in use by
service. Beneficiaries received screenings for breast and cervical cancer at
higher rates than they did immunizations against flu and pneumococcal
disease. Of the services for which data are available, colorectal screening
rates were the lowest, with 25 percent of the beneficiaries receiving a
recommended fecal occult blood test within the past year, and 40 percent
receiving a recommended colonoscopy or sigmoidoscopy procedure within the
last 5 years.

Relatively few beneficiaries receive multiple services. While 1999
utilization data show progress in improving receipt of preventive services,
and in some cases relatively high rates of use for individual services, a
small number of beneficiaries access most of the services. For example,
although 91 percent of female Medicare beneficiaries received at least 1
preventive service, only 10

percent of female beneficiaries were screened for cervical, breast, and
colon cancer, and immunized against both flu and pneumonia.

Although national rates provide an overall picture of current use, they mask
substantial differences in how seniors living in different states use some
services. For example, the national breast cancer screening rate for
Medicare beneficiaries was 75 percent in 1999, but rates for individual
states ranged from a low of 66 percent to a high of 86 percent. Individual
states also ranged from 27 percent to 46 percent in the extent to which
beneficiaries receiving a colonoscopy or sigmoidoscopy for cancer screening.
Usage rates also varied based by beneficiary, income, and education. Among
ethnicity groups, the biggest differences occurred in use of immunization

services. For example, 1999 data show that about 57 percent of whites and 54
percent of ?other? ethnic groups were immunized against pneumonia, compared
to about 37 percent of African Americans and Hispanics. Similarly, about 70

percent of whites and ?other? ethnic groups received flu shots during the
year compared to 49 percent of African Americans. Beneficiaries with higher
incomes and levels of education tend to use preventive services more than
those at lower levels. Use of Preventive Services is Growing but

Varies Widely

Page 7 GAO- 02- 777T CMS has conducted a variety of efforts to increase the
use of preventive services. These include identifying which approaches work
best and sponsoring specific

initiatives to apply these approaches in every state. To identify how best
to increase use of preventive services needed by the Medicare population,
CMS sponsors reviews of studies that examine various kinds of interventions
used in the past. 9 Among the CMS- sponsored reviews was one that examined
the effectiveness of various interventions for flu and pneumonia
immunizations and screenings for breast, cervical, and colon cancer. 10 This
evaluation, which consolidated evidence from more than 200 prior studies,

concluded that no specific intervention was consistently most effective for
all services and settings.

While no one approach appears to work in all situations, the CMS evaluation
concluded that system changes and financial incentives were the most
consistent at producing the largest increase in the use of preventive
services.

System changes. These interventions change the way a health system operates
so that patients are more likely to receive services. For example, standing
orders may be implemented in nursing homes to allow nurses or other
nonphysician medical personnel to administer immunizations.

Incentives. These interventions include gifts or vouchers to patients for
free services. Medicare allows providers to use this type of approach only
in limited circumstances. 11 For example, in order to encourage the use of
preventive services, providers may forgo some compensation by waiving
coinsurance and deductible payments for Medicare preventive services. In
addition, other types of incentives- such as free transportation or gift
certificates- are also allowed so

long as the incentive is not disproportionately large in relationship to the
value of the preventive service.

9 CMS also conducts a variety of health promotion activities to educate
beneficiaries about the benefits of preventive services and to encourage
their use. These include the publication of brochures on certain covered
services and media campaigns. 10 Health Care Financing Administration,
Evidence Report and Evidence- Based Recommendations: Interventions that
Increase the Utilization of Medicare- Funded Preventive Services for Persons
Age 65 and Older, Publication No. HCFA- 02151 (Prepared by Southern
California Evidence- based Practice Center/ RAND, 1999). 11 Under
regulations that became effective on April 26, 2000, Medicare providers may
offer certain incentives for preventive services. Under no circumstances may
cash or instruments convertible to cash be used. See 42 CFR sect. 1003. 101.
Efforts Under Way to

Increase Use of Some Preventive Services

Studies Identify Effective Methods to Increase Use of Services

Page 8 GAO- 02- 777T Other interventions found to be effective- though to a
lesser degree than the categories above- are reminder systems and education
programs.

Reminders. These interventions include approaches to (1) remind physicians
to provide the preventive service as part of services performed during a
medical visit or (2) generate notices to patients that it is time to make an
appointment for the service. Studies show that reminders to either
physicians or patients can effectively improve rates for cancer screening.
However, if a computerized information system is present in a medical
office, computerized provider reminders are consistently more cost-
effective than notifying the patient directly.

Patient reminders that are personalized or signed by the patient?s physician
are more effective than generic reminders.

Education. These interventions include pamphlets, classes, or public events
providing information for physicians or beneficiaries on coverage, benefits,
and time frames for services. The review found that while the effect of
patient

education is significant, it has the least effect of any of these types of
interventions. CMS contracts with 37 Quality Improvement Organizations
(QIOs), each responsible for monitoring and improving the quality of care
for Medicare beneficiaries in one or more states, in the District of
Columbia, or in U. S. territories. 12 QIO activities currently aim to
increase use of three Medicare preventive services- immunizations against
flu and pneumonia and screening for

breast cancer. QIOs are using various methods of increasing the use of these
preventive services. For example, they are developing reminder systems, such
as chart stickers or computer- based alerts, that remind physicians to
contact patients on a timely basis for breast cancer screening. QIOs are
also conducting activities to educate patients and providers on the
importance of flu and pneumonia shots.

CMS has taken steps to evaluate the success of these efforts. CMS officials
explained that the contracts with the QIO organizations are ?performance
based? and provide financial incentives as a reward for superior outcomes.
CMS officials expect information on the results by the summer of 2002.

12 CMS formerly referred to this program as the Peer Review Organization
program. During the course of our review CMS began referring to these
entities as Quality Improvement Organizations. CMS officials told us that
CMS plans to formalize the name change in a future Federal Register notice.
CMS Is Sponsoring Efforts to Increase Use of Services

Page 9 GAO- 02- 777T CMS plans to expand these efforts by QIOs. While the
current efforts include only 3 of the preventive services covered by
Medicare, CMS is also planning to

include requirements for the QIOs to increase the use of screening services
for osteoporosis, colorectal, and prostate cancer in future QIO contracts.
CMS is not currently planning to include QIO contract requirements for the
remaining preventive services covered by Medicare- hepatitis B immunizations
or screenings for glaucoma and vaginal cancer. Other specific efforts have
been started to increase use of preventive services by minorities and low-
income Medicare beneficiaries in each state. CMS- funded research on
successful interventions for the general Medicare population 65 and older
concluded that evidence was insufficient to determine how best to increase
use of services by minority and low- income seniors. To address this lack of
information, CMS has tasked each QIO to undertake a project aimed at
increasing the use of a preventive service in a given population. For
example, the

QIO may work with community organizations, such as African American
churches, in order to convince more women to receive mammograms. CMS expects
to publish a summary of QIO efforts to increase services for minorities and
low- income seniors after the spring of 2002.

Finally, other studies or projects that CMS has under way aim to identify
barriers and increase use of services by certain Medicare populations. For
example, the Congress directed CMS to conduct a demonstration project to,
among other things, develop and evaluate methods to eliminate disparities in
cancer prevention screening measures. 13 These demonstration projects are in
the

planning stages. A report evaluating the cost- effectiveness of the
demonstration projects, the quality of preventive services provided, and
beneficiary and health care provider satisfaction is due to the Congress in
2004.

Medicare beneficiaries are making more use of preventive services than ever
before, but there is still room for improvement. While most preventive
services are used by a majority of beneficiaries, few beneficiaries receive
multiple

services. Also, disparities exist in the rates that beneficiaries of
different ethnic groups, income and education levels use Medicare covered
preventive services. CMS has activities underway that have the potential to
increase usage of

13 See the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection
Act of 2000, Public Law 106- 554, Appendix F, sect. 122, 114 Stat. 2763, 2763A-
476 classified to 42 U. S. C. sect. 1395b- 1 nt. Concluding Observations

Page 10 GAO- 02- 777T preventive services. However, the full effect of these
activities will not be known for quite some time.

As the Subcommittee and Congress consider broadening Medicare?s coverage of
preventive services, it is important to recognize the difficulty of
translating some preventive service recommendations into covered benefits.
For example,

inclusion of behavioral counseling services may be beneficial, but reaching
consensus on common definitions of these services remains a major challenge.
Establishing Medicare coverage for some screening activities such as blood
pressure and cholesterol screening may not be necessary since most
beneficiaries already receive these services. Nevertheless, we believe that
it is important to

regularly review Medicare?s coverage of preventive services as information
on the effectiveness of such services becomes available. It is also
important to continue to explore new approaches to encourage beneficiaries
to avail themselves of the preventive services Medicare covers. This
concludes my prepared statement, Mr. Chairman. I will be happy to respond

to any questions that you or Members of the Subcommittee may have. For
future contacts regarding this testimony, please call Janet Heinrich,
Director, Health Care- Public Health Issues, at (202) 512- 7119, or Frank
Pasquier at (206) 287- 4861. Other individuals who made key contributions
include Matthew Byer,

Behn Miller, and Stan Stenersen. Contacts and Acknowledgements (290197)
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