Preventive Health Services for Medicare

Beneficiaries: Policy and Research Issues

February 1990

OTA-H-416

NTIS order #PB90-219999
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Preventive Health Services for Medicare

Beneficiaries: Policy and Research Issues, OTA-H-416 (Washington, DC: U.S. Government

Printing Office, February 1990).

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402-9325

(order form can be found in the back of this special report)
Foreword

Interest in health promotion and disease prevention strategies for elderly people has

grown in the past ten years, in part because of the need to find ways to moderate the rising costs

of health care in this rapidly growing segment of the population. Reflecting this interest, the

House Committee on Ways and Means requested that OTA analyze the effectiveness and costs

of providing selected preventive health services to the elderly under the Medicare program.

The Senate Labor and Human Resources Committee had earlier requested that OTA provide

information on the value of preventive services for the American people. OTA responded with

a study of the effectiveness and costs of four specific preventive services for the elderly:

glaucoma screening; cholesterol screening; cervical cancer screening; and colorectal cancer

screening. Background papers on each of these services are now or will soon be available. As

mother part of the assessment, OTA prepared a staff paper on the factors affecting older

people’s use of preventive services, with particular emphasis on how insurance coverage could

be expected to alter such patterns of use.

This Special Report analyzes policy and research issues raised in considering Medicare

coverage of preventive services. OTA examines how decisions are currently made about

coverage of specific preventive services under Medicare and lays out options for altering the

process and criteria governing those decisions. The Special Report also reviews and critiques

ongoing demonstration projects and summarizes the results of OTA studies of the costs and

effectiveness of specific preventive services for the elderly.

~zf GA&L&6- .

JOHN H. GIBBONS

- Directo r

. . . Ill
Advisory Panel—Project on Preventive Health Services Under Medicare

Gordon De Friese, Panel Chair

Health Services Research Center

University of North Carolina, Chapel Hill, NC

Marianne C. Fahs

Department of Health Economics

Mt. Sinai Medical Center

New York, NY

John Frank

Department of Preventive Medicine & Biostatistics

University of Toronto

Ontario, Canada

Gary D. Friedman

Epidemiology and Biostatistics Division

Permanence Medical Group, Inc.

Oakland, CA

Lawrence Gottlieb

Clinical Guidelines Program

Harvard Community Health Plan

Brookline Village, MA

Mary Knapp

John Whitman and Associates

Philadelphia, PA

Risa Lavizzo-Mourey

Geriatrics Program

University of Pennsylvania

Philadelphia, PA

M. Cristina Leske

Department of Preventive Medicine

SUNY at Stony Brook

Stony Brook, NY

Donald Logsdon

INSURE Project

New York, NY

Mildred B. McCauley

American Association of Retired Persons

Washington, DC

Peter McMenamin

Chevy Chase, MD

Meredith Minkler

Center on Aging

University of California, Berkeley

Berkeley, CA

Marilyn Moon

Public Policy Institute

American Association of Retired Persons

Washington, DC

George Morley

Department of Obstetrics/Gynecology

University of Michigan Medical Center

Ann Arbor, MI

Gilbert Omenn

Dean, School of Public Health & Community Medicine

University of Washington

Seattle, WA

George Pickett

Department of Public Health Policy

School of Public Health

University of Michigan

Ann Arbor. MI

Donald Shepard

Department of Health Policy and Management

Harvard School of Public Health

Boston, MA

Barry Stults

Division of General Internal Medicine

University of Utah Medical Center

Salt Lake City, UT

NOTE: Advisory Panel members provide valuable guidance during the preparation of OTA reports. However, the presence of ar

individual on the Advisory Panel does not mean that individual agrees with or endorses the conclusions of this particular report

iv
OTA Project Staff—

Preventive Health Services for Medicare Beneficiaries:

Policy and Research Issues

Roger C. Herdman, Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Project Staff

Judith L. Wagner, Project Director

Elaine J. Power, Analyst

Michael Gluck, Analyst

Brigitte M. Duffy, Research Analyst

Administrative Staff

Virginia Cwalina, Administrative Assistant

Carol Ann Guntow, P.C. Specialist

Karen T. Davis, Word Processor Specialist

Carolyn Martin, Secretary
Contents

Page

Chapter 1. Executive Summary .......................... . 1

Criteria for Including Preventive Services as Covered Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Locus of Responsibility for Coverage Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Research Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Chapter 2. Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 3. Defining Preventive Services for the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 4. The Medicare Program and Preventive Services , . . . . 0 . 9 . . . . . . . . . . . . . . . . . . . 9

Current Status of Medicare Funding for Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Strengths and Weaknesses of Medicare as a Source of Funding for Preventive Services . . . . . 9

Policy Issues in Developing a Medicare Strategy for Preventive Services . . . . . . . . . . . . . . . . . . 10

The Unit of Payment: Individual Procedures v. Service Package . . . . . . . . . . . . . . . . . . . . . . . . 11

Standards of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Locus of Responsibility for Coverage Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter 5. Evaluating the Evidence of the Cost-Effectiveness of Preventive

Services for the Elderly: Selected Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Under What Conditions Is It Appropriate To Generalize About the Effectiveness of a

Service on the Elderly From Evidence of Its Effectiveness

in Nonelderly Populations? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

How Should the Effects of Services Provided Together in a Package Be

Attributed to Specific Procedures? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

How Should the Costs of a Visit Be Apportioned Among the Individual

Procedures and Interventions Provided in the Visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

What Allowances in Cost Estimates, if Any, Should Be Made for Inefficiencies

Inherent in the Medical Care System? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

How Should Uncertainties Be Treated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 16

Chapter 6. Research Issues ● ...............................................,.... . . . . . . . . . . ..... , 17

Appendix A. Acknowledgments . . . . . . . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . 19

Appendix B. Summary of OTA Studies of Preventive Services for the Elderly . . . . . . . . . 20

Appendix C. The Medicare Preventive Services Demonstration Projects . . . . . . . . . . . . . . . 22

Appendix D. Summary of Recommendations for Periodic Health Examinations

in the Elderly ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 28

References ...... ...... . . . . . . . . . ...,...,...,. ● ...... . . . . . . . . . . . . . 34

Box

Page

A. Health Problems of the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 7

Tables

Page

l. Selected Potential Clinical Preventive Services for the Elderly . . . . . . . . . . . . . . . . . . . . . . . . 6

C-1. Design of Medicare Preventive Services Demonstration Projects . . . . . . . . . . . . . . . . . . . . . 23

C-2. Preventive Services Offered in the Medicare Demonstration Projects . . . . . . . . . . . . . . . . . . 24

D-1. Recommendations for Physician Visits for the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

D-2. Published Recommendations for the Use of Selected Preventive Services

by Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

D-3. Recommendations for Screening for Colorectal Cancer in the Elderly . . . . . . . . . . . . . . . . . 33
Chapter 1

Executive Summary

Medicare is prohibited by law from offering

benefits for preventive services except when they are

specifically added to the scope of covered benefits

through amendments to the Medicare act. So far,

vaccines for pneumococcal pneumonia and Hepatitis B and screening Pap smears are the only

preventive services covered by Medicare. The wisdom of this blanket exclusion with legislated exceptions has been questioned by many experts.

How should decisions be made about Medicare

coverage of preventive services? This question has

two components:

. What criteria should govern the decisionmaking process?

. Where should the responsibility for such decisions lie?

CRITERIA FOR INCLUDING

PREVENTIVE SERVICES AS

COVERED BENEFITS

Because they have traditionally been excluded

from insurance benefit packages, preventive services have been held to a burden of proof of

effectiveness or cost-effectiveness that exceeds that

required for diagnostic and therapeutic procedures.

Third-party payers, including Medicare, generally

accept diagnostic or therapeutic services as “reasonable and necessary’ unless obvious abuse is encountered. In contrast, for preventive services to be

included in a benefit package, evidence must exist

that they are at least effective, and sometimes that

their medical benefits are worth their costs. This

standard may seem unduly harsh, and proponents of

preventive services often argue that it is unfair to

hold preventive services to a higher standard than

that required for other medical services. Two powerful arguments favor a tough standard for preventive

services, however. First, like all services, preventive

services involve potential risks as well as potential

benefit. However, unlike diagnostic and therapeutic

services, which are rendered in response to patient

complaints or symptoms, preventive services are

offered to ostensibly healthy individuals and therefore involve an implied promise that they will

improve the patient’s health. Second, the more

appropriate response to the double standard may be

to raise the level of evidence required for diagnostic

and therapeutic services, not to lower that for

preventive services. That one genie is out of the

bottle is no justification for letting others out, too.

Even accepting that the decision to include

preventive services as an insured benefit requires

explicit evidence, criteria must be selected to govern

the coverage decision and the standards of validity

required of the evidence that does exist. Possible

criteria include:

●

●

●

effectiveness of the intervention in prolonging

life or improving its quality,

cost-effectiveness of the intervention in achieving given levels of health effects at the lowest

possible cost, and

impact of the intervention on net Medicare

outlays.

The notion that a preventive health service should

be effective is widely accepted by health care

providers and policymakers. There is less agreement

about whether the cost of such services should be

considered in either coverage or clinical decisions.

The U.S. Preventive Services Task Force, convened

in 1984 to develop guidelines for preventive services, adopted stringent standards of effectiveness but

explicitly rejected cost-effectiveness as a criterion

for their task in judging these services. In fact, no

professional group in the United States making

recommendations on preventive services for the

elderly has explicitly accepted cost-effectiveness as

a criterion for making such judgments.

Using the net impact on Medicare expenditures as

the criterion for coverage is unduly stringent,

because it assumes that if a preventive intervention

costs Medicare money, it is not worth it, regardless

of whatever health benefits it provides. A highly

effective preventive service could also fail the test of

being cost-saving to Medicare if by prolonging life

it induces additional future Medicare expenditures

for unrelated illnesses.

Even specifying a criterion for decisions leaves a

great deal of potential for differing judgments.

Evidence on the effectiveness of preventive services

is often poor and conflicting. Little effectiveness

research has been conducted in elderly populations,

and the validity of applying findings generated from

studies of other populations to the elderly population

is questionable. The Medicare Preventive Services

–l–
2 . Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations

Demonstration Projects currently underway will not

add much to the information base on the effectiveness or cost-effectiveness of these services, although

they will tell a great deal about how elderly people

respond to financial incentives to use such services.

To collect adequate data on effectiveness of preventive services in the elderly would take many years

and many millions of dollars.

Those responsible for the decision of whether to

make preventive services a Medicare benefit will be

taking risks either way. On the one hand, including

these benefits in the Medicare package could increase Medicare outlays without appreciably reducing older people’s mortality, morbidity, or disability. On the other hand, if preventive services

continue to be excluded from Medicare payment,

real opportunities for better health or savings in

health care costs could be lost for years to come.

LOCUS OF RESPONSIBILITY FOR

COVERAGE DECISIONS

Responsibility for expanding Medicare to cover

preventive services currently resides with Congress.

To date, such expansions have been limited to

specific procedures, but Congress could authorize

the Health Care Financing Administration (HCFA)

to offer an “appropriate” package of preventive

services to elderly Medicare beneficiaries. Authorizing legislation could include criteria for assessing

the “appropriateness” of such services. For example, Congress could direct HCFA to consider the

cost-effectiveness of alternative packages in its

implementation of regulations.

Vesting HCFA with the authority to decide about

specific packages of services would probably increase the flexibility of the Medicare program to

respond to new evidence on effectiveness or costeffectiveness as it arises. By removing specific

coverage decisions from the legislative process,

preventive services would not have to compete for

approval directly with other uses of the Federal

health budget. However, if the authority for coverage decisions is vested in HCFA, the resulting

package of services offered to the elderly would be

unpredictable. As was noted just above, conclusions

about the health and cost consequences of specific

preventive services depend in poorly understood

ways on the composition of the recommending

groups and the criteria and standards used to judge

the evidence. Even directing HCFA to use costeffectiveness as a criterion for coverage decisions

would leave a great deal of uncertainty about how

the available evidence would be assessed. A process

administered by HCFA, however, might be no more

unpredictable than the current legislative process

and would still be subject to oversight by Congress.

RESEARCH PRIORITIES

The Health Care Financing Administration is

currently supporting six Medicare demonstration

projects that offer preventive health services to

Medicare beneficiaries. Although these projects are

unlikely to provide much additional evidence on

effectiveness, opportunities do exist for obtaining

some effectiveness data at relatively low additional

cost if extended follow-up studies are funded at

selected demonstration sites where participation

rates have been high. Since all but one of these

demonstrations were congressionally mandated, extending their length might require an amendment to

the legislation.

Because effectiveness research is costly, it should

be targeted to services that offer the potential for

large impacts on health status or health care costs of

the elderly. Research to clarify the appropriate

components of and target populations for comprehensive geriatric assessments has been recommended by a National Institute of Health consensus

conference panel (65). Because the costs of institutional care for the disabled elderly are high, these

tertiary preventive health services are a promising

subject for effectiveness and cost-effectiveness research.
Chapter 2

Introduction

As the primary source of health insurance for the

Nation’s 31 million elderly people, Medicare provides access to a wide range of health services for

diagnosis, therapy, and rehabilitation. Medicare is

prohibited by law from offering benefits for preventive services except for a small number that have

been added to the scope of covered benefits through

amendments to the Medicare Act. * When compelling evidence has accumulated about the health

benefits or savings in health care costs achievable

from specific preventive services, Congress has

legislated expansions of the Medicare benefit. So

far, vaccines for pneumococcal pneumonia and

hepatitis B and, most recently, screening mammography2 and Pap smears are the only preventive

services covered by Medicare.

In recent years, the wisdom of this blanket

exclusion of preventive services has been questioned by numerous experts and interested groups

(5,12,13,22,40,90,96). Interest in health promotion

and disease prevention for the elderly has grown as

the U.S. population has aged. The high cost of

providing acute and chronic health care has led

researchers to search for ways to prevent or delay the

need for those services. The obligation of Medicare

to pay for the consequences of not preventing

episodes of illness or disability, at the same time that

it does not pay for interventions that might prevent

such episodes, seems to be shortsighted. Sometimes

the investment in preventive services can actually

save Medicare program costs.3 Even when prevention does not save money for Medicare, it may

improve the health of Medicare beneficiaries or save

health care costs for other payers enough to justify

the added costs.4

Congress has actively considered proposals to

expand Medicare benefits for health promotion or

preventive services. In the past 2 years, numerous

proposals were made to expand coverage for such

services as Pap smears, fecal occult blood testing,

and cholesterol testing. Indirect expansions of benefits have also been proposed. For example, S.358

(99th Cong.) would have raised the Medicare Part B

deductible but would have allowed the cost of

disease screening, immunizations, and anti-hypertension drugs to count towards that deductible.

Another proposal considered for the Medicare Catastrophic Coverage Act of 1988 (Public Law 100-

360) would have allowed a long list of preventive

services to count against the catastrophic deductible

limit. One proposal (S. 357, 99th Cong.) would have

lowered the Part B premium for nonsmokers by $1

per month. The House considered a proposal (HR

1402) that would allow beneficiaries to purchase

through Medicare a supplemental insurance option

to cover the cost of an annual preventive health

physician visit.

In the absence of reliable information about the

health and financial consequences of such proposals,

Congress has moved cautiously. Except for covering

the two vaccines, Pap smears and, for a time,

mammography, legislation has been limited to

establishing demonstration projects to study the

effects of offering packages of preventive health

services to Medicare beneficiaries (Public Law

99-272) and a demonstration of the effectiveness of

offering the influenza vaccine as a covered benefit

(Public Law 100-203). As part of its effort to obtain

information on the consequences of expanding

Medicare benefits for preventive services, the House

Committee on Ways and Means asked the Office of

Technology Assessment (OTA) to study the effectiveness and cost of selected preventive services for

the elderly. OTA selected four screening services for

study: glaucoma screening; cholesterol screening;

colorectal cancer screening; and cervical cancer

screening. Separate papers on each of these technologies have been or soon will be released. A staff

paper has also been prepared on preventive services

IMedic~e will pay for “reasonable and necess~’ medical and o~er he~th services offer~ by certified providers if they are diagnostic, th(Yap31tiC,

surgical, consultative, or rehabilitative. Some experts define preventive services broadly to include some therapies and rehabilitation. Medicare’s stricture

against payment for preventive services pertains to those services not offered in direct response to patient complaints, symptoms, or clinical signs.

2ScEning m~ography was briefly slat~ to become a covered benefit, but because it was enacted as part of the Medicare Catasmwhic Coverage

Act of 1988 (Public Law 100-360), the benefit was repealed with the other provisions of that law late in 1989.

sFmexaple, a 197’9 OTA study of Pnewococcal pneumonia vaccine in the elder]y Conc]uded that, under certain assurnp[ions, the cOSt Of the V21CCiIle

would be more than made up for by savings to the Medicare program (86,88).

4For exmple, abiannu~ m~mography Scr=ning is not likely to save Medicare costs but h~ the Potential to detect e~ly bre=t cancers ~d ProlOng

the life of Medicare beneficiaries (89).

–3-
4 ● Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations

utilization by the elderly. (See app. B for a brief

summary of each of these papers.)

This Special Report is also part of OTA’s study of

preventive services for the elderly. Its purpose is to

examine the strengths and weaknesses of the Medicare program as a vehicle for funding the delivery of

preventive services to the elderly. Chapter 3 contains

a general description of the range of preventive

services that are possibly useful to the elderly. This

section is not intended to evaluate the effectiveness

of such services; rather, it will focus on the major

health problems of the elderly and the kinds of

preventive interventions that have been suggested to

deal with those problems. Chapter 4 describes the

elements of the Medicare program that influence the

receipt of effective and efficient preventive services

by the elderly. Chapter 5 discusses issues that arise

in evaluating the effectiveness and cost-effectiveness of offering preventive services to the elderly

under Medicare. Chapter 6 concludes with a discussion of research priorities.

As supplementary material, this report also contains: abstracts of OTA studies of the costs and

effectiveness of preventive services for the elderly

(see app. B); a review and critique of the Medicare

Preventive Services Demonstration Projects mandated by Congress in 1986 (Public Law 99-509) and

currently underway (see app. C); and a compendium

of recommendations by expert groups for preventive

services for elderly people (see app. D).
Chapter 3

Defining Preventive Service for the Elderly

Although prevention encompasses a wide variety

of actions by individuals or organizations whose

goal is to improve health, the term “preventive

services” refers here to a narrower set of interventions comprising medical procedures, tests, or visits

with health care providers that are undertaken for the

purpose of promoting health, not for responding to

patient signs, symptoms, or complaints. Preventive

services in this report are interactions between

elderly people and health care providers, not interventions such as education through the mass media,

seat-belt safety laws, etc.

A distinction is also necessary between preventive services and individual preventive behavior. For

example, elderly people who quit smoking are

engaging in an exceedingly effective preventive

behavior (41,49), but the behavior is not a preventive

service. A smoking cessation program or counseling

would constitute a preventive service as defined

here. This distinction is important, because different

kinds of services designed to bring about the same

change in behavior may vary widely in effectiveness

and costs. Medicare would pay for the service, not

for the change in behavior; hence, Medicare’s

interest is not only in the effectiveness of the change

in behavior on health outcomes, but also in the

effectiveness and costs of the service whose purpose

is to bring about the change in behavior. In the case

of smoking cessation for example, the effectiveness

of smoking cessation counseling by physicians

appears to vary widely across population groups and

counseling techniques (17,20,52,53,84,1 00). 1 Advocates of increased Medicare support for preventive

services often fail to distinguish between the effectiveness of behavior change and the effectiveness of

services in citing evidence to support their views

(13).

Preventive services have been described by two

general frameworks. The traditional approach, used

by most experts, classifies preventive services according to their ultimate goal (48,55):

. Primary preventive services are intended to

prevent or delay the onset of disease. Immunizations and counseling on lifestyle changes

are classic examples of primary prevention.

●

●

Secondary preventive services are efforts to

detect a disease or condition before it is

clinically recognizable to avoid or delay its

further progression. Screening procedures, such

as mammography or Pap smears, fall into this

category.

Tertiary preventive services attempt to reduce

the impact of already existing disease on the

quality of a person’s life by maintaining or

improving his or her ability to function. These

would include services such as education for

diabetic patients or rehabilitation for stroke

victims.

Health insurers, including Medicare, typically

pay providers for undertaking defined activities, not

for accomplishing goals. Many services whose goal

is tertiary prevention are currently covered under

Medicare as therapeutic or rehabilitative services.

An alternative typology, shown in table 1, identifies

preventive services that are generally excluded from

Medicare coverage and are more in keeping with the

fee-for-service payment system than is the traditional typology. There, selected preventive services

are classified into three major categories: immunization; screening; and education or counseling. Health

insurers typically offer specific services whose

delivery can be audited; a “primary prevention”

benefit unrelated to defined services would be too

amorphous for a health insurance package.

The differences between the two taxonomies

reflect the limitations of health insurance programs

as mechanisms for providing appropriate preventive

services. The goal-based taxonomy recognizes the

importance of integrating prevention into the larger

health care system. By including tertiary preventive

services within the scope of prevention, the taxonomy also makes preventive services relevant for all

people regardless of their health status. This is

particularly important for the elderly (31).

The increasing incidence of chronic and disabling

diseases with age and the frequency of multiple

coexisting conditions in the elderly threaten the

ability of many to live independently (see box A). In

1985, about 1 in 20 elderly residents of the United

States were in nursing homes. Among people 85

years and older, however, about 1 in 5 were in

IN~te, however, hat the impact of smoking cessation on llfe ex~t~cy is so gr~t mat even if coun~ling brings forth a very sm~l reduction in the

smoking rate, it may be very cost-effective (20).

-5–
6 ● Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations

nursing homes (43). If preventive services can avert

the need for some of that institutional care, the

payoff in terms of both better health and lower health

care costs could be high.

Recent experience with programs of comprehensive geriatric assessment for impaired elderly people

(e.g., the very old, frail, hospitalized, or disabled)

suggests that these services, when undertaken by a

well-trained team of professionals and when coupled

with adequate follow-up services, can measurably

improve the health status of the served group

(16,65,79). The effectiveness of such programs

depend on the target group selected and the scope of

services offered and actually received (14,56,65,71,

79,83,85). Because such services must be tailored to

the individual needs of the patient, which must be

carefully identified, they may also be costly (26,79).

Regardless of whether these services are worth

their costs for some portion of the elderly population, health insurance programs, including Medicare, do not encourage their development, and the

current organization of health care delivery for the

elderly inhibits their use. Because it is difficult to

control the content of a visit, health insurers are

reluctant to pay for comprehensive health assessments and follow-up activities. The delivery of

health care to the elderly is often fragmented: the

patient will often see a different specialist for each

particular chronic condition, and frequently no one

provider is managing the overall case. The high

frequency of inappropriate prescribing and use of

medications in the elderly is, at least in part, a

reflection of this fragmentation of care (59,95).

Today, such programs are typically affiliated with

medical schools, teaching hospitals, or Department

of Veterans Affairs’ Medical Centers. In 1985, 114

such units were identified as operating in these

institutions (26).

Table 1--Selected Potential Clinical Preventive

Services for the Elderly

Immunizations :

. Influenza

. Tetanus

 . Pneumococcusa

● Hepatitis Bb

Screening:

●

●

●

●

●

●

●

●

●

●

●

●

●

e

●

●

Cancer-screening:

—Breast cancer (clinical examination; mammography)

-Colorectal cancer (occult blood stool; sigmoidoscopy)

-Cervical and uterine cancer (clinical examination; Pap smearc

;

endometrial biopsy)

—Prostate cancer (clinical examination; ultrasound)

-Skin cancer (clinical examination)

—Melanoma (clinical examination)

Blood pressure measurement

Vision examination

Glaucoma screening

Hearing test

Cholesterol measurement

Mental status/dementia

Osteoporosis (standard X-ray; quantitative CT; other radiological techniques)

Diabetes screening

Asymptomatic coronary artery disease (exercise stress test)

Dental health assessment

Multiple health risks appraisal/assessment

Functional status assessment

Depression screening

Screening for hyperthyroidism or hypothyroidism

Urine testing

Education and counseling:

. Nutrition

. Weight control

. Smoking cessation

. Home safety/injury prevention

. Stress management

. Appropriate use of medications

. Alcohol use

. Exercise

ABBREVIATION: CT. computed tomography.

a -currently covered by Medicare.

b -currently covered by Medicare for high risk patients.

c -coverage effective July 1, 1990.

SOURCE: Office of Technology Assessment, 1990.
Chapter 3--Defining Preventive Services for the Elderly ● 7

Box A—Health Problems of the Elderly*

“Progressive decrements in physical, mental and social function may occur with advancing age. Multiple

factors contribute to this decline. . . First, there is a physiologic age-related decline in organ function from the fourth

through the ninth decades, the magnitude of which varies considerably among different persons. While these

physiologic losses do not significantly compromise the overall function of an elderly person, in the event of a

superimposed illness or injury they may result in more profound dysfunction and a longer recuperation time than

in younger persons, Physical and mental inactivity (disuse) may also compromise organ function with advancing

age. Some of the decline in organ function that has been attributed to physiologic aging may instead be due to disuse

and therefore be preventable or reversible with appropriate therapy. The prevalence of chronic physical and mental

illness increases dramatically with age, particularly in persons 75 and older. The rates for chronic illnesses in the

elderly such as arthritis, hypertension, organic heart disease, sensory impairments and urinary incontinence are

about twice the rates in persons younger than 65. Nearly 25% of community-dwelling elderly have symptomatic

mental illness, including 10% with significant depression and 5% with dementia. Potentially serious psychosocial

stresses are common and include undesired retirement, inadequate finances, death of a spouse or the necessity of

moving away from the family home. Many elderly persons will simultaneously suffer from several of these chronic

physical or mental conditions.

‘‘The magnitude of the decrements in physical, mental and social function varies tremendously among elderly

persons. The vast majority of the elderly are able to tolerate and adjust to their functional impairments or disabilities

and remain independent within the community. However, a significant minority have major functional disability.

Nearly 20% of the elderly aged 75 through 84 and 30% aged 85 and older are unable to carry on major activities

such as leaving home, doing housework or cooking, compared with 7% with similar disability who are younger than

65. Nearly 10% to 20% of persons aged 80 and older are unable to carry on even basic activities of daily living

(bathing, dressing, eating, toileting) versus 4% younger than 65. Because of this dependency many of these elderly

persons will require placement in a nursing home unless adequate social support can be obtained from family,

friends, or the community. Whereas only 570 of persons older than 65 years are in nursing homes, 20% older than

85 reside in them; the elderly have a 20% chance of requiring at least temporary nursing home placement at some

time in their life. ”

*Quoted from B.M. Stults, “Preventive Health Care for the Elderly, ” Western J. Med. 141(6):832-844, 1984.
Chapter 4

The Medicare Program and Preventive Services

CURRENT STATUS OF

MEDICARE FUNDING FOR

PREVENTIVE SERVICES

Despite the statutory exclusion of preventive

services from Medicare coverage, today Medicare

pays for some preventive services that are not

explicitly mandated by legislation, although the

frequency and distribution of these reimbursed

services in the elderly population have not been

estimated.

First, a substantial number of procedures, particularly screening tests, may be reimbursed in part or in

full as diagnostic rather than as screening procedures. Whether Medicare reimburses for a visit or

procedure depends on how the visit is characterized

on the Medicare claim. If a visit is initiated by a

patient because of a medical complaint, the physician fee is covered. Similarly, a test is covered if it

is performed because of a symptom or suspected

diagnosis.

Anecdotal examples suggest that some procedures done for screening purposes may be paid for

by Medicare as diagnostic procedures. A recent

review of over 200 medical records of lower GI

endoscopies (sigmoidoscopy and colonoscopy) performed on Medicare patients and reimbursed by

Medicare found that at least 13 percent were

performed for cancer screening purposes, not for

diagnostic reasons (94).

Second, many tertiary preventive services (e.g.,

hypertension control or treatment of hypercholesterolemia) are reimbursable expenses under Medicare,

because they are defined as therapeutic. Visits made

for monitoring, counseling, or prescribing of treatment would be reimbursable by Medicare.

Finally, an unknown percentage of the almost 1

million Medicare beneficiaries currently enrolled in

health maintenance organizations (HMOs) or other

competitive medical plans (CMPs) may receive

additional preventive care. Since 1982, Medicare

has provided cavitation payments on a riskcontracting basis to HMOs and CMPs who enroll

Medicare beneficiaries (Public Law 97-248). Such

Medicare plans receive a fixed price per capita for

Medicare enrollees, based on age, sex, whether or

not the enrollee resides in a nursing home or other

institution, and whether or not the enrollee is

Medicaid eligible. In exchange, the HMOs and

CMPs are required to cover all part A and part B

benefits, and they may also offer additional benefits

such as preventive services. One large HMO reported to OTA that over one-half of its elderly

enrollees had a complete check-up within the

previous year and 71 percent of its elderly female

enrollees had had a Pap smear within the previous 3

years (37). In some Medicare HMOs, particularly

those organized as independent practice associations

(IPAs), the decision regarding provision of specific

services may be made by the individual physician,

not by plan administrators (44). Thus, even within

specific HMOs, some beneficiaries may be offered

such services while others are not.

When a preventive service is legislated as a new

Medicare covered benefit, beneficiaries enrolled in

Medicare risk-contracting plans are automatically

entitled to it. Thus, a legislative decision to add a

preventive service as a covered benefit not only

provides access to beneficiaries under a fee-forservice payment but also reduces the variation in the

scope of services available to Medicare beneficiaries

enrolled in cavitation plans.

STRENGTHS AND WEAKNESSES

OF MEDICARE AS A SOURCE OF

FUNDING FOR PREVENTIVE

SERVICES

Paying for preventive services through Medicare

is, in many respects, an efficient and simple way to

provide financial access to such services for the

elderly. To the extent that a service can be defined

and assigned a procedure code,l it can be incorporated very easily into the existing payment system.

It is also a relatively simple administrative task to

exempt such services from the deductible and

coinsurance requirements that apply to other Medicare services. For a number of reasons, however,

covering a preventive service as a Medicare benefit

may be insufficient to bring about appropriate

patterns of use.

I All reimb~sable Medicare procedures and visits are assigned a unique five-digit code and published as the Health Care Procedural Coding system

(HCPCS), which is an expansion of the American Medical Association’s Currenl Procedural Term”nofogy ( 19).

-9–
10 ● Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations

The decision to use a preventive service may

depend more on the information available to the

consumer or physician, and the attitudes of each,

than on its out-of-pocket cost. OTA’s study suggests

that the use of preventive services by the elderly may

depend more on characteristics of the consumer,

physician, and service than on the out-of pocket

costs (37). Although adding a preventive service to

the list of covered Medicare benefits would certainly

not reduce its utilization, it is questionable whether,

in the absence of concerted efforts to educate

physicians and Medicare beneficiaries about the

value of such services and to encourage their use,

overall rates of use would increase substantially

(63,80,101 ).2 Moreover, to the extent that people

who would benefit most are the least likely to use

such services, as appears to be the case with cervical

cancer screening (61), the real medical benefits

deriving from coverage could be minimal in some

cases.

Some services are beneficial only to people with

conditions or circumstances that render them particularly “at-risk” for the preventable condition, but it

can be difficult and costly to limit payment for a

preventive service to an at-risk population. For

example, the health benefits of cervical cancer

screening appear to be great for women at or near the

poverty level who have never been previously

screened (61), but it might be impractical to restrict

Medicare coverage of cervical cancer screening to

high-risk women defined in this way. Medicare is

not designed as a means-tested program of benefits.

A Medicare cervical cancer screening benefit may

have to be offered to all women, including those who

stand to gain little from repeated screening. Other

approaches such as direct grant programs, or coverage of such services through Medicaid, might allow

targeting of services to elderly groups most in need,

but these alternatives also have limitations.3

Some preventive services (particularly screening

tests) are highly effective if offered at infrequent

intervals, but as the frequency of use increases, the

added effectiveness declines. A Medicare benefit

can be limited to a maximum frequency, such as

every 2 years, but under the existing claims payment

structure of the Medicare program, it is difficult for

Medicare carriers to monitor compliance with and

enforce such limitations on use (42). As the technology of claims payment improves, this problem may

disappear.

Like most “cognitive” medical services, counseling and education are inherently difficult to

standardize or audit. Because such services would be

delivered in outpatient or office settings, they could

not easily be incorporated in quality assurance

programs focusing on content. Hence, providers

could deliver services of low quality (and low

effectiveness) and still receive payment from Medicare.

Some preventive services, particularly education

and counseling, may be most efficiently and effectively delivered by nonphysician personnel. The

Medicare program, however, requires nonphysician

services such as those of physical or occupational

therapists, nurse practitioners, and clinical psychologists to be provided under the supervision of a

physician. 4 This requirement adds to the cost of

providing services that may not require such supervision. In addition, most physician practices are not

organized to supervise a wide variety of nonphysician personnel, and their Medicare patient loads are

not large enough to justify hiring staff trained in

multiple disciplines for the purpose of delivering an

array of preventive services to the elderly (56).

POLICY ISSUES IN DEVELOPING

A MEDICARE STRATEGY FOR

PREVENTIVE SERVICES

Despite the problems with Medicare as a mechanism for implementing preventive services for the

elderly, it is nevertheless a potential vehicle for

enhancing access to these services. The current

strategy for adding preventive services to Medicare

is ad hoc and procedure specific. It is worth

considering approaches to developing a more com- — .

z~e c= ofpnemococc~ vaccine may be ins~ctive. Despite Medicare coverage of this vaccine in 1982 for all beneficiaries, rates of use did not

increase in the United States between 1982 and 1986. In 1985, only about 11 percent of all elderly people were immunized with the pneumococcal vaccine

(27).

3Dimt ~m~s t. providers of ~mices t. elder]y women in pove~y would superimpose a separate service delivery system on the eXisting System of

care and might interfere with the continuity of care for these women.

4This is lwgely, but not ~c~y, ~e. Since 1988 tie ~N1ces Of clinical psychologists can be directly reimbursed if they are deliver~ in a CommunitY

Mental Heakh Clinic or a Rural Health Clinic as defined by the Public Health Service, Otherwise, clinical psychologists can be separately reimbursed

for services only when the services are delivered under the supervision of a physician.
Chapter 4--The Medicare Program and Preventive Services ● 11

plete strategy for incorporating preventive services

into the Medicare benefit package. The formulation

of such a policy requires choices in the following

areas:

The Unit of Payment: Individual Procedures

v. Service Package

Up to now, newly covered preventive procedures

have been added to the list of billable payment

codes, giving physicians the power to bill for these

services as they do for other medical procedures.

Payment is made only for the procedure itself (e.g.,

the cost of administering a vaccine) and not for the

physician’s visit in which the procedure is administered. Implicit in this policy is the assumption that

the preventive procedure will be delivered as part of

a visit made for a nonpreventive purpose. This

approach to adding new services is both simple and

consistent with existing Medicare billing systems.

This incremental procedure-specific approach ignores the potential benefits of offering services in a

package that may economize on the total cost of

providing any given set of such services. If a

periodic Pap smear were added to the list of covered

services, for example, the additional cost of a

clinical breast examination or a digital rectal examination during the same visit would be minimal.

Counseling sessions on smoking cessation or appropriate medication use could be easily and inexpensively expanded to include information on nutrition.

The fixed costs associated with patient scheduling

and preparation, medical recordkeeping, and billing

could be spread across a number of specific interventions.

Paying for a package of preventive procedures or

activities in a defined visit schedule provides the

physician or other provider with the opportunity to

integrate related services with one another. It is also

compatible with the introduction of educational

materials and encounter forms for physicians as a

guide for providing such services (60). This very

integration also has disadvantages, however. One is

that the package approach can force the patient into

a rather inflexible mode of service delivery that

could ultimately lower his or her use of such

services. Paying by the procedure allows any physician to provide a specific preventive service, such as

a vaccination, as part of a visit for another purpose.

About 85 percent of elderly people made at least one

ambulatory health care visit in 1980 (34). Some

elderly people might accept a single quick intervention as part of another visit but might not be willing

to make a special trip to the doctor each year to

receive a more comprehensive package of services.

Two major preventive services demonstration

projects have adopted the package approach to

payment for preventive services. The frost, Project

INSURE, was begun in 1980 by a consortium of

public and private sources (60). An age-specific

schedule of preventive visits containing a defined set

of preventive services was specified for the study

population. (See app. D for the package of services

provided under Project INSURE for people 65 years

of age and older.) Participants were eligible for and

encouraged to receive the package of services at no

cost; providers were paid on a fee-for-service basis

for services rendered as part of the package.

A more recent set of federally funded studies

currently underway at six sites is testing the feasibility and effects of offering different defined packages

of preventive care to elderly Medicare beneficiaries

and paying providers for the package of services

delivered during the visit or over a period of time.

These projects should provide information on how

Medicare recipients respond to service offered in

packages. (See app. C for a description of these

Medicare demonstration projects.)

Standards of Evidence

Because they have traditionally been excluded

from insurance benefit packages, preventive services have been held to a burden of proof of

effectiveness or cost-effectiveness that is not typically required of diagnostic and therapeutic procedures. For the most part, third-party payers, including Medicare, accept diagnostic or therapeutic

services as “reasonable and necessary” unless

obvious abuse is encountered.5 In contrast, for

preventive services to be included in a benefit

package, evidence must exist that they are at least

effective, and sometimes that their medical benefits

are worth their costs. This standard may seem

unduly harsh, and proponents of preventive services

5~e situation is changing. Diagnostic and therapeutic procedures we incre~ingly scrutin~ ~ough utilization review and quality assurance

activities undertaken by insurers or providers such as hospitals or health maintenance organizations. Medicare’s process for covering new medical

procedures has also recently been strengthened and revised; proposed regulations issued in Janwuy 1989 would change the criterion for coverage from

effectiveness to cost-effectiveness (91).
12 ● Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations

often argue that it is unfair to hold prevention to a

higher standard than that required for other medical

services (48,96). Two powerful arguments favor a

tough standard for preventive services, however.

First, like all services, preventive services involve

potential risks as well as potential benefits. However, unlike diagnostic and therapeutic services,

which are rendered in response to patient complaints

or symptoms, preventive services are offered to

ostensibly healthy individuals and therefore involve

an implied promise that they will improve the

patient’s health (74). Second, the more appropriate

response to the double standard may be to raise the

level of evidence required for diagnostic and therapeutic services, not to lower those for preventive

services. That one genie is out of the bottle is no

justification for letting others out, too.

Even accepting that the decision to include

preventive services as an insured benefit requires

explicit evidence, choices exist about the criteria

that will be used to govern the coverage decision and

the standards of validity required of the evidence

that does exist. Possible criteria include:

●

●

Effectiveness (impact on health status)---

Evidence would be required that the expected

length or quality of life would be increased for

the person receiving a preventive service. This

criterion also requires the assessment of medical risks associated with the use of the service.

X-ray screening procedures, for example, may

subject the user to a small cancer risk associated with ionizing radiation; these risks would

be weighed against the potential beneficial

effects of the screening procedure on longevity

or quality of life.

Cost-electiveness—The health effects of a

preventive service would be arrayed against the

net health care costs of achieving those effects.

Whether the health effects are worth their costs

is a policy judgment. If the health effects can be

reduced to a single dimension (through the use

of a health status index or a quality-adjusted

life-years scale), the ratio of health care costs to

effectiveness can be computed and used as the

basis for judgments about whether the service

is worth its costs. If a preventive service both

improves health (i.e., lengthens life or improves the quality of a person’s remaining

years) and reduces health care costs (by averting costly therapy), then it is not only costeffective but also cost-saving to the health care

system, and unequivocally desirable under this

criterion.

Impact on Medicare outlays—The net effect of

the preventive service on Medicare expenditures would be the basis for a coverage decision.6 A preventive service would be covered if

it can be expected to reduce net Medicare

outlays by averting expenditures for covered

diagnostic and therapeutic services. If expected

net Medicare outlays are positive, policy makers

would have to decide whether the health

outcomes are worth the net outlay, thus implicitly returning to the cost-effectiveness criterion.

Highly effective preventive services could fail

the test of being cost-saving to Medicare,

because in prolonging life, they could induce

future Medicare expenditures for unrelated

illnesses.

Net economic benefits-This criterion combines all consequences of a preventive strategy

(health effects and health care costs) into

monetary values. The economic value of health

benefits is compared to the cost of the strategy.

If the net economic benefits are positive, then

the service is worth its costs; if negative, it is

not. This benefit-cost framework is attractive in

principle but almost impossible to implement.

Major conceptual, methodological, and social

problems exist in placing dollar values on the

health effects of specific strategies (99).

The notion that a preventive health service should

be effective is widely accepted by health care

providers and policymakers. There is less agreement

about whether the cost of such services should be

considered in either coverage or clinical decisions.

The U.S. Preventive Services Task Force, convened

in 1984 to develop guidelines for preventive services, adopted stringent standards of effectiveness but

explicitly rejected cost-effectiveness as a criterion

for their task in judging these services. (See app. D

for a description of the Task Force and its recommendations for the elderly.) In fact, no professional group

in the United States making recommendations on

preventive services for the elderly has explicitly

b~~rnatively, tie d~ision could be based on a preventive service’s net impact on total Federal expenditures, including Medicare, Medicaid, and

income transfer programs.
Chapter 4-The Medicare Program and Preventive Services . 13

accepted cost-effectiveness as a criterion for making

such judgments.7

Still, expert groups making recommendations

differ widely on specific preventive services. Appendix D contains a summary of such recommendations pertaining to the elderly. Recommendations for

colorectal cancer screening, for example, vary widely.

The U.S. Preventive Services Task Force and the

Canadian Task Force on the Periodic Health Examination have concluded that the evidence does not

support a recommendation for routine screening of

older Americans for colorectal cancer; in contrast,

the Working Guidelines adopted by the National

Cancer Institute include a relatively aggressive

screening schedule.

Why do such differences remain even when the

criterion for judging the service---effectiveness-is

the same across recommending groups? The answer

seems to lie in how different groups interpret the

available evidence. At one end of the spectrum is the

requirement that any recommendation be buttressed

by well-designed controlled trials documenting the

effectiveness of an intervention; at the other is the

acceptance of either anecdotes or professional opinions about the effectiveness of a procedure as

sufficient to justify recommending it. For many

(perhaps most) preventive services, unequivocal

evidence about positive or negative health benefits

does not exist; the evidence may be weak or

conflicting. Even when there is general agreement

about the standards of scientific validity, the application of those standards to interpretation of specific

studies may differ. Studies are conducted in different

populations, measure different outcomes, and apply

different protocols and measurement techniques.

Judgments about the importance of one study versus

another are made continually, and methods for

synthesizing the results of many studies are currently unstandardized.8

LOCUS of Responsibility for

Coverage Decisions

Responsibility for expanding Medicare to cover

preventive services presently resides with Congress.

To date, such expansions have been limited to

specific procedures, but Congress could authorize

the Health Care Financing Administration (HCFA)

to offer an “appropriate” package of preventive

services to elderly Medicare beneficiaries. Authorizing legislation could include criteria for assessing

the “appropriateness” of such services. For example, Congress could direct HCFA to consider the

cost-effectiveness of alternative packages in its

implementing regulations.

Vesting HCFA with the authority to decide about

specific packages of services would probably increase the flexibility of the Medicare program to

respond to new evidence on effectiveness or costeffectiveness as it arises. By removing specific

coverage decisions from the legislative process,

preventive services would not have to compete for

approval directly with other uses of the Federal

health budget. However, if the authority for coverage decisions is vested in HCFA, the resulting

package of services offered to the elderly would be

unpredictable. As was noted just above, conclusions

about the health and cost consequences of specific

preventive services depend, in poorly understood

ways, on the composition of the recommending

groups and the criteria and standards used to judge

the evidence. Even directing HCFA to use costeffectiveness as a criterion for coverage decisions

would leave a great deal of uncertainty about how

the available evidence would be assessed. A process

administered by HCFA, however, might be no more

unpredictable than the current legislative process

and would still be subject to oversight by Congress.

TEvidence fiat a preventive service is actually cost saving is often used as secondary supporting information to buttress a recommendation made on

effectiveness grounds alone, but, to our knowledge, an effective service has never been denied a recommendation by such a group on the argument that

it is too costly.

s@er tie past d~~q a new approach, referred to as ‘‘meta-analysis of research’ has been developed to provide rules for integrating the results

of many studies of the same intervention into an overall finding (36). Even with comparatively standardized m’ethods for pooling the results of individual

studies, however, the criteria governing inclusion or exclusion of specific studies and the comprehensiveness of the search for relevant studies can

influence the outcomes of meta-analysis (35,36). F~L. ex~ple, a mem-analysis of a preventive intervention that includes only studies whose results are

published in peer-reviewed journals will ignore many studies in the so-called “phantom literature, ” and may be biased in favor of finding that the

intervention is successful (36).
Chapter 5

Evaluating the Evidence on the Cost-Effectiveness of

Preventive Services for the Elderly: Selected Issues

In the past decade, OTA has studied the effectiveness and costs of seven preventive services for the

elderly. l The general approaches followed in these

studies are consistent with the principles of economic evaluation of medical procedures laid out in

recent primers on the subject (23,73,99) and will not

be described here. (See app. B for a summary of

these studies.) Common to all cost-effectiveness

analyses are unresolved methodological issues such

as how to come up with an index of effectiveness

that incorporates all important dimensions of health

outcomes, what discount rate to use for costs and

effects expected to occur in the future, how to place

a value on unpaid services provided by volunteers or

family members, and which nonhealth care costs to

include in the cost estimates. Applying the general

principles of economic evaluation to preventive

services for the elderly raises an additional set of

questions that, depending on how they are resolved,

may have a major influence on the final estimates of

effectiveness or cost.

Issue: Under what conditions is it appropriate to

generalize about the effectiveness of a

service on the elderly from evidence of its

effectiveness in nonelderly populations?

This issue arises frequently because so little

effectiveness research is conducted on elderly populations. For example, neither mammography nor

cervical cancer screening have ever been rigorously

tested for effectiveness in the general population of

elderly women (64a,89). To date no studies of the

impact of cholesterol reduction on heart disease or

death have reported on elderly patients as a separate

group (32). To generalize from information on the

nonelderly, assumptions are required about the

natural course of the disease in the elderly relative to

the nonelderly and the relative response of the

elderly to preventive interventions or to therapy

initiated in response to screening. Some hold the

view that such extrapolations are always unacceptable, that without evidence directly pertaining to the

elderly, no valid conclusions about the elderly are

possible. This position seems extreme and perhaps

unfair to elderly people if services are withheld

because studies have never been conducted in their

age group (47). But, extrapolating evidence opens up

the possibility for errors of judgment and is one

reason the conclusions of different expert groups can

vary widely.

Issue: How should the effects of services provided

together in a package be attributed to

specific procedures?

Quite often, studies of preventive services examine programs that deliver a number of procedures or

interventions in a combined visit or set of visits.

Unless an evaluation study has a very large number

of subjects and has detailed information on the exact

set of services received by each subject, it is

impossible to distinguish the effects of individual

components. The ongoing HCFA Preventive Services Demonstration projects, for example, which

offer defined service packages to experimental

groups, will not be able to determine which specific

tests or services are responsible for the observed

outcomes. This weakness of the evaluation studies is

important because the composition of the package

can have a major impact on the cost of an intervention and therefore on its estimated costeffectiveness.

Issue: How should the costs of a visit be apportioned among the individual procedures

and interventions provided in the visit?

In estimating the cost-effectiveness of a specific

preventive intervention, the issue invariably arises

whether some or aIl of the costs of the visit in which

the specific services is delivered should be considered costs of the service itself. Some preventive

procedures are by themselves very inexpensive. In

1986, Medicare paid less than $7 for a total

cholesterol determination, for example. The Medicare reimbursement for a Pap smear was about $10

including a small fee for preparation. Nevertheless,

the physician may charge a visit fee, and Medicare

paid an average $21 in 1986 for a “brief” visit (67).

The estimated screening costs for either of these

procedures would more than triple if the full cost of

a brief visit were included in the estimate. Not to

attribute any visit costs to the procedure implies that

the visit was made for another purpose altogether

I~ey me: pneumococc~ Pnemonia vaccination (86,88); influenza vaccination (87); mammography (89); glaucoma screening (70); cholesterol

screening (32); cervical cancer screening (64a); and colorectal cancer screening (in preparation for early 1990 release).

-15-
16 ● preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations

and the delivery of the preventive service is incidental. To fully attribute the costs of the visit to the

preventive intervention implies that the purpose of

the visit was entirely to receive the preventive

service. OTA’s study of cholesterol screening costs

assumed that such tests would be conducted as an

incidental part of a visit for other purposes (32);

conversely, the cervical cancer screening analysis

assumed that a proportion of the visit costs were

attributable to the procedure (64a).

Issue: What allowances in cost estimates, if any,

should be made for inefficiencies inherent

in the medical care system?

Preventive services are layered on an existing

delivery system that may not be organized to offer

such services in the least costly way possible. For

example, what are the costs of providing screening

mammograms to elderly women? The answer to that

question presupposes a specific level of capacity

utilization of mammography facilities. Reasonable

geographical access to facilities, particularly in rural

areas, may require some excess capacity. The

estimated cost per examination will be much lower

if full capacity operation is assumed than it would be

if, say, only 50-percent capacity is assumed. Or, if

substantial excess mammography capacity already

exists in the health care system for diagnostic uses,

the extra costs of performing screening examinations might be even less than the estimated average

costs of a dedicated screening facility operating at

full capacity.

Issue: How should uncertainties be treated?

There is no single comet answer to the questions

posed above; the most appropriate approach depends

on the particular preventive service being evaluated

and the context for the evaluation. In cases where the

most appropriate approach is not obvious, analysts

can show how changing assumptions will affect the

findings (commonly referred to as sensitivity analysis), but when changing the assumptions leads to

major changes in findings, sensitivity analysis may

be tantamount to refusing to conclude anything

about the magnitude of effectiveness and cost.

Although this can be very frustrating to the users of

such analyses, it is a necessary component of a sound

analysis. The analysis is informing decisionmakers

that better data are needed to make better decisions.

At the very least, any analysis of preventive services

for the elderly should explicitly identify the choices

that are made in the areas enumerated above, so that

the resulting findings can be held up to careful

scrutiny by interested users of the analysis.
Chapter 6

Research Issues

The paucity of direct evidence on the effectiveness of preventive services for the elderly is strikingly similar across all kinds of services. In response

to congressional mandate, HCFA is currently supporting six demonstration projects whose goal is to

assess the costs and effectiveness of providing

preventive health services under the Medicare program. These projects are unlikely to provide enough

evidence on effectiveness to improve the state of

knowledge substantially in that regard. Problems of

design, inadequate funding and follow-up periods

that are too short, and basic problems of organizing

services so that the elderly will use them, all suggest

that the evidence arising from these studies is likely

to be limited (see app. C). The demonstration

projects will tell a great deal about how elderly

people respond to the financial incentives to use

such services, and how their use affects their

preventive behaviors. At the very least, consideration should be given as soon as possible to funding

extended follow-up periods at selected demonstration sites where participation rates have been high.

By extending these projects, more information

would be captured on the health effects of the

preventive interventions. Since these demonstrations were congressionally mandated, extending

their length might require a technical amendment to

the legislation.

Because effectiveness research is costly, it should

be targeted to services that offer the potential for

large impacts on health status or health care costs of

the elderly. Research to clarify the appropriate

components of and target populations for comprehensive geriatric assessments has been recommended by an NIH consensus conference panel (65).

Because the costs of institutional care for the

disabled elderly are so high, these tertiary preventive

health services are a promising research subject for

effectiveness and cost-effectiveness research.

Even when direct evidence on effectiveness is

available, the process of translating that evidence

into guidelines for practice has a major impact on

final recommendations. Not only does the composition of deciding groups appear to affect the final

recommendations, but the standards used to interpret

the evidence are critical. There is little consensus

among professional groups that have periodically

addressed issues of specific preventive services as to

the standards of evidence that should guide the

development of recommendations. The extent to

which the net health care costs of preventive

interventions should be considered in Medicare

payment decisions is a question that has not been,

but could be, answered explicitly.

-17–
Appendix A

Acknowledgments

This report has benefited from the advice and review of many people in addition to the advisory panel. The staff

would like to express its appreciation to the following people for their valuable help and guidance.

William Antes Robert Kane

Health Care Financing Administration University of Minnesota

Baltimore, MD Minneapolis, MN

William F. Bridgers Mary Grace Kovar

Director, Lister Hill Center National Center for Health Statistics

The University of Alabama Hyattsville, MD

in Birmingham

Birmingham, AL Lewis H. Kuller

University of Pennsylvania

Mary Cummiings Pittsburgh, PA

National Center for Health

Services Research F. Marc LaForce

Rockville, MD The Genesee Hospital

Rochester, NY

Bonnie M. Edington

Health Care Financing Administration Robert S. Lawrence

Baltimore, MD The Cambridge Hospital

Cambridge, MA

Al Esposito

Office of Research and Demonstrations Benjamin Littenberg

Health Care Financing Administration Veterans Administration

Baltimore, MD Medical Center

Palo Alto, CA

David Fedson

University of Virginia Health John Meitl

Science Center- Health Care Financing Administration

Charlottesville, VA Baltimore, MD

Robert Fried Sam Merrill

University of Colorado School Congressional Research Service

of Medicine Washington, DC

Denver, CO

Angela Michelide

Alan Garber U.S. Department of Health and

National Bureau of Economic Research Human Services

Stanford CA Washington, DC

Michael Gemmell Steven Moore

Association of Schools of Food and Drug Administration

Public Health Washington, DC

Washington, DC

Joseph Morrissey

Pearl S. German The University of North Carolina

Johns Hopkins University Chapel Hill, NC

Baltimore, MD

Allison Mayer Oaks

University of California at Los Angeles

Los Angeles, CA

Michael Parkinson

USAF School of Aerospace Medicine

Brooks Air Force Base, TX

Louise Russell

Rutgers University

New Brunswick, NJ

Clyde Schechter

Mt. Sinai School of Medicine

New York, NY

Stuart O. Schweitzer

University of California, Los Angeles

Los Angeles, CA

Katharine Bauer Sommers

Institute of Medicine

Washington, DC

Stephen J. Williams

San Diego State University

San Diego, CA

T. Franklin Williams

National Institute on Aging

Bethesda, MD

Steven H. Woolf

U.S. Department of Health and

Human Services

Washington, DC

Steffie Woolhandler

Cambridge, MA

–19 -
Appendix B

Summary of OTA Studies of Preventive Services for the Elderly

The Office of Technology Assessment has conducted

a number of assessments of preventive services for the

elderly over the past decade. This section summarizes the

main findings of each study.

Breast Cancer Screening

OTA conducted an analysis of the effectiveness and

costs to Medicare of breast cancer screening for Medicare

beneficiaries in 1987 (89). It was estimated that a

screening program begun in 1987, in which 30 percent of

female Medicare beneficiaries ages 65 to 74 accepted

annual screening, would result in avoidance of about

2,500 advanced-stage breast cancers every year from

1990 to 2020, with a total of 85,041 advanced-stage breast

cancers prevented and 268,000 life-years saved by 2020.

As far as costs to Medicare are concerned, the analysis

showed that breast cancer screening cannot be expected to

save enough money in decreased treatment costs to offset

the costs of screening and workups. There are savings due

to a reduction in initial and terminal treatment costs for

breast cancer, but the cost of screening far exceeds these

savings. The analysis found that abreast cancer screening

program would cost Medicare about $185 million in

1990. The cost to Medicare per life-year saved by 2020

(costs discounted at 5 percent, life-years undiscounted)

would be approximately $13,200.

Pneumococcal Vaccine

OTA analyzed the cost-effectiveness of the pneumococcal vaccine in elderly people (86,88). In 1983, the

estimated net discounted costs per discounted healthy

year of life gained (at 5 percent discount rate) ranged from

negative net costs to $6154, depending on the assumptions adopted regarding the percent of pneumonias that

are pneumoccocal and the duration of immunity conferred

by the vaccine.

Influenza Vaccine

OTA performed a retrospective analysis of the costeffectiveness of the influenza vaccination among elderly

people in the 1972-78 period (87). The annual vaccination

was found to be cost-saving to the medical care system

when costs were discounted at 5 percent per year. If

medical care costs for unrelated illnesses occurring in

extended years of life gained from the vaccination are

included, the vaccination would have cost $1,782 per

added healthy year of life.

Cholesterol Screening

In a study of the effectiveness and costs of cholesterol

screening in the elderly, OTA found that the cholesterol

level does not appear to be a significant predictor of

overall survival in either elderly men or women (33). The

few studies of the elderly found either that the cholesterol

level does not predict mortality at all or that it is a

statistically significant predictor of lower mortality. There

are no randomized trials of the impact of cholesterol

reduction in the elderly, so the effectiveness of treatment

must be inferred from the studies in middle-aged populations. While cholesterol reduction can reduce CHD

incidence and death in middle-aged men, it has not been

shown to lower overall mortality in this population. It may

be that the studies on which such findings have been based

have had insufficient power or too few years of followup,

but benefits delayed for many years might not be pertinent

to the elderly, who have a high rate of death from other

causes.

The equivocal nature of the evidence on the effectiveness of cholesterol screening and treatment in the elderly

must be considered in light of the potential costs

associated with this preventive intervention. If all people

65 years of age and older were to fully comply with the

National Cholesterol Education program’s (NCEP) Adult

Treatment Panel Guidelines, the annual national health

care expenditures associated with screening and treatment

would range from at least $2.9 billion to $14.2 billion,

depending on the prevalence of certain risk factors and the

mix of drugs prescribed. The costs of screening and

followup alone area small fraction of that total, about $57

million per year. Drugs and monitoring services constitute the bulk of the annual health cost burden.

Medicare’s share of national health expenditures for

cholesterol screening and treatment is likely to be high. If

the entire elderly population were to fully comply with the

NCEP guidelines, Medicare expenditures for testing and

monitoring would range from $1 billion to $5.4 billion per

year.

Cervical Cancer Screening

OTA evaluated the costs and effectiveness of screening

for cervical cancer among elderly women (64a). Studies

have found that women who have been screened are two

to ten times less likely than others to develop cervical

cancer. The protection associated with prior screening is

found in elderly women as well as younger women.

Elderly women, however, are less likely to be screened

than younger women and have seen less reduction in

mortality rates than other groups. Medicare coverage of

Pap smear screening (which was mandated in the

Omnibus Reconciliation Act of 1989) might induce

increased utilization of this test among elderly women.

Additionally, Pap smear screening in elderly women does

not appear to be very costly for the potential life years

saved from this technology, although it is unlikely to

actually save health care costs.

-20-
Appendix B-Summary of OTA Studies of Preventive Services for the Elderly . 21

OTA estimated that a single screening of women at age

65, when they become eligible for Medicare, would save

14,400 life-years per 1 million women screened (lifeyears and costs discounted at 5 percent) and would cost

the health care system $1,666 per year of life saved. The

incremental cost per year of life saved is least for 5-year

screening ($1 ,453) and is progressive y greater as screening frequency increases. It amounts to $5,956 per life-year

saved for the incremental effects of a 3-year screening

cycle over a 5-year cycle, and rises to $39,693 per

life-year saved for annual screening.

The cost-effectiveness ratio for Pap smear screening

depends heavily on the extent to which high-risk, rather

than low-risk, women are screened. Low-risk women

derive some benefit from screening, but at very high cost

to the health care system. Screening only high-risk

women, on the other hand, has a very low cost per

life-year saved.

Glaucoma Screening

OTA examined the existing evidence regarding the

effectiveness and potential costs to Medicare of screening

for open angle glaucoma (OAG) in the elderly (70). Three

methods of screening for OAG exist: tonometry, which

measures intraocular pressure (IOP); ophthalmoscopy,

which identifies abnormalities of the optic disc; and

perimetry, which identifies visual field defects. None of

the methods has been tested for accuracy in everyday

office settings, and all have the potential to be highly

inaccurate. Tonometry, for example, produces many false

positives and negatives because elevated IOP and OAG

are not always related. Although tonometry itself is

inexpensive, diagnostic workups of individuals with false

positive tests and treatment of many people who would

not have developed OAG in any case result in substantial

associated costs.

The accuracy of screening tests is not the only source

of uncertainty. Considerable uncertainty also surrounds

the effectiveness of medical treatment in preventing

visual disability in individuals with high IOP or suspected

OAG. The published, objective evidence on the effectiveness of treatment is highly contradictory. Many individuals suffer progression of disease despite treatment;

conversely, many untreated persons go for years without

suffering loss of vision. Few adequate studies of treatment

have been undertaken, and those available do not show

consistent results. Studies currently underway may help

resolve the uncertainty.

Screening elderly individuals for OAG may well

eventually prove to be a highly beneficial technology. At

present, however, the contradictory evidence on the

effectiveness of treatment, combined with the unknown

accuracy of screening tests, makes widespread screening

of the elderly a very uncertain, and probably costly,

endeavor.
Appendix C

The Medicare Preventive Services Demonstration Projects

Description of the Projects

Authority and Funding

The Health Care Financing Administration (HCFA) is

currently supporting six projects whose goal is to

demonstrate the costs and effectiveness of providing

preventive health services under the Medicare program.

These projects provide a mix of health status assessments,

immunizations, clinical screening services, and educational services to elderly individuals enrolled in the

experimental arms of the projects.

The first of the six ongoing projects, administered by

the University of North Carolina, was funded at HCFA’s

own initiative. HCFA solicited applications for preventive services projects in 1983 (48 FR 36660) and awarded

funds to the University of North Carolina and Blue

Cross/Blue Shield of Massachusetts in October 1985. The

North Carolina study began offering services to the first

participants in October 1986, completed recruitment of

2,400 participants in June 1988, and is now in its fourth

year of operation. The Massachusetts study was ended

after 18 months due to difficulty recruiting beneficiaries

(64). The design of this study required participants to be

randomized to one of three clinics to receive services, and

many of the individuals asked to participate did not

understand the purpose of the study or were unwilling to

go to a provider other than their usual physician.

The remaining five of the six ongoing demonstration

projects have only just begun. Unlike the North Carolina

project, these projects were mandated by law (Public Law

99-272, as amended by Public Law 99-509 ).1 Applications for these projects were solicited in May 1987 (52 FR

20148), and funds were awarded in May 1988 (24). Each

project had a 6-month developmental phase prior to

recruitment. In addition, in order to carry out the

demonstration, each project must receive permission to

waive the usual Medicare coverage rules (which do not

permit reimbursement for most preventive services) for

the duration of the study. These waivers are subject to

review by the Office of Management and Budget (OMB),

which did not approve them until April 1989. Thus, these

five projects could not begin recruiting subjects until May

1, 1989 (24).

Project funding for fiscal year 1989 is approximately

$300,000 per study (range $290,000 to $330,000) (24).

HCFA will renew funding on a noncompetitive basis each

year subject to funding availability and to each project’s

ability to meet its objectives (52 FR 20148), The five

mandated studies are subject to a collective maximum

funding amount of $5.9 million for their administrative

costs (Public Law 99-509), which covers items such as

researchers’ salaries, patient and physician recruitment,

and data collection and analysis.

The costs of the actual preventive health services

provided under the waivers are not reimbursed from the

project research funds and are not subject to any legislated

cap. HCFA estimates that the cost of these services will

be approximately $150 per person per year (24). These

costs are paid out of ordinary part B Medicare funds.

Design

All six demonstration projects share certain similarities

in objective and design. In each study, all study participants undergo an extensive health status assessment,

performed by a nonphysician. Individuals in the experimental groups are also referred for appropriate screening,

immunization, and educational services, with the exact

services they receive varying by project and usually

depending on their individual medical history and risk

status. Control group patients get their usual care.

All studies randomize patients to experimental and

control groups, although the groups being compared

differ among studies (see table C-l). (In most cases,

patients in both groups see their usual provider rather than

being randomized to a particular provider.) In addition to

examining the costs and effectiveness of preventive

services, the projects test alternative methods of payment

for these services (e.g., prepayment, fee-for-service) and

involve a variety of different settings and health care

providers in the provision of the services.

The scope of services provided by the demonstration

projects is presented in table C-2. In general:

The North Carolina project, which served as an

example for the designs of the later projects, offers

a mix of services that are fairly evenly divided

between screening and counseling services. This

project’s design emphasizes a comparison of the

effects of the broad components of a prevention

program (screening alone, counseling alone, or both

together) provided by a subject’s usual primary care

physician.

Seattle incorporates the preventive services into the

scope of care provided to the experimental patients

in a health maintenance organization (HMO). This

project offers the most comprehensive prevention

package. It emphasizes immunization, cancer screenl~e law ~Wifi~ that tie demon~~ation ~rojm~ must ~ administer~ by “accr~ited public or private nonprofit schools of public health or

preventive medicine departments accredited by the Council on Education for Public Health’ (Public Law 99-272). Thirty-four programs-twenty-four

schools of public health and ten programs in community health/preventive medicine—meet these requirements (18). Eleven of them submitted proposals,

and five of those proposals were funded (64).

-22-
Table C-1—Design of Medicare Preventive Services Demonstration Projects

Raleigh-Durham,

Location NC Seattle, WA San Diego, CA Los Angeles, CA Baltimore, MD Pittsburgh, PA area

Directing University of North

organization Carolina

Service provider Physicians’ offices,

clinics

Number of 13

providing sites

Sample pool Elderly patients of

participating

practices

Sample size(total 2,538

participants)

Control group 958

Experimental Screening only (307)

group(s)

Health promotion only

(317)

Both screening and

promotion (900)

University of

Washington

Group Health of Puget

Sound (HMO)

4

Elderly HMO

enrollees

2,250’

1,125a

Receive services

(1,625)

San Diego State University

Project team personnel, in

conjunction with Secure

Horizons (HMO)

5 health assessment sites;

5 screening sites;

approximately 11 health

promotion sites in the

community

Elderly HMO enrollees

2,400’

1,200a

Receive services (1 ,200)

University of California

Health prevention clinic

staff/allied health

professions

1

Elderly patients of

participating physicians

1,800a

900’

Receive services (900)

Johns Hopkins

University

Beneficiary's usual care

provider

Many

Efderly Medicare

beneficiaries in Iocal area

4,400’

2,200’

Receive services at usual

source of care (2,200)

University of Pittsburgh

Rural hospitals, clinics,

physicians’ offices

Many

Elderly Medicare

beneficiaries in local area

4,500’

1 ,500’

Receive preventive

services from clinic(2,000)

Receive services from

private physician (2,000)

aAntlcipated sample size as of November 1989 (recruitment still ongoing).

SOURCE: Office of Technology Assessment, 1990. (Information from project proposals and personal communication with project and HCFA personnel. See references.)
24 ● preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations

Table C-2—Preventive Services Offered in the Medicare Demonstration Projects

Raleigh-Durham, Seattle, San Diego, Los Angeles, Baltimore, Pittsburgh,

Service NC WA CA CA MD PA

lmmunizations:

Influenza . . . . . . . . . . . . . . . . . . . . . . . . .

Diphtheria/tetanus. . . . . . . . . . . . . . . . . .

General clinical screening:

Risk assessment review . . . . . . . . . . . .

Height/weight . . . . . . . . . . . . . . . . . . . . .

Blood pressure . . . . . . . . . . . . . . . . . . . .

Dental exam . . . . . . . . . . . . . . . . . . . . . .

Vision screen . . . . . . . . . . . . . . . . . . . . .

Heariscreen . . . . . . . . . . . . . . . . . . . . . . .

Other history/physical at

physician’s discretion . . . . . . . . . . . . .

Laboratory tests:

Hematocrit . . . . . . . . . . . . . . . . . . . . . . .

Cholesterol (fingerstick) . . . . . . . . . . . . .

Blood sugar (fingerstick) . . . . . . . . . . . . .

Urinalysis . . . . . . . . . . . . . . . . . . . . . . . .

Mean cell volume . . . . . . . . . . . . . . . . . .

Creatinine . . . . . . . . . . . . . . . . . . . . . . . . .

Thyroid (TSH) . . . . . . . . . . . . . . . . . . . . .

Cancer screening:

Physical breast exam . . . . . . . . . . . . . . .

Fecal occult blood . . . . . . . . . . . . . . . . .

Digital rectal exam . . . . . . . . . . . . . . . . .

Pap smear . . . . . . . . . . . . . . . . . . . . . . . .

Pelvic exam . . . . . . . . . . . . . . . . . . . . . . .

Mammography . . . . . . . . . . . . . . . . . . . .

Counseling services:

Diet/nutrition . . . . . . . . . . . . . . . . . . . . . .

Stress reduction . . . . . . . . . . . . . . . . . . .

Exercise . . . . . . . . . . . . . . . . . . . . . . . . .

Sleep regulation . . . . . . . . . . . . . . . . . . .

Injury prevention . . . . . . . . . . . . . . . . . . .

Drug/alcohol abuse prevention . . . . . . .

Mental disorder prevention . . . . . . . . . . .

Self-care/medication use . . . . . . . . . . . .

Smoking reduction/cessation . . . . . . . . .

Life planning . . . . . . . . . . . . . . . . . . . . . .

Breast self-exam . . . . . . . . . . . . . . . . . .

Health care utilization . . . . . . . . . . . . . . .

Disease-specific education . . . . . . . . . .

x x

x

x

x

b

b

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x x x x x x

x x

x

x x

x

x

x x x

x

b x

x

x

x

x

x

x

x

x

x

x

x

x

x

b

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

a All demonstration projects include an assessment of immunization history and administration of or referral for pneumococcal pneumonia vaccine, if

appropriate. This vaccine is already a Medicare-covered service.

b UCLA is referring patients to their physicians for these services, as appropriate.

SOURCE: Office of Technology Assessment, 1990. (Data from project proposals and personal communications with project HCFA personnel. See references.)

ing, and extensive organized counseling sessions, ●

but it offers only one laboratory screening test.

Control and experimental patients in this study are

stratified according to their usual level of health care

utilization.

San Diego also stresses immunization and uses a

specific, privately owned education program for the

counseling segment of the protocol. It is the only

project that includes a thyroid screening test. All ●

clinical screening in this project is provided by two

physicians and other supporting members of the

project team.

The Los Angeles project is the only site offering

comprehensive dental screening and services in its

package of preventive services. All services are

provided at a single centralized health prevention

clinic. Physician involvement is minimal and centers on a review of the risk assessment results with

the patient, with followup services provided at the

physicians’ and patients’ discretion.

The Pittsburgh project emphasizes disease-specific

screening and counseling, particularly for hypertension and diabetes. Services are provided through

rural physicians and health clinics, with two experi-
Appendix C—The Medicare Preventive Services Demonstration Projects ● 25

●

mental groups that differ according to the settings in

which subjects receive the screening and counseling

services.

Finally, the Baltimore project includes a moderately

comprehensive array of services; unlike the Pittsburgh project, however, the setting is always the one

in which subjects receive their usual care. This

project differs from the others in that all counseling

is provided by physicians during the office visit.

Reimbursement for the services received by experimental subjects is, with only one exception, based on a

pre-set fee for a specified package of waivered services.

In Seattle and San Diego, the two sites at which services

are provided by pre-paid health plans, the package

includes all services; these sites receive annual perenrollee cavitation payments. At the Baltimore and North

Carolina sites, payment is also based on annual rates per

enrollee. The North Carolina payment is made in two

parts, one for screening services and one for health

promotion services. The Baltimore payment is an inclusive rate for ail services, but there can be an additional

payment for an optional follow-up counseling visit. In the

Los Angeles program, where all reimbursed services

under the waiver are provided at a single site, the provider

is reimbursed a set fee per visit for all clinical and

counseling services provided in that visit.

The exceptional program is Pittsburgh, where there are

two randomized experimental groups. Subjects authorized to receive services through a clinic or hospital are

covered through a single capitated amount (per enrollee

per year for all services) paid to the provider. Subjects

authorized to receive services from private physicians are

covered through a fixed fee for each service (e.g., a pre-set

amount paid to the physician for providing counseling

regarding hypertension). Physicians may, at their option,

refer subjects to clinics for some counseling services; in

this case, the clinic is reimbursed for the individual

service.

Evaluation Plans

The law mandating the five demonstration projects

required the Secretary of the Department of Health and

Human Services (DHHS) to submit a preliminary report

to the Congress by April 7, 1989, regarding their status.

That report has been submitted. Public Law 99-272 also

required the Secretary to submit an evaluation of these

projects to Congress by April 7, 1991. This evaluation is

to include:

● an assessment of the short- and long-term costs and

benefits of providing these services to Medicare

beneficiaries,

. an assessment of how these services might be

financed under Medicare, and

● a recommendation to Congress regarding “appropriate legislative changes to incorporate payment for

cost-effective preventive health services into the

Medicare program” (Public Law 99-272).

The evaluation report due April 7, 1991 will include the

results of the North Carolina project as well as latest

results of the five mandated projects (24).

The five demonstration projects, awarded in April

1988, were scheduled for 6 months of planning, 2 years

of service provision, and 18 months of evaluation. The

five projects began delivering services in the spring of

1989. Consequently, unless it is delayed, the report

planned for the spring of 1991 can only give interim

results of the five projects.

Each project is required to evaluate itself and report the

results of its experiment. In addition, HCFA will undertake a cross-cutting evaluation of the projects. The

primary experimental outcomes to be evaluated include:

●

●

●

●

utilization of preventive services by the experimental groups;

costs of providing the preventive services and any

associated treatment;

changes over time in health status measures of

experimental patients (e.g., improved functional

status, improved self-assessment of well-being,

lower weight, lower cholesterol level); and

changes in utilization of other (nonexperimental)

health care services (e.g., number of hospital days in

general, changes in hospital days associated with

specific diseases).

Abt Associates, under contract to HCFA, will work

with the individual projects to ensure comparability of

reporting of results among projects. In addition, this

contractor will monitor the Medicare claims of a sample

of individuals outside of the five projects in order to assess

the impact of background trends in health care utilization

and cost (51).

Evaluation Issues

Ability To Achieve Results

The ultimate goal of all six projects is to demonstrate

the costs and effectiveness of providing preventive health

services to elderly Medicare beneficiaries. All projects

hope to show both better health status and a trend towards

lower Medicare costs as a result of providing these

services. Unfortunately, the only project with a realistic

chance of yielding confident results on costs and health

outcomes is the North Carolina study. The other five

projects are likely to be most successful in providing

information on the feasibility of providing services and

the utilization of these services by the elderly under

various conditions.
26 ● Preventive Health Servicesfor Medicare Beneficiaries: Policy Issues and Recommendations

The difficulty in obtaining meaningful results regarding costs and effectiveness from the demonstration

projects is due to the fact that only the North Carolina

project will likely have at least 2 full years of data on all

participants in the project by the beginning of 1991, when

HCFA will be composing its evaluation. It is highly

unlikely that any of the other five projects will be able to

show any significant trends towards lower costs by 1991,

even if cost savings might eventually accrue as a result of

lower utilization. It is possible that some improvements in

hospital bed-days for certain diseases (e.g., influenza),

fictional ability, and self-assessed quality of life might

occur within the short time that exists, but the failure to

find an effect would not be surprising even if an effect

exists. Thus, a lack of evidence of lower costs and

improved outcomes could mean that the projects did not

run long enough for the effects (e.g., improved functional

status) to manifest themselves in individual patients in the

experimental group. HCFA has no funds budgeted at this

time for long-term followup of Medicare claims of study

subjects.

The short time frame for service provision and data

collection of the five mandated projects at the time of the

April 1991 mandated report to Congress can be traced to

two factors that contributed to a delay in initiating the

projects. First, the process of soliciting applications,

preparing and submitting proposals, and evaluating the

proposals and awarding funds occupied nearly 2 of the 5

years allotted in the law. Second, the five projects required

waivers of the usual Medicare coverage rules; those

waivers must be approved not only by HCFA but by the

Office of Management and Budget (OMB), which evaluates them as part of the budget process. The waiver

process thus added an extra administrative step to startup

time.

Design Issues

The design of the demonstration projects presents a

number of conceptual problems common to many experiments conducted in the community setting. The most

obvious of these is the difficulty of distinguishing

between the care received by control and experimental

groups. There is no limit to the services that individuals

in the control groups receive; they may request and

receive all of the same clinical services provided to the

experimental group, as long as they pay the costs

themselves. Furthermore, in most cases the same physicians (and nonphysician examiners) will be seeing both

experimental and control patients. The physicians and

associated office personnel may change their own behavior as a result of the project, suggesting or providing more

preventive services as part of the “usual care” they

provide to the control groups.

The potential similarities between control and experimental groups could make an observed lack of difference

in outcomes difficult to interpret. Such a result could have

any of three explanations:

1.

2.

3.

that the preventive services provided to the

experimental groups had no effect on health

outcomes,

that the provision of enhanced services to one

group leads health care providers to alter their

behavior and provide enhanced services to the

remainder of the population, or

that the “enhanced” services provided to the

experimental group did not in fact differ from the

usual care physicians provide to their patients.

If an effect is found, the design issues will center on

what components of the enhanced service package

produced the effect. Some of these components are tested

explicitly within the design of individual projects. Pittsburgh, for example, is testing the comparative effects of

providing services through a centralized clinic v. through

private physicians’ offices. North Carolina is comparing

the relative effects of providing clinical screening only,

health promotion only, and both components. In this case,

however, it is unlikely that the sample size will permit

detailed comparisons of the effectiveness of different

components among groups. Significant results will most

likely be obtained only for combined screening and health

promotion/no screening comparisons.

The individual effects of other components, however,

will be more difficult to identify. For example, the role of

the health status assessment, what it covers, and how it is

administered are slightly different in each project. In

addition, some projects offer an opportunity for physicians to add to the information provided in this assessment by conducting their own patient history, while

others do not. It is uncertain how much the assessments

and clinical screening services in the project protocols

duplicate or replace a standard “history and physical

exam, ’ what extra information they provide, and what

aspects they may miss. Finally, the type and manner of

services provided as a result of the information provided

by the patient in the assessment differ among the projects.

This diversity permits a wide variety of possible combinations to be tested, but it also increases the difficulty of

determining which components contribute to the effectiveness of disease prevention, and which do not.

Implementation Issues

The demonstration projects are artificial settings in

which certain services are packaged, promoted, and

provided. Whatever the results of the demonstrations

themselves, a major issue to be faced is whether those

results will be applicable to ordinary circumstances in the

general medical community, where providers will lack

special preparation, intensive monitoring, and ties to
Appendix C—The Medicare Preventive Services Demonstration Projects ● 27

academic research centers. This problem is, of course,

inherent in many experiments in medical care. A reasonable expectation is that the project outcomes will provide

a maximum estimate for what can be expected to occur

under ordinary conditions, where efforts to recruit and

retain patients do not at present exist. In addition, the

projects should provide important information about the

circumstances under which participation and utilization is

better or worse.

The failed Massachusetts demonstration project has

already provided some indication of potential feasibility

problems. In this project, a random sample of Medicare

beneficiaries was to receive services at specified sites that

were not linked in any way with the site where they

received their usual medical care. After 18 months the

project had not succeeded in recruiting enough patients to

enable it to proceed, and a followup survey suggested that

most individuals were unwilling to change providers,

even temporarily, in order to receive preventive services.

Two projects—the Los Angeles project, which uses a

central service site, and the Pittsburgh project, which has

experimental groups randomized either to a usual care

physician or to a designated clinic site—will be testing

this hypothesis further. Even if these projects do succeed

in encouraging participants to receive care at sites other

than their usual providers, it will still be uncertain whether

beneficiaries under ordinary conditions would do so.

Other areas in which translating project protocols to

real-world circumstances may be difficult are the use of

project interviewers to perform health status assessment

in all projects, and the use of special training for nurses

and physicians performing counseling. To duplicate these

features of the demonstration projects, physicians in

private practice might need to hire additional staff or

coordinate with outside organizations to provide services

such as extensive risk assessment and counseling.

Finally, there is some self-selection on the part of

physicians participating in the projects. These physicians

may be more willing than others to adjust their style of

practice to include (or exclude) specified preventive

services for the elderly. Whether Medicare coverage of

specified preventive services will itself encourage the

same level of utilization as provision of those services in

an experimental setting is a question that can be answered

only after the fact.
Appendix D

Summary of Recommendations for Periodic

Health Examinations in the Elderly

Visit Frequency

In recent years the worth of a yearly, or regularly

scheduled, physical examination by a physician has been

questioned and for the most part rejected by health

professionals. Instead, the concept of a periodic health

examination for the delivery of certain proven preventive

measures at specific intervals has been promoted. Government agencies, professional societies, and consumer

groups have made or are developing recommendations

either directly about periodic health examinations, or

about specific screening or preventive technologies that

require physician visits. Since these types of recommendations are not always specific about when physician

visits are necessary or when care may be provided by a

nonmedical professional, OTA has attempted to review

some of the recommendations and assess how they

translate into physician visits for the elderly. Table D-1

summarizes the recommendations for physician visits

made by leading groups.

The Canadian Task Force on the Periodic Health

Examination (CTF), which was established in 1976 and

issued its first report in 1979, was the first major

organization to formulate a plan for a lifetime program of

periodic health assessments for the Canadian people.

After studying more than 90 potentially preventable

conditions, CTF made recommendations for preventive

services for 78 of them. CTF determined that for the most

part, procedures should be carried out as case-finding

rather than screening techniques (they should be performed during a physician visit for unrelated symptoms

rather than during preventive visits). There are exceptions

to this methodology, however. CTF recommends that

pregnant women, the very young, and the very old

schedule visits specifically for preventive purposes.

The main result of the CTF’s 1979 publication is a set

of age- and sex-specific health packages designed to

ensure the delivery of proven preventive measures at

effective intervals. For the elderly, two health packages

were derived; one for men and women aged 65 to 74, and

one for men and women aged 75 and over. Both contain

the same basic set of tests, immunizations, and health

assessments with the main difference being the frequency

of physician visits recommended for the old and very old.

Since its first report in 1979, CTF has published updates

in 1984, 1986, 1988, and 1989, in which the appropriateness of screening for new conditions is assessed or older

recommendations are reassessed.

With similar goals in mind, the U-

.S. Government

established its own Preventive Services Task Force

(USPSTF). l Appointed in 1984, the Task Force worked

closely with CTF to develop age- and sex-specific

recommendations for clinical preventive services in

addition to addressing “the behavioral and structural

barriers to the successful integration of preventive services into clinical practice” (57). The Task Force adopted

the rules of evidence and classification developed by

CTF. Since April 1987, the Task Force periodically

published its recommendations on specific preventable

medical conditions in the Journal of the American

Medical Association. In addition, its final report, Guide to

Clinical Preventive Services: Report of the U.S. Preventive Services Task Force, which contains all of its age- and

sex-specific guidelines, was published early in 1989.

The task force conveys its findings in two ways: by

constructing age-specific charts suggesting the optimal

frequency of physician visits for different age groups, and

by providing specific recommendations concerning each

of the 60 illnesses and conditions reviewed and the

effectiveness of the screening interventions assessed.

For the elderly, USPSTF recommends a yearly physician visit that includes screening, counseling, and immunization components. Screening, in turn, involves a

history, physical examination, and laboratory procedures. 2 Counseling is geared toward diet, exercise,

substance use, injury prevention, and dental health.

Immunizations for tetanus-diphtheria (every 10 years),

influenza (annually), and pneumonia are suggested. In

addition, glaucoma testing by an eye specialist is recommended.

Other government-sponsored recommendations for

physician visits come from the National Cancer Institute

(NCI) whose published guidelines, “Working Guidelines

for Early Cancer Detection, ” promote physician visits by

encouraging physicians to use available cancer detection

maneuvers. The implication of the guidelines is that the

recommended tests would be done by a physician, or in

conjunction with a physician visit. Since NCI suggests

annual fecal occult blood tests starting at age 50 (both

l~e Task Force is a non-Federal, multidisciplinary, national panel appointed by the government to make recommendations to the public He~th

Service.

2~e physic~ exa would include: height, weight, blood pressure, visual acuity, hearing, and CliniCZd breast ex~ (annu~lY for women ~tll age

75, unless pathology detected); laboratory procedures recommended are: nonfasting total blood cholesterol, dipstick urinalysis, mammogram (every 1

to 2 yews for women until age 75, unless pathology detected), and thyroid function tests (for women). The Task Force also makes specific screening

recommendations for elderly persons who are at high risk for particular conditions; these include: fasting plmrna glucose, tuberculin skin test,

electrocardiogram, Pap smear, fecal occult blood/sigmoidoscopy, and fecal occult blood/co\ onoscopy.

-28-
Appendix Wurnrnary of Recommendatioras For Periodic Health Examinations in the Elderly ● 29

Table D-1--Recommendations for Physician Visits for the Elderly

Scope of Implications for

Group recommendations/study physician visits Comments

— .— — Canadian Task Force, 1979,

1984, 1986, 1988a

U.S. Preventive ServicesTask

Force, 1989b

National Cancer Institute,

1987C

Project INSURE, 1988d

American Cancer Society,

1988e

Health Policy Agenda for

the American People,1986f

Extensive recommendations on appropriate components of physical

examination, immunizations, counseling, and laboratory investigations

Extensive recommendations on appropriate components of physical

examination, immunizations, counseling, and laboratory investigations

Guidelines aimed at encouraging

physicians to screen for cancer

(melanoma and breast, cervical,

prostate, colorectal, testicular, and

oral cancer)

Study participants age 65 or over

received physician examination and

history, laboratory tests, immunizations, and patient education according to Project INSURE’S model

(based on age, sex, and risk factors)

Recommendations for screening

for colorectal, cervical, endometrial, breast, thyroid, testicular, ovarian, lymph node, oral region, and

skin cancer

Describes a minimum set of health

insurance benefits for Americans

Biannual physician visit from

age 65 to 74; annual physician

visit from age 75 on

Annual physician visit recommended from age 65 on

Annual physician visit implied

for women starting at age 50

and men starting at age 40

Biannual physician visit from

age 65 to 74; annual physician

visit from age 75 on

Annual health counseling and

cancer checkup beginning at

age 40

Annual physical examinations

beginning at age 50

CTF also recommends certain tests

be done annually between age 65

and 74:mammography (for Women),

stool occult blood test, and examination of oral cavity and counseling on oral hygiene; these could be

done by other health professionals

For most tests screening frequency

is left to physician’s discretion:

nonfasting cholesterol, urinalysis,

vision and glaucoma screening,

and thyroid function test

NC I emphasizes that these screening maneuvers are part of a physician visit

Mammography and stool occult

blood test given annually; Pap

smears given for three consecutive negative results

In addition, ACS advises that certain tests be done at specific intervals: sigmoidoscopy--every 3 to 5

years after two satisfactory results; stool occult blood test—

annually; digital rectal examination--

annually; Pap test—annually for 3

negative results then at physician’s discretion; breast physical

examination—annually; and mammogram-annually

Specific recommendations for the

components of the physical examination are not made, but Project

INSURE and the Canadian Task

Force on the Periodic Health Examination are cited as sources for

determining the components

a Canadian Periodic Health Examination Task Force, “The Periodic Health Examination,” Car?. Med. Assoc. J. 121(9):1193-1254, 1979; 130(10):1276-1292,

1984; 134(7):724-727, 1986; 138(7):618-626, 1988.

b U.S. Preventive Services Task Force, Guide to Clinical Preventive Services (Baltimore, MD: Williams & Wilkins, 1989).

c Early Detection Branch, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, U.S. Department of Health and

Human Services, “Working Guidelines for Early Cancer DetectIon: Rationale and Supporting Evidence to Decrease Mortality” (Bethesda, MD: December

d Lifecycle Preventive Health services Projecct, “Final Report of the INSURE Project” (New York, NY: Septemkr 1968).

eAmeri~n Camr Swlety, Summ=y of current @&/inesfor the &n@r-Re/#ed ch~up: R~Ornrn8n&tiOnS (New York, Ny: A(X professional Education

Publication, 1988).

fAd HW committee on B~ic Benefits, Health Policy Agenda, “Basic Benefits Package” (Chicago, IL June 1*8).

SOURCE: Office of Technology Assessment, 1990.
Table D-2—Published Recommendations for the Use of Selected Preventive Services by Older Adultsa

Preventive Professional Consumer

service CDCb ACP NIHd CTFe USPSTF societies organizations

Tetanus

immunization

Booster every 10

years if primary

series has been done

Overage 66-once

Overage 65-every

year

— Booster every lo yews Booster every 10 years Booster every 10 years

Pneumococcal

immunization

Influenza

Immunization

Occult blood in

stool

Over age 65--once

Over age 65-every

year

High risk patients-once

Over age 65--every year

Age 65 and over—

once

Age 65 and over—

every year

Annually for those at

high risk

NCI: over age 50--

every year

NCI: over age 50--

every 3-5 years

ACS: over age 50-

every year

ACS over age 50-

every 3 to 5 years after

2 negative tests

ACS: over age 40-

every year

Slgmoidoscopy At physician’s

discretion for those at

high risk

Digital rectal exam NCI: over age 40-

every year

Not recommended for

prostate cancer; no

recommendation for

enlarged prostate

screening

Every year from age 50 to

59

Clinical breast

examination

NCI Age 40-50-every

1 to 2 years with

mammography: age 50

and over—annually

NCI: Age 40-50-every

1 to 2 years with

mammography; age 50

and over-annually

NHLBI over age 20—

every 5 years

Over age 40--every

year

Over age 40-every

year

ACR, ACOG, AMA” Age 40

50-every 1 to 2 years with

mammography, age 50 and

over-annually

ACR, ACOG, AMA: Age 40-

50-every 1 to 2 years with

mammography; age 50 and

over-annually

ACS: Age 40-50--every

1 to 2 years with

mammography, age 50

and over-annually

ACS: Age 40-50-every

1 to 2 years with

mammography; age 50

and over-annually

AHA. supports NHLBI

recommendations

Mammography Over age 50-

annually

Between ages 50 and 59-

every year

Over age 50--every

1 to 2 years

Cholesterol

screening

Recommended at

5-year intervals for

asymptomatic, lowrisk men, optional for

women and elderly

persons

Recommended at

physician’s discretion

Pap smear NCI: over age 18 or if

sexually active--3

consecutive annual Pap

smears and pelvic exams

with negative results,then

less frequently at

discretion of physician

Every 5 years from age

35 to age 60; screening

should continue if prior

smears have been

abnormal

Every 1 to 3 years for

women who have not

had previous

consistently negative

smears

ACOG, AMA, ANA, AAFP,

AND AMWA: support NCI

guidelines

ACS: supports NCI

guidelines

Not recommended for

asymptomatlc

healthy adults

Not recommended

without family history of

diabetes or previous

circulatory problems

Recommended only for

the markedly obese,

persons with family

history of diabetes, or

women with history of

gestational diabetes

ADA” people at risk

should be screened (no

frequency specified) AHA:

every 5 years from age

20 to 75; optional after

age 75 if baselines are

well-documented

Serum glucose
Table D-2--Published Recommendations for the Use of Selected Preventive Services by Older Adults--Continued

Preventive Professional Consumer

service CDCb ACPC NIHd CTFe USPSTFf

societiesg

organizationsh

Blood pressure NHLBI: over age 18— Over age 65-every 2 years Recommended

at least every 2 years,

depending previous

reading

EKG Not recommended m Recommended for

asymptomatlc symptomatic adults only

persons

Vision examination No recommendation to

including glaucoma screen

screening by

tonometry

regularly at interval

determined by

physician

Recommended for

symptomatic adults

only and other other

specific

circumstances

Vision screening

suggested at

physician’s

discretion; glaucoma

screening might be

clinically prudent,

frequency to be

determined by

physician

AHA: every 15 years

starting at age 20

AHA: at ages 20,40,

and 60

AOA: over age 40-every NSPB: over age 35-

year AAO: over age 40- every 2 years

every 2 to 5 years

ABBREVIATIONS AAFP. American Academy of Family Physiclans. AAO = American Academy of Ophthalmology: ACOG. American College of Obstetricians and Gynecologists, ACP = American

College of Physlclans, ACR = American College of Radiologists, ACS = American Cancer Society, ADA = American Diabetes Association, AHA . American Heart Assoclatlon,

AMA. American Medical Assoclatlon, AMWA. American Medical Women’s Assoclation, ANA = American Nurses Association, AOA = American Optometric Assoclation, CDC

= Centers for Disease Control, CTF = Canadian Task Force, EKG = electrocarchogram, NC I = National Cancer Institute, NIH = National Institutes of Health, NSPB = National

Society to Prevent Blindness, and USPSTF = United States Preventive Services Task Force

aThls table does not include screening recommendations for all adults, In some cases where recommendations for younger age groups differ from those for the elderly. only the recommendations

for the elderly are included

Centers for Disease Control, Public Health Service, U S Department of Health and Human Services, Adult Irnrnunlzations Recornrnendation)of the Immunizatlon Practices Committee, undated.

cAmerican College of Physicians-immunizations. American College of Physicians, Committee on Immunlzatlons, Guide for Adult Immunization (Philadelphla, PA: 1985); clinical breast examination

and mammography D M Eddy, “screening for Breast Cancer, ” ArIrJ /rrtern Med 111 (5) 389-399, 1969, cholesterol A M Garber, H C Sex, and B L!ttenberg, “Screening Asymptomatlc Adults

for Cardiac Risk Factors The ~rur-n cholesterol Level “ A~~ /~~efrr Med 11 0(8) 622-63$3 1989, mrurn glumse D E .SInger, J l-i. Samet, C M Coley et al., “Screening for Diabetes Melhtus, h-r.

/ntern Med 109639-649, 1988; EKG H C %x, A M, Garber, and B Lhtenberg, “The Resting Electrocardiogram as a Screening Test, A Chnlcal Analysis,” Ann. htern. Med 111 (6) 469-502, 1989

%ancer Early Detectton Branch, Dlwslon of Cancer PreventIon and Control, National Cancer Instttute, Nat!onal Institutes of Health, U.S. Department of Health and Human ServIc%s, “k%r+mg

Guldelmes for Early Cancer DetectIon Rationale and Supporting Evidence to Decrease Mortallty” (Bethesda, MD Decemtw 1987), and “NatlonaI Organizations Agree on Joint Mammography

Guldelmes,” press release from the National Medical Roundtable on Mammography .screenmg Guidelines, June 27, 1989, cholesterol National Choksterol Education Program, National Heart,

Lung, and Blood Institute, National Institutes of Health, U S Department of Health and Human services, “Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood

Cholesterol In Adults,” (Bethesda, MD October 1987); blood pressure’ Joint Nahonal Committee, “The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of

High Blood Pressure,” Arch Intern. Med. 148(5).1023-1038, 1988.

eCanadianPermdlc Health Examlnatlon Task Force, “The Period/c Health Examlnatfon, ” Can. Med. Asscc J 121 (9)”1 193-1254, 1979, 130(10)”1276-1292, 1984, 134’721 -729, 1986; and

141 :209-216, 1989

fu s, Preventive Styvlms Task Force, Guide to C/mjca/ Preventive Serwces (Balhmore, MD WIllIaMS & Wllkms, 1989).

9Clmlcal breast examination and mammography. AAFP, ACR, AMA, AMWA, “Nat!onalOrganlzatlons Agree on Joint Mammography Guldelmes,” press release from the National MedicalRoundt able

on Mammography Screening Guldelmes, June 27, 1989, American College of Ob.stetnclans and Gynecoioglsts, personal Communlcatton with Lynne Lawrence, Government Relations

Representatwe, Washington, DC, Oct. 31, 1988; Pap smear (ACOG, ACS, NCI, AMA, ANA, AAFP, and AMWA), D.J, Fink, “Change m American Cancer Society Guldehnes for Detection of Cerwcal

Cancer,” CA-A Journa/ for Chmciar?s 38(2) 127-128, 1988; vision examination American Optometric Association, “Optometry and the NatIon’s Health: Recommendations for the Implementation

of Congress’ National Health Priorities,” a working paper prepared by the National Health Dwaon, February 1978, American Academy of Ophthalmology, Policy Statement, “Frequency of Ocular

Examlnatlons,” approved Feb. 6, 1983.

hAmerlmn canar Socwty, summary of Current Guldellnes for the C~@r.Related ch~kup: F@commendatlons” (New yor-k: Acs professional EducahonPublcatlon, 1988), D.J. Fink, “Change

m American Cancer SOclety Gutdellnes for DetectIon of Cerwcal Cancer,” CA-A Jourrra/ for Chrickr?s 38(2):127-128, 1988; and ‘(National Organizations Agree on Joint Mammography Guldehnes,”

press release from the National Medical Roundtable on Mammography Screening Guidelines, June 27, 1989, American Diabetes Association, “AD A. Policy on Screening for Hyperglycemia,” June

1983; American Heart Association (cholesterol screening), ‘( Publ~ Screening Strategies for Measuring Blood Cholesterol in Adults-Issues for Special Conc8rn,” October 1987 (serum glucose,

blood pressure, EKG, and physical examination), S.M, Grundy, P. Greenland, A. Herd et al,, “Cardiovascular and Risk Factor Evaluation of Healthy American Adults,” Cmdation75(6)’1340A -1362A,

1987; and American Society for the Prevention of Blindness, “Facts on Blindness and Prevention,” February 1988,

SOURCE: Office of Technology Assessment, 1990. ●
32 ● Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations

sexes), annual mammography at age 50 (women), and

annual digital rectal examination of the prostate starting

at age 40 (men), an annual physician visit is implied for

all adults over age 65.

In recent years, several professional groups from the

private sector have taken an interest in investigating the

effectiveness of preventive services. The INSURE project

was an 8-year study of prevention in primary medical

care, sponsored by the industry wide Network for Social,

Urban, and Rural Efforts. Project INSURE provided

physicians with a model for providing early detection and

treatment of disease and the provision of health education

that is based on each patient’s age, sex, and risk factors

(the model specifies the appropriate physical examinations, lab tests, immunizations, and x-ray studies to be

provided) and emphasized patient education as a means of

reducing the risk of coronary heart disease, cancer, stroke,

and automobile injuries. The INSURE project included

health packages for the study participants according to

age. The package for adults age 65 to 74 consists of five

physician visits (every 2 years) in addition to an annual

stool occult blood test and mammography (for women).

The four basic components of each visit were the

following:

●

●

●

●

history and physical examination (monitoring of

weight, blood pressure measurement, breast and

rectal exam, and assessment of hearing problems);

lab tests (plasma total cholesterol and glucose, and

a Pap smear every 3 years for 3 annual negatives

(for women));

immunizations (tetanus and influenza shots); and

patient education (counseling about risk factors of

cancer, heart disease, accidents, and aging).

For the elderly age 75 and over the components of the

physical exam are the same but the recommended

frequency is every year.

In June 1988, the Health Policy Agenda for the

American People (HPA), a public and private sector

initiative aimed at identifying and addressing health care

issues, and administratively supported by the American

Medical Association, published its basic benefits package. It promotes periodic medical examinations based on

age, sex, and risk factors. HWA recommends annual

examinations for adults from age 50 onward. The content

of the examinations is based on both the INSURE project

model and Canadian Task Force on the Periodic Health

Examination 1984 Update.

Finally, the American Cancer Society’s (ACS) recommendations for appropriate cancer screening suggests an

annual physician visit for men and women 40 and over for

cancer

cancer

annual

‘detection. In addition, ACS’ disease-specific

screening recommendations would also imply an

physician visit for the elderly.

Specific Preventive Services

Table D-2 summarizes the published recommendations for the use of selected preventive services by older

adults. It includes selected sets of recommendations made

by professional or expert groups for older adults, primarily for those over 65 years old. The summary is not

exhaustive; rather it includes a range of views on the use

of preventive services. As table D-2 indicates, there is

nearly complete agreement among the included groups

making recommendations for immunizations for the

elderly. For screening services there is a high degree of

consistency among groups, but some disagreement does

exist.

A more detailed comparison of recommendations for

colorectal cancer screening highlights the disparities that

can arise among recommending groups (see table D-3).

While the National Cancer Institute, American Cancer

Society, and the American Society of Gastroenterology

support periodic screening for colorectal cancer, the

USPSTF and Canadian Task Force are much less

supportive of this approach.
Appendix D--Summary of Recommendations For Periodic Health Examinations in the Elderly ● 33

Table D-3--Recommendations for Screening for Colorectal Cancer in the Elderly

Screening recommendation by procedure

Country/organization Digital rectal Fecal occult

(date of organization) examination blood testing Sigmoidoscopy

United States:

NCIa (1987) . . . . . . . . . . . . Considered part of routine phys- Annually Every 3 to 5 years

ical examination

ACSb (1988). . . . . . . . . . . Annually Annually Every 3 to 5 years after two negative sigmoidoscopies 1 year apart

ASGE & AGAc (1988). . . . Frequency unspecified Flexible sigmoidoscopy starting at

50, frequency unspecified

SPSTFd (1989) . . . . . . . . . Digital rectal examination is not an effective screening maneuver, Task Force found insufficient evidence

to recommend for or against screening with fecal occult blood test or sigmoidoscopy in asymptomatic

persons, but notes it maybe advisable to offer screening to persons 50 and older with risk factors; Task

Force does not specify a screening frequency

Canada:

CTFe (1988 ).. . . . . . . . . . . Not recommended unless speci- Not recommended unless specified risk factors are present fied risk factors are present

Germany:

Government f (1977) . . . . . Screening is suggested in those

over 45, frequency not specified

ABBREVIATIONS: ACS = American Cancer Society, AGA = American Gastroenterological Association, ASGE = American Society for Gastrointestinal

Endoscopy, CTF = Canadian Task Force, NC I . National Cancer Institute, USPSTF = United States Preventiv

SOURCES:

$National Cancer Institute, Division of Cancer Prevention and Control, Early Detection Branch, “Working Guidelines for Early Cancer Detection: Rationale and

Supporting Evidence to Decrease Mortality,” Bethesda, MD, December 1987.

bAmefi~n can~r Society, “Summ~y of Current Guidelines for the Cancer-Related Checkup: Recommendations” (New York: ACS Professional Edu=tion

Publication), 1868.

Weischer, D., Goldberg, S., Browning, T., et al., “Detection and Surveillance of Colorectal Cancer,” J. A.M.A. 261(4):580-585, 1969.

du.s. preventive ~rvirjgs Task Form, Guide to Clinical Preventive Servi@s (Baltimore, MD: Williams &Wilkins, 1989).

ec~adia T~k For- on the pe~~ic ~~th Examination, “E@ Detection of ~]or~~ can~r,” a~pted for publication in Carr, Mti. ASSOC. J .

141 :209-216, 1989.

fF.w. ~w~,l+. Ho~tein,and J-G. BreCht, IIpreliminary R~rtof Feca[Oqult Blood Testing in Germany,” Co/orec~a/Ca~@r: ~reVe~rjo~, Epidemiology, and

Screening S. Winawer, D, Schottenfeld, and P. Sherlock (eds.) (New York, NY: Raven Press, 1980).
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American Cancer Society, Summary of Current

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For further information on this paper or others in OTA’s series on

Preventive Health Services Under Medicare, contact:

Judith Wagner, Health Program, Office of Technology Assessment,

U.S. Congress, Washington, DC 20510-8025