```

[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]

 
  ASSESSING AMERICA'S HEALTH RISKS: HOW WELL ARE MEDICARE'S CLINICAL 
             PREVENTIVE BENEFITS SERVING AMERICA'S SENIORS?
=======================================================================

                                HEARING

                               before the

                            SUBCOMMITTEE ON
                      OVERSIGHT AND INVESTIGATIONS

                                 of the

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 23, 2002

                               __________

                           Serial No. 107-110

                               __________

       Printed for the use of the Committee on Energy and Commerce

 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 house

                               __________

80-672              U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2002
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512-1800  
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001

                    COMMITTEE ON ENERGY AND COMMERCE

               W.J. ``BILLY'' TAUZIN, Louisiana, Chairman

MICHAEL BILIRAKIS, Florida           JOHN D. DINGELL, Michigan
JOE BARTON, Texas                    HENRY A. WAXMAN, California
FRED UPTON, Michigan                 EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida               RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio                RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania     EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California          FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia                 SHERROD BROWN, Ohio
RICHARD BURR, North Carolina         BART GORDON, Tennessee
ED WHITFIELD, Kentucky               PETER DEUTSCH, Florida
GREG GANSKE, Iowa                    BOBBY L. RUSH, Illinois
CHARLIE NORWOOD, Georgia             ANNA G. ESHOO, California
BARBARA CUBIN, Wyoming               BART STUPAK, Michigan
JOHN SHIMKUS, Illinois               ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico           TOM SAWYER, Ohio
JOHN B. SHADEGG, Arizona             ALBERT R. WYNN, Maryland
CHARLES ``CHIP'' PICKERING,          GENE GREEN, Texas
Mississippi                          KAREN McCARTHY, Missouri
VITO FOSSELLA, New York              TED STRICKLAND, Ohio
ROY BLUNT, Missouri                  DIANA DeGETTE, Colorado
TOM DAVIS, Virginia                  THOMAS M. BARRETT, Wisconsin
ED BRYANT, Tennessee                 BILL LUTHER, Minnesota
ROBERT L. EHRLICH, Jr., Maryland     LOIS CAPPS, California
STEVE BUYER, Indiana                 MICHAEL F. DOYLE, Pennsylvania
GEORGE RADANOVICH, California        CHRISTOPHER JOHN, Louisiana
CHARLES F. BASS, New Hampshire       JANE HARMAN, California
JOSEPH R. PITTS, Pennsylvania
MARY BONO, California
GREG WALDEN, Oregon
LEE TERRY, Nebraska
ERNIE FLETCHER, Kentucky

                  David V. Marventano, Staff Director
                   James D. Barnette, General Counsel
      Reid P.F. Stuntz, Minority Staff Director and Chief Counsel

                                 ______

              Subcommittee on Oversight and Investigations

               JAMES C. GREENWOOD, Pennsylvania, Chairman

MICHAEL BILIRAKIS, Florida           PETER DEUTSCH, Florida
CLIFF STEARNS, Florida               BART STUPAK, Michigan
PAUL E. GILLMOR, Ohio                TED STRICKLAND, Ohio
RICHARD BURR, North Carolina         DIANA DeGETTE, Colorado
ED WHITFIELD, Kentucky               CHRISTOPHER JOHN, Louisiana
  Vice Chairman                      BOBBY L. RUSH, Illinois
CHARLES F. BASS, New Hampshire       JOHN D. DINGELL, Michigan,
ERNIE FLETCHER, Kentucky               (Ex Officio)
W.J. ``BILLY'' TAUZIN, Louisiana
  (Ex Officio)

                                  (ii)

                            C O N T E N T S

                               __________
                                                                   Page

Testimony of:
    Bratzler, Dale, Principal Clinical Coordinator, Oklahoma 
      Foundation for Medical Quality, Inc., the American Health 
      Quality Association........................................    31
    Clancy, Carolyn, Acting Director, Agency for Healthcare 
      Research and Quality, U.S. Department of Health and Human 
      Services...................................................    26
    Fleming, David W., Acting Director, Centers for Disease 
      Control and Prevention, U.S. Department of Health and Human 
      Services...................................................    20
    Gold, Marthe R., Logan Professor and Chair, Department of 
      Community Health and Social Medicine, City University of 
      New York Medical School....................................    57
    Grissom, Tom, Director, Centers for Medicare Management, 
      Centers for Medicare and Medicaid Services.................    14
    Gruman, Jessie C., President and Executive Director, Center 
      for the Advancement of Health..............................    68
    Heinrich, Janet, Director, Health Care--Public Health Issues, 
      U.S. General Accounting Office.............................     7
    Himes, Christine, Director of Geriatrics, Group Health 
      Cooperative................................................    63
    Quirion, Viola, on behalf of Alliance of Retired Americans...    53
Material submitted for the record:
    American Heart Association, prepared statement of............    84
    College of American Pathologists, prepared statement of......    88

                                 (iii)

  ASSESSING AMERICA'S HEALTH RISKS: HOW WELL ARE MEDICARE'S CLINICAL 
             PREVENTIVE BENEFITS SERVING AMERICA'S SENIORS?

                              ----------                              

                         THURSDAY, MAY 23, 2002

                  House of Representatives,
                  Committee on Energy and Commerce,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m., in 
room 2322, Rayburn House Office Building, Hon. James C. 
Greenwood (chairman) presiding.
    Members present: Representatives Greenwood, Burr, Bass, and 
Fletcher.
    Staff present: Joe Greenman, majority professional staff 
member; Brendan Williams, legislative clerk; Karen Folk, 
minority professional staff member; Bridgett Taylor, minority 
professional staff member; and Chris Knauer, minority 
investigator.
    Mr. Greenwood. Good morning. The hearing will come to 
order.
    We are the--good morning to the witnesses. One of the 
benefits of you and all of those in attendance, we expect that 
there will be members coming and going, and we're going to 
begin now, because we ought to.
    I've scheduled this hearing today to examine the importance 
of incorporating wide-ranging preventive practices into common 
patient care and in particular into the Medicare program. 
Health care experts expend a lot of time and energy addressing 
this issue, and Members of Congress have voiced their interest 
in encouraging the use of preventive medical services by their 
constituents. Yet there still appear to be some gaps in our 
knowledge about the effectiveness of these programs and about 
what programs are most appropriate for inclusion in Medicare.
    We're all familiar with the phrase ``an ounce of prevention 
is worth a pound of cure.'' Beyond conventional wisdom, this is 
something health care providers have come to recognize as a 
valuable part of medical care. Preventive services which entail 
not only the early detection of disease but also practices that 
actually prevent the onset of disease have been associated with 
a substantial reduction in morbidity and mortality. Despite 
these widely acknowledged benefits, a gulf exists between the 
potential health gains from delivering the most innovative 
forms of prevention and the gains we presently achieve for 
beneficiaries of U.S. public health care programs.
    Bear in mind that extending Medicare coverage to any 
service that aims to prevent disease requires an act of 
Congress. This means that the ongoing evaluation of the best 
practices and the prevention of chronic illness is the 
responsibility of Members of Congress. Since most of us in this 
body are not medical providers, let alone clinical researchers, 
we must rely on others to provide us with the information that 
will form our decisions on what benefits should be covered by 
Medicare.
    Since 1980, Congress has amended Medicare law several times 
to add coverage for certain preventive services. Preventive 
services currently available to Medicare beneficiaries are 
primarily used for the early detection of noncommunicable 
diseases like cancer or the immunization of beneficiaries from 
common sicknesses like influenza and pneumonia.
    We know there are other preventive services that could be 
offered to beneficiaries. Many of us read the news articles 
that are appearing on a more and more routine basis that report 
the results of preventive care studies. These studies have 
continued to support the notion that the most promising role 
for prevention in current medical practice may lie in changing 
personal health behaviors of patients long before clinical 
disease develops.
    The importance of this aspect of clinical practice is 
evident from a growing body of literature linking some of the 
leading causes of sickness and death in the United States, such 
as heart disease and cancer, to a handful of personal health 
behaviors. Yet the Medicare program does not cover services 
designed to improve the health status of most at-risk 
beneficiaries. The most common behaviors related to the onset 
of chronic illness cannot be addressed by benefits currently 
available in the Medicare program, although these benefits are 
becoming more widely available through private health coverage.
    To improve the performance of the Medicare program in this 
regard, Congress must find the most effective means of 
incorporating these benefits that demonstrate an ability to 
improve the health status of older Americans. Medical research 
and technology has expanded the body of options available for 
addressing the prevention and treatment of chronic illness. 
Prevention can play a role in improving the health of medical 
beneficiaries, as well as offer the potential for controlling 
health care costs if the preventive services are soundly 
structured.
    Today we will hear from a number of witnesses who are 
experts in the fields of public health, prevention programs and 
medical research.
    In an effort to obtain the best information in 
understanding how best to achieve these reforms, I have asked 
the U.S. General Accounting Office to assist us. The GAO has 
prepared a study on the current state of preventive services 
available in the Medicare program. This will be helpful in 
reminding us what is and is not covered by Medicare.
    Additionally, the GAO will tell us what it has learned 
about the initiatives that the Centers for Medicare and 
Medicaid Services, CMS, has conducted to encourage utilization 
of the preventive benefits already offered by Medicare and how 
the rates of utilization of these services have changed over 
time.
    I'm pleased to announce that the GAO will be assisting us 
by preparing a follow-up study that will address issues related 
to the challenges of evaluating and crafting preventive 
services for the benefit of those served by U.S. public health 
programs. I look forward to seeing the positive results that 
this partnership will yield in the months to come.
    Let me stress, finally, that, given the complexities 
inherent in this issue, today's hearing is the beginning of a 
process on prevention promotion in our public health programs. 
Before we know how best to act, we will have to answer 
difficult questions, such as what is the role of government in 
trying to change the health-related behavior of the general 
public? Are these efforts beneficial? Are they ethical? Who 
will be trusted to generate the evidence, and who will be 
responsible for using this evidence to implement policy?
    Today we will hear from witnesses who bring a great deal of 
expertise to this important topic and will help us begin to 
address these questions. I thank all of the witnesses for their 
testimony today.
    [The prepared statement of Hon. James Greenwood follows:]

 PREPARED STATEMENT OF HON. JAMES GREENWOOD, CHAIRMAN, SUBCOMMITTEE ON 
                      OVERSIGHT AND INVESTIGATIONS

    Good morning. I have scheduled this hearing today to examine the 
importance of incorporating wide-ranging preventive practices into 
common patient care--and, in particular, into the Medicare program. 
Health care experts expend a lot of time and energy addressing this 
issue and Members of Congress have voiced their interest in encouraging 
the use of preventive medical services by their constituents. Yet there 
still appear to be some gaps in our knowledge about the effectiveness 
of these programs, and about what programs are most appropriate for 
inclusion in Medicare.
    We're all familiar with the phrase ``an ounce of prevention is 
worth a pound of cure.'' Beyond conventional wisdom, this is something 
health care providers have come to recognize is a valuable part of 
medical care.
    Preventive services--which entail not only the early detection of 
disease, but also practices that actually prevent the onset of 
disease--have been associated with a substantial reduction in morbidity 
and mortality. Despite these widely acknowledged benefits, a gulf 
exists between the potential health gains from delivering the most 
innovative forms of prevention and the gains we presently achieve for 
beneficiaries of U.S. public health programs.
    Bear in mind that extending Medicare coverage to any service that 
aims to prevent disease requires an act of Congress. This means that 
the ongoing evaluation of the best practices in the prevention of 
chronic illness is the responsibility of Members of Congress. Since 
most of us in this body are not medical providers, let alone clinical 
researchers, we must rely on others to provide us with the information 
that will inform our decisions on what benefits should be covered by 
Medicare.
    Since 1980, Congress has amended Medicare law several times to add 
coverage for certain preventive services. The preventive services 
currently available to Medicare beneficiaries are primarily used for 
the early detection of noncommunicable diseases, like cancer, or the 
immunization of beneficiaries from common sickness, like influenza and 
pneumonia.
    We know there are other preventive services that could be offered 
to beneficiaries. Many of us read the news articles appearing on a 
more-and-more routine basis that report the results of preventive care 
studies. These studies have continued to support the notion that the 
most promising role for prevention in current medical practice may lie 
in changing personal health behaviors of patients long before clinical 
disease develops. The importance of this aspect of clinical practice is 
evident from a growing body of literature linking some of the leading 
causes of sickness and death in the United States, such as heart 
disease and cancer, to a handful of personal health behaviors.
    Yet the Medicare program does not cover services designed to 
improve the health status of most at-risk beneficiaries. The most 
common behaviors related to the onset of chronic illness cannot be 
addressed by benefits currently available in the Medicare program--
although these benefits are becoming more widely available through 
private health coverage.
    To improve the performance of the Medicare program in this regard, 
Congress most find the most effective means of incorporating those 
benefits that demonstrate an ability to improve the health status of 
older Americans. Medical research and technology has expanded the body 
of options available for addressing the prevention and treatment of 
chronic illness. Prevention can play a role in improving the health of 
Medicare beneficiaries as well as offer the potential for controlling 
health costs, if the preventive services are soundly structured.
    Today, we will hear from a number of witnesses who are experts in 
the fields of public health, prevention programs and medical research. 
In an effort to obtain the best information in understanding how best 
to achieve these reforms, I have asked the US General Accounting Office 
(GAO) to assist us. The GAO has prepared a study on the current state 
of preventive services available in the Medicare program. This will be 
helpful in reminding us what is, and is not, covered by Medicare. 
Additionally, the GAO will tell us what it has learned about the 
initiatives that the Centers for Medicare and Medicaid Services (CMS) 
has conducted to encourage utilization of the preventive benefits 
offered by Medicare and how the rates of utilization of these services 
has changed over time.
    I am also pleased to announce that the GAO will be assisting us by 
preparing a follow-up study that will address issues related to the 
challenges of evaluating and crafting preventive services for the 
benefit of those served by US public health programs. I look forward to 
seeing the positive results that this partnership will yield in the 
months to come.
    Let me stress, finally, that, given the complexities inherent in 
this issue, today's hearing is the beginning of a process on prevention 
promotion in our public health programs. Before we know how best to 
act, we will have to answer difficult questions such as what is the 
role of government in trying to change the health related behavior of 
the general public? Are these efforts beneficial? Are they ethical? Who 
will be trusted to generate the evidence and who will be responsible 
for using this evidence to implement policy?
    Today, we will hear from witnesses who bring a great deal of 
expertise to this important topic--and will help us begin to address 
these questions. I thank all the witnesses for their testimony today.

    Mr. Greenwood. I note that there is a vote pending, and 
there are no other members to make opening statements. However, 
we have a written statement submitted by Mr. Dingell which will 
be made a part of the official record.
    [Additional statements submitted for the record follow:]

PREPARED STATEMENT OF HON. ERNIE FLETCHER, A REPRESENTATIVE IN CONGRESS 
                       FROM THE STATE OF OKLAHOMA

    Chairman Greenwood, I am pleased you are having this hearing today 
to look into the health of our Nation's Seniors. We have an obligation 
to ensure that Medicare's clinical preventive benefits are serving all 
our Seniors and to ensure that the preventive medical treatments are 
incorporated and promoted in a comprehensive Medicare system that will 
not bankrupt our children and grandchildren and will allow Medicare to 
be around for a long time to come.
    Medicare has provided health care security to millions of Americans 
since 1965. Almost 400 new drugs have been developed in the last decade 
alone to fight diseases like cancer, heart disease, and arthritis. 
However, Medicare has not kept up with rapid advances in medical care. 
Congress has a moral obligation to fulfill Medicare's promise of health 
and security for America's Seniors and people with disabilities. It is 
essential that Congress take steps to improve preventive care. 
Preventive care has proven to be highly effective in reducing the 
seriousness of many diseases and in improving the recovery time and 
quality of life for those who suffer from them. At the same time as we 
consider improving preventive benefits, we must fundamentally reform 
Medicare to ensure that it is a strong and viable system for our 
Seniors.
    At a time when health care costs are soaring and the number of 
uninsured Americans is approximately 40 million, Congress must be 
careful to not place health care mandates on Medicare that will force 
our young workers to pay more for the benefits than they can afford.
    President Bush reminded us in his State of the Union Address that 
health care reform was a domestic priority for his Administration. 
Congress must turn attention to Medicare and Medicaid reform, the 
problem of the uninsured and high costs now. We have a ripe opportunity 
to improve the health of all Americans and make health insurance more 
affordable for all Americans.
    Some say an ounce of prevention is worth a pound of cure. In this 
case access to preventive health care services is the prevention that 
will cure many problems we face today in our health care system. Noted 
businessman and presidential advisor Bernard M. Baruch once stated: 
``There are no such things as incurables; there are only things for 
which man has not found a cure.'' This statement is just as true for 
illness as it is for problems with America's health care system 
including Medicare. While we cannot solve all ills overnight, it's 
important for Congress and the President to work together to provide 
common sense and creative cures for improving health care to benefit 
all Americans.
                                 ______
                                 
 PREPARED STATEMENT OF HON. W.J. ``BILLY'' TAUZIN, CHAIRMAN, COMMITTEE 
                         ON ENERGY AND COMMERCE

    Thank you Chairman Greenwood, and let me commend you for holding 
this oversight hearing on the role of preventive medicine in our 
nation's public health programs.
    Americans today enjoy better overall health care than at any time 
in the nation's history. Rapid advancements in medical technologies, 
increased understanding of the genetic foundations of health and 
illness, improvements in the effectiveness of pharmaceutical 
treatments, and other developments have helped to develop cures for 
many illnesses and to extend and improve the lives of Americans, 
especially those with chronic diseases.
    These steady improvements are certainly a blessing. But by 
themselves, they cannot address some of the most significant challenges 
to improving the health of the coming generation of Medicare 
beneficiaries.
    Just this week, The Washington Post reported a recent AARP study 
that showed Americans over 50 are living longer and suffering with less 
disability than previous generations of midlife adults. But they are 
more likely to be overweight or obese, live with multiple chronic 
health conditions and depend more on prescription drugs.
    If we are to realize the full potential of the investments we have 
made to improve the quality of health care in this country, we must 
undertake a serious effort to assess not only how best to treat these 
chronic diseases but also how to implement what we know about changing 
the behaviors that cause these diseases.
    Fortunately, over the past decade, a growing body of evidence has 
emerged that shows that behavioral and social interventions offer great 
promise to reduce disease morbidity and mortality. But as yet, this 
potential to improve the public's health has been poorly tapped.
    Today, we have an opportunity to begin to address how to improve 
the performance of programs such as Medicare through the use of 
preventive health services that address the behaviors that lead to the 
onset of chronic diseases. These preventive health services, in fact, 
could play an important role in our effort to modernize the Medicare 
program.
    We are beginning to see some good examples of what will emerge in 
the marketplace. Private sector health plans are showing how best to 
incorporate cutting edge and nontraditional benefits for the patients 
they serve. There are numerous examples of Medicare+Choice 
Organizations that have improved health care for their Medicare 
beneficiaries through innovations focused on nutrition screening, 
exercise and fitness programs, and disease management programs, for 
example, which craft interventions to cater to beneficiaries with 
specific chronic illnesses. These services are provided without any 
additional reimbursement, as value added services.
    Today, we will hear from a representative from one such 
Medicare+Choice Organization that has implemented these types of 
programs. I look forward to hearing about the benefits seen in offering 
such a program to Medicare beneficiaries.
    Let me also add that, if we are to succeed, eventually, in 
improving the quality of health care for our Medicare beneficiaries, we 
must focus on the need to enact comprehensive reforms. Our public 
health programs must coordinate efforts to conduct and gather research 
on the most effective means of preventing chronic diseases. Health 
policy leaders must begin to work together to determine how best to 
offer as sound benefits those clinical preventive services that have 
been proven effective. Providers and health plans, both public and 
private, must work together to develop uniform guidelines for working 
with beneficiaries to guide them to the usage of the medical services 
that will truly improve their health status.
    Undertaking an effort to achieve comprehensive Medicare reform 
should ultimately lead to the systemic changes necessary for 
strengthening the longevity of this vital program--and bringing 21rst 
Century style health care to Medicare. We can begin this important 
process by taking measures this year to strengthen the Medicare+Choice 
program and add a prescription drug benefit. Creating a wider variety 
of health plan options, along with access to affordable prescription 
drugs, will begin to provide Americans with the innovation and choices 
needed to ensure their long term health.
    We can also make major improvements to the Medicare Program by 
moving towards a more competitive method of delivering health care 
services to beneficiaries. Our Committee has spent a great deal of time 
thinking through how the Federal Employees Health Benefits Program 
(FEHBP) may be replicated in Medicare. FEHBP, unlike traditional 
Medicare, doesn't require a statutory change to incorporate important 
new preventive services into its benefit package. One of the principal 
reasons why Medicare currently covers such few preventive benefits is 
because seniors need to wait for an Act of Congress. This could change 
if we move aggressively toward an FEHBP style, competitive model of 
delivering health care to seniors.
    I look forward to hearing the presentations of the witnesses today 
and I thank you all for your testimony.
                                 ______
                                 
    PREPARED STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN 
                  CONGRESS FROM THE STATE OF MICHIGAN

    I would like to thank Chairman Greenwood for convening a hearing on 
the important topic of improving Medicare for seniors and the disabled.
    This hearing will focus specifically on increasing seniors' use of 
preventive services, including cancer screenings and immunizations. We 
should not, however, lose sight of the one preventive benefit that we 
all agree must to be added to Medicare--prescription drug coverage. 
Prescription drugs can prevent seniors with diseases from getting 
sicker and enable others to manage chronic illnesses so they can live 
productively. In short, prescription drugs are the most important 
preventive benefit we can give seniors and the disabled.
    Although there is consensus that Congress needs to create a 
Medicare drug benefit, some may argue that we cannot afford to add a 
comprehensive benefit at this time. At one point, there may have been 
arguments that adding preventive services to Medicare was too 
expensive. But we did it. We don't need more study, more evaluation, or 
more demonstration projects to determine whether prescription drugs are 
really the right way to improve the Medicare program. I hope that my 
colleagues will join me this year and create a dependable, 
comprehensive, defined prescription drug benefit that is affordable to 
all seniors, regardless of whether they choose to participate in 
Medicare+Choice or fee-for-service.
    Today's witnesses will inform us about the progress that has been 
made since Congress added a number of preventive services to Medicare 
several years ago. The American Health Quality Association will testify 
that their member organizations that contract with Medicare have 
increased utilization rates of these benefits in the fee-for-service 
program. Still, more work needs to be done to ensure that all seniors 
can take advantage of these services. In particular, we need to examine 
whether the 20 percent coinsurance rate is keeping seniors from getting 
the preventive care they need.
    Some people may argue that the best way to increase coverage for 
preventive services is to pay Medicare+Choice plans extra dollars to 
provide them. It is important, however, to remember that over 85 
percent of seniors are enrolled in the fee-for-service program. Some of 
these seniors have no Medicare+Choice plans available to them, while 
others choose to stay in the traditional plan because it better meets 
their needs. Relying solely on Medicare+Choice plans to provide more 
preventive services would not improve care for the majority of seniors. 
Worse yet, this approach would create a deliberate inequality in a 
program that owes its success to its universality.
    I look forward to the testimony from today's distinguished panels 
and working with Chairman Greenwood to improve the Medicare program.

    Mr. Greenwood. Okay, I should also advise you that it looks 
like we may be in for some procedural battling today. I will 
hope that these disruptions will be at a minimum, but I need to 
run over and vote now. So we will recess only for about 15 
minutes, and then we'll look forward to your testimony. Thank 
you.
    [Brief recess.]
    Mr. Greenwood. The subcommittee will come to order. It 
appears that we have about an hour before the next dilatory 
move.
    So we welcome our witnesses. The first panel consists of 
Dr. Janet Heinrich, who is the Director of Health Care and 
Public Health Issues at the U.S. General Accounting Office. Mr. 
Tom Grissom is the Director for the Centers for Medicare 
Management, Centers for Medicare and Medicaid Services; Dr. 
David W. Fleming, Acting Director of the Centers for Disease 
Control and Prevention; Dr. Carolyn Clancy, Acting Director, 
Agency for Healthcare Research and Quality; and Dr. Dale 
Bratzler, Principal Clinical Coordinator of the Oklahoma 
Foundation for Medical Quality, Incorporated, on behalf of the 
American Health Quality Association.
    We welcome all of you. I assume that you are aware that 
this is an investigative hearing, and it is our custom in this 
committee to hold--take our testimony under oath. Do any of you 
object to giving your testimony under oath? Okay.
    Now, pursuant to the rules of this committee and pursuant 
of the rules of the House, you're entitled to be represented by 
counsel during your testimony. Do any of you wish to be 
represented by counsel?
    Seeing no such requests, then I would ask that you rise and 
raise your right hands.
    [Witnesses sworn.]
    Mr. Greenwood. Okay. You are under oath, and you may give 
your testimony.
    We will begin with Dr. Heinrich. Welcome. Good morning.

  TESTIMONY OF JANET HEINRICH, DIRECTOR, HEALTH CARE--PUBLIC 
  HEALTH ISSUES, U.S. GENERAL ACCOUNTING OFFICE; TOM GRISSOM, 
DIRECTOR, CENTERS FOR MEDICARE MANAGEMENT, CENTERS FOR MEDICARE 
   AND MEDICAID SERVICES; DAVID W. FLEMING, ACTING DIRECTOR, 
CENTERS FOR DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF 
  HEALTH AND HUMAN SERVICES; CAROLYN CLANCY, ACTING DIRECTOR, 
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, U.S. DEPARTMENT OF 
    HEALTH AND HUMAN SERVICES; AND DALE BRATZLER, PRINCIPAL 
CLINICAL COORDINATOR, OKLAHOMA FOUNDATION FOR MEDICAL QUALITY, 
         INC., THE AMERICAN HEALTH QUALITY ASSOCIATION

    Ms. Heinrich. Good morning. Mr. Chairman, we're very 
pleased to be here as you review the existing preventive health 
care services offered in the Medicare program and consider 
proposals for expanding these benefits. At your request, we are 
issuing a report today that examines beneficiaries' use of 
preventive services and actions taken by the Centers for 
Medicare and Medicaid Services, CMS, to increase utilization.
    As originally conceived, the Medicare program covered only 
services for the diagnosis and treatment of illness and injury; 
and, as you noted, since 1980 Congress has amended the Medicare 
law several times to add coverage for certain preventive 
services. These services include immunizations for pneumonia, 
hepatitis B, influenza screening for five types of cancer, as 
well as screening for osteoporosis and glaucoma. Except for flu 
and pneumonia immunizations and laboratory tests, Medicare 
requires some cost sharing by beneficiaries.
    In our review of preventive services offered under 
Medicare, we found that utilization has increased over time, 
but it really does vary significantly by service. Beneficiaries 
received screenings for breast and cervical cancer at high 
rates, less so for immunizations, and the lowest screening 
rates were for colorectal cancer.
    Relatively few beneficiaries receive all of the services 
that are covered. For example, although 91 percent of female 
beneficiaries receive at least one service, only 10 percent 
received the whole array of covered preventive services, for 
example, cancer, breast and colon cancer screening, as well as 
the immunizations.
    In considering the strategies for improving utilization, it 
is clear that targeting specific population groups can be 
effective. Our review of utilization rates also showed 
variation by State, ethnic group, income and education level. 
Although the national breast cancer screening rates are about 
75 percent--at least they were in 1999--rates for individual 
States range from a low of 66 to a high of 86 percent. Among 
ethnic groups, the biggest differences occurred in use of 
immunization services, with over half of whites receiving 
immunization against pneumonia and only about a third of 
Hispanics and African Americans.
    Beneficiaries with higher incomes and levels of education 
tend to use preventive services more than those at lower 
levels. It is evident from the work that CMS has conducted thus 
far that a variety of efforts are needed to increase the use of 
services.
    CMS has sponsored reviews of studies to identify 
interventions that are most effective at increasing 
utilization. While these studies suggest no one approach works 
in all situations, several show promise. For example, allowing 
health care providers to forgo some compensation by waiving 
deductibles has been successful, and reminders to physicians or 
patients can effectively improve cancer screening rates.
    Another positive step CMS has taken is to contract with the 
quality improvement organizations to increase use of three 
services. These are the immunizations for flu and pneumonia and 
for breast cancer screening. These organizations are developing 
reminder systems and conducting activities to educate patients 
and providers. They are also starting demonstrations to 
increase use of preventive services by minorities and low-
income beneficiaries. Evaluating these efforts to identify the 
most effective approaches will be extremely important for 
further improvements in the Medicare program.
    As the Congress considers broadening Medicare's coverage of 
preventive services, you will likely consider the 
recommendations of the U.S. Preventive Services Task Force, a 
group of experts who evaluate evidence to determine 
effectiveness of preventive services for different age and risk 
groups. Medicare covers many but not all of the services 
recommended by the task force. For example, the task force 
recommends blood pressure and cholesterol screening, services 
not explicitly covered by Medicare now.
    This is true for a variety of counseling services as well. 
Older people do report that they are having their blood 
pressure and cholesterol checked. It is not clear, however, 
that counseling intended to change unhealthy behaviors is 
occurring during regular office visits, nor has research 
established the effectiveness of well-defined clinical 
counseling to actually change risky behavior.
    In conclusion, it is important to recognize the difficulty 
of translating some of the preventive service recommendations 
into covered benefits. Nevertheless, we believe that it is 
important to regularly review Medicare coverage of preventive 
services as information on effectiveness of these services 
becomes available. It is also important to continue to explore 
approaches to encourage older Americans to use existing covered 
services.
    Thank you. I'm happy to answer any questions.
    [The prepared statement of Janet Heinrich follows:]

  PREPARED STATEMENT OF JANET HEINRICH, DIRECTOR, HEALTH CARE--PUBLIC 
         HEALTH ISSUES, UNITED STATES ENERAL ACCOUNTING OFFICE

    Mr. Chairman and Members of the Subcommittee: We are pleased to be 
here today as you review existing preventive health care services 
offered in the Medicare program and consider proposals for expanding 
these benefits. At your Subcommittee's request, we have been examining 
several issues related to preventive services and have prepared a 
report that is being released today.1 My statement today 
highlights some of the key aspects of that report.
---------------------------------------------------------------------------
    \1\ U.S. General Accounting Office, Medicare: Beneficiary Use of 
Clinical Preventive Services, GAO-02-422 (Washington, D.C.: April 12, 
2002).
---------------------------------------------------------------------------
    Preventive health care services, such as flu shots and cancer 
screenings, can extend lives and promote the well-being of our nation's 
seniors. Medicare now covers 10 preventive services--3 types of 
immunizations and 7 types of screening--and legislation has been 
introduced to cover additional services.2 However, not all 
beneficiaries avail themselves of Medicare's preventive services. Some 
beneficiaries may simply choose not to use them, but others may be 
unaware that these services are available or covered by Medicare.
---------------------------------------------------------------------------
    \2\ A bill introduced last year proposes adding visual acuity, 
hearing impairment, cholesterol, and hypertension screenings as well as 
expanding the eligibility of individuals for bone density screenings. 
See H.R. 2058, 107th Cong. Sec. 203 (2001).
---------------------------------------------------------------------------
    You asked us to examine two questions regarding preventive services 
for older Americans:

 To what extent are Medicare beneficiaries using covered 
        preventive services?
 What actions have the Centers for Medicare and Medicaid 
        services (CMS), which administers Medicare, taken to increase 
        beneficiaries' use of preventive services?
    Our data on the extent to which beneficiaries are using covered 
services are taken primarily from a survey conducted by the Centers for 
Disease Control and Prevention (CDC), another agency that like CMS is 
within the Department of Health and Human Services. The survey collects 
information on the use of several preventive services covered under 
Medicare, including immunizations for influenza and pneumococcal 
disease, and screening for breast, cervical, and colon cancer.
    In summary, although use of Medicare covered preventive services is 
growing, it varies from service to service and by state, ethnic group, 
income, and level of education. For example, in 1999, 75 percent of 
women had been screened within the previous 2 years for breast cancer, 
compared with 55 percent of beneficiaries who had ever been immunized 
against pneumonia. However, even for a widely used preventive service 
such as breast cancer screening, state-by-state usage rates ranged from 
66 to 86 percent. Among ethnic groups, differences were greatest for 
immunizations. For example, 1999 data show that about 57 percent of 
whites and 54 percent of ``other'' ethnic groups had been immunized 
against pneumonia, compared to about 37 percent of African Americans 
and Hispanics.3 Among income and educational groups, 
variation was greatest for cancer screening.
---------------------------------------------------------------------------
    \3\ ``Other'' ethnic groups include survey respondents who reported 
an ethnicity other than African American, Hispanic, or white.
---------------------------------------------------------------------------
    To help ensure that preventive services are being delivered to 
those beneficiaries who need them, CMS sponsors activities--called 
``interventions''--aimed at increasing use. CMS currently funds 
interventions aimed at increasing the use of three services--breast 
cancer screening and immunizations against flu and pneumonia--in each 
state. CMS also pays for interventions that focus on increasing use of 
services by minorities and low-income beneficiaries who have low usage 
rates. The techniques being used in some of these interventions, such 
as allowing nurses or other nonphysician medical personnel to 
administer vaccinations with a physician's standing order, have been 
found effective in the past. CMS is evaluating the effectiveness of 
current efforts and expects to have the evaluation results later in 
2002.

                        TYPE OF SERVICES COVERED

    When the Medicare program was established in 1965, it only covered 
health care services for the diagnosis or treatment of illness or 
injury. Preventive services did not fall into either of these 
categories and, consequently, were not covered. Since 1980, the 
Congress has amended the Medicare law several times to add coverage for 
certain preventive services for different age and risk groups within 
the Medicare population. These services include three types of 
immunizations--pneumococcal disease, hepatitis B, and influenza. 
Screening for five types of cancer--cervical, vaginal, breast, 
colorectal, and prostate--are also covered, as well as screening for 
osteoporosis and glaucoma. Except for flu and pneumonia immunizations, 
and laboratory tests, Medicare requires some cost-sharing by 
beneficiaries. Most beneficiaries have additional insurance, which may 
cover most, if not all, of these cost-sharing requirements.4
---------------------------------------------------------------------------
    \4\ U.S. General Accounting Office, Medigap Insurance: Plans Are 
Widely Available but Have Limited Benefits and May Have High Costs, 
GAO-01-941 (Washington, D.C.: July 31, 2001).
---------------------------------------------------------------------------
    For a number of reasons, not all Medicare beneficiaries are likely 
to use these services. For some beneficiaries, certain services may not 
be warranted or may be of limited value. Screening women for cervical 
cancer is an example. Survey data show that 44 percent of women age 65 
and over have had hysterectomies--an operation that usually includes 
removing the cervix.5 For these women, researchers state 
that cervical cancer screening may not be necessary unless they have a 
prior history of cervical cancer.6 Also, patients with 
terminal illnesses or of advanced age may decide to forgo services 
because of the limited benefits preventive services would offer. 
Research has shown, for example, that the benefits of cancer screening 
services, such as for prostate, breast, and colon cancer, can take 10 
years or more to materialize. Finally, the controversy over the 
effectiveness of some services, such as mammography and prostate cancer 
screening, may add to the difficulty in further improving screening 
rates for these services.
---------------------------------------------------------------------------
    \5\ Data are from the CDC's Behavioral Risk Factor Surveillance 
System (BRFSS), 2000.
    \6\ CDC researchers report that among the general population, over 
80 percent of hysterectomies are performed for noncancerous conditions 
such as fibroids and endometriosis.
---------------------------------------------------------------------------
    To help determine which preventive services are beneficial among 
various patient populations, the U.S. Department of Health and Human 
Services established a panel of experts in 1984, called the U.S. 
Preventive Services Task Force. The task force identifies and 
systematically evaluates the available evidence to determine the 
effectiveness of preventive services for different age and risk groups, 
and then makes recommendations as to their use. Task force 
recommendations were first published in the Guide to Clinical 
Preventive Services in 1989, and are periodically updated as new 
evidence becomes available. These recommendations are for screening, 
immunizations, and counseling services that are specific for each age 
group, including people 65 and older. See table 1 for the task force 
recommendations for various preventive services including those 
currently covered by Medicare.

                Table 1: Preventive Services Covered by Medicare or Recommended by the Task Force
----------------------------------------------------------------------------------------------------------------
                                              Task force         Year first covered by
               Service                  recommendation for age   Medicare as preventive   Medicare cost-sharing
                                                 65+                    service               requirement a
----------------------------------------------------------------------------------------------------------------
Immunizations
Pneumococcal.........................  Recommended............  1981...................  None
Hepatitis B..........................  No recommendation......  1984...................  Copayment after
                                                                                          deductible
Influenza............................  Recommended............  1993...................  None
Tetanus-diphtheria (Td) boosters.....  Recommended............  Not covered............  N/A
Screening
Cervical cancer--pap smear...........  Recommended b..........  1990...................  Copayment with no
                                                                                          deductible c
Breast cancer--mammography...........  Recommended d..........  1991...................  Copayment with no
                                                                                          deductible
Vaginal cancer--pelvic exam..........  No recommendation......  1998...................  Copayment with no
                                                                                          deductible c
Colorectal cancer--fecal-occult blood  Recommended............  1998...................  No copayment or
 test.                                                                                    deductible
Colorectal cancer--sigmoidoscopy.....  Recommended............  1998...................  Copayment after
                                                                                          deductible e
Colorectal cancer--colonoscopy.......  No recommendation......  1998...................  Copayment after
                                                                                          deductible e
Osteoporosis--bone mass measurement..  No recommendation......  1998...................  Copayment after
                                                                                          deductible
Prostate cancer--prostate-specific     Not recommended........  2000...................  Copayment after
 antigen test and/or digital rectal                                                       deductible c
 examination.
Glaucoma.............................  No recommendation......  2002...................  Copayment after
                                                                                          deductible
Vision impairment....................  Recommended............  Not covered............  N/A
Hearing impairment...................  Recommended............  Not covered............  N/A
Height, weight, and blood pressure...  Recommended............  Not covered............  N/A
Cholesterol measurement..............  Recommended............  Not covered............  N/A
Problem drinking.....................  Recommended............  Not covered............  N/A
Counseling
Diet and exercise, smoking cessation,  Recommendedf...........  Not covered............  N/A
 injury prevention, and dental health.
Postmenopausal hormone prophylaxis...  Recommended............  Not covered............  N/A
Aspirin for primary prevention of      Recommended............  Not covered............  N/A
 cardiovascular events.
----------------------------------------------------------------------------------------------------------------
a Applicable Medicare cost-sharing requirements generally include a 20 percent copayment after a $100 per year
  deductible. Each year, beneficiaries are responsible for 100 percent of the payment amount until those
  payments equal a specified deductible amount, $100 in 2002. Thereafter, beneficiaries are responsible for a
  copayment that is usually 20 percent of the Medicare approved amount. For certain tests, the copayment may be
  higher. See 42 U.S.C. Sec.  1395(a)(1).
b The task force found insufficient evidence to recommend for or against an upper age limit for pap testing, but
  recommendations can be made on other grounds to discontinue regular testing after age 65 in women who have had
  regular previous screenings in which the smears have been consistently normal.
c The costs of the laboratory test portion of these services are not subject to copayment or deductible. The
  beneficiary is subject to a deductible and/or copayment for physician services only.
d The task force recommends routine screening for breast cancer every 1 to 2 years, with mammography alone or
  along with an annual clinical breast examination, for women aged 50 to 69. The task force found insufficient
  evidence to recommend for or against routine mammography or clinical breast examination for women aged 40 to
  49 or aged 70 and older.
e The copayment is increased from 20 to 25 percent for services rendered in an ambulatory surgical center.
f The task force recommends these counseling services on the basis of the proven benefits of modifying harmful
  or risky behaviors. However, the effectiveness of clinician counseling to change these behaviors has not been
  adequately evaluated.
Source: U.S. General Accounting Office, Medicare: Beneficiary Use of Clinical Preventive Services, GAO-02-422
  (Washington, D.C.: Apr. 12, 2002) and U.S. Preventive Services Task Force, Guide to Clinical Preventive
  Services, 2nd ed. (Washington, DC, 1996) and related updates.

    As table 1 shows, Medicare explicitly covers many, but not all, of 
the preventive services recommended by the task force. However, 
beneficiaries may receive some of the preventive services not 
explicitly covered by Medicare. For example, even though blood pressure 
and cholesterol screening are not explicitly covered under Medicare, in 
1999, nearly 98 percent of seniors reported that they had had their 
blood pressure checked within the last 2 years, and more than 88 
percent of seniors reported having their cholesterol checked within the 
prior 5 years.7 Other task force recommended services--such 
as counseling intended to change a patient's unhealthy or risky 
behaviors--may also be occurring during office visits.8 
Determining the extent to which these preventive counseling services 
occur is difficult, in part, because the content of such services is 
not well defined. It is also interesting to note that the task force 
recommends these counseling services on the basis of the proven 
benefits of a good diet, daily physical activity, smoking cessation, 
avoiding household injuries such as falls, and avoiding dental caries 
(tooth decay) and periodontal (gum and bone) disease. However, the 
effectiveness of clinician counseling to actually change these patient 
behaviors has not been established.
---------------------------------------------------------------------------
    \7\ Survey data are from the CDC's BRFSS 1999.
    \8\ Counseling women regarding hormone replacement therapy, and all 
beneficiaries regarding the use of aspirin for the prevention of 
cardiovascular events is not necessarily intended to change behavior. 
Rather, it is intended to provide the patient current information on 
both the potential benefits and risks of these therapies. The task 
force recommends that the decision to undertake these therapies should 
be based on patient risk factors for disease and a clear understanding 
of the probable benefits and risks of these therapies.
---------------------------------------------------------------------------
        USE OF PREVENTIVE SERVICES IS GROWING BUT VARIES WIDELY

    Use of preventive services offered under Medicare has increased 
over time. For example, in 1995, 38 percent of beneficiaries had been 
immunized against pneumonia, compared with 55 percent in 1999. 
Similarly, the use of mammograms at recommended intervals had increased 
from 66 percent in 1995 to 75 percent in 1999. While these examples 
show that use of preventive services generally is increasing, they also 
show variation in use by service. Beneficiaries received screenings for 
breast and cervical cancer at higher rates than they did immunizations 
against flu and pneumococcal disease. Of the services for which data 
are available, colorectal screening rates were the lowest, with 25 
percent of the beneficiaries receiving a recommended fecal occult blood 
test within the past year, and 40 percent receiving a recommended 
colonoscopy or sigmoidoscopy procedure within the last 5 years.
    Relatively few beneficiaries receive multiple services. While 1999 
utilization data show progress in improving receipt of preventive 
services, and in some cases relatively high rates of use for individual 
services, a small number of beneficiaries access most of the services. 
For example, although 91 percent of female Medicare beneficiaries 
received at least 1 preventive service, only 10 percent of female 
beneficiaries were screened for cervical, breast, and colon cancer, and 
immunized against both flu and pneumonia.
    Although national rates provide an overall picture of current use, 
they mask substantial differences in how seniors living in different 
states use some services. For example, the national breast cancer 
screening rate for Medicare beneficiaries was 75 percent in 1999, but 
rates for individual states ranged from a low of 66 percent to a high 
of 86 percent. Individual states also ranged from 27 percent to 46 
percent in the extent to which beneficiaries receiving a colonoscopy or 
sigmoidoscopy for cancer screening.
    Usage rates also varied based by beneficiary, income, and 
education. Among ethnicity groups, the biggest differences occurred in 
use of immunization services. For example, 1999 data show that about 57 
percent of whites and 54 percent of ``other'' ethnic groups were 
immunized against pneumonia, compared to about 37 percent of African 
Americans and Hispanics. Similarly, about 70 percent of whites and 
``other'' ethnic groups received flu shots during the year compared to 
49 percent of African Americans. Beneficiaries with higher incomes and 
levels of education tend to use preventive services more than those at 
lower levels.

      EFFORTS UNDERWAY TO INCREASE USE OF SOME PREVENTIVE SERVICES

    CMS has conducted a variety of efforts to increase the use of 
preventive services. These include identifying which approaches work 
best and sponsoring specific initiatives to apply these approaches in 
every state.

Studies Identify Effective Methods to Increase Use of Services
    To identify how best to increase use of preventive services needed 
by the Medicare population, CMS sponsors reviews of studies that 
examine various kinds of interventions used in the past.9 
Among the CMS-sponsored reviews was one that examined the effectiveness 
of various interventions for flu and pneumonia immunizations and 
screenings for breast, cervical, and colon cancer.10 This 
evaluation, which consolidated evidence from more than 200 prior 
studies, concluded that no specific intervention was consistently most 
effective for all services and settings.
---------------------------------------------------------------------------
    \9\ CMS also conducts a variety of health promotion activities to 
educate beneficiaries about the benefits of preventive services and to 
encourage their use. These include the publication of brochures on 
certain covered services and media campaigns.
    \10\ Health Care Financing Administration, Evidence Report and 
Evidence-Based Recommendations: Interventions that Increase the 
Utilization of Medicare-Funded Preventive Services for Persons Age 65 
and Older, Publication No. HCFA-02151 (Prepared by Southern California 
Evidence-based Practice Center/RAND, 1999).
---------------------------------------------------------------------------
    While no one approach appears to work in all situations, the CMS 
evaluation concluded that system changes and financial incentives were 
the most consistent at producing the largest increase in the use of 
preventive services.
     System changes. These interventions change the way a 
health system operates so that patients are more likely to receive 
services. For example, standing orders may be implemented in nursing 
homes to allow nurses or other nonphysician medical personnel to 
administer immunizations.
     Incentives. These interventions include gifts or vouchers 
to patients for free services. Medicare allows providers to use this 
type of approach only in limited circumstances.11 For 
example, in order to encourage the use of preventive services, 
providers may forgo some compensation by waiving coinsurance and 
deductible payments for Medicare preventive services. In addition, 
other types of incentives--such as free transportation or gift 
certificates--are also allowed so long as the incentive is not 
disproportionately large in relationship to the value of the preventive 
service.
---------------------------------------------------------------------------
    \11\ Under regulations that became effective on April 26, 2000, 
Medicare providers may offer certain incentives for preventive 
services. Under no circumstances may cash or instruments convertible to 
cash be used. See 42 CFR Sec. 1003.101.
---------------------------------------------------------------------------
    Other interventions found to be effective--though to a lesser 
degree than the categories above--are reminder systems and education 
programs.
     Reminders. These interventions include approaches to (1) 
remind physicians to provide the preventive service as part of services 
performed during a medical visit or (2) generate notices to patients 
that it is time to make an appointment for the service. Studies show 
that reminders to either physicians or patients can effectively improve 
rates for cancer screening. However, if a computerized information 
system is present in a medical office, computerized provider reminders 
are consistently more cost-effective than notifying the patient 
directly. Patient reminders that are personalized or signed by the 
patient's physician are more effective than generic reminders.
     Education. These interventions include pamphlets, classes, 
or public events providing information for physicians or beneficiaries 
on coverage, benefits, and time frames for services. The review found 
that while the effect of patient education is significant, it has the 
least effect of any of these types of interventions.

CMS Is Sponsoring Efforts to Increase Use of Services
    CMS contracts with 37 Quality Improvement Organizations (QIOs), 
each responsible for monitoring and improving the quality of care for 
Medicare beneficiaries in one or more states, in the District of 
Columbia, or in U.S. territories.12 QIO activities currently 
aim to increase use of three Medicare preventive services--
immunizations against flu and pneumonia and screening for breast 
cancer.
---------------------------------------------------------------------------
    \12\ CMS formerly referred to this program as the Peer Review 
Organization program. During the course of our review CMS began 
referring to these entities as Quality Improvement Organizations. CMS 
officials told us that CMS plans to formalize the name change in a 
future Federal Register notice.
---------------------------------------------------------------------------
    QIOs are using various methods of increasing the use of these 
preventive services. For example, they are developing reminder systems, 
such as chart stickers or computer-based alerts, that remind physicians 
to contact patients on a timely basis for breast cancer screening. QIOs 
are also conducting activities to educate patients and providers on the 
importance of flu and pneumonia shots. CMS has taken steps to evaluate 
the success of these efforts. CMS officials explained that the 
contracts with the QIO organizations are ``performance based'' and 
provide financial incentives as a reward for superior outcomes. CMS 
officials expect information on the results by the summer of 2002.
    CMS plans to expand these efforts by QIOs. While the current 
efforts include only 3 of the preventive services covered by Medicare, 
CMS is also planning to include requirements for the QIOs to increase 
the use of screening services for osteoporosis, colorectal, and 
prostate cancer in future QIO contracts. CMS is not currently planning 
to include QIO contract requirements for the remaining preventive 
services covered by Medicare--hepatitis B immunizations or screenings 
for glaucoma and vaginal cancer.
    Other specific efforts have been started to increase use of 
preventive services by minorities and low-income Medicare beneficiaries 
in each state. CMS-funded research on successful interventions for the 
general Medicare population 65 and older concluded that evidence was 
insufficient to determine how best to increase use of services by 
minority and low-income seniors. To address this lack of information, 
CMS has tasked each QIO to undertake a project aimed at increasing the 
use of a preventive service in a given population. For example, the QIO 
may work with community organizations, such as African American 
churches, in order to convince more women to receive mammograms. CMS 
expects to publish a summary of QIO efforts to increase services for 
minorities and low-income seniors after the spring of 2002.
    Finally, other studies or projects that CMS has under way aim to 
identify barriers and increase use of services by certain Medicare 
populations. For example, the Congress directed CMS to conduct a 
demonstration project to, among other things, develop and evaluate 
methods to eliminate disparities in cancer prevention screening 
measures.13 These demonstration projects are in the planning 
stages. A report evaluating the cost-effectiveness of the demonstration 
projects, the quality of preventive services provided, and beneficiary 
and health care provider satisfaction is due to the Congress in 2004.
---------------------------------------------------------------------------
    \13\ See the Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act of 2000, Public Law 106-554, Appendix F, Sec. 122, 114 
Stat. 2763, 2763A-476 classified to 42 U.S.C. Sec. 1395b-1 nt.
---------------------------------------------------------------------------
                        CONCLUDING OBSERVATIONS

    Medicare beneficiaries are making more use of preventive services 
than ever before, but there is still room for improvement. While most 
preventive services are used by a majority of beneficiaries, few 
beneficiaries receive multiple services. Also, disparities exist in the 
rates that beneficiaries of different ethnic groups, income and 
education levels use Medicare covered preventive services. CMS has 
activities underway that have the potential to increase usage of 
preventive services. However, the full effect of these activities will 
not be known for quite some time.
    As the Subcommittee and Congress consider broadening Medicare's 
coverage of preventive services, it is important to recognize the 
difficulty of translating some preventive service recommendations into 
covered benefits. For example, inclusion of behavioral counseling 
services may be beneficial, but reaching consensus on common 
definitions of these services remains a major challenge. Establishing 
Medicare coverage for some screening activities such as blood pressure 
and cholesterol screening may not be necessary since most beneficiaries 
already receive these services. Nevertheless, we believe that it is 
important to regularly review Medicare's coverage of preventive 
services as information on the effectiveness of such services becomes 
available. It is also important to continue to explore new approaches 
to encourage beneficiaries to avail themselves of the preventive 
services Medicare covers.
    This concludes my prepared statement, Mr. Chairman. I will be happy 
to respond to any questions that you or Members of the Subcommittee may 
have.

    Mr. Greenwood. Thank you so much.
    Dr. Grissom.

                    TESTIMONY OF TOM GRISSOM

    Mr. Grissom. Thank you, Chairman Greenwood. It is a 
pleasure to be here. Thank you for giving me the opportunity to 
talk with you about coverage of preventive services within the 
Medicare program. We, too, like you, believe that preventive 
services and health screenings do extend lives and improve and 
promote wellness throughout the country.
    The President, the Secretary and the Administrator of CMS 
strongly support preventive health care and recognize the need 
to strengthen and improve the Medicare program by moving its 
benefits package from the current reactive acute care model to 
one which comprehensively and systematically emphasizes health 
promotion and disease prevention.
    When the program was established in 1965, it was 
essentially and exclusively for the diagnosis and treatment of 
illness or injury and is limited to this day by that Medicare 
statute. The law then reflected the health care system at that 
time. Since then Congress, recognizing the changes in health 
practice, began to modify the law first--or most importantly in 
the BBA and later in BIPA in 2000 to increase benefits for 
preventive services, and over time has lowered the threshold, 
increased the coverage and reduced copays and deductibles, 
trying to make the Medicare program commensurate with or mirror 
private health care.
    In addition to the benefits offered under the original fee-
for-service, the Medicare law allows for private health plans, 
Medicare+Choice and the risk plans, which give beneficiaries 
expanded benefits especially in the area of vision care, dental 
care, smoking cessation counseling, as well as disease 
management and care coordination. The administration's goal is 
committed to providing even greater availability of these 
important preventive and innovative benefits by making these 
private plans available more widely and to more beneficiaries.
    Additionally, as part of his overall framework for Medicare 
in the 21st century, President Bush has proposed giving seniors 
better coverage of these benefits by making them cost-free. I'm 
sure this morning we'll talk about the barriers to access and 
the utilization rates of these services, and there is clear 
evidence that cost may be an obstacle for certain kinds of 
beneficiaries and dual eligibles.
    We know that simply offering these benefits is not enough 
to guarantee their utilization. We work at CMS with a variety 
of other agencies, with our quality improvement organizations 
to develop and use efficient approaches and methods to reach 
out to beneficiaries. Education is absolutely essential to 
improving utilization of these services. We include health 
promotion information as part of our Medicare information 
campaigns. We work with the National Cancer Institute, CDC, the 
National Diabetes Institute, the National Eye Institute on 
media campaigns at the local and the national level. We 
integrate these messages in our promotional materials, our 
Medicare and You handbook, and through the use of our 1-800 
hotline. I have an example of those materials, Mr. Chairman, 
and I would enjoy sharing them with you.
    We are also utilizing increasingly tabs and insertions like 
this from the carriers to beneficiaries in their summary of 
notices so that they understand that they do have a benefit, 
and we're trying to coordinate those with national campaigns 
month to month throughout the year with the individual 
preventive services.
    The QIOs, which are groups of physicians in all of the 
States, have a number of projects, Dr. Bratzler will testify 
later, in which they are focusing on improving coverage of 
the--the access to the benefits and utilization. There were 
also focuses on working with minority groups and ethnic groups 
and economically disadvantaged groups, where the utilization 
rate is the lowest. Lots of those programs are innovative. They 
are private-public partnerships, and we think that they are 
quite effective.
    Additionally, we're trying to change the way the 
organizations work, and there is within our agency a regulation 
under way that would alter the conditions of participation for 
nursing homes, hospitals and home health that would allow 
flexibility in standing orders, so that there were no 
regulatory obstacles to beneficiaries receiving flu, hepatitis 
B and pneumococcal vaccinations without having to go through a 
physician's order.
    There is the Healthy Aging Project, which we operate in 
conjunction with AHRQ and the Centers for Disease Control, in 
which we're trying to identify, test and disseminate evidence-
based approaches to promote health and functional decline in 
older adults. We know that 70 percent of the decline in aging 
is a result of environmental, behavioral, lifestyle causes, and 
30 percent only by virtue of genetics. Thus, we are trying to 
do risk appraisals, figure out the best way to identify risks 
and to create educational programs that will have timely 
follow-up and interventions that truly alter an individual's 
behavior. Not much is known about this, certainly not enough, 
and we are in partnership with Brandeis University to develop 
pilot programs and to do so in a way which is education-based.
    We also have a demonstration project about to launch in CMS 
on smoking cessation. It is a result of BIPA 2000. It will 
focus on seven States with four different treatment scenarios 
for about 40,000 beneficiaries, for which we think there is a 
great possibility and great opportunity for improvements.
    Health risk appraisals focus on the area of diet and 
physical activity. There is plenty of empirical evidence to 
suggest that these are important. Secretary Thompson, both 
personally and professionally, has talked about how a little 
prevention won't kill you and is trying to give personal 
leadership to changes in individual behavior as leading to 
healthy lives. Again, our goal is to try increase access to and 
in promotion of these efforts at CMS and in the Medicare 
program.
    We appreciate the opportunity to be here, and are thankful 
for the attention that you're bringing to this. Thank you, and 
I'll be glad to answer any questions.
    [The prepared statement of Tom Grissom follows:]

   PREPARED STATEMENT OF TOM GRISSOM, DIRECTOR, CENTER FOR MEDICARE 
          MANAGEMENT, CENTERS FOR MEDICARE & MEDICAID SERVICES

    Chairman Greenwood, Congressman Deutsch, distinguished Subcommittee 
members, thank you for inviting me to discuss Medicare coverage of 
preventive services. Preventive care services can extend lives and 
promote wellness among America's seniors. The President, the Secretary, 
and CMS strongly support preventive health care services for Medicare 
beneficiaries, and the Administration has proposed several initiatives 
related to prevention that I will discuss in greater detail later in my 
testimony. First, I would like to discuss the nature of preventive 
health care benefits in the Medicare program and what benefits are 
currently covered under Medicare.

                               BACKGROUND

    When Medicare was established in 1965, the program covered only 
those health care services necessary for the diagnosis or treatment of 
illness or injury, as limited by the Medicare statute and reflecting 
the health care system at that time. Consequently, Medicare, as a 
general rule, did not cover routine screening or other purely 
preventive benefits. However, Congress recently has expanded the 
program to come closer to modeling the preventive care concepts in 
private health care programs and has added a number of preventive and 
screening benefits to the program. Both the Balanced Budget Act of 1997 
(BBA) and the Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act of 2000 (BIPA) significantly added to, or expanded, the 
preventive benefits covered by Medicare. These benefits include:

 Screening Mammography: BBA expanded coverage to include an 
    annual screening mammogram for all women Medicare beneficiaries age 
    40 and over, and one baseline mammogram for women age 35-39. BIPA 
    moved payment for screening mammography to the physician fee 
    schedule and also specified payment for two new forms of 
    mammography that use digital technology.
 Screening Pap Smears and Pelvic Exams: BBA provided coverage 
    for a screening Pap smear and pelvic exam (including a clinical 
    breast exam) every 3 years, or annual coverage for women of 
    childbearing age who have had an abnormal Pap smear during the 
    preceding 3 years, or women at high risk for cervical or vaginal 
    cancer. BIPA increased the frequency of coverage for screening Pap 
    smears and pelvic exams (including a clinical breast exam) from 
    every 3 years to every 2 years for women at average risk.
 Colorectal Cancer Screening: BBA provided coverage for 
    colorectal cancer screening procedures including: (1) annual fecal-
    occult blood tests for persons age 50 and over; (2) flexible 
    sigmoidoscopy for persons age 50 and over, every 4 years; (3) 
    colonoscopy for persons at high risk for colorectal cancer, every 2 
    years; and (4) other procedures the Secretary finds appropriate. 
    Barium enemas are also covered as an alternative to flexible 
    sigmoidoscopy or colonoscopy. BIPA expanded coverage of screening 
    colonoscopies to include all beneficiaries, not just those at high 
    risk for colorectal cancer.
 Prostate Cancer Screening: BBA provided coverage of annual 
    prostate cancer screening for men over age 50, including: (1) 
    digital rectal exams; (2) prostate-specific antigen (PSA) blood 
    tests; and (3) after 2002, other procedures the Secretary finds 
    appropriate.
 Glaucoma Screening: BIPA provided coverage of annual glaucoma 
    screening for individuals at high risk for glaucoma, individuals 
    with a family history of glaucoma, and individuals with diabetes.
 Diabetes Self-Management Benefits: BBA provided coverage for 
    outpatient diabetes self-management training in both hospital-based 
    and non-hospital-based programs, and for blood glucose monitors and 
    testing strips for all diabetics.
 Medical Nutrition Therapy Services: BIPA provided coverage of 
    medical nutrition therapy services for beneficiaries who have 
    diabetes or a renal disease. Covered services include nutritional 
    diagnostic, therapy and counseling services for the purpose of 
    disease management, which are furnished by a registered dietician 
    or nutrition professional, pursuant to a physician's referral.
 Standardization of Coverage for Bone Mass Measurements: BBA 
    provided coverage for bone mass measurement procedures, including a 
    physician's interpretation of the results, for estrogen-deficient 
    women at risk for osteoporosis, and persons: (1) with vertebral 
    abnormalities; (2) receiving long-term glucocorticoid steroid 
    therapy; (3) with primary hyperparathyroidism; and (4) being 
    monitored for response to an osteoporosis drug.
 Vaccines Outreach Extension: BBA extended, through FY 2002, 
    the existing Influenza and Pneumococcal Vaccination Campaign 
    conducted by our Agency in conjunction with CDC and the National 
    Coalition for Adult Immunization. Medicare covers influenza, 
    pneumococcal, and hepatitis B vaccinations, including payment for 
    the vaccine plus payment for a physician's administration of the 
    vaccine.
    The BBA and BIPA also required CMS to conduct analyses of Medicare 
preventive benefits. Under the BBA, we worked in conjunction with the 
Institute of Medicine and the U.S. Preventive Services Task Force to 
conduct a study of short- and long-term costs and benefits of expanding 
or modifying preventive or other services covered by Medicare. This 
analysis was completed in December 1999. Similarly, we are currently 
working with the National Academy of Sciences in conjunction with the 
U.S. Preventive Services Task Force to conduct, as required under BIPA, 
a study on the addition of coverage of routine thyroid screening using 
a thyroid stimulating hormone test as a preventive benefit.
    In addition to the prevention benefits added to the program since 
1997, Medicare has begun to offer additional preventive health care 
services through the Medicare+Choice program. Unlike the Medicare fee-
for-service program whose benefits are tied to statute, the private 
companies that provide Medicare+Choice have the flexibility to cover 
additional services, such as immunizations, exercise programs, cancer 
screening, and health education, that are not covered under the 
traditional Medicare benefits package. For example, one Medicare+Choice 
plan in California has a successful outreach program to increase 
influenza vaccination rates among their elderly and chronically ill 
beneficiaries to reduce mortality and morbidity among these at-risk 
populations. And a Boston Medicare+Choice plan has a comprehensive 
disease management program for its enrollees with diabetes. The result 
has been significant increases in the share of enrollees who receive 
preventive treatments like annual retinal eye exams and kidney tests, 
and better blood sugar control and cholesterol levels, all of which 
prevent the life-threatening complications of diabetes. The 
Administration is committed to providing greater availability of 
innovative preventive benefits by making private plan options more 
widely available to beneficiaries. This is key to improving beneficiary 
access to preventive benefits and to strengthening the overall Medicare 
program.
    In addition, Medicare+Choice programs typically provide some form 
of disease management or care coordination program, a service not 
covered in traditional Medicare. Several studies have suggested that 
case management and disease management programs can improve medical 
treatment plans, reduce avoidable hospital admissions, and promote 
other desirable outcomes. Coordination of care has the potential to 
improve the health status and quality of life for beneficiaries with 
chronic illnesses. We believe disease management has potential for 
preventing the worsening of chronic health conditions, and we are 
currently undertaking a series of disease management demonstration 
projects to explore a variety of ways to improve beneficiary care in 
the traditional Medicare plan.

           THE ADMINISTRATION'S COMMITMENT TO PREVENTIVE CARE

    Obviously, Medicare's coverage of preventive benefits has come a 
long way since the statute was written in the 1960s when the positive 
impact of preventive services was not fully understood. However, 
Medicare's coverage of preventive services can be improved. Under 
current law, Congress must enact legislation authorizing Medicare to 
cover specific preventive benefits. This approach can lead to 
fragmentation, and may not be consistent with a comprehensive, 
evidence-based approach to health promotion. The President recognizes 
the need to improve and strengthen the Medicare program by moving its 
benefits package from a reactive, acute care model to one that 
comprehensively and systematically emphasizes health promotion and 
disease prevention. As part of his principles for strengthening 
Medicare, the President has proposed to give seniors better coverage of 
preventive treatments by making existing preventive benefits cost-free 
for seniors.
    Secretary Thompson has reinforced the Administration's commitment 
to disease prevention by promoting healthy behavior as a priority for 
his Department, and even discussing in recent weeks his personal 
efforts to adopt a healthier lifestyle. To this end, HHS supports a 
number of programs to promote better health for all Americans, 
including:

 Healthy Communities Innovation Initiative. President Bush's 
    fiscal year 2003 budget includes $20 million for a new Healthy 
    Communities Innovation Initiative, an effort to bring together 
    community-wide resources to help prevent diabetes, asthma and 
    obesity.
 Healthy People 2010. Healthy People 2010, a comprehensive set 
    of objectives for the nation to meet by the end of this decade, 
    identifies the most significant preventable threats to health and 
    establishes national goals to reduce these threats.
 Leading Health Indicators. The first annual report on the 10 
    leading health indicators, critical factors that have a profound 
    influence on the health of individual communities and the nation, 
    will be released this year. They represent the major public health 
    concerns in the United States where individuals and communities can 
    take action to realize significant health improvements.

                      HEALTH PROMOTION ACTIVITIES

    Secretary Thompson, Administrator Scully, and I support the 
President's commitment to expand beneficiary access to preventive 
health services, and we are working on ways to improve health quality 
for America's most vulnerable citizens. As you may know, simply 
offering coverage for preventive health care services is not always 
enough to guarantee that Medicare beneficiaries take advantage of the 
benefits. That is why we strive to use efficient and cost effective 
approaches by partnering with other agencies and organizations, 
utilizing Medicare contractors to educate people with Medicare about 
covered preventive services and encouraging beneficiaries to use these 
services. To this end, we include health promotion information as a 
part of many education campaigns that address different aspects of the 
Medicare program or Medicare+Choice options. We have established 
partnerships with other HHS agencies, such as the Centers for Disease 
Control and Prevention (CDC) and the NIH's National Cancer Institute 
(NCI) to carry out health promotion initiatives, distribute outreach 
kits, and produce multi-media, multi-year campaigns involving numerous 
partners at the local and national level.
    In addition, we integrate communications about preventive services 
with other Medicare educational initiatives, such as:

 The Medicare and You handbook, which is distributed to all 
    beneficiary households, includes information on Medicare-covered 
    preventive services. We also publish and distribute a brochure 
    entitled, Medicare Preventive Services . . . To Help Keep You 
    Healthy that provides more detailed information about Medicare's 
    preventive benefits, plus reminder cards showing how often 
    beneficiaries should receive screenings.
 Medicare carriers and intermediaries include messages on the 
    importance of preventive services when they send out Medicare 
    Summary Notices. These messages are sent during certain months of 
    the year to correspond with health themes, such as Colorectal 
    Cancer Awareness Month. The carriers and intermediaries also 
    discuss these services and distribute materials to Medicare 
    beneficiaries when they give talks on other Medicare issues. And 
    they include articles on preventive services in their newsletters 
    and on their websites.
 Our regional offices also are involved in outreach. They 
    disseminate information on preventive services during other 
    information campaigns, such as during our successful Regional 
    Education About Choices in Health (REACH) campaigns.
 Our 1-800-MEDICARE help line and Medicare.gov Internet site 
    also include information on preventive health services, including 
    coverage, screening techniques, and where to locate additional 
    information.
 We also use targeted promotions to educate beneficiaries about 
    particular preventive services. For example, we have produced and 
    distributed more than 23,000 ``Screen-for-life'' posters with tear-
    off sheets that beneficiaries can take with them to their physician 
    as a reminder to discuss colorectal cancer screening options.
 Another example of a coordinated national activity was the 
    presentation of ``Beyond the Barriers: Effective Breast Cancer 
    Early Detection Strategies for Older Women.'' This national 
    satellite videoconference was broadcast live last year to 133 sites 
    in 40 states across the country.
    In addition, we emphasize the importance of prevention in education 
campaigns on the radio and through television public service 
announcements, print materials and media kits, websites, and articles 
in journals and newsletters. Through these campaigns, we are targeting 
high-risk populations and health care practitioners whom we know have a 
tremendous influence in encouraging healthy behavior.
    We are actively working to find out how best to increase use of 
preventive services needed by the Medicare population. We are studying 
a variety of successful interventions to test their effectiveness in 
the elderly population. In addition, we are working closely at the 
state level with our Quality Improvement Organizations (QIOs, formerly 
Peer Review Organizations) to monitor and to improve usage and quality 
of care for Medicare beneficiaries. We have set a goal for the QIOs of 
improving the utilization of flu and pneumonia vaccinations and breast 
cancer screening. To this end, the QIOs are actively reaching out to 
Medicare beneficiaries to increase the use of these three preventive 
services. They are also targeting racial and ethnic groups that have 
low rates of use. We are currently evaluating the success of these QIO 
efforts, and expect results later this year.
    Through our work with the QIOs and through other research, we know 
that compelling evidence exists that race and ethnicity correlate with 
health disparities. We are exploring a demonstration project to 
identify and test cost-effective models of intervention that have a 
high probability of positively impacting one or more health outcomes; 
including health status, functional status, quality of life, health-
related behavior, consumer satisfaction, health care costs, and 
appropriate utilization of covered services. We have contracted with 
Brandeis University to report on interventions that could be used among 
the targeted ethnic and racial minority populations. At the conclusion 
of the demonstrations, we will deliver a report to Congress on the 
cost-effectiveness of the projects, as well as the quality of 
preventive services provided and beneficiary satisfaction.

              CMS' INNOVATIONS IN PREVENTIVE CARE SERVICES

    A growing body of literature indicates that chronic disease and 
functional disability can be measurably reduced or postponed through 
lifestyle changes, and that healthy behaviors are particularly 
beneficial for the elderly. We have addressed some of the clinical 
preventive services that contribute to a healthy aging experience, and 
are just beginning to explore how to address behavioral risk factors, 
which account for 70 percent of the physical decline that occurs with 
aging, with the remaining 30 percent due to genetic factors. To this 
end, we developed the Healthy Aging Project in collaboration with the 
Agency for Healthcare Research and Quality, the Centers for Disease 
Control and Prevention, the Administration on Aging, and the National 
Institutes of Health. The Healthy Aging Project aims to identify, test, 
and disseminate evidence-based approaches to promote health and prevent 
functional decline in older adults.
    We contracted with RAND to produce several reports synthesizing the 
evidence on how to improve the delivery of Medicare clinical preventive 
and screening benefits and exploring how behavioral risk factor 
reduction interventions might be implemented in Medicare. We have been 
using these reports to guide demonstration projects testing ways to 
improve Medicare beneficiaries' health--and have already identified 
ways to change our policies for the better. The first report, 
Interventions That Increase the Utilization of Medicare-funded 
Preventive Services for Persons Aged 65 and Older, states that 
organizational changes are effective in improving the delivery of 
preventive services. As a result of this research and a 14-state pilot 
conducted in collaboration with CDC, we are making regulatory changes. 
These changes will promote vaccinations, and encourage the use of 
standing orders for flu and pneumococcal vaccinations in all health 
care settings. Standing orders permit appropriate non-physician staff 
to offer these services.
    In addition to the regulatory changes for standing orders that have 
come out of the Healthy Aging Project, we are using the research 
gleaned from this project to explore methods to encourage behavioral 
changes in the Medicare population, which could form the basis for the 
``next generation'' of Medicare benefits.
    Additionally, we, along with our partners at NIH and AHRQ, have 
developed a demonstration to test the most effective strategies for 
achieving smoking cessation in Medicare beneficiaries. The 
demonstration will compare the impact of offering three different 
approaches to smoking cessation on quit rates. We expect to start 
recruiting smokers to participate in the demonstration this fall. The 
study will be completed in 2004.
    We also are developing a potential project that would examine the 
use of health risk appraisal programs with targeted follow-up 
interventions. We have reviewed evidence related to health risk 
appraisal programs and their effectiveness in achieving positive 
behavior change, particularly in the areas of diet and physical 
activity. There is evidence that these programs improve physical 
activity levels and reduce blood pressure. We are in the process of 
developing a test of how health risk appraisal programs could improve 
Medicare beneficiaries' health. We look forward to working with 
Congress as we continue to develop groundbreaking ways to integrate 
preventive health care services into the Medicare program.

                               CONCLUSION

    Empirical evidence shows that preventive health care services are 
vital for improving the quality and duration of life. Just last month, 
Secretary Thompson, speaking at the National Press Club, emphasized his 
philosophy, ``a little prevention won't kill you,'' and noted that even 
modest behavioral changes and increased attention to health can prevent 
or control myriad diseases and chronic conditions. We here at CMS, 
along with the Secretary and the President recognize the benefits that 
preventive health services provide. We are working to improve access to 
these services and to develop innovative ways to offer prevention-
related health services to the Medicare population. In closing, I would 
like to thank Congressman Greenwood for his interest in preventive 
health care and the Committee for inviting me to testify today. We look 
forward to Congress' continued interest and support for this vital 
issue. I am happy to answer any questions.

    Mr. Greenwood. Thank you, Mr. Grissom.
    Dr. Fleming.

                 TESTIMONY OF DAVID W. FLEMING

    Mr. Fleming. Thank you, Mr. Chairman, for providing CDC the 
opportunity to be here with our colleagues today. We appreciate 
being given the time to talk with you about the prevention 
opportunities that are available to improve the health of 
America's seniors.
    You know, unfortunately, there is one thing that links 
everybody in this room, and that is that we're all getting 
older, and we're not alone. The population of older adult in 
this country, both in number and in proportion, is increasing 
at a much faster rate than we've ever experienced before. And 
we have yet to encounter that rapidly rising tide of baby 
boomers that will begin to reach age 65 just 8 years from now.
    We have a potential health crisis on our hands, but the 
operative word is ``potential.'' Poor health is not an 
inevitable consequence of aging. While we can't live forever, 
the evidence is overwhelming that prevention works for older 
adults. We can postpone illness and disability so that the need 
for long-term care is reduced and our seniors are able to enjoy 
full, independent and healthy lives as long as possible.
    And Medicare has brought the benefits of prevention to 
millions of older adults by capitalizing on research, by 
evaluating interventions, like you're going to hear about in a 
minute, with the Guide to Preventive Services, and covering 
services with preventive health care benefits.
    So what role does CDC and public health have in this health 
care arena? You know, there is still much work to be done, and 
public health has a role in four of our most important 
strategies: First, to make sure that covered benefits are 
received. Unfortunately, just knowing what works and providing 
it isn't enough. If you build it, everyone doesn't come. Today, 
for example, instead of needlessly taking thousands of lives of 
otherwise healthy Americans each winter, influenza can be 
largely prevented. There is a highly effective vaccine which 
has been recommended for use and is provided under Medicare, 
but millions of America's seniors don't receive it. Public 
health and epidemiological expertise can be used to identify 
system solutions, like reminder recall in providers' offices 
that you've heard about, like standing orders in nursing homes, 
like immunization registries at the local level that can be 
used within the health care system to improve the delivery of 
preventive services.
    And we can work on the patient side, too. In the last flu 
season I called my 85-year-old dad and asked if he got his flu 
shot. He said ``no;'' and I said, ``why?'' He said, ``no one 
offered it to me.'' And I said, ``Did you think about asking 
for it?'' He said, ``no.'' And I said, give that a try. One 
week later he called and said, ``I asked for it, I got it, and 
now I'm immunized.''
    Public health can play an important role in community 
education so that not only the medical system is trying to 
deliver preventive services, but the patients out there are 
actively trying to receive them as well. One successful model 
is a model called SPARC. That is a public-private partnership 
in Massachusetts, New York and Connecticut, and it serves a 
role of serving as a catalyst, as the glue to bring together 
seniors, health care providers and existing community 
resources. These kinds of programs have dramatically increased 
the use of Medicare-covered preventive services, and older 
adults around the country should have access to the same kinds 
of services that SPARC, for example, provides.
    Now, second, we need to go beyond the medical services that 
can be provided in the physician's office. We need to use tried 
and true public health methods to help people make healthy 
choices, as you said in your opening statements, because 
contrary to widespread perception, it is never too late to 
start healthy habits and gain benefits.
    Even the most frail elderly are capable of increasing their 
strength, balance and fitness. Just walking several days a week 
yields significant health benefits. In fact, physical activity 
may be the closest thing we have to a silver bullet against 
aging. Not only can seniors improve cardiovascular fitness, but 
exercise can reduce the impact of serious conditions like 
diabetes, the risk of falling and costly hip fractures, and 
help anxiety and depression.
    Yet nowhere is the gap wider between what we know how to do 
and what we can provide in this area. Few seniors engage in 
regular activities that improve balance and strength, and 
seniors have too few opportunities to do the beneficial 
activities they like to do, like safe walking and gardening.
    But, programs that influence these behaviors pay off. In 
heart disease, for example, medical interventions reap 
substantial benefits in added life expectancy, estimated by the 
Institute of Medicine at 4 to 1 when costs are considered. But 
interventions and behavioral change produce remarkable returns 
at the 30-to-1 investment level.
    Third, we need to engage our partners in this. We need to 
take advantage of the aging network's resources. The 
Administration on Aging, for example, reaches into virtually 
every community in this country with its network of over 600 
area Agencies on Aging. AOA has the mandate through the Older 
Americans Act to address health promotion and disease 
prevention, yet much of the expertise in how to do that rests 
in public health. We need to work together, and some creative 
integration could lead the medical system, public health and 
the aging network, working together in communities and in the 
home, to provide prevention services such as how to prevent 
falls, reviewing medicines that our seniors are taking, and 
vision screening. We know that these interventions work. We 
just need to make use of the potential delivery systems that 
are already in place.
    Fourth and finally, we need to look upstream. Those of us 
in this room who because of age are not yet Medicare-eligible 
hopefully someday will be, and if each of us were successful at 
just three things, maintaining healthy weight, engaging in 
moderate physical activity and not smoking, we could delay the 
onset of disability for a decade on average. Wise prevention 
investments today in our younger adult population will yield a 
generation of healthier seniors in the future.
    So in conclusion, the science is compelling. We know that 
it is never too late to take advantage of the promise of 
prevention, but as a Nation, we focus primarily on providing 
quality health, really illness care, for our older adults. Our 
challenge now is to ensure that as life span lengthens, the 
added years are quality years, and we need to create a 
sustainable health care system that provides the very best 
opportunities and incentives to stay healthy for our seniors as 
long as possible.
    I'd like to thank the committee for its leadership and 
commitment in this arena, and I wanted to let you know we think 
you're making a wise investment. Thank you very much.
    [The prepared statement of David W. Fleming follows:]

 PREPARED STATEMENT OF DAVID W. FLEMING, ACTING DIRECTOR, CENTERS FOR 
  DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                                SERVICES

    Thank you, Mr. Chairman, and Members of the Committee, for the 
opportunity to speak to you today about an issue that is of critical 
and increasing importance at the Centers for Disease Control and 
Prevention (CDC), and indeed for the American people. We at CDC are 
pleased to join our federal and non-federal partners in addressing the 
challenges facing Medicare, and identifying opportunities to improve 
the health of older.
    Before talking more specifically about improving the health of 
older adults, I would like to provide some context. Chronic diseases 
account for nearly 75 percent of the deaths in this country, are the 
leading causes of disability and long-term care needs, and represent 
nearly 75 percent of all health-related costs. Although chronic 
diseases are not limited to older adults, these conditions, such as 
cardiovascular disease, cancer, diabetes, and arthritis are heavily 
concentrated in adults age 50 and over. Among the 10 leading causes of 
death, the top six are concentrated in older adults. Premature death 
and much of the illness and disability associated with these diseases 
is preventable, even among older adults.
    This is critically important because we are now entering the time 
in our nation's history when the population of older adults--both in 
number and in proportion--is increasing at a much faster rate than we 
have ever experienced. The current anxiety and debate around Medicare 
costs is motivated by the aging of the baby boomers. The baby boom 
generation's leading edge is currently 56 years old. As this segment of 
the population ages, the proportion of adults age 65 and over in the 
U.S. will more than double, such that by 2030, 20 percent of all 
Americans will be older adults. If we don't take some steps now to do 
what we can to influence the health habits of the baby boomers, we may 
never catch up to the upcoming demands on the health care system.
    Current health and aging trends may have enormous implications for 
the public health system, the health care system, and our existing 
network of aging and social services. The cost of health care for a 65-
year-old person is four times as much as that for a 40-year old. People 
age 65 and over even now consume 33 percent of our health care dollars, 
or more than $300 billion each year. By 2030, those costs will increase 
by 25 percent, for the sole reason that our population will be older--
even before inflation and the costs of new technology are taken into 
account.
    Recent CDC projections of just one major disease--diabetes--
illustrate the magnitude of what we face if we don't act. Today 
diabetes alone accounts for about 6 percent of Medicare costs. The 
number of people with diabetes is expected to almost triple from 11 to 
29 million by 2050. Aging baby boomers will contribute to the increased 
number of cases, but what's alarming is that among adults, diabetes 
rates increased 49 percent between 1990 and 2000, in large part due to 
unhealthy lifestyles. Clearly, we may not be able to sustain our 
current health care system unless we address in a more aggressive 
manner the prevention of chronic diseases and injuries. Until now, we 
have not maximized our prevention opportunities among older Americans. 
Too many believe the myth that older adults have lived beyond the time 
when prevention can be beneficial.
    The evidence is convincing that prevention is worth the investment 
for the health and safety of older adults. A recent Institute of 
Medicine report noted that the return on investment in medical care for 
cardiovascular disease reaped benefits at 4 to 1, but investment in 
behavioral change returned a remarkable 30 to 1 advantage. We should 
bring the health advantages of prevention to older adults across the 
country.
    We at CDC, together with Centers for Medicare and Medicaid Services 
(CMS), National Institutes of Health (NIH), the Administration on Aging 
(AoA), and others are committed to improving health and independence, 
and reducing long-term care needs among older adults. Medicare coverage 
has a critical role to play here--and we should maximize the use of 
currently covered services and identify additional effective prevention 
and control measures that can enhance the health of Medicare 
beneficiaries.
    Through basic research at NIH and other institutions, CDC's 
prevention research programs, and other institutions, we know quite a 
lot about how to prevent or postpone illness, injury, and disability 
experienced by older adults today. Unfortunately, just knowing what 
works is not enough. Even when covered by Medicare, older adults often 
may not be receiving recommended preventive services.
    For example, only two-thirds of adults age 65 and older reported 
receiving a flu shot in the previous year, and more than half report 
that they have never been vaccinated against pneumococcal disease--even 
though Medicare covers the cost of both immunizations.
    Despite the lifesaving benefits of screening and early detection 
for chronic disease, one in five women age 65-69 has never had a 
mammogram, and half of older adults do not receive recommended 
screening for colorectal cancer. Again, Medicare covers both of these 
screening services.
    It is clear that solving the basic research problem--developing 
proven prevention measures--is just the first step. There are 
significant gaps in getting what we know about prevention to 
individuals who can benefit. We are likely close to the limits of what 
the health care system as currently structured can do to increase 
preventive services. Research conducted at RAND with support from CMS 
showed that immunizations and screening improve when health care 
organizational changes are made and patients are involved in their own 
management. Clearly, improvements in prevention services for older 
adults will require creative approaches that support new ways of 
delivering preventive services and links to the community.
    We can do better. To help ensure prevention benefits currently 
covered through Medicare reach beneficiaries, we would propose more 
closely linking CDC's public health expertise in disease prevention and 
health promotion with the aging expertise and extensive outreach 
capability of the aging network--the Administration on Aging and its 
state and local counterparts. This network, analogous in ways to the 
public health network but with a specific population focus, reaches 
into virtually every community in the country with its network of over 
600 area agencies on aging and associated senior centers. CDC and AoA 
are currently working with state chronic disease directors and state 
units on aging to stimulate local prevention activities. To commemorate 
Older Americans Month in May, mini-grants of $5,000 to $10,000 will be 
announced that will allow state and local representatives to develop 
prevention programs that reflect local priorities.
    While Medicare has made preventive services a priority through the 
PROs, some creative approaches for increasing preventive services have 
been tested that link the health care system to community-based 
resources.
    At CDC, we provided some funding to a program aptly named SPARC, or 
Sickness Prevention Achieved through Regional Collaboration. This 
program, serving counties where the borders of New York, Connecticut, 
and Massachusetts meet, acts as a broker to bring together existing 
health care and community resources. SPARC does not deliver services; 
instead, it consolidates and coordinates, serving as the missing 
catalyst, or the glue. Because providers do not see SPARC as a 
competitor, they welcome a service that helps them and their patients.
    SPARC has helped the communities it serves achieve dramatic results 
in extending critical preventive health services to older adults. For 
example, Medicare data shows that in 1997 in Litchfield County, 
Connecticut, a community served by SPARC, pneumococcal immunizations 
increased at twice the rate compared to seven surrounding counties 
without the benefit of SPARC. The SPARC model has demonstrated its 
value in bringing lifesaving preventive services to older adults. 
Communities around the country could benefit from innovative and 
successful models like SPARC.
    CDC also participated in CMS's recent effort to permit ``standing 
orders'' that allow institutions like nursing homes to routinely 
provide immunizations without requiring providers and staff to 
coordinate new written orders annually for individual patients. Support 
for this type of systems change is critical in improving prevention 
under Medicare.
    While there are real gains to be achieved through the broader use 
of covered preventive services, Medicare has just begun to support 
benefits that target lifestyle issues so critical to reducing the toll 
of chronic illness.
    Research has shown that practicing a healthy lifestyle is more 
influential than genetic factors in helping older people avoid the 
deterioration traditionally associated with aging. Several weeks of 
inactivity take a greater toll on the body than decades of aging. 
People who are physically active, eat a low-fat, high-fiber diet, and 
do not use tobacco products significantly reduce their risk for chronic 
disease, such as cardiovascular diseases, diabetes, chronic obstructive 
lung disease and arthritis, as well as for injuries related to falls. 
Perhaps more important, practicing just these three healthy habits 
delays the onset of disability by more than a decade on average. For a 
society concerned about the public and private costs of long-term care, 
delaying disability has enormous potential economic implications.
    For the purposes of today's hearing, I'd like to focus on physical 
activity as a preventive tool that deserves Medicare's support. Besides 
reducing the risk for a variety of chronic diseases, regular activity 
also helps older adults reduce their risk of falling, alleviate anxiety 
and depression, maintain a healthy body weight, and improve joint 
strength and mobility. And yet, nowhere is the gap wider between what 
we know and what we do.
    Two-thirds of older adults do not get regular physical activity. 
Less than half of older adults served by Medicare say that their 
healthcare provider asks them about physical activity. The potential 
exists to reverse this by ensuring that older adults have access to 
physical activity programs that address their unique health, lifestyle, 
functional, and motivational needs. Even the frailest of elders can 
benefit from low-stress activities tailored for their needs, such as 
gardening ``which, by the way, is the third most popular physical 
activity among seniors. All individuals, and particularly older adults, 
should receive counseling from their health care providers on the 
benefits of physical activity.
    Let me give you an example of what moderate physical activity can 
mean for people at high risk for diabetes, with its debilitating 
complications and enormous Medicare costs each year. In a recent NIH 
study, in which CDC collaborated, overweight adults with above-normal 
glucose levels who walked five times a week and lost as few as five 
pounds were able to reduce their risk of developing diabetes by nearly 
60 percent. People in the study aged 60 and older were among those most 
successful in reducing their risk.
    There is a groundswell of interest across the country in promoting 
physical activity among older adults. Over 800 candidate communities 
recently registered their intent to apply for funding available from 
the Robert Wood Johnson Foundation for the ``Active for Life'' program. 
Unfortunately, only eight sites will receive funding for this program 
to increase physical activity among older adults. Given the benefits of 
physical activity, CDC is currently working with the National Institute 
on Aging (NIA) and the Older Women's League to evaluate the 
effectiveness of NIA's recently developed physical activity materials 
in getting older adults to exercise.
    There is recognized, science-based value in physical activity 
programs, but they aren't reaching older adults. Learning how to get 
the benefits of such programs out to seniors in communities across the 
country should be a national priority.
    Physical activity also plays a key role in reducing an older 
person's risk of falling. One of every three older Americans--about 12 
million seniors--falls each year, with devastating consequences. More 
than 10,000 will die from the fall; another 340,000 will sustain a hip 
fracture. Half of the older adults who break their hip in a fall are 
never able to return home and live independently again. The risk of 
falling and loss of independence has been shown to be a primary concern 
for older adults. A recently-published study involving women age 75 and 
older found that 80 percent would rather be dead than experience the 
loss of independence and quality of life from a bad hip fracture and 
admission to a nursing home.
    Risk factors for falls include: a previous fall, muscle weakness, 
problems with balance and walking, being underweight, vision and 
hearing loss, taking four or more medications or psychotropic drugs 
(such as sleeping pills and tranquilizers). Reducing the risk of falls 
would make an enormous impact on reducing disability and long-term care 
needs. Every year, falls among older people cost the nation more than 
$20 billion, and these costs will rise to an estimated $32 billion by 
2020.
    Weight resistance exercises and regimens such as Tai Chi help 
seniors maintain and improve balance, strength, and coordination at any 
age. Other means to address fall risk include insuring proper 
medication management for older people--a current priority of the 
Assistant Secretary for Health, Dr. Slater; making physical changes in 
the home environment; and educating seniors and their caregivers, 
formal and informal, about factors that contribute to falls. Simple 
changes in an older person's home, such as securing rugs and adding 
grab bars in bathrooms can quickly and easily reduce fall risk. Because 
vision problems can increase a person's risk for falling by as much as 
60 percent, improved lighting in the home is also an effective strategy 
for preventing falls. Despite the known benefits of such measures, more 
than two million older Americans live in homes that have not had simple 
modifications that can reduce their risk of falls. One-fourth of older 
adults have an outdated or wrong eyeglass lens prescription, 
contributing to poor vision and the increased likelihood of falls.
    Screening older adults for fall risk should be a routine part of 
medical care, just as we screen for cancer or diabetes complications. 
Such screening should include identifying adults who have previously 
fallen or who have multiple fall risk factors as I cited above, 
followed by appropriate and necessary treatment, for example, training 
to improve balance and muscle weakness, medication review and 
management, vision screening and correction, and assessment of and 
education on needed home modifications. Such efforts are already 
underway in other developed nations, where collaboration between 
government agencies and aging networks are providing easily accessed 
and effective physical activity and falls prevention programs for 
seniors.
    Another area of importance to Medicare beneficiaries is medical 
errors occurring while hospitalized or as a resident of a long-term 
care facility. Based on a landmark report by the Institute of Medicine, 
medical errors are responsible for 44,000 to 98,000 deaths each year 
with additional healthcare costs of 17 to 29 billion dollars each year. 
CDC is working with several partners including the Agency for 
Healthcare Research and Quality, the Veterans Administration, and the 
Centers for Medicare and Medicaid Services, along with private sector 
partners, to better understand why these events occur, and to implement 
programs to prevent them.
    Finally, I'd like to address one last area today that holds 
considerable promise in improving seniors' health and quality of life, 
and in reducing the demands on the health care system. That area is 
self-care for those with chronic diseases or for those at increased 
risk for disease or complications.
    Self-care can be undertaken in a variety of ways and for a variety 
of conditions, from diabetes to arthritis. We know that people will 
``self-manage'' their disease even when they are pursuing remedies with 
no known health benefits. Programs are widely available, but no 
criteria exist to determine what the programs should include. The 
challenge, and the opportunity, is to ensure that older adults receive 
the quality education they need to become knowledgeable about what they 
can do to take responsibility for their own health and disease 
management.
    For an individual with diabetes, this might mean optimally managing 
blood glucose levels. The individual not only fares better physically 
but derives benefit and satisfaction from being an active participant 
in his or her own care. Self-management has been shown to be of 
particular value for people with arthritis, the leading cause of 
disability and a problem for almost two-thirds of Medicare enrollees. 
In selected states and in cooperation with the Arthritis Foundation, 
CDC supports an arthritis self-management education program that 
teaches people how to better manage their arthritis and lessen its 
disabling effects. This six-week course has been shown to reduce 
arthritis pain by 20 percent and physician visits by 40 percent. Again, 
however, there is a gap in getting the benefits of this program out to 
individuals. Currently, less than one percent of the 43 million 
Americans with arthritis participate in such programs and courses are 
not offered in all areas.
    In conclusion, I would like to thank the Committee again for its 
leadership and commitment in the important area of older adult health. 
While the risk for disease and disability clearly increases with 
advancing age, poor health does not have to be an inevitable 
consequence of aging. Far from being too old for prevention, Medicare 
recipients offer some of our most promising prevention opportunities. 
The science base is compelling, but we should refocus our attention on 
the real barriers to implementation and financing. Priority needs are 
evaluating promising programs in real-world settings and making the 
system flexible enough to accommodate the new types of benefits that 
are required. Our nation has contributed to an unprecedented increase 
in the human life span during the 20th century through improvements in 
public health and medical care. Since the 1960s we have been committed 
to providing health care for older adults. Our challenge now is to 
insure that added years are quality years and to create a sustainable 
health care system that provides the very best opportunities and 
incentives to stay healthy and independent as long as possible.
    Thank you. I'd be happy to answer any questions.

    Mr. Greenwood. Thank you very much.
    Dr. Clancy. I probably should have said earlier, since we 
don't have a bevy of members here waiting to answer questions, 
don't worry too much about the red light. Just speak until 
you're finished.

                 TESTIMONY OF CAROLYN M. CLANCY

    Ms. Clancy. Good morning, Mr. Chairman, members of the 
subcommittee. I'm very pleased to be here today to discuss the 
work of the U.S. Preventive Services Task Force and the role of 
the Agency for Health Care Research and Quality, or AHRQ, which 
provides the task force with scientific and administrative 
support.
    You might have seen Tuesday's Washington Post article this 
week about the task force's new recommendations urging primary 
care physicians to screen their adult patients for depression, 
or you may have seen this week's Newsweek article highlighting 
a recommendation recently released by the task force on the use 
of aspirin to prevent heart disease. Indeed, we could never 
have planned this, but it turns out that as we speak, people 
are calling in to hear more about aspirin and heart disease as 
well. These are both excellent examples of the work of the task 
force and AHRQ as its sponsor to improve the scientific basis 
in the quality of clinical preventive services.
    The task force itself is an independent private sector 
panel of experts in prevention and primary care who review the 
scientific evidence and make recommendations on clinical 
preventive services. These services specifically include 
screening tests, immunizations and counseling. The work of the 
task force is a natural fit with AHRQ's mission to support 
research designed to improve the quality of health care, reduce 
its costs, improve patient safety, address medical errors and 
broaden access to essential services.
    In 1999, the Congress directed AHRQ to provide scientific 
and administrative support to the task force, and in 2000, 
legislation required AHRQ to produce an annual report to the 
Congress on preventive services for older adults, and a copy of 
that has been submitted for the record.
    I'd like to note since you're hearing from all of us who 
work together that the work of AHRQ and the task force 
complements the preventive services at the NIH and the Centers 
for Disease Control and Prevention. While AHRQ studies the use 
of clinical preventive services in everyday practice, NIH 
research identifies preventive interventions that work under 
ideal conditions, and for its part, CDC assesses the 
effectiveness of community-based public health interventions, 
as Dr. Fleming has just noted before.
    I'd like to now describe briefly how the task force 
formulates its recommendations and the support that we as an 
agency provide.
    The recommendations of the task force are based on state-
of-the-science evidence in health care. This is an interative 
process. This is actually the third task force to make 
recommendations based on evidence or on preventive services. 
The first such task force was convened in 1984, and the 
recommendations were released in 1989. A subsequent update was 
completed by the second task force in 1996 after 5 years of 
work.
    To formulate its recommendations, the task force conducts 
comprehensive reviews of the scientific evidence regarding the 
effectiveness, risks and benefits of specific preventive 
services. Because reviewing all of this evidence is a 
significant task that requires specialized expertise, the task 
force works with two of AHRQ's 12 evidence-based practice 
centers, or EPCs, to do the analysis and synthesis. The task 
force reviews the evidence synthesized by the evidence-based 
practice centers and then makes recommendations.
    Unlike its predecessors, the current task force is issuing 
its recommendations serially rather than a single update--a 
single volume at the end of its term. This allows them to 
provide updated information in a much more timely fashion. To 
date, this task force has released recommendations on screening 
for depression, on breast cancer, chlamydia, bacterial 
vaginosis in pregnancy, skin cancer, newborn hearing problems, 
cholesterol and the use of aspirin to prevent heart disease.
    But it is very important that we believe that AHRQ's work 
on preventive services doesn't end with the task force 
recommendations. As part of our effort to translate research 
into practice, AHRQ also sponsors something called the Put 
Prevention Into Practice program, which translates the 
recommendations of the U.S. Preventive Services Task Force for 
clinicians, health systems and patients in order to increase 
the delivery of recommended preventive services.
    Task force recommendations and the products of Put 
Prevention Into Practice are used widely throughout the health 
care system to improve the preventive services provided to the 
Nation's citizens. So just by way of example, I have here two 
booklets, one in English and one in Spanish, Staying Healthy 
Over 50, which is done in partnership with the AARP to try to 
get the message out broadly.
    I'd like to now take a brief moment to discuss the 
important issue of clinical preventive services in the elderly. 
Just to echo what Dr. Fleming said, contrary to common 
misperception, you're never too old to benefit from effective 
preventive interventions, and prevention is especially 
important for older Americans, since the risk for many 
preventable conditions such as heart disease and cancer does 
rise steadily with age. The challenge, of course, is 
identifying which services are most effective for which 
patients and finding ways to make sure that those patients get 
the services from which they're likely to benefit.
    Over the years the U.S. Preventive Services Task Forces 
have documented the scientific evidence that preventive 
services can significantly improve health. For older patients 
they have found compelling evidence to recommend screening for 
a long list of conditions included with my written testimony.
    We're pleased and gratified that the importance of clinical 
preventive services is now increasingly recognized throughout 
the health care system, and we feel that the impartial 
evidence-based recommendations of the task force have played a 
major role in this development.
    As AHRQ notes in its report to Congress on preventive 
services, Medicare now covers nearly all of the screening 
recommendations provided--recommended by the task force. 
However, there is clearly more work to be done. A report on 
clinical priorities and prevention from the Partnership for 
Prevention documented the number of preventive service that, 
although of great benefit, are received by less than half of 
elderly patients in this country. They include, for example, 
smoking cessation counseling, colorectal cancer screening and 
pneumonia vaccinations.
    AHRQ, which helps support the Partnership for Prevention 
report, is working to improve the provision of these services 
to the elderly and other underserved patients. In addition to 
our Put Prevention Into Practice program, we're working with 
other Federal agencies to support research and to identify and 
overcome barriers to the use of appropriate preventive care.
    In conclusion, AHRQ and the U.S. Preventive Services Task 
Force are helping to ensure that the American public is 
receiving high-quality, evidence-based clinical preventive 
services. While we have achieved a great deal, and we're proud 
of that, we know that a lot more needs to be done. And I'd be 
happy to answer any questions.
    [The prepared statement of Carolyn M. Clancy follows:]

 PREPARED STATEMENT OF CAROLYN M. CLANCY, ACTING DIRECTOR, AGENCY FOR 
    HEALTHCARE RESEARCH AND QUALITY, DEPARTMENT OF HEALTH AND HUMAN 
                                SERVICES

    Mr. Chairman, I appreciate this opportunity to discuss the work of 
the U. S. Preventive Services Task Force (Task Force) and the role of 
the Department of Health and Human Services's (HHS) Agency for 
Healthcare Research and Quality (AHRQ), which provides the Task Force 
with scientific and administrative support. Because the Task Force 
chair and vice chair were unable to attend today's hearing, I have been 
asked to provide an overview of AHRQ's role in developing scientific 
evidence of the effectiveness of preventive health care services and 
how the Task Force, an independent group of prevention experts, uses 
that scientific evidence.
     role of the agency for healthcare research and quality (ahrq)
    The primary focus of the Agency for Healthcare Research and Quality 
(AHRQ) is on clinical services--the care patients receive from health 
care providers--and the health care systems through which those 
services are provided. AHRQ research provides the scientific evidence 
to improve the outcomes, quality, and safety of health care, reduce its 
cost, broaden access to effective services, and improve the efficiency 
and effectiveness of the ways we organize, deliver, and finance those 
services.
    Clinical preventive services--which include common screening tests, 
immunizations, preventive medications like aspirin to prevent heart 
attacks, and counseling about lifestyle that are delivered by 
clinicians--are an important focus of AHRQ research. Our research 
develops new scientific evidence regarding their effectiveness and 
cost-effectiveness, synthesizes existing scientific knowledge, and 
assesses strategies for facilitating their delivery and appropriate 
use.
    AHRQ's focus on the effectiveness of clinical preventive services--
what works best in daily practice--complements the research at the 
National Institutes of Health (NIH) and Centers for Disease Control and 
Prevention (CDC).
    In addition, in 1999, the Congress directed the agency to provide 
scientific and administrative support to the U.S. Preventive Services 
Task Force, and legislation enacted in 2000 requires AHRQ to produce an 
annual report to Congress on what preventive services are effective for 
older Americans. A copy of our first report is attached to my 
testimony.

     THE STRENGTHS AND LIMITATIONS OF EXISTING SCIENTIFIC EVIDENCE

    To ensure that Americans benefit from our existing knowledge, AHRQ 
supports Evidence-based Practice Centers (EPCs) that undertake 
comprehensive reviews of the scientific evidence regarding the 
effectiveness, risks, and benefits of specific health care services. 
The evidence reports they produce provide unbiased summaries of 
existing knowledge without recommendations, so that those who need to 
make decisions about health care and health systems, such as patients, 
providers, health plans, insurers and policy makers, can make more 
informed decisions. In response to requests from the Task Force, AHRQ 
relies primarily upon two of these EPCs to assess the scientific 
evidence regarding clinical preventive services.
    How do they do that? Before the EPCs can begin to synthesize the 
findings of available studies, they undertake a rigorous methodological 
review of each study, asking questions such as: Did the investigators 
use an appropriate research design for the question being asked? Did 
they control for other factors that might affect the outcome (what 
researchers call ``threats to validity'')? Did they use the right 
statistical tests and calculate them properly? Did they examine health 
outcomes that are most important to patients? Not surprisingly, there 
are many studies that do not survive scrutiny; they were poorly 
designed, poorly executed, or both. Unfortunately, the number of solid, 
well-designed, well-executed research studies is often smaller than 
policy makers would prefer.
    Because a determination of effectiveness often has significant 
implications in controversies over coverage or reimbursement, it is 
critical that policy makers understand one important distinction. A 
conclusion that there is not evidence of the effectiveness of a service 
is different from a conclusion that the service is ineffective. ``No 
evidence of effectiveness'' can simply mean there are no studies on the 
subject, the studies that exist are flawed and cannot be trusted, or an 
existing good study involved so few patients that it is not 
generalizable. No judgment is implied regarding the effectiveness or 
ineffectiveness of the service; it simply means there are too few good 
scientific studies on the subject to guide your decision-making.
    In its obligation to provide scientific support for the Task Force, 
AHRQ follows this same approach and identifies the strengths and 
limitations of the existing knowledge base but makes no 
recommendations.

                THE U.S. PREVENTIVE SERVICES TASK FORCE

    The U.S. Preventive Services Task Force is in its third 
incarnation. The HHS first convened a Task Force of independent 
prevention experts in 1984; their report was released in 1989, and then 
completely updated by the second Task Force in 1996. In 1999, Congress 
established the Task Force as an ongoing body so that it could 
regularly review and update its recommendations based upon new 
scientific findings. A list of the current membership of the Task Force 
is attached.
    For each topic that the Task Force addresses, it requests an 
updated evidence report, which AHRQ then commissions from one of its 
EPCs. After reviewing the evidence report, the Task Force develops 
recommendations based upon the strength of the scientific evidence and 
their collective expert judgment regarding the balance of benefits and 
harms of a specific service. These recommendations are then circulated 
widely for comment from Federal agencies and private organizations, but 
the final recommendations reflect the conclusions of the independent 
Task Force, rather than policy decisions of HHS or any organization. 
Task Force recommendations are not binding on public or private sector 
providers or funders of care.
    The Task Force requires evidence that a given intervention will 
actually improve important health outcomes, such as lowering morbidity 
or mortality, not simply detecting more disease or improving some 
laboratory test result. As a result, Task Force recommendations are 
sometimes more conservative than those of specialty groups. The 
principle that clinical recommendations should be based on careful and 
objective assessments of the evidence, rather than simply the opinions 
of experts, is at the heart of the movement known as ``evidence-based 
medicine''. These principles are especially important in prevention, 
because an intervention, such as testing for colon cancer, will be 
offered to large populations of healthy people.
    The Task Force experience has demonstrated we still have 
substantial room for progress in providing preventive services that are 
supported by good evidence. Often the Task Force concludes that the 
existing evidence is not sufficient to prove or disprove whether a 
service is effective, indicating that more good scientific studies are 
needed and that clinicians must use their own judgment with individual 
patients until more definitive research is completed.
    Since its first report, the Task Force has been recognized for 
producing rigorous and unbiased assessments of what works in clinical 
prevention. As a result, the influence of its recommendations goes far 
beyond its primary mission, which is to make recommendations for 
doctors and nurses to guide clinical practice. In fact, its 
recommendations have formed the basis of prevention guidelines of the 
American Academy of Family Physicians and other professional societies, 
are used by health plans and insurers in developing their prevention 
policies, and have figured prominently in the development of health 
care quality measures and national health objectives. Finally, the Task 
Force's Guide to Clinical Preventive Services is used widely in 
undergraduate and post-graduate medical and nursing education as the 
definitive reference for teaching preventive care.

              CLINICAL PREVENTIVE SERVICES AND THE ELDERLY

    Primary care clinicians play a central role in prevention for older 
Americans. The average Medicare recipient makes 13 medical visits per 
year, providing opportunities for doctors and nurses to deliver a range 
of clinical preventive services, including screening tests, counseling, 
immunizations, and advice about preventive medications such as aspirin 
or hormone therapy.
    Contrary to common misperceptions, one is never too old to benefit 
from effective preventive interventions. Prevention is especially 
important for older Americans, since preventive measures even at this 
age can help delay the onset of disease. The challenge in prevention is 
identifying which services are most effective for which patients and 
finding ways to ensure they are delivered to all eligible patients.
    In its comprehensive 1996 report, and in updates released over the 
past 2 years, the Task Force has documented the scientific evidence 
that preventive services can significantly improve health. For older 
patients, it found compelling evidence to recommend that clinicians 
regularly provide the following services: screening for high blood 
pressure and high cholesterol; screening for cancers of the breast, 
colon, and cervix; screening for vision and hearing problems; 
immunization against influenza, pneumococcal disease and tetanus; and 
discussions with patients about aspirin to prevent heart attacks. In 
addition, the Task Force has noted the importance of counseling to 
reduce tobacco and alcohol use, to promote healthy diets and physical 
activity, and to prevent injuries. The general conclusions of the Task 
Force urge clinicians to be more selective in their use of some 
screening tests, pay more attention to behavioral health issues, and 
find opportunities to deliver preventive services outside of the 
traditional ``annual check-up. ``

                           MEDICARE COVERAGE

    Thanks to the combined efforts of the Task Force and many other 
agencies and organizations committed to prevention, the landscape for 
prevention in 2002 is dramatically different from the one facing the 
first Task Force in 1984. At that time, delivery of preventive care was 
uneven, insurance coverage was rare, and attitudes of patients and 
providers were often skeptical.
    As AHRQ notes in its report to Congress on preventive services, 
Medicare now covers nearly all of the screening services recommended by 
the Task Force. The one exception, cholesterol screening, is often 
covered as a part of follow-up care or treatment of other problems. 
Similar progress has been documented in the private sector--among 
employer-based health plans, over 90% cover mammograms and Pap tests, 
and over 85% cover routine physicals and gynecological exams.

        ENSURING THAT AMERICANS BENEFIT FROM PREVENTIVE SERVICES

    Mr. Chairman, deciding what works is only the first step toward 
quality preventive care. A report on clinical priorities in prevention 
from the Partnership for Prevention, developed with support from CDC 
and AHRQ, documented that a number of high priority services relevant 
to older Americans are delivered to less than half of the population 
nationally. These include smoking cessation counseling, colorectal 
cancer screening, and pneumococcal vaccination.
    Addressing this problem--facilitating the use of effective and 
cost-effective health care services--is another aspect of AHRQ's 
mission, which we term ``Translating Research into Practice.'' We do 
this in two ways. First, we develop a variety of materials and tools 
that help providers ensure that patients receive the right preventive 
service at the right time. An example is AHRQ's ``Put Prevention Into 
Practice'' effort that provides materials to help primary care 
clinicians effectively deliver preventive services to patients, 
educates patients about the services they should receive, and asks 
patients to remind their physician if a useful service is not provided.
    The second approach is through research designed to identify ways 
to overcome barriers that may lead to under-use of effective preventive 
services. For example, a recent research solicitation, co-funded by 
AHRQ and the NIH's National Cancer Institute, solicits research to 
identify the most effective ways to improve the delivery of preventive 
colorectal cancer screening services in the clinical setting.
    We are also working closely with our colleagues at the Centers for 
Medicare and Medicaid Services (CMS) to increase the utilization of 
clinical preventive services by Medicare beneficiaries. Through an 
interagency agreement with CMS, we have funded our Evidence-based 
Practice Center at RTI International to develop messages for patients 
and providers about new preventive services covered under Medicare. 
AHRQ is also funding several projects examining the best ways to 
implement smoking cessation guidelines, and we support the ongoing 
efforts of the CMS to fund demonstration programs to assess the costs 
and benefits of expanding Medicare coverage for smoking cessation

                               CONCLUSION

    In conclusion, Mr. Chairman, the effort to ensure that Americans 
benefit from effective clinical preventive services is a multi-pronged 
effort. It requires systematic scientific studies to fill the gaps in 
our knowledge regarding existing and emerging preventive services, 
objective assessments of what works by independent bodies like the Task 
Force, and continuing research on how to improve the delivery and 
quality of those services. In this way, we can continue the progress of 
the past two decades in prevention for older patients and the American 
public.
    That concludes my testimony. I would be happy to answer any 
questions.

    Mr. Greenwood. Thank you, Dr. Clancy.
    Dr. Bratzler, do you like that with a short A or a long A?

                   TESTIMONY OF DALE BRATZLER

    Mr. Bratzler. Bratzler.
    Good morning, Mr. Chairman, members of the subcommittee, 
and thank you for inviting me here today. I am the principal 
clinical coordinator of the Oklahoma Foundation for Medical 
Quality, which is the Medicare quality improvement organization 
for the State of Oklahoma, and I'm here today to testify on 
behalf of the American Health Quality Association, or AHQA. 
AHQA represents the national network of quality improvement 
organizations that were formerly called peer review 
organizations in the Medicare program.
    The QIO's primary mission is to monitor and measurably 
improve the quality of health care delivered to Medicare 
beneficiaries. QIOs concentrate on systems of care rather than 
care delivered to one patient at a time. A systems-based 
approach improves the quality of care for all Americans 
receiving services at health care facilities that are working 
with the QIOs.
    I want to make the point that QIOs are on the ground 
promoting preventive services by taking evidence-based 
preventive health practices from the bookshelf to the bedside. 
QIOs promote and enhance the delivery of preventive services to 
seniors and work to resolve barriers to greater utilization of 
these services.
    The Centers for Medicare and Medicaid Services, or CMS, 
selects the clinical areas and the quality indicators that we 
work on, and they are based on public health importance and on 
the feasibility of measuring and improving quality on those 
specific indicators. These clinical conditions are important 
causes of morbidity and mortality among the Medicare population 
and the U.S. population as a whole and account for substantial 
numbers of hospitalizations and a large share of the health 
care costs of this country.
    QIOs work to improve care for both fee-for-service Medicare 
beneficiaries as well as those enrolled in M+C plans. Although 
the data-gathering phase of our quality improvement techniques 
may differ depending on payment arrangements, in either case 
the QIOs tend to employ systems-based approaches to improving 
quality of care.
    I'd like to give a few examples of ways the QIOs work to 
promote primary prevention. With respect to immunizations, 
we've heard a lot about immunizations already this morning. 
There is certainly universal agreement among health care 
providers regarding the value of immunizing seniors against 
influenza and pneumonia, and yet we know that immunization 
rates among our senior population are far below the Healthy 
People 2010 goals, even for patients in institutional settings 
that are very high risk, like nursing homes.
    QIOs promote vaccination in two ways. First, QIOs educate 
consumers on the importance of receiving these vaccinations for 
both influenza and pneumonia. And second, QIOs promote 
screening of patients to check if they have received them so 
that doctors and nurses can provide vaccine when needed.
    An example of one of the most successful interventions 
employed by QIOs is to promote implementation of standing 
orders to enhance vaccination rates. Regardless of the health 
care setting, the use of standing orders allows appropriately 
trained health care providers to administer vaccines to 
patients in need. Now, there are barriers. Despite the evidence 
that standing orders are sound intervention, I think Mr. 
Grissom already mentioned this morning that there has been a 
frustrating barrier in regulations in the Medicare condition of 
participation which basically prevented institutions from 
implementing standing orders without having an individually 
signed physician order for each patient. I know there is work 
ongoing now to correct that problem.
    QIOs have also implemented programs to address barriers to 
immunization with disparate populations. In Oklahoma we 
surveyed African American and Caucasian beneficiaries to 
determine the cause of disparity in immunization rates between 
these two populations. We found that there were significant 
differences in patient understanding and physician education 
between the two groups regarding the need for pneumonia and 
influenza immunizations. Attached to my testimony you'll find 
table 1 and 2, which summarizes some of the key differences 
that we found between African American beneficiaries and 
Caucasian beneficiaries.
    California's QIO also identified similar barriers to 
immunization among African American populations living in 
Alameda and Los Angeles Counties. They found that a 
recommendation from a trusted physician was a key motivator for 
vaccination, and they also found that the leaders of churches 
and community centers can be effective partners in improving 
awareness and building trust among African American seniors.
    With respect to diabetes, we've heard of its real important 
role in terms of morbidity in the Medicare population. QIOs are 
directed by CMS to focus on prevention initiatives with 
diabetics. Examples would include prevention of blindness by 
promoting regular retinal examinations, and prevention of 
cardiac complications by promoting regular testing of lipid 
levels.
    One of the barriers to patients receiving regular 
screenings is that many physicians do not have medical record 
information systems that allow them to access a list of their 
diabetic patients that ought to be receiving regular reminders 
for preventive care services. In many States, including 
Washington, Oregon and Wisconsin, QIOs provide physician 
offices with software that they can use to develop a disease 
registry or a patient data base that tracks the provision of 
preventive care and services and can generate physician 
reminders regarding preventive care. In many cases the QIO 
staff in those States is working directly with the physician to 
actually populate the data bases.
    QIOs have also found disparities between racial groups and 
diabetes care. The Florida QIO routinely analyzes part B claims 
data by each zip code in the State and then takes this data to 
providers to show them the care received in their communities.
    The South Dakota QIO working with local Native American 
reservation health facilities found that Native--the Native 
language is primarily spoken and not written, particularly 
among the elderly. So as a result of those interactions, the 
QIO is working to educate Native American elderly through radio 
and television messages translated into the local languages.
    In my testimony is table 3 that summarizes the progress of 
some of the QIOs to date on our primary prevention efforts.
    Now, let me finish by talking about some of the secondary 
prevention efforts. Mammography clearly is the gold standard 
diagnostic tool for early detection of breast cancer. The 
barriers associated with increased mammography rates may be due 
to access, especially in rural areas. I recently met with the 
primary care providers at a hospital in Harmen County in 
Oklahoma. It is the far southwest corner of the State, and the 
county's only resource for mammography is a mobile unit that 
comes to the county twice a year.
    Even in areas of the country where there is better access 
to care, QIOs have found that patients may not be receiving 
adequate education counseling and reminders about the 
importance of getting a mammogram. My QIO delivered 3,000 tool 
kits to primary care physicians throughout the State. The tool 
kit contained educational resources including patient education 
videotapes and materials to assist physician offices in setting 
up mammography reminder systems.
    Some populations are especially vulnerable to underusing 
mammography screening. In some Hispanic communities it is 
culturally inappropriate to speak about mammography. The 
Colorado QIO created a project to overcome these social 
barriers by having female leaders in the Hispanic community 
speak to other women in the Hispanic Roman Catholic churches, a 
place where they found that these conversations were safe to 
have. The Colorado QIO is also working with the staff of area 
clinics that care for largely Hispanic populations to make sure 
that the messages are reinforced by health care professionals 
that the patients trust so that patients are scheduled for 
mammograms.
    The QIOs are also directed to increase utilization of 
certain pharmaceutical therapies that are known to decrease 
rehospitalization, recurrence and progressive worsening of 
diseases. We heard about the aspirin issue for heart disease 
today. For example, patients who are discharged from the 
hospital following a heart attack should be on at least beta 
blockers and aspirin unless there are contraindications. These 
medications reduce mortality and reduce hospitalization. In 
table 4, we show some of the progress that QIOs have made in 
this area.
    The QIOs are specifically working with hospitals to ensure 
that there are systems in place for every patient, including 
putting checklists in the patient records to remind clinicians 
of recommended practices, developing discharge screening 
procedures to make sure patients do not leave the hospital 
without appropriate prescriptions, and making sure that follow-
up appointments are scheduled before they leave the hospital.
    Finally, one barrier to more effective use of 
pharmacotherapy for secondary prevention is the lack of the 
Medicare outpatient drug benefit. As you do think about 
developing drug benefits for seniors, remember that the QIOs 
could work with those data sets, including health claims, 
medical records data and drug claims to improve continuity of 
care. QIOs can do this new work under any drug benefit 
structure, anything ranging from discount cards to a full 
prescription drug benefit.
    Mr. Chairman, I hope the subcommittee will look to the 
national network of quality improvement organizations to expand 
outreach to Medicare beneficiaries and their caregivers about 
important preventive benefits under the Medicare program. Under 
current law QIO activities to promote prevention may be funded 
through the Medicare Trust Funds. I thank you for the time, and 
I'll certainly be happy to answer questions.
    [The prepared statement of Dale Bratzler follows:]

 PREPARED STATEMENT OF DALE BRATZLER, OKLAHOMA FOUNDATION FOR MEDICAL 
   QUALITY CARE ON BEHALF OF THE AMERICAN HEALTH QUALITY ASSOCIATION

    Good morning Mr. Chairman, Mr. Deutsch, and Members of the 
Subcommittee. Thank you for inviting me here today. I am Dr. Dale 
Bratzler, Principal Clinical Coordinator at the Oklahoma Foundation for 
Medical Quality, the Medicare Quality Improvement Organization (QIO) 
for the state of Oklahoma. I am here today testifying on behalf of The 
American Health Quality Association (AHQA). AHQA represents the 
national network of Quality Improvement Organizations (QIOs, formerly 
known as Peer Review Organizations).
    The QIOs' primary mission is to monitor and measurably improve the 
quality of health care delivered to Medicare beneficiaries. QIOs 
concentrate on systems of care, rather than the care delivered to one 
patient at a time. This systems approach improves the quality of care 
for all Americans receiving services at health facilities working with 
QIOs. I am here today because the vast majority of the quality 
improvement tasks assigned to QIOs are preventive in nature whether 
they are primary prevention efforts, which prevent the onset of a 
disease, or secondary prevention efforts, which prevent the recurrence 
or progression of a diagnosed disease.
    This panel already understands the importance of preventive health 
services. I want you to know that QIOs are on the ground promoting 
these services by taking evidence based preventive health practices 
from the ``bookshelf to the bedside.'' I am here to tell you what QIOs 
do to promote and enhance the delivery of preventive services to 
seniors, and resolve the barriers to greater utilization of preventive 
services. I will also describe some additional interventions that QIOs 
are using to target vulnerable and underserved populations across 
America. CMS requires every QIO to perform this additional, targeted 
outreach.
    The work of the QIOs in the Medicare program is defined by the 
Centers for Medicare and Medicaid Services (CMS). CMS selects the 
clinical areas and the quality indicators that the QIOs use based on 
their public health importance and their feasibility in measuring and 
improving quality. All of the clinical conditions discussed in my 
testimony this morning are important causes of morbidity and mortality 
among the Medicare population, and the U.S. population as a whole, and 
account for substantial numbers of hospitalizations and a large share 
of health care costs.
    Here are some examples of what QIOs do to enhance the utilization 
of services recognized by experts as best practices:

 We teach clinical staff how to abstract data from patient 
        medical records to evaluate performance and track progress in 
        improving care.
 We interpret a vast amount of medical information obtained 
        through medical records and health care claims data, as well as 
        develop interventions specific to a particular hospital or 
        doctor's patient population's needs.
 We develop ``toolkits'' with step-by-step instructions on how 
        to assess and change systems of care to make sure the right 
        things are done in certain ways all the time.
 We implement various kinds of reminder systems that not only 
        help prompt patients to seek care, but also prompt clinicians 
        to provide certain types of care.
 We develop software or paper-based tracking systems or provide 
        access to online services that a facility would not otherwise 
        have.
    It is important to note that QIOs work in the fee for service 
Medicare system as well as with Medicare+Choice (M+C) managed care 
plans. Although the data-gathering phase of our quality improvement 
techniques may differ depending on the payment arrangements, in either 
case QIOs employ a systems improvement approach.
    Here is the way QIOs work to promote primary prevention through 
immunizations and diabetic care.

Immunizations
    There is universal agreement among health care providers regarding 
the value of immunizing seniors against community acquired pneumonia 
and influenza. Yet, immunization rates among the senior population are 
generally very low, especially in the institutional settings like 
nursing homes. QIOs promote vaccines in two ways: First, QIOs educate 
consumers on the importance of receiving vaccinations for pneumonia and 
influenza. Second, QIOs promote screening of patients to check if they 
have received these vaccines, so doctors and nurses can provide the 
vaccine when needed.
    One of the most successful interventions employed by the QIOs to 
enhance immunization rates is the implementation of ``standing 
orders.'' Regardless of the health care setting, the use of standing 
orders allows appropriately trained health care providers to administer 
immunizations to patients in need.
    Despite the evidence that standing orders are a sound intervention 
strategy, there are barriers to implementing standing orders programs 
nationally. A particularly frustrating barrier is the regulatory 
prohibition of standing orders contained in Medicare facility 
``Conditions of Participation'' rules. Medicare CoPs generally prohibit 
the use of standing orders in institutional settings. Another barrier 
is manufacturers' recent inability to supply the market with adequate 
quantities of vaccine doses.
    QIOs have also implemented programs to address barriers to 
immunization within disparate populations. My QIO in Oklahoma surveyed 
African American and Caucasian beneficiaries to determine the cause of 
the disparity between immunization rates for these two populations.
    We found that there were significant differences in patient 
understanding and physician education between the two groups regarding 
the pneumonia and influenza immunizations. Attached to my testimony the 
Subcommittee will find Table 1 and Table 2 that summarize the answers 
to four key questions that our survey asked about each vaccine.
    California's QIO, which is called CMRI, identified similar barriers 
to immunization among the African American populations living in 
Alameda and Los Angeles counties. Through discussion groups and a 
telephone survey, CMRI identified barriers such as lack of awareness 
about the need for vaccination and misconceptions about adverse effects 
of vaccinations. They found that a recommendation from a trusted 
physician is a key motivator for vaccination. They also found that 
leaders of churches and community centers could be effective partners 
in improving awareness and building trust among African American 
seniors.

Diabetes
    QIOs are directed by CMS to focus on two primary prevention 
initiatives with diabetics: prevention of blindness through regular 
retinal exams and prevention of cardiac complications through regular 
testing of lipid levels. The QIOs are also engaged in a high priority 
secondary prevention effort to decrease the progression of diabetes by 
testing diabetics regularly for glycosylated hemoglobin (a blood test 
that measures a diabetic's exposure to unacceptably high glucose levels 
over a long period of time).
    One of the barriers to patients receiving regular screenings is 
that most physicians do not have medical record information systems 
that allow them to access a ``list'' of diabetic patients that ought to 
be receiving regular reminders for preventive care services. Medical 
records are not filed by disease state, so patients who need reminders 
cannot be easily identified. In many states, including Washington, 
Oregon, and Wisconsin, QIOs provide physician offices with software 
that they can use to develop a disease registry, or patient database, 
that tracks the provision of preventive care and can generate physician 
reminders regarding preventive care. In many cases, the QIO staff work 
directly with the physician to populate the database and minimize the 
burden on physicians when they start-up reminder systems.
    QIOs have also found disparities between racial groups in diabetes 
care. The Florida QIO, called Florida Medical Quality Assurance, also 
uses the faith-based approach to community-wide education of the 
African American population in the state. They developed educational 
materials to train ministers and others within the church to help 
parishioners recognize and manage their condition. At the same time, 
FMQA analyzes Part B claims data by each zip code in the state and then 
takes this data to providers to draw attention to the disparities in 
diabetes care that exist in their communities.
    The South Dakota QIO is working closely with local Native-American 
reservation health facilities to increase diabetes hemoglobin testing. 
During the development of relationships with diabetes educators in the 
field, the QIO found that the native language is primarily spoken and 
not written, particularly among the elderly. As a result, the QIO is 
working to educate Native American elderly through radio and television 
messages translated into local languages.
    Attached to my testimony is Table 3 that summarizes the progress of 
some of the QIOs to date related to our primary prevention efforts. The 
table shows the median statewide ``failure rate'' for these QIO 
indicators. The ``failure rate'' is the percentage of people who are 
eligible for a particular kind of care, and are appropriate candidates 
for the care, but were not receiving this care as of 1998. The results 
of projects to reduce the failure rate are in from two-thirds of the 
QIOs right now. We expect complete results later this summer.
    QIOs also promote secondary prevention in mammography, heart 
attack, and congestive heart failure.

Mammography
    Mammography continues to be the gold standard diagnostic tool for 
early detection of breast cancer. QIOs strive to increase the number of 
cases of breast cancer diagnosed in ``Stage 1,'' when the cancer is 
most responsive to treatment. The barriers associated with increased 
mammography rates are primarily due to access, especially in rural 
areas. In my state, Harman County is a rural county in the extreme 
Southwestern portion of Oklahoma. This county's only resource for 
mammography services is a van that visits that county only two days 
each year. Even in areas of the country where there is better access to 
care, QIOs have found that patients may not be receiving adequate 
education, counseling, and reminders about the importance of getting a 
mammogram.
    My QIO delivered 3000 ``Mammogram Toolkits'' to practitioners 
throughout the state. The toolkit contained instructions, which 
included an educational video, to teach physician offices how to set up 
mammogram reminder systems.
    Some populations are especially vulnerable to underusing 
mammography screening. In some Hispanic communities, it is culturally 
inappropriate to speak about mammography. The Colorado QIO, the 
Colorado Foundation for Medical Care, created a project to overcome 
these social barriers by having female leaders in the Hispanic 
community speak to other women in Hispanic Roman Catholic Churches--a 
place where these conversations are safe to have. The Colorado QIO is 
also working with the staff of area clinics that care for largely 
Hispanic populations to make sure the messages are reinforced by health 
care professionals that patients trust, so patients are scheduled for 
mammograms.
    In California, the QIO developed a multi-lingual, culturally 
appropriate program targeted to Asian Pacific Islander women who suffer 
high rates of breast cancer. Because one-third of this target 
population is not proficient in English, CMRI developed educational 
literature in Chinese, Tagalog, and Vietnamese. Both the National 
Cancer Institute and CMS plan to conduct focus group tests across the 
country to implement a nationwide rollout of this program.

Heart Attack and Congestive Heart Failure
    The QIOs are directed to increase the utilization of certain 
pharmaceutical therapies that are known to decrease rehospitalization, 
reoccurrence, and progressive worsening of these diseases. For example, 
patients who are discharged from the hospital following a heart attack 
should be on at least beta-blockers and aspirin. When these medications 
are administered together and appropriately, mortality rates (both 30 
days and one year after their first heart attack) and the readmission 
rates due to another heart attack can be reduced by up to one third.
    Table 4, attached to my testimony, shows the failure rate in these 
secondary prevention indicators and the progress that some of the QIOs 
have made in reducing those rates. To improve these secondary 
prevention failure rates, QIOs employ several techniques to assure that 
a system is in place that helps every patient, including: putting 
checklists in patient records to remind clinicians of the best 
practices that should be followed; developing discharge screening 
questions and checklists to make sure patients do not leave the 
hospital without the appropriate prescriptions; making sure follow-up 
appointments are scheduled with their doctors before they leave the 
hospital.
    Congress has a lot to say about one barrier to more effective use 
of secondary prevention for heart attack. The work of the QIOs in the 
area of pharmacotherapy is focused only on the inpatient setting right 
now in the absence of Medicare outpatient drug data. As you develop a 
drug benefit for seniors, remember that the QIOs are ready and willing 
to extend their quality improvement work to the outpatient environment. 
They can present physicians with a complete picture of their patient 
populations, which will greatly improve the continuity of care in the 
health care system. QIOs can do this new work under any drug benefit 
structure from discount cards to a full prescription drug benefit. As 
long as the QIOs have access to the claims data that will be generated, 
they can expand their work to promote secondary prevention.
    Mr. Chairman, I hope that the Subcommittee will look to the 
national network of Quality Improvement Organizations to expand 
outreach to Medicare beneficiaries and their caregivers about important 
preventive benefits covered under the Medicare program. Under current 
law, QIO activities to promote prevention may be funded through the 
Medicare trust funds.

                                 Table 1
                          Evaluating Disparity
                    Why didn't you get the flu shot?
------------------------------------------------------------------------
                                   African
                                  Americans    Caucasians         P
                                   N=1252         N=660
------------------------------------------------------------------------
Didn't know I needed one......          20%            9%        Pneumonia Vaccines
                                              (data for 36 states)
----------------------------------------------------------------------------------------------------------------
                                                            Median State       Median State       Median State
                                                          Failure Rate At    Failure Rate At     Improvement in
                                                              Baseline        Remeasurement       Failure Rate
----------------------------------------------------------------------------------------------------------------
State Immunization Rates
  Influenza............................................              25.2               22.3               11.6
  Pneumonia............................................              52.6               41.1               21.9
Hospital Screening and Immunization Rates
  Influenza............................................              88.5               78.1               11.7
  Pneumonia............................................              81.4               72.1               11.4
----------------------------------------------------------------------------------------------------------------

                                                     Table 4
                                            QIO Secondary Prevention
          Increased Use of Preventive and Timely Services for Breast Cancer, Heart Attack, and Diabetes
                                              (data for 36 states)
----------------------------------------------------------------------------------------------------------------
                                                            Median State       Median State       Median State
                                                          Failure Rate At    Failure Rate At     Improvement in
                                                              Baseline        Remeasurement       Failure Rate
----------------------------------------------------------------------------------------------------------------
Mammography............................................              44.5               39.7               10.8
Heart Attack (AMI)
  Aspirin at discharge.................................              16.5               14.3               13.3
  Beta blocker at discharge............................              24.7               16.9               31.6
Diabetes
  Glycosylated hemoglobin blood test...................              43.0               30.7               28.6
  Eye examinations.....................................              25.2               24.1                4.4
  Measure lipid profiles (``cholesterol'').............              39.4               23.2               41.1
----------------------------------------------------------------------------------------------------------------

    Mr. Greenwood. Thank you, Dr. Bratzler.
    Thank you all.
    The Chair recognizes himself for 10 minutes for questions.
    I think I'm fairly typical in that the only thing that 
keeps me healthy is--the most important factor--I just turned 
51. So I need to pay a little more attention to that. But the 
most important factor is that somebody calls me and says that 
it is time for your annual checkup, and when it is time for my 
annual checkup, I go in and do all of the tests and the screens 
and all of that. And without that, I mean, I certainly--I 
certainly would not wake up one morning and say I think I need 
and want a colonoscopy. It requires somebody to say, come in. 
Okay. This is where you are on this milestone. This is what you 
need to do.
    And so the first question I have is what do we know? What 
information do we have with regard to what percentage of 
Medicare beneficiaries even get an annual physical, because I 
just--I think to me intuitively that seems to be--if every 
Medicare beneficiary had an annual checkup--and I know that 
there are barriers to this. I know that physicians are rushed 
and don't feel that they have the time to go through a 
comprehensive checklist that I might get when I go over to the 
Capitol for my physical. I know that there are--I don't think 
beneficiaries are regularly notified unless they take the 
initiative or unless they're already into a regime with a 
physician about annual checkups.
    What do we know, if anything, about how many beneficiaries 
even get an annual exam?
    Mr. Grissom. There are a lot of people looking at me.
    The Medicare program and the way in which the claims 
processing operates is based on the presentation by the patient 
with a symptom or a problem. There is no covered benefit for 
annual physicals. We have not done a screening of the entire 
claims processing data base to ascertain whether or not people 
are presenting for physicals. We would typically not pay for 
that. They would have to present with a symptom or an illness 
or an injury, and in the course of that, it follows, well, 
would they be--would there be follow-up? Would the physician 
ask, have you had your physical? Would the physician look at 
the medical record? Would the physician have a way of indexing 
the care received versus the benefits?
    The answer to that question is some doctors do. Some 
doctors don't. We do know this: That in all of our surveys of 
beneficiaries, when we ask them, why did you not get a flu 
vaccine, why did you not have colorectal screening, why have 
you not had glaucoma, the reasons are always the same and in 
the same proportion.
    The second answer is, the doctor didn't tell me. The doctor 
didn't say anything. I didn't hear from the doctor, which is 
why our efforts have been focused on beneficiary education, and 
through Dr. Bratzler's group, the QIOs on physician education.
    Mr. Greenwood. Let me interrupt you, because it seems to me 
to be a colossal mistake not a cover the basic annual checkup. 
My understanding is that Medigap policies and Medicare+Choice 
policies do, and my assumption is that they do that because 
they have decided it saves them money to do that.
    Ms. Clancy. Without getting into the issue of what the law 
covers or not, I have been reminded that the average 
beneficiary makes about 13 visits a year. So the real challenge 
is, how do you ensure the provision of preventive care in the 
visits they are already making.
    This is not easy. For many people it is within the context 
of something called the annual exam that they are likely to do 
it. At the same time, the additional challenge for older 
people, whether or not you cover the annual exam, is going to 
be to make sure that they get the preventive care they need 
because, as you get older, you have more competing illnesses, 
and sometimes those acute needs tend to drive out paying 
attention to preventive services.
    Mr. Greenwood. The average beneficiary makes 13 visits to 
some sort of health care provider a year?
    Ms. Clancy. Usually many providers.
    Mr. Greenwood. I can imagine that, as Dr. Grissom just 
described, the way the fee-for-service program works 
essentially is, you present with something wrong with you, and 
you get reimbursed for that service; but there is no systematic 
way of making sure that all your systems are checked.
    If I didn't have an annual inspection on my automobile, I 
just take it in every time it ran out of oil or when the tires 
went bald and I went off the road, that would be a very 
expensive way to maintain my automobile. Yet I would never take 
it in for someone to do all of the preventive maintenance.
    It seems to me to be an obvious reform that we ought to 
make.
    There ought to be incentives in the system for both the 
health care provider and the beneficiary to get that annual 
exam, and maybe they would be making seven trips to the 
providers instead of 13 and would save a lot of money.
    Mr. Bratzler. I would say your illustration is excellent. 
Patients do not wake up thinking about what preventive services 
they need. That is the limitation of consumer education 
efforts. I don't think that they will work.
    Also, when you go to the physician, particularly if the 
patient has a lot of chronic medical problems, there are lots 
of issues to deal with, and that is why we are focusing hard on 
putting systems into place to build those reminder systems so 
they think about routinely needed preventive services and, 
perhaps, recall systems to bring patients back in to get those 
services.
    Mr. Greenwood. Dr. Grissom, you mentioned that CMS is 
developing a potential project that would examine the use of 
health risk appraisal programs with targeted follow-up 
interventions. What stage is the project in? Is there anything 
Congress can do to speed up the process of development of an 
approval to get a project like this up and running?
    Mr. Grissom. We are in the process of developing that. I 
can't give you a specific deadline or timetable. We 
commissioned a report from Brandeis on risk appraisals, which 
we have received with recommendations from them on what to do 
and how to go forward.
    I can get you a specific answer. I am not aware of anything 
that Congress can do that is keeping us from moving forward on 
that project. But I will be glad to give you a written 
response.
    Mr. Greenwood. Is there data within or without the Medicare 
system that would indicate whether or not, if we had a system 
where there was a minimal incentive for an annual health check; 
and it seems to me that it is covered. I could imagine other 
incentive systems where you would have a different payment in 
your Part B premium or your Social Security check would go up 
or a different deductible for your hospitalization, if you got 
the annual checkup; and it would seem to me, in order for that 
to be a good and comprehensive health checkup, you would need 
to reimburse physicians in such a way that they would be 
incentivized to spend the time to go down a comprehensive list 
of screens, et cetera.
    What do we know in the whole history of health care as to 
what data--where would I turn to find out whether that would, 
A, significantly increase health, reduce expensive treatments; 
and B, be less costly to the health care system as a whole?
    Mr. Grissom. I asked this question of our clinicians at CMS 
before I came over. Their answer is, and this is really 
fortunate, is because there is no evidence, it is not 
definitive. There is no scientific evidence that increased 
physicals, by themselves, would improve health outcomes.
    Mr. Greenwood. Is that because no one has done the study?
    Mr. Grissom. It is because no one has done the studies. And 
No. 2, it assumes that there are other ways that people can 
obtain preventive services and immunizations and vaccinations 
without having a physical.
    The way the Medicare program works now is, you can call 
your physician up and say it is time for my mammogram; or can I 
come in for my flu shot. If the physician looks at your record 
and you need it, and the physician offers a service, they have 
an opportunity to bill.
    Mr. Greenwood. We know most people do not do that, right?
    Mr. Grissom. Not nearly enough people do that because not 
nearly enough Medicare beneficiaries understand the benefits.
    Mr. Greenwood. The best utilization for immunizations is 
about a half among Caucasians, and it goes down to a third for 
minorities, is my understanding.
    Mr. Grissom. It is a little different. Let me give the 
correct immunization rates. For pneumococcal vaccination, and 
that is a lifetime vaccination, 63 percent of beneficiaries are 
covered. Last year, 73 percent of beneficiaries had a flu shot.
    Mammograms, in the 10-year baseline period it has gone from 
37 percent mammograms, annual mammograms, up to 54 percent.
    Pap smears and cervical pelvic exams is in the area of 35 
percent.
    AMA reported yesterday that in the last year, the rate of 
mammograms has gone up in 43 out of 47 States. The rate for flu 
vaccination is up in 44 out of 49. Pneumococcal up in 48 out of 
49. Trailing is cholesterol which is not a covered benefit; 
cholesterol screening only went up in 13 States. Cervical 
cancer screening up in 13 of 49 States.
    We are making improvements, but those are gross numbers, by 
State, and they are not the same across all populations. The 
rate of increase and the numbers of people getting those 
screenings is not what it should be.
    Mr. Greenwood. My time has expired, and I want to recognize 
Mr. Strickland. It just seems to me that even the best of those 
utilization rates are sort of rifle shots, whereas we know if 
someone came in for a comprehensive physical exam, and if 
someone talked to them about their physical activity and 
getting a flu shot and talked to them about smoking.
    Mr. Grissom. And exercise, right.
    Mr. Greenwood. All of those things in a comprehensive form, 
it would seem to me to be much more beneficial. That is what 
people with good health care systems get.
    Mr. Strickland is recognized for 10 minutes.
    Mr. Strickland. Thank you, Mr. Chairman.
    The managed care organizations seem to emphasize the fact 
that one of the real advantages of the Medicare+Choice program 
is that the beneficiaries are much more likely to get 
preventive services. I am wondering, do we know that for sure? 
Is there anything in the research that you are aware of that 
would indicate that that, in fact, is the case?
    If you are in a managed care plan, you are more likely to 
get an annual physical, for example, than if you are in a fee-
for-service plan?
    Ms. Heinrich. In the process of doing the work for this 
report, we did come across studies that looked at managed care 
organizations and utilization of preventive services as opposed 
to fee-for-service. It is difficult, though, because there are 
not many studies that actually target the 65-and-over 
population. Much of the information is for younger age groups.
    What we do find is that the strongest relationship in terms 
of utilization of preventive services is economic level and 
education level. Oftentimes, when you adjust for that, the 
differences that you might see in use by people in managed care 
as opposed to people in fee-for-service may disappear.
    Others may have some information on that.
    Mr. Strickland. Does anyone else have a desire to respond 
to that question?
    Mr. Bratzler. I can give you anecdotal data.
    I am in a State that has relatively low managed care 
penetration. And so when we go in and measure performance on 
preventive services like immunizations, diabetic screening and 
things like that, we look at a practice which includes both 
managed care, Plus Choice, and Medicare fee-for-service. We do 
not find much difference, mainly because we do not find that 
physicians in their practices, particularly when they have a 
mixed practice, treat the patients any differently based on 
payer source. That is in a State with relatively low 
penetration.
    Mr. Fleming. Regardless whether someone is in managed care 
or fee-for-service, the more approximate predictor is that the 
receipt of predictive services is going to be whether or not 
there is a reminder recall system in place so that when the 
patient comes in, the physician knows the preventive services 
that are needed, whether or not there is a copay or preventive 
services can be delivered for free. There is a whole list of 
interventions that are independent of whether they are fee-for-
service or managed care that you can put in place to increase 
the likelihood that preventive services are being delivered.
    Mr. Strickland. So is it a correct statement that although 
we seem to accept the fact that managed care does provide 
greater access to preventive services, we do not know that for 
sure, based upon the research that is available to us?
    Mr. Grissom. Based on our surveys of beneficiaries that are 
in the risk programs, we know that they do get more preventive 
services than the fee-for-service beneficiary. We also know 
that the more managed the managed care program, the more likely 
they are to get those preventive services.
    The old Kaiser model of HMOs that existed still does exist, 
but was more predominant years ago in which patients had a 
long-term, standing relationship with a group of physicians in 
a fixed facility, it did result in that.
    Mr. Strickland. The reason I am smiling is some people may 
find it surprising that I used to be a strong advocate of the 
concept of an HMO because it seems to me that in the early days 
of this movement, what you described was much more likely to 
occur. There was an emphasis on keeping people well rather than 
treating them when they get sick; and prevention was a big part 
of the justification for the HMO movement.
    But it seems to me that in recent times, perhaps because of 
cost constraints or whatever, that there is less and less 
emphasis on the preventive aspects of a managed care program.
    Ms. Heinrich. One thing I would add is that managed care 
organizations have changed over time, and there are a lot of 
variations in how they are structured and the kind of services 
that they do provide.
    I know one study that was done by CMS, doing a comparison 
of beneficiaries by managed care versus fee-for-service, was 
really old data. I think it was data from 1996, and at that 
point in time your fee-for-service Medicare system did not have 
the same array of services that Medicare now offers. I don't 
think it is so clear.
    I think you are right, it is not clear that beneficiaries 
in managed care necessarily receive more preventive services 
than those in fee-for-service.
    Mr. Strickland. If I can direct a question to Mr. Grissom, 
I was struck by the chairman's question earlier regarding 
whether or not, as I understood the question, we know for sure 
that an annual exam, for example, is going to lead to cost 
savings. I believe that was the gist of the question, and I 
think your answer was that we don't know that for sure; is that 
correct?
    Mr. Grissom. My answer is, I am not aware of any science-
based evidence that an annual physical would either in the 
short term or long term reduce health care costs or improve 
health care outcomes.
    Mr. Strickland. I just find that fascinating, because I 
think that is such a basic bit of information that is crucial 
to what we are trying to do in terms of provide the best, most 
efficient care and treatment.
    Is it possible, and I am wondering whether it is because 
the research has not been done. Or is it because of the way 
that we factor in cost savings under our system up here that 
preventive care may not demonstrate a benefit for 10 or 15 
years or 20 years into the future, and so as we look at 
potential cost savings, we are looking more in the near-term 
paradigm, and that we may be experiencing cost savings, but we 
are unable to factor that into the scoring that we do here in 
the Congress, or you do at CMS or whatever? Is that a 
possibility?
    Ms. Clancy. If I can jump in here, your comments and the 
comments and the questions of the Chair have been focused on 
the annual physical exam. In general, the focus of the U.S. 
Preventive Services Task Force and other expert bodies has been 
to focus on the specific components of what takes place within 
a physical exam, specific services, because, for example, what 
a 51-year-old man needs in terms of detecting disease early and 
preventing future diseases is different than an 18-year-old man 
or a 25-year-old woman.
    For that reason, most of the literature is organized around 
whether specific services are cost effective or not. There are 
very specific examples. Some services save money, a small 
subset. Immunizations generally fall into that category. Some 
actually delay the onset of bad outcomes, and over the time 
horizon, that is to say, they can be shown to be cost 
effective.
    Where possible, the Preventive Services Task Force actually 
presents the information if cost effectiveness analyses have 
been done, but they are not systematically and routinely done 
when gathering the evidence on effectiveness.
    Mr. Fleming. Just to follow up on that point, there is much 
evidence that shows that the delivery of the preventive 
services that we are talking about yield substantial returns on 
that investment in terms of improving quality of life, 
generally far more so than waiting until somebody becomes sick 
and investing that same amount of money in acute medical care.
    I think the issue is whether or not it is best to think 
about delivering those preventive services all at once in some 
sort of separate exam where we essentially divorce prevention 
from routine medical care; or alternatively, looking toward a 
system where preventive services are naturally integrated into 
every visit that someone seeks.
    If you are a smoker, hearing once a year at an annual exam 
that you should not smoke will provide some incentive to quit, 
but the better incentive is, every time you as a smoker come 
in, including the times that you are in there for your 
bronchitis or pneumonia as a result of your smoking, you hear 
that message from your provider that you need to quit. That is 
going to be the more effective way of delivering preventive 
services.
    Mr. Strickland. Thank you, Mr. Chairman. I yield back the 
balance of my time.
    Mr. Greenwood. Thank you.
    I recognize the gentleman from New Hampshire, Mr. Bass, for 
10 minutes.
    Mr. Bass. Thank you, Mr. Chairman. I was not that 
enthusiastic when I read the title for the hearing, which is 
about half a paragraph long, but this is a very interesting 
hearing.
    The fundamental issue here obviously is how the Medicare 
system is able to deal with issues that are not traditional to 
its original mission, and it is a most interesting subject. Mr. 
Strickland has gotten into the issue of Medicare+Choice versus 
fee-for-service.
    I would like to recount the first exposure I had to this 
issue in 1996 or 1997 when our former Speaker walked into a 
Republican Caucus in July and announced that every Member, 
during the August recess, was going to do an event to support 
the cause of finding a cure for diabetes, and that we were 
going to increase the budget for NIH. The Medicare system was 
going to be studied because we were going to do everything that 
we could to make sure diabetics were properly treated, because 
26 percent of the total cost of Medicare is associated with one 
illness, which is diabetes. That is the answer, and we didn't 
have to worry about anything else related to Medicare.
    Dr. Coburn, a former Member, stood up and said, Mr. 
Speaker, that makes a lot of sense, sort of; but the real issue 
here is diet, and you can't legislate diet. A doctor cannot 
guarantee that a potential diabetic follows a diet.
    I will not go on to discuss the Speaker's response to that, 
but suffice it to say that it was not government's issue to 
determine what diet is.
    What we are really talking about here is providing services 
that have very little to do with, or may not have a lot to do 
with, prescriptions or operations or annual physicals and so 
forth, but being able to make a system such as the Medicare 
system responsive and flexible enough to be able to work these 
issues and do it successfully in light of the debate which is 
occurring as to whether or not the traditional Medicare system 
works as well as perhaps some other alternative health care 
delivery systems that have been around for awhile.
    My only question is: Is it possible that Medicare will have 
to change some of its reimbursement policies to not only 
provide reimbursements to qualified nonphysicians, outside of 
the Medi-care+Choice program, who provide assistance to seniors 
that may not be clinical in nature?
    Does anybody want to answer that?
    Mr. Grissom. Congressman, as you well know, in 1997 in the 
BBA, there was a benefit for diabetes self-management written 
into law which was to increase patient education, and it 
reimbursed physicians for providing that service. And then in 
2000 with BIPA, we had the first medical nutrition therapy 
benefit, and it was to help people with their diet, and that 
referral to a physician occurs because they are probably under 
the care of a physician for diabetes. That benefit does allow 
reimbursement directly to nutritional therapists or registered 
dieticians and does not depend on a physician for that service.
    Mr. Fleming. Just to reinforce that point, to get back to 
your question about diabetes, studies recently done by NIH show 
that the best way to prevent someone who is at risk of getting 
diabetes is not through medication and not through legislation, 
but through counseling about diet and physical activity and 
creating circumstances in their home life and in their 
environment where they can eat the right things and they can 
exercise.
    So if we really are looking for ways to reduce health care 
costs from diabetes in the future, the place to focus now is on 
people who are at risk and making sure that they have the 
nutritional counseling that they need and advice about exercise 
and they have an understanding about the kinds of things that 
they need to do to prevent getting that disease in the future.
    Mr. Bass. Mr. Grissom answered by saying there is indeed a 
benefit or system or a way in which this issue, diabetes 
specifically, can be addressed.
    My question is: Is Medicare going to be able to be a 
flexible enough system to address this issue in such a fashion? 
First of all, the management of chronic illness, some seniors 
have as many as 5 or 6 chronic illnesses to manage, and can 
this system--that was established 35 years ago, I think, to 
treat illness in one manner--going to be able to in its current 
configuration, deal with this and do it successfully?
    Mr. Grissom. We are authorized by Congress to do some 
disease management and coordination-of-care demos, and we have 
5 or 6 demos for which proposals are out on the street which 
will do precisely what you are suggesting, which is disease 
management, especially in the area of chronic diseases, mostly 
congestive heart failure and diabetes; and they are going to be 
available not only in the Medicare+Choice but in the Medicare 
fee-for-service program, which is an effort by the Secretary, 
the Administrator, to push these kinds of alternative treatment 
schemes down into the fee-for-service area.
    Additionally, we do at Medicare commit increasingly 
significant sums of money to partnerships and educational 
programs in this particular area with the Association of State 
and Territory Officials, with the National Diabetes Foundation, 
to try to reach out to significant groups responsible within 
the family or within the individual subculture for care and 
care-giving decisions to educate in the area of diabetes.
    So both in demonstrations and in education, I think we have 
the tools, and I think we are using them appropriately to 
address the problems that you are concerned with.
    Ms. Clancy. I think you are highlighting some very 
important problems.
    Last year, the Institute of Medicine published a report 
called ``Crossing the Quality Chasm,'' and they used ``chasm'' 
instead of ``gap'' to signify a huge gap between the kind of 
quality of care we could provide across the system, across the 
life span, and what is actually being provided on average. 
Medicare faces that problem, but it confronts all payers, and 
it is a very big focus of the research that we are supporting.
    One of the strategies that has been used that Medicare has 
been very much part of, and is part of accreditation and so 
forth, is actually reporting on how we are doing. Where health 
plans do participate in accreditation, there are reports in 
terms of clinical preventive services, they do have better 
results than the State average.
    Next year, my agency will be submitting to the Congress a 
national report on the quality of care in this country, and I 
think that can be an important lever to drive change. The 
issues that you are identifying are fundamental to how we 
deliver care, and most health care systems right now are 
struggling.
    Mr. Bass. This may not require an answer. I ask it anyway. 
Does managed health care work better on providing preventive 
services than fee-for-service or Medicare? Is that too simple a 
question?
    Ms. Clancy. No. It is breathtakingly clear.
    The problem has been that the definition of managed care 
has changed almost continuously over the past 10-20 years. 
Overall, most studies would say that managed care systems have 
an edge in terms of providing preventive services. I think 
people disagree about what that means. Is that because the care 
system is doing it, or because managed care tends to attract 
people who are healthier and more interested in prevention and, 
in some cases, the plans have less cost-sharing? In general, 
their track record is pretty good.
    Ms. Heinrich. Although there have been studies, I know we 
did one, which was a comparison of managed care and fee-for-
service, on the treatment following cardiac arrest; there was 
really no measurable difference. So the evidence is mixed.
    Mr. Bass. Thank you. Mr. Chairman, I will end by saying I 
wish I could compare in my own home State Medicare+Choice with 
fee-for-service. Unfortunately, the reimbursement formula 
discriminates against rural America.
    I yield back the balance of my time.
    Mr. Fletcher [presiding]. Thank you. I am sorry I wasn't 
here for the testimony, I have reviewed most of them. I thank 
you for coming here today, and I want to thank the chairman, 
who is out just briefly, for hosting this hearing.
    Prevention is one of the areas I was involved in in a 
former life, and if the election goes well it will continue to 
be a former life. I think it looks good so far. In any case, 
thank you all for coming.
    Let me make a statement and see if you concur with this or 
not. Managed care, early on, changed probably the perspective 
of physicians and the practice of medicine in the sense that a 
lot more emphasis was put on prevention and chronic disease 
management, and probably changed a little bit the way the 
practice of medicine has evolved, particularly in the reports 
that I used to get back on the vaccination rates for children, 
the rates of mammograms on women that were of the proper age to 
receive those under the recommendations, as well as other 
issues.
    Would you say--and I think it has already been stated--the 
degree of prevention and screening depends more on the practice 
than on the insurance product? However, if you reimburse for 
those, things you are more likely to get them than not?
    I just want to hear a few comments.
    Mr. Bratzler. That is our experience in Oklahoma where, in 
our metropolitan areas, we have managed care penetration; it is 
practice dependent, it is not based on who is actually paying 
for the care. I do think that incentivizing certain preventive 
services would probably increase services. In our State, we do 
not find differences between managed care patients and fee-for-
service patients. We see differences, though, between 
practices.
    Ms. Clancy. In general, the literature is pretty consistent 
that knowing the right thing to do on the part of providers or 
patients does not necessarily mean that it gets done. Knowing 
it is the first step; the next step is having a supportive 
practice environment and an incentive for change, which can be 
financial and otherwise.
    Mr. Grissom. The reason that CMS in the Medicare program 
has focused on outreach to minority groups, ethnic groups, and 
economically disadvantaged groups is because the evidence is 
overwhelming that there is a high association between certain 
demographic groups and their access or utilization of these 
benefits and services.
    Underlying that data is probably also a subset of providers 
to whom certain individuals go by demographic, ethnic and 
economic group, and thus, there is a high degree of correlation 
between types of providers with their practices and types of 
patients.
    None of that has much to do with who is paying for it.
    Mr. Fletcher. It seems to be a pretty good consensus there.
    Let me ask a specific question. Dr. Fleming, I think it is 
in your report on page 5, you say a recent Institute of 
Medicine report noted that the return on investment in medical 
care for vascular disease reaped benefits, four to one, but 
investments in behavioral change returned a remarkable 30 to 1 
advantage.
    What is the scale? What are the units there?
    Mr. Fleming. I will be happy to provide that report to you 
as well. The bottom line of what the Institute of Medicine was 
saying, medical therapy to treat an illness, once someone has 
heart disease, does provide that person improved quality of 
life, but it is fairly expensive and in general cannot remove 
the symptoms entirely.
    In contrast, if you can work with that person on preventive 
measures by changing their behavior--stopping smoking, diet, 
exercise, for example--such that they never develop heart 
disease in the first place, first, those interventions tend to 
be less expensive; and second, the return on them, which is the 
absence of symptoms versus reduced symptoms, is far greater.
    So if you have a fixed number of dollars to spend and your 
goal is to improve quality of life, investing those dollars in 
behavioral interventions early to prevent illness is going to 
yield a better return than investing those dollars late once 
illness has occurred.
    Mr. Fletcher. Is this four to one?
    Mr. Fleming. We can provide the report, but to do these 
economic analyses, you have to look at what the cost of 
intervention is and then look at the quality of life that is 
produced and assign some economic value to that improved 
quality of life.
    Mr. Fletcher. It is an estimated economic value due to the 
quality of life and the ability of the individual to continue 
in the workplace, et cetera?
    Mr. Fleming. Continue in the workplace and carry out day-
to-day activities, yes.
    Mr. Fletcher. Dr. Clancy, when I was practicing, it was 
always very difficult to decide what screening tests were good 
and cost effective. We also were concerned at one time on the 
liability because we had posted in our charts, we went through 
the prevention task forces and posted what we needed, and if we 
missed someone, we documented our own record of not getting 
something done.
    Let me ask you, and you mentioned, obviously there is some 
very clear evidence on some studies, or on some diagnostic 
procedures or clinical procedures that shows a tremendous 
advantage; and others, it is rather murky. And I think this 
goes to the physical exam, which is something that we are all 
familiar with, but the content of that is really important, and 
it is tailored to the individual person and risk factors as 
well.
    What are you doing as far as what you see on the horizon? 
And you mentioned in here some studies that are not clear, that 
are not effective, maybe not good studies in general. What do 
you see coming in a way of being able to more pinpoint 
diagnostics, clinical interventions, et cetera, for prevention 
and disease management?
    Ms. Clancy. You have highlighted something that I think 
gives people great angst about the use of evidence to inform 
practice, which is that lack of evidence of effectiveness is 
not the same thing as saying that something does not work; and 
that makes people very nervous, especially if we start to tie 
payment to evidence and so forth.
    The evidence the Task Force considers in making their 
recommendations generally comes out of an evidence report, 
which is a systematic review of the available scientific 
evidence, on that particular service. Frequently they will 
review services for which the evidence is indeterminate. Part 
of that report actually articulates priorities for research 
which we try to share with our colleagues at NIH and so forth, 
to try to make sure that for areas where there are important 
questions and great concerns and issues of public health, that 
they are aware of what the specific questions are that need to 
be addressed by research.
    PSA may be one, for example. The U.S. Preventive Services 
Task Force has not recommended it as effective because the jury 
is still out. The studies are being done right now, but that is 
the process.
    Mr. Fletcher. In light of that, though, we are all doing 
PSAs because of the hopeful fact that the studies may indicate 
that we do save lives and decrease morbidity and mortality.
    Mr. Grissom, it is good to have you here from Kentucky, and 
let me ask you, I was looking through what particular 
preventive measures and diagnostic tests are available on 
Medicare. Just looking at this, it looks like we in Congress 
tend to practice a lot of medicine here. We have to look at 
your evidence data, weigh it, and see what it is going to cost, 
and every time we want something new on the regular Medicare 
fee-for-service, we say let us authorize that or not.
    Let me ask you how effective that is, given what Dr. Clancy 
and Dr. Fleming have mentioned, and I am sure some of the 
others, in the fact that medicine is evolving very quickly. The 
questions are not easy, and the answers are even more 
difficult.
    Does a program where you have the flexibility like the 
Federal employees health plan or Medicare+Choice, does that 
give you a lot more flexibility to have plans that meet the 
needs and evolve with the science of medicine, rather than the 
typical Medicare situation where we have to come up here and 
fight politically to get things done?
    Mr. Grissom. I was doing good on a panel of doctors until 
the chairman became a doctor.
    You are absolutely right. The fee-for-service program is a 
disease diagnostic and treatment program, and the Secretary is 
authorized by that statute to make decisions and has great 
discretionary authority to decide what is an appropriate 
service for the treatment and diagnosis of those illnesses and 
diseases.
    In the preventive area, there is no discretion, and so it 
is Congress telling us specifically when they want this to be 
covered as a benefit, when screening is appropriate. And I am 
sure it gives clinicians great pause to see that in 1997 the 
recommendation was for every 3 years, and for women at high 
risk or child-bearing age; and 3 years later the threshold goes 
down, and it is every 2 years, or all persons regardless of 
age.
    What you are seeing is a progression, expansion, increase 
of the universe, increase in frequency.
    I think there are those--I don't think there are any 
problems, but I think there are those that think that this 
process could be improved upon, and that legislation is not 
ordinarily science-based and that these are very heavy 
decisions that the Congress is making and that there may well 
be opportunities to give others some authority or discretion to 
make those decisions.
    I am unaware, in those payment plans that you referred to, 
whether or not they routinely have those benefits or that there 
is greater utilization of them than there is in the fee-for-
service or Medicare+Choice program. But we are bound by 
statute, and the discretion and flexibility in the prevention 
area does not exist as it does for diagnosis and treatment 
procedures.
    Mr. Fletcher. I was going to get some comments from the 
rest of the panel because the fee-for-service Medicare, which 
has been a tremendously effective program, is probably the 
ultimate managed care program when you have 535 folks up here 
managing every preventive measure that is reimbursed.
    I wonder, from your comments, do the other possibilities 
that I mentioned and some other ways of managing Medicare seem 
a little more positive and better, to be sure that we are able 
to address the needs of our seniors regarding disease 
prevention and chronic disease management?
    Ms. Heinrich. Certainly in our work we did not actually 
examine the process that Congress uses to determine coverage 
for preventive services. I know that there have been 
suggestions that various groups in the private sector, or CMS, 
consider evidence, the evidence phase that is developed by the 
U.S. Preventive Services Task Force; that these organizations 
could make recommendations based on evidence to the Congress, 
and then the Congress could consider them as one possibility.
    I think it is really important that we understand that not 
all the recommendations from the Preventive Services Task Force 
are so easily translated into a benefit for the 65-and-over 
population. I think we have to think through very carefully the 
evidence and differentiate, for example, the difference between 
a behavior being good and healthy and reducing risk, and 
understanding that we do not necessarily know how best to 
counsel people to achieve that behavior.
    Mr. Fleming. The fact is that the reality of these issues 
that we are confronting is changing. This is an evolving time. 
The numbers of people that are elderly are increasing. Our 
understanding of what works and does not work is changing, and 
our knowledge regarding preventive services is growing. I don't 
know what the right system is for incorporating that into 
Medicare.
    I do know whatever system you choose to put in place is one 
that is going to have to deal with these complex issues. It is 
going to have to be flexible and adapt to changing knowledge 
over time, and it is going to have to be knowledge-driven. 
There is science that can tell us what to do, and whatever 
system you put in place needs to be able to take that knowledge 
and incorporate it into policy.
    Ms. Clancy. I like the image of ``535 managers of the 
Medicare program.'' You have alluded to managing what the 
program covers and what is the scope. I think that is one part 
of the puzzle, and I know Dr. Gold is going to speak to that.
    The second thing is what happens at the level of practice. 
That is a local phenomenon, and that is where the quality 
improvement organizations are important. With the help of 
science, to help clinicians know how to make sure that they get 
the preventive services delivered is important.
    For example, we know from a lot of studies that people with 
multiple chronic illnesses are far less likely to get 
prevention. Why should that be? The very people you would like 
to reach and are in there all the time are the people least 
likely to get recommended preventive services.
    There are a lot of factors that contribute to that, but I 
don't think that is something that is going to be dictated at 
the level of the scope of the program or what the structure and 
the financing is. I think that is going to be much more local.
    Mr. Bratzler. I am not going to try to make recommendations 
about what Congress should do about changing the Medicare 
program for preventive services, but there needs to be 
flexibility to have pilot projects to test some of these 
preventive measures to see if they work. I think the Medicare 
stop-smoking program is an outstanding example of a pilot that 
is coming up that may result in recommendations for a new 
preventive service that should be provided to all Medicare 
patients, if it is a successful project--so continuing to have 
flexibility to the pilots when there is evidence from AHRQ and 
others.
    Mr. Fletcher. I thank you, and I will turn the hearing back 
over to the chairman.
    Mr. Greenwood. Just a few additional questions.
    Mr. Grissom, you mentioned a couple of times that Medicare 
is statutorily structured for the diagnosis and treatment of 
diseases, and does not have a mandate on prevention. What would 
happen if we went into that statute and added preventive 
services to the mandate?
    Mr. Grissom. I looked at the literature, and I do not think 
that there is any preventive service or screening that is 
absolutely--that all clinicians would say, this is the next 
thing or that this is what we need to do.
    I think Dr. Clancy probably can speak to the 
recommendations from the United States Preventive Services Task 
Force. I believe probably that cholesterol screening is one 
that is in play. However, I think what we are seeing for a 
variety of reasons, blood pressure screening and cholesterol 
screening, because they can be done in a shopping center, are 
increasingly being done, being accessed by a lot of seniors. I 
think, except for cholesterol screening and some thyroid 
monitoring, there is no consensus on what else ought to be 
covered.
    The issue, though, that I think you are maybe also alluding 
to is, if it could be shown that an annual physical, because it 
either increased access to preventive services or it was, in 
itself, a preventive service--if it could be shown to be 
beneficial, would the Secretary use authority or discretion to 
implement that, is a good question. I must say I don't have the 
answer. I know that we don't have scientific evidence upon 
which to make the determination.
    Those are the things that I think in the area of preventive 
screening are next steps or in play.
    Ms. Clancy. I think there is a very solid body of 
literature that says that economic barriers are a very 
important deterrent to the receipt of effective clinical 
preventive services, so higher cost-sharing and not having 
coverage for the service actually do effect people not getting 
the service. To that extent, there is an opportunity if 
preventive services are covered.
    At the same time, in addition to focusing on quality of 
care prevention, we also have a lot of economists who study 
economic behavior. So if Congress were simply to say, we will 
cover preventive services, I think you could set your watch 
until new things people wanted covered would be defined as 
prevention, so you would need to be specific about what you 
mean by ``preventive services.''
    Mr. Greenwood. According to GAO's report, CMS's current 
efforts to increase beneficiary utilization of Medicare-funded 
preventive services for persons 65 and older centered around 
four components reviewed in a 1999 evidence report prepared by 
RAND. These are systems change, financial incentives, reminders 
and education.
    The key conclusion that the report drew was that 
organizational and systems change, such as the use of standing 
orders, which has been referred to, and the use of financial 
incentives, were the most consistent at producing the largest 
increase in the use of preventive services.
    What kind of financial incentives were the most effective? 
Are you familiar with that, Dr. Grissom?
    Mr. Grissom. I think the financial incentives were, A, 
reimbursement for those services for physicians; and, B, the 
existence of copays and deductibles.
    As you are aware, the President has recommended removing 
the remaining barriers to copays and deductibles. Since the 
start of this administration, we have tried to address 
physician fees on the administration of vaccines as well as all 
preventive services. Secretary Thompson has specifically 
addressed the issue of mammography, mammograms, and we have 
increased coverage for different kinds of digital 
mammographies, and we intend to address that issue again this 
year in the physician fee schedule.
    I think those are the kinds of incentives that our report 
has focused on and referred to.
    Ms. Heinrich. Just one comment.
    There were some other examples, for example, travel 
reimbursement or gift certificates that have been used; but 
again you have mixed evidence about how effective they are. But 
there are some other examples of what you can do.
    Mr. Greenwood. When we have health fairs back home, we give 
a spaghetti lunch and people come in and get their blood 
pressure tested.
    Ms. Heinrich. Right. It seems logical that removing 
economic barriers should be a very effective strategy, but when 
you look at utilization, you see that the use of immunizations 
is relatively low. There is no copay formula.
    Mr. Greenwood. It goes back to the comment made earlier, 
which is when you ask, why didn't you utilize this service, 
nobody told me that I could. Nobody said that it was out there.
    Mr. Grissom. We need to get all of the rates up, but the 
rates are highest for those screenings for which there is no 
copay or deductible.
    Mr. Greenwood. I thank each and every one of you for 
spending the last couple of hours with us.
    We will call forward the next panel which consists of Dr. 
Marthe Gold, Logan Professor and Chair, Department of Community 
Health and Social Medicine, City University of New York Medical 
School; Dr. Christine Himes, Director of Geriatrics, Group 
Health Cooperative in Seattle; Viola Quirion, on behalf 
Alliance for Retired Americans in Washington; and Dr. Jessie 
Gruman, President and Executive Director, Center for the 
Advancement of Health, also in Washington.
    Welcome to all of you, and thank you for being with us this 
afternoon. If you were here when we began the hearing, you 
heard me say that this is an investigative hearing and it is 
our custom to take testimony under oath.
    Does anyone object to giving your testimony under oath? And 
you are entitled to be represented by counsel. Do any of you 
wish to be represented by counsel?
    Nothing to hide, okay.
    In that case, I will swear you in.
    [Witnesses sworn.]
    Mr. Greenwood. We will start with Ms. Quirion.

 TESTIMONY OF VIOLA QUIRION, ON BEHALF OF ALLIANCE OF RETIRED 
     AMERICANS; MARTHE R. GOLD, LOGAN PROFESSOR AND CHAIR, 
   DEPARTMENT OF COMMUNITY HEALTH AND SOCIAL MEDICINE, CITY 
    UNIVERSITY OF NEW YORK MEDICAL SCHOOL; CHRISTINE HIMES, 
DIRECTOR OF GERIATRICS, GROUP HEALTH COOPERATIVE; AND JESSIE C. 
   GRUMAN, PRESIDENT AND EXECUTIVE DIRECTOR, CENTER FOR THE 
                     ADVANCEMENT OF HEALTH

    Ms. Quirion. Thank you, Chairman Greenwood and members of 
the subcommittee, for this invitation to testify today. I am 
Viola Quirion from Waterville, Maine. I am a member of the 
Alliance for Retired Americans.
    Before I go further in my testimony, I would like to stop 
all distractions or anything. I figure you might wonder why I 
have a hat which says Washington, DC, and that is because I 
forgot my wig at home. I decided to buy a hat, and I bought one 
with Washington, DC, because I love Washington.
    Although I have been fighting for this for 9 years, for 
affordable health care and prescription drugs, and it is pretty 
discouraging we have not gone very far with it; but I am still 
confident and I have hope in all you people that this year it 
will come.
    Mr. Greenwood. And you look great in your cap.
    Ms. Quirion. Thank you.
    I am accompanied today by John Carr, the President of the 
Alliance for Retired Americans, which was established in 
January 2001. It now has 2.5 million members across the Nation. 
Retirees from affiliates of the AFL-CIO, community-based 
organizations and individual seniors have joined the Alliance 
to create a strong, new voice for retired workers and their 
families.
    I want to congratulate you for holding this hearing, as I 
believe that preventive services under the Medicare program are 
very important. Because of Medicare coverage of pap smears, 
mammograms and flu shots, many lives have probably been 
extended. I think physical exams also should be considered a 
preventive service. For many people on limited income, however, 
that 20 percent copayment for preventive services may be an 
immediate luxury they cannot afford even though it may 
ultimately be life-saving.
    It is not in my testimony, but I believe that preventive 
service and mammograms were not always covered by Medicare, and 
physical exams were not. In my case, it would have saved a lot 
of illnesses. I will go, later on, and you will see it would 
have helped me a lot if I would have had these.
    I am from Waterville, Maine. I worked in the Hathaway shirt 
factory for 44 years until I retired in 1994. I live on two 
small pensions and Social Security, which comes to $1,466 a 
month. I never had to worry about health care expenses until I 
retired. I now have a supplemental plan to cover some of the 
costs Medicare does not cover, but it is not sufficient for 
everything.
    I was diagnosed with ovarian cancer in late December 2000, 
and had surgery in January 2001. The surgeons who operated 
found that different parts of the cancer had cemented together 
my ovaries and many parts, so they could not cut into it 
because I would have bled to death.
    Consequently, I took a series of chemotherapy treatments 
lasting 5\1/2\ hours each time. It took 7 days for me to 
recover after each of these treatments. For these treatments, I 
was in a nursing home for 6 months.
    In December of 2001, I had knee surgery. While recovering 
at home, I suffered from a number of infections. I needed 
intravenous transfusions, but since Medicare does not pay for 
those at home, I had to go into a skilled nursing home facility 
for 6 weeks where they are covered. Consequently, Medicare paid 
for the skilled nursing care and the IVs which were much more 
costly than the $400 treatments I could have received at home. 
Although IV transfusions may not be considered a preventive 
service, it does not make sense to me to spend extra money 
unnecessarily.
    Currently, I am taking 1\1/2\ hour chemotherapy treatments 
for the ovarian cancer and don't experience negative 
aftereffects. The blood test shows that the mass is dissolving. 
I am happy to say that Medicare does cover the chemo 
treatments, but follow-up is just as critical to survival as 
preventive service.
    I am here today primarily to tell you the importance of 
prescription drugs as a preventive measure that has extended 
and enhanced everyday life for millions of Americans. 
Technological advances in treating disease include use of new 
drugs that can arrest or cure many cancers, heart disease, high 
blood pressure and other life-threatening conditions. 
Prescription drugs save costs in reducing surgeries in 
hospitals and nursing home care. However, new drugs are more 
expensive than old drugs and three times more costly than 
generic drugs.
    Because of my--they give me blood work before every chemo, 
and at one point my blood was low; they talk about giving me a 
drug that would have cost me $2,000 for a cancer drug. That is 
more than I earn every month. So if it ever comes to that, I'll 
just have to wait and die, because there is no way even the 
Canadian drugs would pay for something as heavy as that.
    I have taken seven bus trips to Canada over the past years, 
which were sponsored by the Maine Council of Senior Citizens 
and the Alliance for Retired Americans. I take Prilosec for 
stomach ailments, which in the U.S. costs me $5 a pill, and 
Relafin for my back and knees. I estimate that I save $1,000 
every trip.
    Unfortunately, it took me a week to recover from the last 
trip because of my knees. I probably won't be able to make any 
more trips, but I'm not alone. There are so many people who 
could benefit from these trips, but are physically unable to 
board a bus.
    And the last trip that I made, it was January when I came 
out of the nursing home. I needed prescription drugs, but I 
also had some new ones, and of course I wasn't in a condition 
to go to Canada. So I had one drug that cost me $301.54, one 
$264.78, $34.98, $16.78, which is a total of $558.08. My 
monthly expenses are my rent, $271; my supplement insurance, 
$113.50; phone, $25; cable, $23; a total of $432.50. So with my 
income of $1,466, that left me for the month for food $125.58. 
And, of course, I couldn't buy it for the month because they 
keep changing my prescriptions, and I had to make sure that I 
had extra money to pay for something in case they changed them, 
because I couldn't make the trip to Canada.
    So the real point, however, is that we should not have to 
make these trips at all. Prescription drugs should be one of 
the benefits of the Medicare program.
    Despite all of the hopes placed in the Medicare Choice 
program, it is not a solution. The share of Medicare Choice 
enrollees with prescription drug coverage declined from 84 
percent in 1999 to 67 percent in 2001. At the same time, 
premiums, copayments are more costly. In half of the 33 States, 
Medicare Choice plans that provide drug coverage, the average 
premium rose more than 100 percent in the past 3 years.
    Sadly for Maine's residents, even if some were able to 
afford these increases, it doesn't make any difference. There 
is no Medicare Choice program in Maine. So trying to add 
preventive service coverage here would be no help either.
    The Alliance for Retired Americans has developed a set of 
principles for comprehensive Medicare prescription drug 
program. The program should provide full access to all 
medically necessary medications. Most importantly, the benefits 
should be affordable. It should include a monthly premium of no 
more than $25, 20 percent coinsurance, a $100 deductible, and a 
$2,000 out-of-pocket annual cap.
    Mr. Chairman and members of the committee, I would like to 
close by telling you about a husband and wife that I met on the 
bus trips who both take a number of medications. However, they 
can't afford them. They have ``resolved'' this dilemma by 
taking turns buying their medications. One month, they pay for 
the husband's prescription drug; the next month, it is his 
wife's turn and so on. Neither bus trips nor cutting back on 
medication that are necessary not only for health but for life 
itself are the answer.
    As you probably know, the State of Maine has taken steps on 
behalf of its citizens to ensure affordable prescription drugs 
because of inaction on the Federal level. However, the Maine Rx 
Program has been challenged in the courts by the pharmaceutical 
companies all the way up to the Supreme Court.
    While we in Maine support our State's action, we also 
believe this is a national policy problem. The real solution is 
within the power of Congress, and that is to add a prescription 
drug benefit to the Medicare program, as well as increase 
access to the preventive services.
    And I would also encourage you to go after the general 
attorney to get our bill out of captivity and bring it to Maine 
so at least we would be covered until something else is done.
    Thank you very much.
    [The prepared statement of Viola Quirion follows:]

  PREPARED STATEMENT OF VIOLA QUIRION, ALLIANCE FOR RETIRED AMERICANS

    Thank you, Chairman Greenwood and all of the Members of this 
subcommittee, for this invitation to testify today. I am Viola Quirion 
from Waterville, Maine and a member of the Alliance for Retired 
Americans. I am accompanied today by John Carr, president of the Maine 
Council of Senior Citizens. The Alliance for Retired Americans, which 
was established in January 2001, now has 2.5 million members across the 
nation. Retirees from affiliates of the AFL-CIO, community-based 
organizations and individual seniors have joined the Alliance to create 
a strong new voice for retired workers and their families.
    I want to congratulate you for holding this hearing as I believe 
that preventive services under the Medicare program are very important. 
Because of Medicare coverage of pap smears, mammograms and flu shots, 
many lives have probably been extended. I think physical exams also 
should be considered a preventive service. For many people on a limited 
income, however, the 20 percent co-payment for most preventive services 
may be an immediate luxury they cannot afford even though it may 
ultimately be life-saving.
    As I mentioned, I am from Waterville, Maine. I worked in the 
Hathaway shirt factory there for 44 years until I retired in 1994. I 
live on two small pensions and Social Security, which comes to $1,466 a 
month. I never had to worry about health care expenses until I retired. 
I now have a supplemental plan to cover some of the costs Medicare does 
not cover, but it is not sufficient for everything.
    I was diagnosed with ovarian cancer in late December 2000, and had 
surgery in mid-January, 2001. The surgeons who operated found that 
different parts of the cancer had cemented together in my ovaries and 
if they tried to cut it out, I would have bled to death. Consequently, 
I took a series of chemotherapy treatments lasting 5 + hours each time. 
It took 7 days for me to recover after each of these treatments. For 
these treatments and my recovery, I was in a nursing home for six 
months.
    In December of 2001, I had knee surgery. While recovering at home, 
I suffered from a number of infections. I needed intravenous 
transfusions but since Medicare does not pay for those at home, I had 
to go into a skilled nursing facility for six weeks where they are 
covered. Consequently, Medicare paid for the skilled nursing care and 
the IVs which was much more costly than the $400 treatments I could 
have received at home. Although IV transfusions may not be considered a 
preventive service, it does not make sense to me to spend extra money 
unnecessarily.
    Currently, I am taking 1\1/2\ hour chemotherapy treatments and 
don't experience negative after effects. And the numbers on the blood 
tests show that the mass is dissolving. I am happy to say that Medicare 
does cover the chemo treatments. Follow-up is just as critical to 
survival as preventive services.
    I am here today to tell you of the importance of prescriptions 
drugs as a preventive measure that has extended and enhanced the 
quality of everyday life for millions of Americans. Technological 
advances in treating diseases include use of new drugs that can arrest 
or cure many cancers, heart disease, high blood pressure and other 
life-threatening conditions. Prescription drugs have saved costs in 
reducing surgeries and hospital and nursing home care. However, new 
drugs are more expensive than old drugs and three times more costly 
than generic drugs.
    I have taken 7 bus trips to Canada over the past few years which 
were sponsored by the Maine Council of Senior Citizens and the Alliance 
for Retired Americans. I take Prilosec for stomach ailments, which in 
the U.S. costs me $5 a pill, and Relafin for my back and knees. I 
estimate that I saved $1,000 every trip. Unfortunately, it took me a 
week to recover from the last trip because of my knees. I probably 
won't be able to make any more. But I am not alone, there are so many 
people that could benefit from these trips but are physically unable to 
board a bus.
    The real point is, however, that we should not have to make these 
trips at all. Prescription drugs should be one of the benefits of the 
Medicare program. Despite all the hopes placed in the Medicare+Choice 
program, it is not a solution. The share of Medicare+Choice enrollees 
with prescription drug coverage declined from 84 percent in 1999 to 67 
percent in 2001. At the same time, premiums and co-payments are more 
costly. In half of the 33 states with Medicare+Choice plans with drug 
coverage, the average premium rose more than 100 percent in the past 3 
years. Sadly for Maine residents, even if some were able to afford 
these increases, it doesn't make any difference--there is no 
Medicare+Choice plan in Maine. So trying to add preventive services 
coverage here would be no help either.
    The Alliance for Retired Americans has developed a set of 
principles for a comprehensive Medicare prescription drug program. The 
program should provide full access to all medically necessary 
medications. Most importantly, the benefit should be affordable. It 
should include a monthly premium of no more than $25, 20 percent co-
insurance, a $100 deductible, and a $2,000 out-of-pocket annual cap.
    Mr. Chairman and members of the committee, I would like to close by 
telling you about a husband and wife that I met on the bus trips who 
both take a number of medications. However, they can't afford them. 
They have ``resolved'' this dilemma by taking turns buying their 
medications. One month, they pay for the husband's prescription drugs, 
the next month, it is his wife's turn and so on. Neither bus trips nor 
cutting back on medications that are necessary, not only for health but 
for life itself, are the answer. As you probably know, the state of 
Maine has taken steps on behalf of its citizens to ensure affordable 
prescription drugs because of inaction on the federal level. However, 
the Maine Rx Program has been challenged in the courts by the 
pharmaceutical companies all the way up to the Supreme Court. While we 
in Maine support our state's actions, we also believe this is a 
national policy problem. The real solution is within the power of 
Congress and that is to add a prescription drug benefit to the Medicare 
program as well as increase access to other preventive services.
    Thank you.

    Mr. Greenwood. Well, thank you, Ms. Quirion, and you're a 
courageous woman to come here and be with us and wait for your 
turn, and I thank you for it. I'm proud of you for doing it.
    Ms. Quirion. You're welcome.
    Mr. Greenwood. We're going to try like heck, and we'll 
succeed here in the House, in moving a bill out to expand 
Medicare+Choice funding. It should never have been allowed to 
drop down in reimbursements so that it couldn't cover 
prescription drugs; and we're going to have a prescription drug 
benefit in that bill and fight like heck to get it through the 
Senate after we get it through here. But I'm pretty sure we 
will get it through the House and that will happen next month.
    Dr. Gold.

                   TESTIMONY OF MARTHE R. GOLD

    Ms. Gold. Good afternoon. Thank you for inviting me to 
testify today, Mr. Chairman, and members who are not here.
    My name is Marthe Gold. I'm Logan Professor and Chair of 
the Department of Community Health and Social Medicine at the 
City University of New York Medical School, and I served as a 
member of the Institute of Medicine's Committee on Medicare 
Coverage Extensions, whose report was issued in 2000. I'm 
pleased to be here.
    My comments today will draw from conclusions of the IOM 
report that are relevant to this hearing, and I'm also going to 
draw from my own background in cost-effectiveness analysis, 
clinical preventive services and patient care as a practicing 
physician at Settlement House in New York City Community Health 
Center.
    As you've heard and as you know, primary prevention is 
directed toward averting health problems. Secondary prevention 
is aimed at discovering existing abnormalities before they do 
harm. And tertiary prevention, which is really a form of 
treatment, is intended to prevent worsening of complications in 
individuals who have an established disease. Some of us in the 
prevention community don't think that there is too much of a 
difference; it is just a matter of a continuum.
    By definition, preventive interventions are administered to 
people who are not experiencing illness, and therefore the 
possibilities of side effects, false positive findings and 
costs of care must always be weighed against the health 
improvements the interventions provide. On a population basis, 
preventive services should, at minimum, create more good than 
harm.
    Medically delivered prevention has been undersubscribed in 
this country as other insurers, along with Medicare, have 
increased their coverage. We've seen that uptake of the 
services has improved. Insurance is certainly necessary, but 
not sufficient for increasing uptake of preventive services. 
This uptake has particularly benefited the low-income 
individuals whose health is known already to be poorer and 
whose life expectancy is shorter than other Americans.
    Medicare extends coverage to Americans age 65 or over and 
to some individuals with disabilities or permanent kidney 
failure. With certain exceptions, Congress explicitly excluded 
coverage for primary and secondary prevention and outpatient 
prescription drugs, among other services.
    Over the years selective preventive services have been 
added on a case-by-case basis through congressional action. As 
a result, Medicare now covers many, but not all secondary and 
tertiary preventive services that would be of value to its 
beneficiaries. Medicare also covers some services whose value 
is unproven.
    For example, in 2000, Congress extended Medicare coverage 
to prostate-specific antigen and digital rectal exam, to screen 
for prostate cancer, despite evidence-based recommendations by 
some scientific and professional bodies to the contrary. In the 
case of PSA, the combination of yet unproven survival advantage 
and the not-infrequent serious side effects associated with 
treatment of prostate cancer led the U.S. Preventive Services 
Task Force, the American College of Physicians and the American 
College of Preventive Medicine to specifically recommend 
against the use of routine screening by PSA. Two studies 
conducted early in the 1990's estimated that an initial 
screening of PSA would cost between $6 to $28 billion.
    From the other side, Medicare fails to cover a number of 
effective preventive services. For example, the Task Force 
recommends blood pressure screening and screening for vision 
and hearing impairment, depression and problem drinking. In 
addition, it recommends that patients be educated and/or 
counseled about tobacco cessation, diet, alcohol, dental 
hygiene, physical activity, fall prevention and other safety-
related issues. None of these are currently covered by 
Medicare.
    In 2001, Partnership for Prevention sponsored a 
prioritization project which had contributions from scientists 
from CDC, CMS and AHRQ. That prioritization project ranked 
preventive services on the basis of the burden of disease they 
prevented and their cost effectiveness, and they placed 
tobacco-cessation counseling and screening for vision 
impairment among adults age 64 and over as two of the top three 
most valuable services, neither of which is included. Childhood 
immunizations were ranked No. 1, just so you understand the 
continuum there.
    Blood pressure and cholesterol screening had priority 
scores that were equivalent to those of vaccination for 
influenza, a Medicare-covered service. Priority scores for 
screening for blood pressure and cholesterol were predicated on 
pharmaceutical treatment of elevations of blood pressure and 
cholesterol to bring them to normal levels. Obviously, 
medication is not covered by Medicare.
    Prevention wisely accomplished should save pain, mental 
anguish and cost. Why then would a public program like Medicare 
pay $75,000 for coronary artery bypass surgery in some 
situations and decline to pay for the smoking cessation 
counseling and blood pressure and cholesterol-lowering agents 
that would obviate the need for some of these surgeries? Why 
would Medicare pay for the hip fractures suffered by elderly 
Americans and not cover the screening and counseling of elders 
that could substantially decrease the falls that cause the 
fractures?
    The IOM report on Medicare coverage of clinical preventive 
services made several points about the coverage decisionmaking 
process. In brief, the cost accounting framework that supported 
IOM committee recommendations and is used by the Congressional 
Budget Office looks at costs and offsets over a 5-year period 
of time, a period that is too short for many preventive 
interventions to achieve their benefit. Formal cost-
effectiveness analysis where the health effects of differing 
interventions are compared over an appropriate timeframe and 
evaluated along with their costs would provide a truer picture 
of both the economic and the health impact of medical care.
    Second, the IOM committee strongly endorsed the utility of 
evidence-based reviews of health services for guiding clinical 
and policy decisions. Reviews guide clinicians and health care 
organizations to abandon practices that are clearly not 
beneficial and to apply and recommend practices that are 
identified as worthwhile. They support governments and others 
who pay for care in revising coverage, reimbursement, quality 
assessment and related policies to discourage nonbeneficial 
services.
    The committee also favored more extensive reliance on 
formal cost-effectiveness analysis for informing coverage 
determinations. The status quo coverage apparatus makes it 
difficult to compare the expected benefit's harms and costs of 
different health care decisions. The procedure relied on by 
Congress for estimating the cost to Medicare of covering a new 
service provides an incomplete picture of the value for money 
for such an action.
    Finally, the committee suggested that methods toward 
rationalizing coverage policy for preventive and other Medicare 
services should be pursued. For example, Congress could 
encourage and provide funding support for AHRQ, CMS and other 
relevant agencies in preparing evidence evaluations and cost-
effectiveness analyses. Congress could also direct CMS to 
assess the services recommended by the U.S. Preventive Services 
Task Force in the context of the Medicare program and to make 
coverage recommendations. The systematic analysis of the 
potential benefits, harms and costs of covering additional 
services would protect against the piecemeal addition of less 
valuable services at the expense of more valuable ones.
    To conclude, more systematic evaluations of the 
effectiveness and cost effectiveness of health care 
interventions and using that information to inform coverage 
decisions will create a more effective and efficient health 
care system that better meets the needs of Americans. For those 
of us in the prevention community who have long been troubled 
by the practice of scrupulously holding preventive 
interventions to stringent standards of accountability and 
cost-saving while leaving many other interventions unexamined, 
a more systematic approach to coverage policy would indeed be a 
breath of fresh air.
    [The prepared statement of Marthe R. Gold follows:]

  PREPARED STATEMENT OF MARTHE R. GOLD, ARTHUR C. LOGAN PROFESSOR AND 
   CHAIR, DEPARTMENT OF COMMUNITY MEDICINE AND SOCIAL MEDICINE, CITY 
UNIVERSITY OF NEW YORK MEDICAL SCHOOL AND MEMBER, COMMITTEE ON MEDICARE 
  COVERAGE EXTENSIONS, DIVISION OF HEALTH CARE SERVICES, INSTITUTE OF 
                                MEDICINE

    Good morning, Mr. Chairman and members of the Committee. My name is 
Marthe Gold. I am Logan Professor and Chair of the Department of 
Community Health and Social Medicine at the City University of New York 
Medical School and served as a member of the Institute of Medicine's 
Committee on Medicare Coverage Extensions. The Institute of Medicine is 
part of the National Academy of Sciences, a private, nonprofit 
organization that was chartered by Congress in 1863 to advise the 
government on matters and technology. The committee report on its 
findings and recommendations was published in 2000.
    My closing comments (``Report Findings'') will cover certain 
conclusions of the IOM report that are relevant to this hearing. I will 
also draw on my background in cost-effectiveness analysis, clinical 
preventive services, and patient care as a family practitioner, 
currently seeing patients in a community health center in East Harlem, 
in New York City.

Preventive Services
    It would be lovely if we could live long lives without disability 
or illness, and slip off softly in our sleep somewhere in our 9th or 
10th decade. Second best is to catch illness early, and intervene in a 
manner that reasonably maintains health and longevity. Prevention 
supports both of these scenarios. Primary prevention is directed 
towards averting a health problem, e.g., we immunize to prevent 
infectious illness, we fluoridate to prevent tooth decay, we stop 
people from smoking and avoid heart and lung disease. Primary 
prevention can occur at the population health level--in communities 
through public health educational campaigns--or it can occur in 
clinical settings. Primary prevention leads us toward scenario one. 
Secondary prevention is aimed at discovering existing abnormalities 
before they do us harm; hopefully before they interfere too much with 
quality of life and life span. We catch cervical cancer early with Pap 
tests, or decrease the risk of heart disease by lowering cholesterol or 
blood pressure. Secondary prevention occurs in the medical care 
setting. Tertiary prevention, in reality a form of treatment, aims to 
prevent worsening of complications for patients who already have a 
specific disease. Examples of tertiary prevention include controlling 
blood sugar in diabetic patients and performing coronary artery bypass 
grafting on individuals with narrowed coronary arteries to prevent 
heart attacks.
    Medically delivered prevention has been under subscribed in this 
country. There are many reasons for this, a number of which will have 
been discussed by others at this hearing, but certainly a major factor 
historically has had to do with insurance coverage. As insurance 
coverage has improved through Medicare and other insurers, so has 
uptake of preventive services. Low income individuals and uninsured 
persons whose health is known to be poorer and whose life expectancy 
shorter, have lower levels of uptake of preventive services. We know 
from the health services research literature that as insurance covers 
preventive services, more low income persons make use of them.
    Although an ounce of prevention is held to be worth a pound of 
cure, there is always fine print to be read. Preventive interventions, 
by definition, occur in asymptomatic people. They can cause 
uncomfortable side effects (e.g. pain or perforation associated with 
colonoscopy, untoward effects of immunizations); precipitate worry, 
pain and unnecessary further testing in association with false positive 
results (e.g., a mammogram detects a mass that after biopsy turns out 
not to be malignant); interfere with peoples' self perception by 
assigning them a disease ``label'' (people assigned a diagnosis have 
been found to miss more work post-labeling); and use up financial 
resources. On a population basis, preventive services should, at 
minimum, create more good than harm. In addition, they should represent 
a reasonable investment of resources. Money used in one place is not 
available for use elsewhere. Certainly the IOM committee was mindful 
during its deliberations of Congress's budget rules for itself that 
require that decisions to increase most types of federal spending be 
accompanied by explicit decisions to reduce spending elsewhere, or to 
raise taxes.

Medicare Coverage (and lack thereof) of Preventive Services
    Medicare extends coverage to Americans age 65 or over and to some 
individuals with disabilities or permanent kidney failure. From the 
outset, the program has focused on coverage for hospital, physician and 
certain other services that are ``reasonable and necessary for the 
diagnosis or treatment of illness or injury, or to improve the function 
of a malformed body member'' (section 1862 of the Social Security Act.) 
With certain exceptions, Congress explicitly excluded coverage for 
primary and secondary prevention and outpatient prescription drugs, 
among other services. Over the years, selected preventive services have 
been added on a case-by-case basis through Congressional action.
    Given the considerations outlined, sensible policy making would 
favor that all services that are insured and promoted by Medicare are 
ones that are known to be appropriate and effective in increasing the 
health of Americans. This is not currently the case. For example, in 
1998, Congress extended Medicare coverage to bone densitometry (to 
screen for osteoporosis) and in 2000, to prostate-specific antigen 
(PSA) and digital rectal examination (to screen for prostate cancer) 
despite evidence-based recommendations by scientific and professional 
bodies such as the U.S. Preventive Services Task Force (USPSTF), the 
American College of Physicians, the American College of Preventive 
Medicine, and the Canadian Task Force on Preventive Health Care. In the 
case of PSA, for example, the combination of no known survival 
advantage and the not infrequent serious side effects associated with 
treatment of prostate cancer, led the USPSTF to specifically recommend 
against the use of routine screening by PSA. Two studies conducted a 
decade ago estimated that an initial screening of PSA would cost 6 to 
28 billion dollars (Kramer et al, 1993; Optenberg SA and Thompson IM, 
1990.)
    From the other side, sensible policy would favor Medicare coverage 
of all appropriate and effective preventive services. This, also is not 
the case. For example, the USPSTF recommends blood pressure screening, 
and screening for vision and hearing impairment, depression and problem 
drinking. In addition it recommends that patients be educated and/or 
counseled about tobaccos cessation, diet, alcohol, dental hygiene, 
physical activity, fall prevention and other safety-related issues. 
None of these are currently covered by Medicare. A 2001 prioritization 
project that ranked preventive services on the basis of burden of 
disease prevented and cost-effectiveness placed tobacco cessation 
counseling and screening for vision impairment among adults aged >64 in 
the top three services. The report was co-authored by prevention 
specialists and researchers from the Centers for Disease Control, the 
Agency for Healthcare Research and Quality, and Partnership for 
Prevention (Coffield et al, 2001.)
    The priorities project ranked blood pressure and cholesterol 
screening equivalently with vaccination for influenza--a Medicare 
covered service. Priority scores for screening for blood pressure and 
cholesterol were predicated on pharmaceutical treatment of elevations 
of blood pressure and cholesterol to bring them to normal levels. And 
yet, as you are well aware, Medicare does not provide coverage for 
drugs. Low and moderate income individuals are often left with highly 
treatable risk factors for diseases that they lack the economic 
wherewithal to control.
    Prevention, wisely accomplished, should save pain, mental anguish, 
and cost. Why then would a public program pay $75,000 (Peigh, 1994) for 
coronary artery bypass surgery and decline to pay for the smoking 
cessation counseling and blood pressure and cholesterol lowering agents 
that would obviate the need for some of these surgeries. Why would 
Medicare pay for the hip fractures suffered by elder Americans, and not 
cover the screening and counseling that could substantially decrease 
the falls that cause the fractures?

Coverage Determinations
    Coverage determinations for the Medicare program currently take in 
a range of considerations, many of them non-aligned. When Congress 
considers preventive care and other interventions that are now 
statutorily excluded from Medicare coverage, costs are routinely 
weighed as part of the decision making. When CMS makes coverage 
determinations about new technologies that fit under existing 
categories of covered services, its decisions are not directly governed 
by the ``budget neutrality''' rules that Congress has adopted for 
itself. Instead, CMS applies criteria of effectiveness. These, in turn, 
are not applied to established technologies and interventions.
    Congress has been restrained in its addition of new services to the 
Medicare package. A major component of the Balanced Budget Act of 1997 
was a set of measures intended to slow the growth in program spending 
and at least delay the date at which Medicare spending is projected to 
exceed revenues. The cost-accounting that supported IOM committee 
recommendations on coverage of the services we examined was that used 
by the Congressional Budget Office, which looks at costs and off-sets 
over a five year period of time. Often, however, a short time horizon 
will not permit an adequate evaluation of the long-term costs or 
savings associated with an intervention. For example, smoking cessation 
treatment or cholesterol lowering medications may not show their 
benefit till a decade or two after the intervention has occurred. 
Formal cost-effectiveness analysis, where the health effects of 
differing interventions are compared over an appropriate time frame and 
evaluated along with their costs, provides a truer picture of both the 
economic and health impacts of medical care.
    During the first three decades following the establishment of 
Medicare, Congress was highly sensitive to issues of clinical 
effectiveness and cost-effectiveness. For example, at the behest of 
Congress, the now defunct Office of Technology Assessment (OTA) 
undertook state-or the-art analyses of the cost-effectiveness of 
several preventive services. A study of congressional coverage 
decisions from 1965-1990 identified evidence of favorable cost-
effectiveness ratios as one factor differentiating preventive services 
approved for coverage from those not approved.

Report Findings
    The IOM committee strongly endorsed the utility of evidence-based 
reviews of health services for guiding clinical and policy decisions. 
For both new technologies and current practices, these reviews help 
make clear the extent to which there is good evidence about the 
benefits and harms of a particular intervention. At the same time they 
highlight important health problems for which good evidence is still 
missing and point the way toward needed research. Reviews place 
pressure on clinicians to abandon practices that are clearly not 
beneficial and to apply and recommend practices that are identified as 
worthwhile. They support governments and others who pay for care in 
revising coverage, reimbursement, quality assessment, and related 
policies to discourage nonbeneficial services and encourage effective 
care.
    The committee also favored more extensive reliance on formal cost-
effectiveness analyses for informing coverage determinations. Our point 
was not that cost-effectiveness analyses should be conducted on all 
currently covered services Medicare services (a massive task) nor that 
cost-effectiveness should be the only criterion for coverage decisions. 
It was, rather, that the status quo coverage apparatus makes it 
difficult to compare the expected benefits, harms, and costs of 
different health care decisions. The procedure relied on by Congress 
for estimating the costs to Medicare of covering a new service--the one 
adopted for the report of the committee--provides an incomplete picture 
of the value for money of such an action.
    The committee's endorsement of the tools of evidenced-based 
medicine and cost-effectiveness analysis led it to be strongly 
concerned by the fluctuating policy support for technology assessment 
and evidence-based recommendations for clinical practice and coverage 
policy. Ironically, at a time when the methodology for assessing 
effectiveness and cost-effectiveness has been strengthened by the 
health services research community, the coordination of decision making 
for coverage appears to have eroded.
    The committee believed that it is possible to take some steps 
toward rationalizing coverage policy for preventive and other services. 
For example, a modest step in this direction would be for Congress to 
encourage and provide funding support for AHRQ, CMS, and other relevant 
agencies in preparing evidence evaluations and cost-effectiveness 
analyses. With respect to preventive services, Congress could direct 
CMS through the Secretary of Health and Human Services to assess the 
services recommended by the USPSTF in the context of the Medicare 
program and to make coverage recommendations. The systematic analyses 
of the potential benefits, harms, and costs of covering additional 
services would protect against the piece-meal addition of less valuable 
services at the expense of more important ones. At the clinical level, 
this is likely to play out with doctors and other health professionals 
placing emphasis on higher priority services for their patients.
    Enlarging the apparatus for systematic evaluations of the 
effectiveness and cost-effectiveness of health care interventions and 
using that information to inform coverage decisions will create a more 
effective and efficient health care system that will better meet the 
needs of Americans. For those of us in the prevention community, who 
have long been troubled by the practice of scrupulously holding 
preventive interventions to various form of accountability, while 
leaving many extant interventions unexamined, a more systematic 
approach to coverage policy would indeed be a breath of fresh air.
    Thank you for the opportunity to present these views. I would be 
pleased to answer any questions.

                            References Cited

    Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among 
recommended clinical preventive services. Am J Prev Med 2001;21:1-9
    Institute of Medicine. Extending Medicare Coverage for Preventive 
and other Services. Field MJ, Lawrence RL, Zwanziger, L (eds). 2000. 
National Academy Press. Washington, D.C.
    Kramer BS, Brown ML, Protok PC et al. Prostate cancer screening: 
what we know and what we need to know. Ann Intern Med 1993;119:914-923
    Optenberg SA and IM Thompson. Economics of screening for carcinoma 
of the prostate. Urol Clin North Am 1990;17:719-737
    Peigh PS, Swartz MT, Vaca KJ, et al. Effect of advancing age on 
cost and outcome or coronary artery bypass grafting. Ann Thorac Surg. 
1994;58:1362-1366

    Mr. Greenwood. Thank you, Dr. Gold.
    Dr. Himes.

                  TESTIMONY OF CHRISTINE HIMES

    Ms. Himes. Thank you very much.
    It is amazing to me when I came here. I'm a primary care 
doc. I'm the way other side of the spectrum. I'm the person who 
sits in the room with patients every day and talks about these 
kinds of issues.
    I'm also the Director of Geriatrics for Group Health 
Cooperative, and it has been interesting to me to listen this 
morning to all of the comments about the good old guys in 
managed care and how the days used to be. And the truth is, 
having been first birthed in 1947, group health, I think, is 
still one of the old guys, and we've benefited tremendously 
from our relationships with the Medicare program.
    In 1976, we became the first demonstration project for 
Medicare risk, and in 1982, became one of the first-ever risk 
contracts. So I've enjoyed a very long history of relationship 
not only with Medicare but the ability afforded by risk 
contracts, and now Medicare+Choice, to really take a systems 
view and look at, how do we take care of our patients.
    Our charge to ourselves has always been, if we said we were 
the very best health care organization for seniors in the 
world, what would that look like and how do we try to get 
there? And as I listen today, I've been--I've never been to 
Congress before.
    This area is a personal area of passion of mine, healthy 
aging. We were asked to come and talk primarily because of some 
physical activity programs we have, which are my biggest 
passion areas, and I brought some--so you all could benefit 
from having some little exercise--tools while you sit here for 
these long hours, I think. So I'll make a few comments about 
that in your everyday practice a little while later.
    But I want to talk about, I think, two things that have not 
been mentioned so far today.
    We depend--our system depends on being able to step back 
and look at all of the evidence that is available. We look at 
all of the wonderful reports that are put out by all of the 
folks who have been on this panel, as well as all of the 
literature in general; and the geriatric literature over the 
past 15 or 20 years has really provided us with a really clear 
way, I think personally, of where to go.
    And when I look at you all here on this committee and hear 
about your responsibilities and how you think about them in 
terms of Medicare, I think we're the same. I think you have the 
same charge on the national level that I have for our 60,000 
Medicare recipients at Group Health. So I'll share what I know. 
I'll be happy to share anything in the future that I can be 
helpful or that Group Health can be helpful in clarifying, and 
really am very happy and privileged that you all are taking 
such a close look at preventive services for seniors.
    Prevention is an interesting idea that really changes as we 
get older. In our 50's, it is different than it is for people 
who are 65 or than it is for people who are 75, 85, 95. Many of 
the cancer screens that you've heard about earlier today and 
even many of the medications that are used, whether it is 
aspirin or whether it is beta blockers, et cetera, as people 
get older and older, there is not clear evidence anymore about 
the efficacy of those interventions on the prevention scale, 
partly because we think of prevention traditionally in our own 
minds as preventing premature disease.
    What is premature disease when you are 85 or 95 or 100 
years old? Hard to know. So the truth is, really prevention as 
we get older and older is a question of how do we prevent our 
life from falling apart? How do we prevent a downward spiral 
where our quality of life is the pits? How are we to live our 
lives the best ways that we can for all of our lives?
    The geriatric literature shows us really clearly something 
about prevention. There is a set of syndromes, called the 
``geriatric syndromes,'' which include urinary incontinence, 
depression, all of those really obnoxious things that totally 
screw up quality of life. All of them lead you in an amazing 
downward spiral, and all of them have some very clear evidence-
based interventions that can really make a difference in 
people's quality of life.
    There is a wonderful report that was just put out, 
sponsored by the Robert Wood Johnson Foundation and AAHP, 
called ``Improving Care of Older Adults With Common Geriatric 
Conditions''; and it is probably the best literature and most 
current literature review around the geriatric conditions.
    But if we talk about getting older, we want to focus on 
geriatric conditions. The most important geriatric condition is 
lack of physical activity. If there is one prescription 
physicians can write in their office that is the most important 
prescription, it is a prescription for regular physical 
activity. At Group Health, we've developed a series of physical 
activity programs that we'll be happy to talk about more in the 
question-and-answer time, if you'd like--or they are in the 
written testimony--that really address that one problem, and in 
doing so, improve very clearly not only the costs and 
utilizations for seniors, but also quality of life and allowing 
or helping seniors to be the best they can be for all of their 
lives.
    Thank you.
    [The prepared statement of Christine Himes follows:]

PREPARED STATEMENT OF CHRISTINE HIMES, GROUP HEALTH COOPERATIVE, GROUP 
                    HEALTH PERMANENTE MEDICAL GROUP

                            I. INTRODUCTION

    Mr. Chairman and members of the Subcommittee, thank you for 
inviting me to testify today on the important topic of preventive 
benefits offered under the Medicare program. I am Dr. Chris Himes, 
primary care physician and Director of Geriatrics for Group Health 
Cooperative, based in Seattle, Washington. I also am a member of the 
Group Health Permanente Medical Group, which with 1,217 physicians, is 
among the largest medical groups in the state of Washington. Group 
Health Permanente contracts exclusively with Group Health Cooperative.
    Founded in 1947, Group Health is a not-for-profit and with nearly 
600,000 members, is the nation's largest consumer-governed health care 
organization. Group Health has a long-standing commitment to serving 
Medicare beneficiaries. Shortly after Medicare's creation, we began 
working with the government to design a program that would allow 
Medicare to work with prepaid health care organizations like Group 
Health. In 1976, we were the first organization to partner with the 
government under what was then referred to as the Medicare risk 
program. At present, we serve nearly 60,000 Washington state 
beneficiaries under Medicare+Choice.
    Since our founding, Group Health has focused on preventive care 
programs to help people stay healthy, while at the same time making 
sure people receive the comprehensive care they need when they are ill. 
Pre-payment has been fundamental to our ability to pursue both of these 
objectives simultaneously. Pre-payment allows us to direct resources to 
areas of greatest need and to be creative and innovative in designing 
programs. Simply stated, when you are not paid on an encounter-by-
encounter or procedure-by-procedure basis, you can shift your focus to 
include longer-term improvement in health outcomes.
    Group Health has developed programs related to chronic illnesses 
common in the elderly including depression, diabetes, and heart 
disease. We also have initiatives in prevention and acute care for 
conditions such as breast, cervical, and colorectal cancer. At present, 
work is underway to unify these initiatives with other special needs of 
seniors, such as fall prevention. Although the programs span a wide 
spectrum of health care conditions and approaches, they all reflect the 
collaborative relationships between an organization, patients, 
clinicians, and other providers.

           II. PROMOTING HEALTHY AGING: PREVENTIVE CARE MODEL

    Today, I'd like to focus on the concept of ``healthy aging''--a 
topic that has long been a passion of mine. The concept of ``healthy 
aging'' is not a magical or fanciful quest for the ``fountain of 
youth'', but rather a clearly attainable road to being the ``best we 
can be''--physically, mentally and spiritually. Healthy aging is not 
dependent on high cost medical technology--although certainly, 
technology can sometimes extend the length of life, improve functional 
ability and overall quality of life.
    To achieve healthy aging, individual relationships between patients 
and their providers must take center stage; providers need to 
understand fully their patients needs, desires and things that most 
impact their ability to live their lives well. Patients need to have 
confidence that their providers will listen and partner with them to 
make the best choices for their own lives and circumstances.
    With the baby boomers aging and individuals over age 85 becoming 
our nation's fastest growing population segment, the definition of good 
preventive health care models are changing and expanding. In addition 
to disease prevention, the focus is gradually shifting to include a 
greater emphasis on helping people live with chronic illness and 
maintaining and improving functional abilities and quality of life.
    Helping our providers keep up with changes and the best approaches 
to care--including ways to promote healthy aging--is one of the most 
important contributions of Group Health's care delivery model. Our 
focus on evidence-based medicine--a systematic approach to collecting 
and critically evaluating available scientific evidence on treatment 
options--seeks to offer practitioners and patients the information they 
need to make informed decisions about treatment options. It also helps 
ensure that health care dollars are being spent on treatments that have 
proven benefits.
    For today's--and tomorrow's--Medicare beneficiaries, the growing 
body of geriatric literature clearly points the way. In achieving 
healthy aging, studies point to the need for regular geriatric 
assessments and evidence-based interventions in areas known to threaten 
functional ability, commonly called the ``geriatric syndromes'' (e.g., 
physical inactivity, depression, urinary incontinence, falls, cognitive 
impairment, medication-related complications and poor nutrition). For 
the most part, these interventions are low cost and do not involve 
advanced technologies. Yet, studies have clearly shown that 
assessments, certain interventions and close follow-up of these 
syndromes can help avoid deterioration in health and costly 
complications, while dramatically improving the quality of life for 
seniors in six to twelve months. From a medical perspective that is a 
relatively fast timeframe for improvement, especially when considering 
that beneficiaries often experience geriatric syndromes for lengthy 
periods of time.

  III. GROUP HEALTH'S WORK TO IMPROVE BENEFICIARIES' HEALTH AND WELL-
                         BEING THROUGH EXERCISE

    Today, I want to focus on perhaps one of the best examples of a 
low-cost, low-technology intervention that can have a dramatic impact 
on seniors' health and well-being: Group Health's simple, but 
pioneering research and resulting strategies in promoting senior 
fitness.
    Group Health not only has focused on learning from the geriatric 
literature, but also has made significant contributions to it over the 
last twenty-five years. In the 1980s, researchers from Group Health's 
Center for Health Studies and their colleagues at the University of 
Washington examined key determinants of overall health outcomes for 
seniors. The results were quite clear. There are only two statistically 
significant predictors: social isolation has a negative impact on 
health, while regular physical activity had a very positive effect on 
health. In assessing the types of physical activity, the researchers 
found--and many others have since validated--that in addition to 
endurance activity, such as walking, gardening, swimming, muscle 
strengthening and flexibility exercises are also important, especially 
for seniors with functional deficits or balance problems as they age.
    The joint Group Health-University of Washington work led to the 
development of an exercise program known as Lifetime Fitness, offered 
by Group Health at local senior centers through a community partnership 
with Senior Services of Seattle-King County. Group Health paid the 
start-up costs for the weights used for muscle strengthening and the 
training and salaries for the exercise instructors. Senior centers 
provided the space and logistics for the classes, which were offered to 
all comers in the community, three times a week in five-week sessions.
    Each class has segments that focus on improving balance, 
flexibility, and aerobic capacity. Participants perform exercises both 
standing up, holding the back of a chair for balance, as well seated in 
chairs. In addition to the actual exercise components, the class offers 
participants a chance to socialize--they talk about their weekends, 
their grandchildren, and visits with their families. Couples exercise 
together; group lunches are occasionally arranged after class.
    Based on the positive response from participants, Group Health soon 
expanded the availability of classes throughout our entire service area 
by partnering not only with community senior centers, but also with 
YMCA's. Lifetime Fitness is now offered in 34 locations.
    To further contribute to the evidence-base in healthy aging, the 
same Group Health Cooperative-University of Washington research team, 
in partnership with Senior Services of Seattle-King County Health 
Enhancement Project, developed and tested a model of geriatric 
assessment with accompanying interventions and follow-up by a nurse 
practitioner. Over the study period, a nurse practitioner stationed in 
a senior center that offered Lifetime Fitness classes performed regular 
assessments on patients 70 years and older from Group Health and 
Pacific Medical Center who participated in Lifetime Fitness. The 
improvements in health and well-being were dramatic as evidenced by 
reductions in ``geriatric syndrome visits.'' The nurse practitioner, 
along with a social worker, was able to demonstrate significant cost 
and utilization savings--a 72 percent reduction in six to twelve 
months.
    It became clear that regular exercise was key to the intervention's 
success. The study's positive findings with respect to avoided 
deteriorations in health and costly complications served as a catalyst 
for Group Health to move regular assessment and intervention support 
into all primary care settings. Senior Services, a local not-for-profit 
organization, also expanded the Health Enhancement Program to senior 
centers around the country.

    IV. INTEGRATING FITNESS INTO GROUP HEALTH'S MEDICARE+CHOICE PLAN

    Once we understood that increasing physical activity for all 
seniors was the most important key to healthy aging, Group Health began 
to develop a ``full spectrum'' of exercise opportunities that could be 
individualized according to patient preference and ability. Whether 
robust and healthy or frail, living independently or in nursing homes, 
Group Health is working to bring the benefits of exercise to all our 
Medicare members. Today, in addition to Lifetime Fitness, Group Health 
offers Medicare+Choice enrollees a benefit called ``Silver Sneakers'' 
which enables them to join local health clubs and YMCA's at which they 
can take senior-focused fitness classes. At present, 1,300 Medicare 
beneficiaries participate in Lifetime Fitness, of whom 1,000 are Group 
Health Medicare+Choice members. Nearly 10,500 Group Health 
Medicare+Choice members have participated in Silver Sneakers. In April 
alone, 3,748 Group Health Medicare beneficiaries--6.3 percent of our 
membership--used their Silver Sneakers benefit.
    In addition, Group Health is ``rolling out'' our new geriatric 
assessment protocol to all primary care clinics. Physicians will be 
asked to write ``exercise prescriptions'' for all of their senior 
patients and to conduct regular follow-up on their progress. We have 
developed a set of tools and supports, as well as planned training for 
all practitioners in addressing and monitoring geriatric syndromes. The 
key message in this training is that recommending exercise is among the 
most important prescriptions to write, individualize, and assure 
compliance.
    While these two exercise programs have been overwhelmingly 
successful in improving quality of life, they are beyond the ability of 
many seniors with disabilities and multiple chronic diseases. These 
seniors, however, often have the most to gain from increasing physical 
activity. Virtually all guidelines and care coordination programs for 
conditions such as diabetes, heart disease, chronic obstructive 
pulmonary disease, hypertension, depression, osteoporosis, arthritis, 
to name a few, call out exercise as a central strategy to improve 
health.
    Let me give you a few examples of why this can be so effective and 
life changing for the most frail among us. Group Health currently has 
an exercise program beginning at our nursing home, Kelsey Creek, and 
has started our first program in a retirement community next to one of 
our clinics. For several years in my own practice, I have written 
exercise prescriptions based on individual needs and preferences for 
all senior patients, promoting the value of regular exercise in 
managing virtually every medical condition and disability. In doing so, 
there was a particular group of patients who caught my attention--my 
patients who visited me often with various ailments and complaints that 
did not have a specific etiology. Simply stated, they were in 
``downward spirals''.
    As I did with all my patients, I encouraged them to exercise and 
get out socially but they just couldn't. They lacked the motivation and 
will, and they had real obstacles--chronic pain, significant medical 
diseases and functional deficits, depression, social isolation, lack of 
transportation; the list goes on. Perhaps most importantly each of 
these people was facing huge losses--death of their spouse, a move from 
their life long home to a retirement apartment. They felt like they 
were simply burdens on their families and friends. They most common 
word they used to describe themselves was ``useless''.
    I knew that these were the very people who would benefit most from 
an exercise regimen so I decided to start a muscle strengthening and 
flexibility program at Group Health's Northgate Medical Center, where I 
practice, tailored specifically to their needs and disabilities. I 
asked this group to commit to coming to class three times a week for 
four and a half months, stay for lunch together once a week after 
class, and participate in a community performance at the end to share 
with their families and community all I knew they would accomplish. 
Within weeks I could see them getting stronger, becoming an incredible 
support group for each other, and perhaps most importantly, truly 
embracing and enjoying life again.
    It's been two and a half years since the first class, and they are 
still coming. Some have died, they are old and frail. But at their 
funerals, each of their families talked about how much better their 
mom's last year of life had been as a result of the ``dancing ladies 
and their few good men'' program. As for the rest, I don't see them as 
much for these ``unspecified ailments'', though I regularly see them at 
the lunches and in class where we talk about a whole range of healthy 
aging issues. With sponsorship from Group Health, the group recently 
made an exercise video of this class to be used as an inspiration and 
entry-level in-home exercise option for our frail populations.

  V. UPDATING MEDICARE TO INCLUDE BENEFITS THAT PROMOTE HEALTHY AGING

    Limited health care resources mandate that physicians, health plans 
and payers alike identify new and innovative ways to improve the 
overall health outcomes for the Medicare population and control costs. 
Care coordination programs for high-risk, high-cost conditions have and 
continue to promote cost-effective delivery of services and avoid 
deteriorations in health. That said, we as a nation must persist in 
looking ``upstream'' for additional strategies. In my view, one such 
strategy is the promotion of healthy aging.
    Regular geriatric assessments and follow-up of geriatric syndromes 
are key to healthy aging. The most important of these follow-up 
activities is increasing regular physical activity for all patients, 
whether they are healthy or frail. We know that fitness can make a 
difference not only in terms of beneficiaries' physical and mental 
well-being, but also in terms of expenditures. A recent controlled 
analysis of health cost and utilization of 1,124 Group Health 
Medicare+Choice members enrolled in Lifetime Fitness who were compared 
to 3,342 age and gender ``matched'' control beneficiaries. The baseline 
per year expenditures on members of the control group and individuals 
who participated in more than 120 Lifetime Fitness Classes were 
virtually the same: $3,932 and $3,940 respectively. However, the change 
in the subsequent year's expenditures differed dramatically: costs for 
individuals who did not participate in Lifetime Fitness increased by 
$1,175, while costs for Lifetime Fitness participants decreased by $71. 
The study also showed that costs for members who increased their 
participation by just one time a week decreased by 14 percent, while 
the annualized number of inpatient days fell by half a day.
    Writing and assuring compliance with exercise prescriptions is the 
single most important intervention physicians can do for their 
patients. Health plans need to continue to develop a full spectrum of 
exercise opportunities for their members and their communities, in 
partnership with community, private and governmental organizations. 
Toward this end a national effort, cosponsored by the Center for 
Disease Control and the Robert Wood Johnson Foundation, is currently 
underway bringing health plans, government agencies, seniors themselves 
and community organizations together in support of the ``National 
Blueprint on Increasing Physical Activity Among Adults Age 50 and 
Older''. The Blueprint work will continue to support the development of 
the exercise and behavior change literature base, as well as broadly 
``spreading the word''. Group Health, as well as many others like us, 
fully embrace and support this work, understanding its central 
importance to the health of the health, our members, and ourselves.

                             VI. CONCLUSION

    There is no doubt that the Medicare benefits package needs to be 
updated. As a practitioner, I applaud Congress' work in recent years to 
improve the availability of important preventive benefits for our 
nation's Medicare beneficiaries. But as I have presented here today, 
prevention of illness or deterioration in health does not always result 
from a screening test, but rather it can result from even more simpler, 
fundamental, low cost approaches like fitness programs. As Congress 
continues its work in this important area, I urge you to continue to 
think creatively and to take a broader perspective on seniors' health.
    Our Medicare members have told us loudly and clearly that they want 
to live life fully with dignity and grace. Group Health is committed to 
fulfilling their request. As you can tell, we are proud of our 
accomplishments, but we know that more can and must be done to ensure 
that all Medicare beneficiaries achieve ``healthy aging.'' We again 
want to thank you for the opportunity to share our work in this area 
and to contribute to the Subcommittee's deliberations on this important 
issue.

    Mr. Greenwood. Thank you.
    Dr. Gruman.

                  TESTIMONY OF JESSIE C. GRUMAN

    Ms. Gruman. Thank you, Mr. Chairman. I represent the Center 
for the Advancement of Health, which is an independent, 
nonpartisan, nonprofit organization that promotes the greater 
recognition of how nonbiological factors affect health; that 
is, what we do and where we live and what we eat and what 
resources are available to us influence health and illness. The 
fundamental aim of the Center is to ensure that everything 
we're learning about health through scientific inquiry, not 
just what we're learning about physiology and genetics, is 
applied and translated into policy and practice to improve the 
health of individuals in the public. And it is that mission 
that brings me here today.
    As Dr. Fleming in the previous panel pointed out, no single 
group of Americans more--has more to gain than the elderly from 
putting into practice the medical--what medical evidence 
strongly suggests, and that is that behavior matters. From 
avoiding risky behavior to taking pills on time, to getting 
appropriate medical screenings, a solid core of evidence exists 
on how to stay healthy and productive for as long as we can.
    In the past 5 years, Congress has doubled the funding for 
the National Institutes of Health, and the payoff should be 
seen in dramatically improved health outcomes in the years 
ahead. Or maybe not. The investment we've made in basic science 
is going to be diluted if we do not translate these advances 
into use, and use implies systematic changes in the behavior of 
doctors, of health systems and of individuals. Let me give you 
an example of what I'm talking about.
    Biomedical researchers tell us that we are on the verge of 
seeing a new genetic test that will tell people their genetic 
risk for colon cancer. This development is a triumph of 
science. If anything, it vindicates our Nation's investment in 
discovery of research at NIH by promising a tectonic shift in 
the burden of colon cancer, the cause of 56,000 deaths a year 
in the United States. But this incredible advance coming from 
basic science necessitates a more powerful understanding of 
behavior if we are going to make use of it.
    From this one test alone, many new questions will need to 
be answered in order to realize the promise of fewer colon 
cancer deaths. For example, how do you persuade people to take 
a test that may indicate with a pretty high degree of certainty 
that they are going to get a deadly disease? What environmental 
and behavioral factors influence whether people who test 
positive actually get colon cancer or not?
    And following on that, what life-style changes can 
individuals make to reduce the probability that they will get 
colon cancer? What constitutes good medical care for patients 
who test positive on such a test? What are the implications of 
this test for insurance generally and for Medicare in 
particular to cover the cost of the test, to cover the cost of 
monitoring and to cover the cost of treatment for those who 
test positive? How will we train and deploy a workforce of 
genetics counselors to introduce the entire U.S. population to 
the idea that they ought to have a test that very well may 
change their lives and prospects?
    Now, these are questions that are not going to be answered 
by geneticists or biochemists or biologists. Rather, they are 
questions that will be answered by experts in learning, in 
cognition, in human factors, organizational development, health 
research, epidemiology, economics, psychology and sociology, 
and others probably.
    Basic biological science was the starting point of the 
test, but scientific attention must then be paid to changes in 
the behavior of patients, of doctors, of insurers, of managed 
care executives and others if we are to successfully complete 
the production arc from laboratory to living room. Without 
systematic attention to these questions, the most sophisticated 
genetic test is functionally as useless as a cell phone on the 
dark side of the moon.
    As the GAO report shows, even time-tested effective 
technologies, mammograms and immunizations are not finding 
their way often enough to the people who need them. Physicians 
forget to recommend them, patients don't ask for them, they're 
confused about how often they need them, they fail to comply 
with their doctor's orders.
    One recent action by the CMS is an important and, 
unfortunately, too-rare instance of really attending to the 
behavior that connects the technology to its target: CMS's 
review that you mentioned earlier of the evidence on 
interventions that are directed at doctors, health care 
facilities and individuals to increase vaccine use. Based on 
that review, CMS implemented standing orders to increase the 
chances that the right immunizations get to the right seniors 
at the right time.
    But behavior doesn't just matter in realizing the health 
benefits of clinical preventive services covered by Medicare. 
There is overwhelming scientific evidence, as we discussed 
earlier, that demonstrates the great gains to be had by 
reducing behavioral risks, including smoking, increasing 
physical activity, preventing falls. All are extraordinarily 
important, but until quite recently have not been viewed by CMS 
as part of the Medicare mandate for prevention.
    The new CMS-sponsored stop-smoking demonstration project is 
the agency's first effort to systematically address a major 
behavioral risk factor for disease and disability, and evidence 
has been gathered by the Healthy Aging Program on the 
feasibility of pilot programs to assess risk, prevent falls, 
better manage chronic conditions; and each of these might have 
an important role to play in a Medicare program that aims to 
help Americans live as well as they can for as long as they 
can.
    Mr. Chairman, it would be a terrible waste of the Nation's 
health and wealth if the bulk of the health research that 
Congress has sponsored sits in the file cabinets in Bethesda 
and is not used to benefit the American public. The 
pharmaceutical and technology industries are responsible for 
bringing some of that knowledge to the marketplace, but they 
are not responsible for ensuring that we know--that what we 
know about quitting smoking or getting people to participate in 
screening tests becomes part of routine health care and 
community services.
    There are several ways that Congress can act to make 
certain that we realize the full benefits of all of our 
investments in health research. First, by raising the priority 
within CMS for addressing behavioral risks like physical 
activities, reducing the impact of falls, assessing health 
risks.
    Second, by increasing the extent to which CMS makes use of 
the evidence on how to overcome behavioral barriers in 
implementing preventive services and other medical care 
services, as the Agency did with it standing orders for 
immunizations.
    Third, by fostering better cooperation among Federal 
agencies with responsibilities for senior health. Center for 
Medicare and Medicare services, CDC, Administration on Aging, 
AHRQ and NIH all have important roles to play to ensure that 
the evidence drives the implementation of effective programs to 
improve health and prevent disease.
    And finally, by balancing the Federal research portfolio 
better between basic and applied research. Just as we plan 
retirement security in our investment portfolio, by creating a 
mix of stocks and bonds and cash, the Nation's science 
portfolio must also be balanced. Basic discovery research, 
balanced by research on application, translation and behavior.
    The challenge before us is to figure out how to make sure 
that when medical breakthroughs are made, they get translated 
at the right time by the right people in ways that are going to 
make a difference. Because when it comes to health, biology 
matters and drugs matter and genetics matter, but behavior 
really matters, and it is not just the behavior of individuals, 
it is the behavior of individuals, health care professionals 
and systems.
    Thank you.
    [The prepared statement of Jessie C. Gruman follows:]

    PREPARED STATEMENT OF JESSIE C. GRUMAN, PRESIDENT AND EXECUTIVE 
             DIRECTOR, CENTER FOR THE ADVANCEMENT OF HEALTH

    Thank you, Mr. Chairman.
    I represent the Center for the Advancement of Health, an 
independent, non-partisan nonprofit organization funded by the John D. 
and Catherine T. MacArthur Foundation. The Center promotes greater 
recognition of how non-biological factors affect health--that is, how 
what we do, where we live, what we eat, and the resources available to 
us influence health and illness. The fundamental aim of the Center is 
to ensure that everything we are learning about health through 
scientific inquiry --not just physiology and genetics--is translated 
into policy and practice to improve the health of individuals and the 
public.
    It is this mission that brings me here today. As Dr. Fleming has 
pointed out in his testimony, no single group of Americans more than 
the elderly has as much to gain from putting into practice what medical 
evidence strongly suggests--that behavior matters.
    From avoiding risky behavior, to taking your pills on time, to 
getting appropriate medical screenings, a solid core of evidence exists 
on how to stay healthy and productive for as long as we can. In the 
past five years, Congress has doubled the funding for the National 
Institutes of Health, and the payoff should be seen in dramatically 
improved health outcomes in the years ahead. Or maybe not.
    The investment we have made in basic science will be diluted if we 
do not translate these advances into use--and use implies systematic 
changes in the behavior of doctors, health systems and individuals.
    Let me give you an example of what I am talking about. Biomedical 
researchers say that we are on the verge of seeing a new genetic test 
that will tell people whether or not they will get colon cancer. This 
development is a triumph of science; for many, it vindicates the 
nation's investment in discovery research at NIH by promising a 
tectonic shift in the burden of colon cancer, the cause of 56,000 
deaths a year in the United States. But this incredible advance coming 
from basic science necessitates a more powerful understanding of human 
behavior if we are to make the best use of it.
    From this one new test alone, many new questions will need to be 
answered to realize the promise of fewer colon cancer deaths. For 
instance:

1. How do you persuade people to take a test that may indicate with 
        high certainty that they are going to get a deadly disease?
2. What environmental and behavioral factors influence whether people 
        who test positive actually get the disease? And following on 
        that, what lifestyle changes can individuals make to reduce the 
        probability that they would?
3. What programs can we put in place to help people change and maintain 
        those long-held habits?
4. What constitutes good medical care for patients who test positive on 
        this test?
5. How can we ensure that physicians routinely provide such care?
6. What are the implications of this test for insurance generally and 
        for Medicare in particular--to cover the cost of the test, to 
        cover monitoring and to cover treatment for those who test 
        positive?
7. How will we train and deploy a workforce of genetics counselors to 
        introduce the entire U.S. population to the idea that they 
        ought to have a test that may very well change their lives and 
        prospects?
    These are questions that will not be answered by geneticists or 
biochemists or biologists. Rather, they are questions that will be 
answered by experts in learning, cognition, human factors, 
organizational development, health services research, epidemiology, 
economics, psychology and sociology.
    Biological science was the basis of developing the test. But that 
is only the first of several steps required to convert this discovery 
into an effect on the health of the population. Scientific attention 
must be paid to changes in the behaviors of patients, doctors, insurers 
and managed care executives if we are to successfully complete the 
production arc from laboratory to living room. Without systematic 
attention to these questions, the most sophisticated genetic test is as 
useless as a cell phone on the dark side of the moon.
    Even time-tested, effective technologies--mammograms and 
immunizations--are not finding their way often enough to the people who 
need them. Physicians forget to recommend them, patients don't ask for 
them, are confused about how often they need them and fail to comply 
with their doctors' advice to get them. The technology is brilliant but 
it requires human behavior to make it work.
    One recent action by CMS is an important, and unfortunately too 
rare, instance of attending to the behavior that connects the 
technology to its target. CMS reviewed the evidence on interventions 
directed at doctors, health care facilities and individuals to increase 
vaccine use, and, based on this review, implemented with CDC an 
effective pilot program in nursing home, creating standing orders to 
increase the possibility that the right immunizations get to the right 
seniors at the right time. CMS is proposing to take the next step to 
facilitate the delivery of immunizations and the use of standing orders 
in health care facilities.
    But behavior doesn't just matter in realizing the health benefits 
of the clinical preventive services covered by Medicare. There is 
overwhelming scientific evidence demonstrating the great gains to be 
had by reducing behavioral risks. Quitting smoking, increasing physical 
activity and preventing falls, are extraordinarily important but until 
quite recently have not been viewed by CMS as part of the Medicare 
prevention mandate.
    The new CMS-sponsored stop-smoking demonstration project is the 
agency's first effort to systematically address a major behavioral risk 
for disease and disability. And evidence has been gathered on the 
feasibility of pilot programs to assess risk, prevent falls and better 
manage chronic conditions. Each of these might have an important role 
to play in a Medicare program that aims to help Americans live as well 
as they can for as long as they can.
    Mr. Chairman, it would a terrible waste of the nation's health and 
resources if the knowledge generated by the health research sponsored 
by Congress sits in file cabinets in Bethesda and is not used to 
benefit the American public.
    The pharmaceutical and technology industries are responsible for 
bringing some of that knowledge to the marketplace, but they are not 
responsible for ensuring that what we know about quitting smoking or 
getting people to participate in screening tests becomes part of 
routine health care and community services.
    There are several ways Congress can act to make certain that we 
realize the full benefit of our investment in health research. Congress 
can:
    1. Raise the priority within CMS for addressing behavioral risks in 
the Medicare program, for example, by supporting demonstration projects 
to help seniors increase physical activity, reduce the impact of falls, 
manage chronic conditions, reduce alcohol and substance abuse and 
improve nutrition. These risks are critically important for seniors, 
and their health stands to gain from widespread availability of 
services to support behavior change to reduce them. We applaud the 
efforts of CMS to address expansion of prevention efforts to include 
smoking and other risk behaviors based on careful scientific review. 
Increased commitment on the part of CMS would expedite program and 
benefit design and feasibility assessment that would ultimately result 
in more effective prevention efforts.
    But medical care, even with Medicare reimbursement, is neither 
organized nor equipped to shoulder the entire burden for reducing risk 
behaviors among seniors.
    2. Foster better cooperation among federal agencies--CMS, CDC, 
AHRQ, AoA and NIA--to ensure that evidence drives the implementation of 
effective programs to improve health and prevent disease. Each agency 
brings different knowledge and resources to solving the problem of the 
health of seniors. Each agency is connected to seniors in different 
ways--through state and local health departments, local senior services 
or specialized research programs. More frequent communication and 
stronger collaboration among these agencies would benefit those 
individuals and families that each of these agencies claim to serve.
    But the federal government is by no means the only advocate for the 
health of seniors, and federal agencies play only a partial role in 
ensuring that the prevention programs for seniors are widely available.
    3. Encourage public-private partnerships among federal agencies 
with responsibility for seniors and the organizations that can act on 
evidence-based strategies to improve the health of individual seniors 
in the communities in which they live. The most effective programs will 
be ones that integrate the authority of health care with delivery 
capacity of local services that support seniors in living full lives.
    4. Increase the extent to which CMS makes use of evidence on how to 
overcome behavioral barriers in implementing preventive services. In 
implementing standing orders for immunizations, CMS showed that it 
understood just covering a service as a benefit is not enough; 
consistent policies and practices are necessary to get the right 
preventive procedure to be used right. More attention must be paid to 
ensuring that health care systems, group practices, physicians and 
other health professionals are encouraged to act on the evidence of the 
most effective means of ensuring that clinical preventive services 
reach the right individuals in a timely manner.
    5. Finally, by promoting better balance of basic and applied 
research in the federal health research portfolio. Just as we plan 
retirement security in our investment portfolio by creating a mix of 
stocks and bonds and cash, the nation's science portfolio must also be 
balanced--with an emphasis on application, translation and behavior.
    Although it is not the direct responsibility of this subcommittee, 
I would make the point that while funding for the NIH is going up by 16 
percent this year, funding for the lead agency for translating 
research--AHRQ--is being reduced by 16 percent. I am told that at CDC, 
less than 1 percent of its budget is spent figuring out how to apply 
what it spends the other 99 percent learning.
    The challenge before us is to figure out how to make sure that when 
medical breakthroughs are made, they get translated at the right time, 
to the right people, in ways that will make a difference. Because when 
it comes to health, biology matters, pharmaceuticals matter, genes 
matter, but behavior really matters.
    Thank you, Mr. Chairman.

    Mr. Greenwood. Thank you. Appreciate it. All of you.
    The Chair recognizes himself for 10 minutes for questions.
    Ms. Quirion, you, in your comments, mentioned--sort of 
referred to the fact that perhaps if you'd had some preventive 
care early on, or some access to some advice, information, that 
you might have spared yourself some of--you might have been 
spared some of what has befallen you.
    Ms. Quirion. I think I would have found out sooner that I 
had ovarian cancer, and they might have did the surgery very 
successfully. But because that I didn't have a pap smear, 
because they didn't pay for them, or annual checkup, I had the 
pain----
    Mr. Greenwood. That's what I wanted to get at. You had no 
idea that you----
    Ms. Quirion. No idea whatsoever. I've always been active, 
but I had abdominal pain that I knew there was something wrong. 
So I went to see my doctor right away. She was very alarmed.
    Mr. Greenwood. Were you going for any kind of regular--you 
weren't going for regular physicals?
    Ms. Quirion. I go once a year for a checkup, but not a 
physical because they didn't pay for it. So right away she 
suspected it wasn't good, and she sent me to all specialists. 
She called me in her office the next day to tell me that I had 
ovarian cancer. And there are four stages, and they found out 
that my stage was 3.2. So it might not have been as serious if 
I could have detected it before.
    Mr. Greenwood. And when you said you had an annual checkup, 
but not a physical, what do you mean?
    Ms. Quirion. Well, they just checked the blood pressure and 
the blood work for sugar and something like this.
    Mr. Greenwood. But it wasn't a thorough physical exam?
    Ms. Quirion. No, not a final one.
    Mr. Greenwood. Let me address a question to Dr. Himes, if I 
may.
    Within the Medicare+Choice program that you work for, what 
are the utilization rates of preventive services covered--that 
are also covered by traditional Medicare, like flu and 
pneumonia vaccine, breast cancer screening, for the Medicare 
beneficiaries under your care?
    Ms. Himes. We just looked that up because we heard that 
question earlier. For flu shots, our latest available data is 
84 percent; for mammograms, 83 percent; for cholesterol 
testing, 78 percent for primary and secondary prevention of 
heart disease.
    Mr. Greenwood. I'm assuming that those rates are higher 
than they are for--I don't know if you have that data, but 
they're higher than they are for--they sound to be probably 
much higher than they are for----
    Ms. Himes. For the general community.
    Mr. Greenwood. For the general community, certainly, for 
the fee-for-service folks.
    Which raises the question, of course, how did you get those 
rates that high? What do you do that encourages----
    Ms. Himes. We do several things on all kinds of levels. The 
first is patient education and awareness about all of those 
things, now on the Web site, but it used to be in a whole 
variety of ways through pamphlets, through cards that we have 
people carry around in their pocket that say what adult 
screening schedules and preventive care schedules should be.
    Mr. Greenwood. Let me interrupt you for a second. I 
apologize for doing it, but I want to get something clear.
    Ms. Himes. Please.
    Mr. Greenwood. Do you have 60,000 lives?
    Ms. Himes. Yes.
    Mr. Greenwood. How do they compare demographically to the 
country at large? Do they tend to be--because there's a self-
selecting process that goes----
    Ms. Himes. Right. We have a Center for Health Studies 
Research wing that works with the University of Washington, 
and--oh, I think two times now, one in the early 1990's and one 
in the late 1990's--we had CHS do a look at our community, the 
western Washington area--catchment area and compare Group 
Health patients, according to chronic disease scores, with our 
community in general. And it looks like we're about the same. 
So it doesn't look----
    Mr. Greenwood. In terms of disease?
    Ms. Himes. In terms of chronic diseases.
    Mr. Greenwood. But I was referring to----
    Ms. Himes. Oh, I'm sorry. Are you referring to weights?
    Mr. Greenwood. The demographics--the educational, the 
income demographics. Do your 60,000 folks tend to be younger, 
healthier, wealthier, better educated than the average; or do 
you think that they are fairly much a cross-section?
    Ms. Himes. What we think is, their demographics in general 
are essentially the same as the community in general. In part, 
that is because most of our folks, 80 percent of our folks, 
have been with us forever; and so originally joining the 
program as young adults, aged into the program. We've been 
around for 54 years.
    So we've had a very stable number of Medicare recipients 
over the years, and in recent years have added another, oh, 
13,000 or 14,000 with the new influx of Medicare+Choice 
enrollees, but essentially kept our stable population. It 
appears to reflect demographically, and in terms of burden of 
illness, our community.
    Mr. Greenwood. Ms. Quirion, I should point out to you that 
I believe your Congressman is here, Mr. Allen is here too.
    Ms. Himes. We then have registries that allow us to follow 
up on immunization registries and general disease registries 
that allow us to follow up on patients through our primary care 
practices. So we feed back to our primary care physicians and 
nurses on a regular basis four times a year what their rates 
are for all of these screening tests on mammographies, 
immunizations, et cetera.
    And finally, then, organizationally, we put systems in 
place to remind patients so that, for example, patients get 
postcards in the mail to remind them when their mammogram is 
due; they get postcards about flu shots, et cetera. So there 
are a whole variety of systems that get put in place.
    That is really, in many ways, the benefit of the 
Medicare+Choice program for us.
    Mr. Greenwood. Is there a program for--a Healthy Aging 
initiative, or is that something separate?
    Ms. Himes. It is part of our, in general, preventive health 
care promotion initiative. I mean, it includes the entire 
organization, if that is the question.
    Mr. Greenwood. Okay.
    For any of you, I--Ms. Quirion, it was clear to me from 
your response that you think that if Medicare covered--paid for 
a regular physical examination, that you would have come in 
regularly to get them, and that might have spared you a lot of 
the suffering.
    Let me ask the other three of you. You've listened to the 
rest of this hearing. I'm interested in your views on that very 
forward and simple question, because as I said earlier, it 
seems intuitive to me that if Medicare, A, reimbursed 
physicians for a fairly comprehensive annual physical exam, 
like most people with good health care plans get, that a lot 
of--there would be a lot of advantage to that, both in steering 
people toward screening activities, toward looking at the 
questions that have been raised here with things like blood 
pressure, vision, hearing, depression problems, tobacco 
cessation, dental hygiene, physical activity, fall prevention. 
All of those things could be part of the questioning process 
that went on in an annual physical exam, it seems to me.
    I don't know in my own mind yet whether I think it actually 
saves the Medicare program money in the long run or not, but it 
seems it would promote a heck of a lot of well-being and 
prevent a lot of suffering.
    I'd like your thoughts on that, Dr. Gold, Dr. Himes and Dr. 
Gruman.
    Ms. Gold. The short answer is yes.
    It is interesting. When you look at what the Task Force 
suggests, they sort of say, every exam should be an opportunity 
for prevention, and I think that that is great wisdom for a 
practicing doctor. But I think the reality in today's world is 
that you're seeing a lot of people who have a lot of 
difficulties, and to actually seize that opportunity and create 
that time to spend the time counseling, or to do some of the 
risk assessment, just doesn't--it gets lost in the shuffle.
    Mr. Greenwood. And that is true in any--when something is 
bugging me, when I've got a headache or something is hurting 
me, and I go see the doctor in the Capitol, he doesn't take 
that opportunity to ask me 25 questions about the rest of my 
health care. He gives me what I need, and I'm out of there. And 
I would assume that is the same with Medicare beneficiaries as 
well.
    Ms. Gold. I think that is exactly right.
    A number of years ago--I was in Washington for a number of 
years, and we did a study for Health and Human Services that 
looked at the cost of sort of bundling preventive services into 
an annual visit, and did some costing out for Medicare; and 
that might be an interesting report to get to you folks. It 
really added, at that time, perhaps $18 or $20 a year, as I 
recall, to the overall expenditure per capita; and that seems 
like a pretty good deal.
    The only other thing I want to say, and it is just sort of 
a throwaway line, is the notion that prevention should be cost 
saving is one that really sticks in my craw a little bit. That 
is not--the design of health care is not to be cost saving. The 
design of health care is to promote health.
    I think the whole notion of cost-effectiveness analysis, 
which is a different issue--how much health do you buy for the 
money you invest--is actually a lot more useful way to be 
thinking about Federal investments.
    Mr. Greenwood. If I can interrupt you on that, I quite 
agree with that. It helps, because of the straitjacket of 
budget tiering around here, if we can show that something pays 
for itself. So it just makes our life a heck of a lot easier.
    But the fact of the matter is that, A, if preventive health 
care keeps our parents and eventually ourselves happier and 
healthier and avoids Ms. Quirion's suffering, that is what the 
whole system is supposed to be there for; and that is justified 
in itself.
    But there are so many other related costs that can be 
prevented. For instance, wage loss. I mean, you think of how 
many people are not out in the world earning a living because 
they've lost their wages. But if Dr. Himes and Dr. Gruman can 
respond as well----
    Ms. Himes. A couple of points: The first is that, just for 
your information, we do, of course, pay for--or there is no 
extra, added expense, except for copay in some cases, and often 
not that--for a physical exam; and we get 25 percent of our 
seniors who self-select for a physical every year. So just to 
let you know in kind of a general way in our population.
    But a second part of all of this is this big bugaboo of a 
question of what is entailed in a complete physical. And that 
is a very interesting question, and what I would argue here, 
and the one point I really want to make that I tried to make 
earlier and made in my written statement, is that what we do 
know from the literature--and some of this literature, we've 
contributed at group 2 at Group Health--is that if, as people 
get older, you focus the preventive care or health promotion 
visit on the geriatric syndromes that really interfere with 
functional status and that include physical activity, et 
cetera, smoking cessation and all of the things we've talked 
about today--if you focus on those things, rather than 
distracting your time on the millions of complaints you could 
possibly talk about, then in only--we have really clear data 
that in only 6 to 12 months you can make huge decreases in 
costs, in utilization; so that physicals for seniors, if you 
will, that are done in the geriatric assessment model really do 
show very quick results, quicker than any other preventive care 
work that we do around diabetes or anything else--so something 
to very seriously take a look at covering.
    Thank you.
    Mr. Greenwood. Thank you.
    Ms. Gruman. I have two comments, kind of add-on to those. 
One is that it strikes me that all these questions about a 
physical exam kind of raise the problem of something that has 
just been a really important health policy issue for a while, 
which is what is the role of the primary care physician, and 
particularly for older people, what is the role of the 
geriatrician in serving that role of the primary care 
physician, which is not only to coordinate prevention care, but 
also, once you find something, to coordinate the rest of the 
care?
    And, you know, this is an issue that managed care tried to 
kind of manage into place, and I think with not too much 
success. Raising the capacity of primary care physicians to 
serve as--in this very care-coordinated role, as well as 
professional, in a 7-minute office visit has been a really 
tough thing.
    And that actually raises----
    Mr. Greenwood. Let me interrupt you. What drives--I mean, 
this is somewhat of a--I think I know the answer to this 
question, but what drives it to be 7 minutes instead of 20 
minutes?
    Is it not what Medicare will pay for that?
    Ms. Gruman. No. I think it probably has more to do with how 
people are organizing their patients these days; and, you know, 
probably also how much time they spend complaining about being 
in managed care programs. You know, it cuts down on the medical 
visit.
    Anyway, I think that it does raise another--two--that kind 
of raises two other issues. And one is that it is possible that 
there is a need to really expand the kind of people who deliver 
those--who help to deliver the kinds of preventive services 
that we're talking about, primarily if you move into the zone 
of doing counseling or referring people to other kinds of 
expertise, for example, with smoking cessation.
    I think a more creative approach to what is covered--I 
mean, is a telephone call covered to coordinate care versus 
only an office visit? Can Medicare--can CMS support telephone 
counseling lines and nurse advice lines that would help to cut 
down on some of the kind of extra time that physicians might 
take to take care of their patients and to really address all 
of these preventive issues that are important?
    And I think that the final point that your question raises 
is something that actually came up in your first question. You 
said something, your first question to the first panel when you 
said something about, well, you know, if I could just go to the 
doctor and get my exam, then I would be healthy. And I'd just 
like to remind us all that going to the doctor and having an 
exam once a year is not the thing that is going to make us 
healthy, that that hour is one tiny piece of time when you're 
under the supervision of a physician, but the things that you 
do every day--what you eat and how you exercise, or don't--
really make much more of a difference than that 1 hour.
    So just to kind of keep that in perspective, I think, is 
important.
    Mr. Greenwood. Well, I think it is exactly the case. I 
think what I'm trying to get at is this recurring information 
that we hear that if you look at the people with the worst 
health outcomes, they seem to be the ones who are not availing 
themselves of any of the preventive modalities--not the 
screenings, not the--and not the smoking cessation and not the 
diet and not the activity.
    And if you ask, why is that, it seems to me that the 
recurring answer is--in large measure is because nobody has 
suggested it to them. Nobody counseled them about it. Nobody 
pointed them in that direction.
    And obviously there are a lot of ways we can try to 
communicate with these beneficiaries, other than in the 
doctor's office, but it is just my intuitive sense that having 
that regular opportunity to know that you can go in and spend 
some quality time with your primary care physician or 
geriatrician and cover a variety of issues, it would seem to be 
a very effective way at steering people to all of these, both 
tests and behaviors.
    Ms. Gruman. I think that you're right, that there's an 
incredible authority that that still resides with physicians 
and the ability of physicians to use that, to not only say, you 
know, you need to take these drugs in this way, but also there 
are other things that you need to be thinking about.
    And to help people set priorities is really critically 
important. I think there need to be other ways of linking that 
advice to individuals--individuals to services in the 
community, that it's not just--it can't just be a one shot, 
gee, I think you should stop smoking, and not be able to give 
people other ways to kind of act on that advice.
    Mr. Greenwood. Thank you.
    The Chair recognizes the gentleman from Kentucky, Dr. 
Fletcher, for 10 minutes.
    Mr. Fletcher. Well, thank you, Mr. Chairman, and I thank 
the panelists. I wasn't here for all of it; I had some 
constituents come to visit. But again, thank you for your 
testimony.
    One of the things--let me address this to--I think, Dr. 
Himes, you talked about physical fitness, and I know we have 
referenced here the New England Journal of Medicine. There was 
a study that was reported in the New England Journal of 
Medicine that talked about poor physical fitness as an 
indicator of poor outcomes and even a stronger indicator than 
some of the other things we usually look at--whether it is 
smoking or some of the other high potential for risk things.
    And I know you mentioned in the Medicare+Choice--are there 
plans that provide for physical fitness, and what can we do, 
and what are the roadblocks that we face here in, say, in the 
typical Medicare fee-for-service from trying to put more 
emphasis on the physical fitness programs?
    Ms. Himes. The literature clearly shows that if you look at 
all of the indicators or all of the things that we commonly 
think of as screwing up people's lives as they get older, that 
physical fitness, on the very positive side, is the one thing 
that statistically, significantly is relevant in terms of 
positive health care outcomes for all seniors, if you look at 
the entire Medicare population.
    The only other thing that is statistically significant 
actually is social isolation on the very negative side.
    So physical activity then becomes a real mainstay. It is 
the biggest bang for the buck, as I personally look at it, 
individually for my patients and for others.
    The question then becomes, what do we do about that as an 
organization? If I look at Group Health's 60,000 seniors, what 
do I say we're going to do about that? In the--for us, once we 
understood that literature base, we then went on to look at, 
okay, what kind of exercise is the most important? It turns out 
that not only aerobic or endurance exercise, but muscle-
strengthening and flexibility is really important. And it also 
turns out that actually, as with everything, people who are the 
most disabled or the most frail are the folks who have the most 
to benefit.
    So in looking at those populations, then how do you develop 
exercise programs that health care organizations can sponsor to 
send people to? Because you're exactly right, if you don't have 
programs to send people to, I can talk until I'm blue in the 
face to an individual patient in my office about starting to 
exercise, but if I don't have some specific ways for that 
person to exercise, especially the more disabled they are, it 
rarely does any good.
    So we developed a program called the Lifetime Fitness 
Program, which we actually just finished doing some outcome 
studies around, and showed about a 20 percent decrease over 1 
year for a Lifetime Fitness participant as compared to our 
senior Medicare population in general, in terms of both overall 
costs and health care utilizations. And 3 or 4 years ago, we 
decided that we would start to cover as a Medicare benefit some 
exercise programs.
    We contracted with local health clubs for a program called 
Silver Sneakers, and with local senior centers for our Lifetime 
Fitness Program and started to offer those two programs as 
benefits for our Medicare recipients. Since that time, I've 
sent a lot of my--I write prescriptions for patients, and I 
send a lot of my patients to those programs.
    A lot of folks won't go, especially my most disabled 
people, so I started a program, actually in my own clinic just 
for my folks, to see what would make a difference for them and 
what would get them to exercise; and we just made a video of 
these guys there called ``The Dancing Ladies and Their Few Good 
Men,'' and they've become an inspiration to many people. So we 
are making a home exercise video.
    So I think that bottom line here is that health care 
organizations, Medicare--Medicare programs in general need to 
be promoting, but not only promoting, really developing and 
sponsoring physical activity programs for the entire range of 
folks, whether they live in nursing homes, whether they live at 
home, whether they can go to a health club, or whether they 
live in an assisted living facility. We need to figure out ways 
to get people exercising across the board.
    And just for you all's information, there is a brand-new 
effort that has just started called the ``National Blueprint on 
increasing Physical Activity in Folks 50 Years and Older,'' 
that is sponsored by the Robert Wood Johnson Foundation and the 
CDC. And we are going to make a difference.
    Mr. Fletcher. Okay. Thank you.
    Let me ask, one of the--you know, in my practice, one of 
the problems I had--and the chairman mentioned this. When a 
patient comes in with an acute problem, the last thing they 
want to hear is a lecture on probably something else, because 
they are not feeling well, they've got a problem, their family 
is concerned about that, and it's just--you know, not now, this 
is not the time.
    So I think the utilization of a lot of extenders, or other 
individuals that can help in the educational process, is very 
important. Physicians do, and studies seem to have a certain 
degree of credibility that is very important to emphasize those 
things.
    One of the things that we were never able to implement--and 
I'm very interested in what I call e-medicine--is the fact of 
having information come up that's specific for the patient, 
based on evidence, but additionally in what's probably 
considered some of the best practices, so that that pops up 
electronically to provide information to the patient, can be 
some reinforcement.
    And Dr. Gruman, let me ask you, what work is being done in 
that regard? And what can we look forward to, or some of the 
things we could do in Medicare to help implement some tools for 
practitioners to really start putting a greater emphasis on 
prevention?
    Ms. Gruman. I think there's a tremendous amount of work 
that is being done to try to develop different technologies, 
using the Web, using various kinds of search engines to find 
the best--to match the right information to the right person at 
the right time.
    Right now, there's a bit of a forest-and-the-trees problem 
in that consumers have one sense of what information they need 
and how to set the sort--set the--kind of the filter; and 
physicians have another--another set of concerns that may--in 
many cases, includes keeping a lot of that information out of 
the physician-patient relationship because it's just too 
confusing. They'd much rather have the old-fashioned 
relationship, where physicians get to tell the patients what to 
do and what not.
    So I think we actually are in a time of great change right 
now. I think that--in terms of the Medicare program, I think 
that looking at the range of ways that patients can interact 
with authoritative sources and ensuring that those 
authoritative sources really are good and having some 
flexibility about how those things are covered and what kind of 
access people have is really important.
    For example, I know that the demonstration project on 
smoking cessation that CMS is going to be sponsoring features a 
1-800 QUIT LINE; and, you know, if they can generate enough 
demand through physicians telling their patients that they 
should stop smoking and that they should use this, that could 
be a really wonderful extender.
    I think that there are lots of other kinds of technologies 
that are available, like that, that just--that really haven't--
haven't even really been considered. Because no one has really 
said to CMS, you know, you've got to figure out a way to help 
physicians use their time better; and what are the central 
things that we could support, we could control quality on, that 
wouldn't involve kind of licensing a whole other guild to 
deliver services, but would in fact serve to make accessible to 
individuals information that they need in order to stay 
healthy?
    And I think kind of liberalizing, or asking CMS to really 
look at some of those technologies, would be a really wonderful 
thing.
    Mr. Fletcher. Thank you.
    Ms. Quirion, you mentioned that if some of the preventive 
measures would have been available and paid for and things, 
that it would have helped you tremendously.
    One of the things I noticed--or one of the things in my 
experience--it's probably been presented here in the last 
couple of panels--is, it's extremely difficult to get 
information out to the general population on the importance of 
prevention in a way that will spur them to actually act in 
common and do something about it. And I wondered, since you 
represent a lot of folks on behalf of this--a lot of retired 
Americans, what can we do?
    And let me just throw out something. You know, when we go 
get a driver's license, there are certain things we have to 
know before we get the privilege of driving on the roads. What 
can we do to make sure that there is some personal 
responsibility here for seniors, but we do what--through 
Medicare, whatever, to make sure that there's a certain 
educational level regarding the prevention and their 
responsibility for the health care, to make sure they get 
there?
    I'm just wondering if you have any ideas on that for us.
    Ms. Quirion. Well, all that they say here is true, about 
smoking and drinking, and that's something I've never done. And 
I exercised, and I worked. After I stopped working and I 
retired, I took another job, a second job, and I've been 
working hard for 12 years. So I did all those things.
    I try to eat well. But that did not prevent the fact that 
if I would have had a physical, anything like this, it would 
have prevented it from being--being in the state that I was, 
and I would have had a better chance really of recovering 
better from this. I might have had the surgery, no chemo.
    And there's a lot of people that die of those things, and I 
think never even know what they have. They don't tell their 
physician the reason--I went there because I started to have 
abdominal pain, and I knew that there was something wrong, but 
some don't do that. They just--once they discover it, it's too 
late for them, period.
    Mr. Fletcher. Dr. Gold, would you have some comments on 
that, as far as educating the general population and the 
responsibility there that might be included in some Medicare 
programs, whether it's some educational things that encouraged 
or incentivized or required?
    Ms. Gold. It's interesting. I've been thinking about 
incentivizing, but I've been thinking about it in a slightly 
different way. I was thinking about the UK experience where 
physicians are actually incentivized to deliver preventive 
services, so in your panel you get paid your per capita rate.
    But if you can bring more people in for preventive services 
because that is seen as a social good--which, I would argue, is 
the same in the United States as in the UK--it might be worth 
thinking about setting priorities of clinicians and physicians 
more toward prevention.
    Medicare has been sort of heavy-handed in the way it 
reimburses for technological procedures, and so light-handed in 
the way it deals with the sort of less technological and more 
behaviorally based kinds of things. So that is one reflection.
    The other thing I would say, having spent my clinical 
career really serving low-income populations--first, rural and 
now, urban--some of the notion of education, I think, is a 
tricky one. You know, how many lower-income Americans sit in 
their living room with computers? How many less-educated 
people, you know, have had that benefit? You know, 30 years 
from now, we may be fine, but that is not where we are now.
    And I think that there is something else also about health 
which is very intimate, and the whole notion of the 
relationship one develops with a primary care provider and the 
sort of power-of-the-profession thing is a real one, and so it 
is fine. I mean, I think it's enhancements you plug into your 
computer, and up comes your--you should do this thing. But the 
reality is that a lot of people are pushed toward taking action 
because somebody is concerned about them and makes a specific, 
tailored point about them, the individual.
    Mr. Fletcher. So let me sum up. Do you think something 
where incentivizing the providers or the physicians is going to 
have a greater impact than a direct response to the general 
population; for example, making sure that there's--that they 
become familiar with preventive measures that have been shown 
to be effective?
    Ms. Gold. I think that would be a great thing, and I think 
that particularly in underserved populations or underinsured 
populations, where there's an excess of morbidity anyway, when 
the patients are coming in, you're sort of riveted on the 
diabetes out of control, the hypertension out of control. To 
get those practices and those doctors to find ways--innovative 
ways, different programs at the grass-roots level that bring 
people in--takes some extra work on the part of those 
organizations and those providers; and I think if you can build 
in that kind of incentive, that is a great policy piece to 
think about.
    Mr. Fletcher. Thank you. My time has expired.
    Mr. Greenwood. We thank the gentleman.
    And I think--ultimately, as I grapple with this issue, I 
think you need to have incentives for the provider. I think you 
have to pay providers a decent reimbursement for a good, 
thorough examination, and I think that we need to think of the 
incentives for the patients.
    I mentioned earlier--you know, I'm just playing around with 
these thoughts--but whether your premium changes or you lose--
you have a benefit in terms of a deductible for hospitalization 
because you've avoided hospitalization by doing certain things, 
I think you can keep it pretty simple and figure out some ways 
to attract people in to get these exams.
    Let me just--one final question. And we've covered the fact 
that we all think it is in the best interest of us as a 
society, out of just pure compassion and quality of life, to do 
these things so that the people live longer, healthier, happier 
lives; but we do have to, here in Washington, deal with this 
darn issue of cost effectiveness and does it save us money in 
the long run.
    It seems that there is a dearth of really good information 
on that subject and it is shocking to me. It is shocking to me 
that not CMS, not CDC, no one has really been able to say, yes, 
this is such an obvious question, it has been asked a thousand 
times and the answer is very clear with regard to how 
preventive services do or do not save dollars, and how to 
maximize that.
    My question is: What do you think we ought to do about this 
dearth of knowledge? Is this something that the CMS ought to be 
tasked to, in a very comprehensive way with supercomputers, be 
gathering all of this information from the field and doing 
longitudinal studies; or do you think we need to pay for 
somebody like the Academy of Sciences or GAO to do a massive 
study? Is the data all sitting there and we just need to 
collect it from insurance companies? What do you think we ought 
to do so we can be real smart about this question of cost 
effectiveness?
    Ms. Gold. Let me go back to this whole notion of the 
continuum between primary, secondary, and tertiary prevention. 
Tertiary prevention is real treatment.
    One question which arises when beginning to scrutinize 
everything in terms of its cost effectiveness is will you do 
everything; and the answer is you can never do everything 
because it would take a lot of person-power hours. The analytic 
piece itself would be challenging. There are lots of procedures 
that we do in medicine which have been grandfathered and 
grandmothered in. We will never really know how effective they 
are. They just sort of state what goes on.
    I am very much a proponent of thinking about how effective 
what we do in medicine is. Evidence-based medicine has been 
extremely helpful to me on a personal practitioner basis and 
also in the teaching that I do.
    I do think that incorporating the cost piece is really 
important. There have been some sort of major breakthroughs in 
standardization of cost-effectiveness analysis over the last 
several years. I think in reality many of the Federal agencies 
are not adequately funded to be able to incorporate some of 
those kinds of evaluations. If there were a concerted effort 
from the Congress to say we really would like to know as we 
begin to grow the Medicare program in different ways, what the 
health effect we are getting for the investment is, that would 
be an extremely large contribution to sane policymaking.
    Again the problem we have to solve is to think smartly 
about what set of services we are going to put that charge 
around, and how are you going to make those decisions. We can 
look at top medical conditions for which Medicare is paying, 
and say is there effectiveness information? I think it is a 
large charge. I think it is a very, very important one, but 
will be a difficult one to figure out exactly how you want to 
approach.
    Ms. Himes. I think there are two issues. Essentially one 
is, what is good preventive care? Coming up with that idealized 
model, if you will, of what we want to be telling seniors or 
docs that they should be doing for seniors in the preventive 
care mode is essential. I don't think there is clear agreement 
on that, overall, at this point in time. There is lots of 
individual evidence around individual preventive measures but I 
think you are right, the overall piece is not there.
    Then my personal bias is that CMS and Congress ought to 
sponsor a series of demonstration projects to just look very, 
very clearly at how can systems do this. In my own system the 
question of our network model versus our group model, where we 
have got physicians out there in the world who have very few 
group health practitioners and other physicians who contract 
exclusively with group health, we have learned a lot from those 
two separate models. We focus much more on patient education in 
that external world; much more on physician education, and 
patient, in the internal world.
    So I think a series of demonstration projects really 
looking at what is good preventive care, No. 1, and then how do 
you put it out there. And what, not only money does it save, 
but what changes does it make in the quality of life of folks.
    Ms. Gruman. I think it is a really interesting question 
that you would raise, and especially the assumption that 
someplace out there, there should be all of this information. 
It is not like prevention is just a new thing that we do not 
know anything about.
    I think this goes back to a point that I made earlier which 
is that the NIH budget for this year is $23 billion; and the 
budget for the Agency for Health Care Research and Quality, 
which is the federally mandated organization whose role it is 
to translate research into policy and practice, has a budget of 
$307 million. That is slightly over 1 percent of the NIH 
budget.
    We have this huge bonus of new science coming down the 
pike, and we don't even know what the right preventive services 
package is. I think we need to really think about balancing the 
research portfolio so that some of these questions can be 
answered, and not just for the Medicare population. These are 
questions that really need to drive health care generally in 
this country.
    Mr. Greenwood. Okay. I want to thank each of you, 
particularly you, Mrs. Quirion, for your courage in being with 
us. We will take your words to heart.
    I thank each of you for your testimony, and the hearing is 
adjourned.
    [Whereupon, at 1:20 p.m., the subcommittee was adjourned.]
    [Additional material submitted for the record follows:]
          Prepared Statement of the American Heart Association
    Mr. Chairman and distinguished members of the Subcommittee on 
Oversight and Investigations: The American Heart Association commends 
you for holding this hearing entitled ``Assessing America's Health 
Risks: How Well Are Medicare's Clinical Preventive Benefits Serving 
America's Seniors? How Will the Next Generation of Preventive Medical 
Treatments be Incorporated and Promoted in the Health Care System?'' on 
May 23, 2002. The Association presents to the subcommittee the 
following statement, and we appreciate the opportunity to be heard on 
this important topic.
    The American Heart Association works to reduce disability and death 
from heart attack, stroke and other cardiovascular diseases through 
research, the development and distribution of consumer education 
materials, and grassroots advocacy. The American Heart Association 
currently spends over $380 million of its own resources annually on 
research support, public and professional education, and community 
programs. The Association does not accept government funding.
    Nationwide, the organization has grown to include more than 22.5 
million volunteers and supporters who carry out its mission in 
communities across the country. The Association is the largest 
nonprofit voluntary health organization fighting heart disease, stroke 
and other cardiovascular diseases, which annually kill about 960,000 
Americans.
    Heart disease, stroke and other cardiovascular diseases have been 
America's number one killer since at least 1919, and today these 
diseases account for more than 40 percent of American deaths. These 
conditions are a major cause of disability as well. Heart disease 
alone, for example, is the major cause of premature, permanent 
disability of American workers and accounts for nearly 20 percent of 
Social Security disability payments.
    Nationwide nearly 62 million people, or 1 in every 5 Americans, 
live with one or more of these diseases. Both genders and all age 
groups suffer from these diseases, and in many cases, cardiovascular 
diseases strike down otherwise healthy individuals for reasons not yet 
fully understood.
    Tens of millions of Americans have major risk factors for these 
diseases that can be modified with appropriate interventions: an 
estimated 50 million have high blood pressure, more than 41 million 
adults have elevated blood cholesterol (240 mg/dL or above), 48 million 
adults smoke, more than 108 million adults are overweight or obese and 
nearly 11 million have physician-diagnosed diabetes. Clearly, as the 
``baby boomer'' generation ages, the number of Americans afflicted by 
these often lethal and disabling diseases will increase substantially.
    What is perhaps most shocking is the cost of cardiovascular 
diseases. These conditions cost Americans more than any other disease--
an estimated $330 billion in medical expenses and lost productivity in 
calendar year 2002 alone. Three of the top five hospital costs for all 
payers (excluding childbirth and its complications) and three of the 
top five Medicare hospital costs are cardiovascular diseases.
    While the American Heart Association strives to find breakthroughs 
in the treatment for these conditions through our support of research, 
the organization is also devoted to the prevention of cardiovascular 
diseases as well. We strongly believe that mortality rates can be 
drastically lowered, and disability from cardiovascular diseases can be 
greatly reduced through scientifically proven prevention methods.
    Congress has discussed preventive measures in recent months and has 
passed many into law in recent years. While the Association supports 
breast, vaginal, prostate and colon cancer screenings, glaucoma 
screenings, bone mass measurements, pneumococcal and influenza 
immunizations, and all of the other preventive measures that Congress 
has enacted on behalf of Medicare beneficiaries since 1981, none of 
these measures focus on the number one and number three killers in the 
nation--heart disease and stroke.
    Periodic cholesterol screenings, healthy diets combined with even 
moderate amounts of exercise, and kicking the cigarette habit for those 
who smoke have all produced dramatic results. It is important to note 
that scientific studies have shown these results can be achieved in 
both young and elderly individuals alike, and that it is never too late 
to have an impact on your long-term health outcomes through preventive 
measures.

                    CHOLESTEROL AND LIPID SCREENING

    Perhaps the best example of a preventive benefit that Congress 
should add to the Medicare Program as quickly as possible is coverage 
for periodic screening of cholesterol and lipid levels. The American 
Heart Association urges Congress to add coverage for this important 
preventive test. Consider the following:

 In separate federal initiatives conducted by NIH and AHRQ 
        (discussed below), both agencies published recommendations over 
        a year ago stating that all elderly Americans should undergo 
        periodic screening of their cholesterol and lipid levels.
 In relation to other health care costs and preventive 
        benefits, the annual cost of adding this coverage to the 
        Medicare Program would be relatively modest (even without 
        considering the potential financial savings of preventing acute 
        events such as heart attacks and strokes).
 Cholesterol screening is becoming more widely recognized by 
        Americans as an important aspect of basic health care, and as 
        such, Medicare coverage of cholesterol and lipid screening 
        would be meaningful to Medicare beneficiaries.
    The need for covering cholesterol and lipid screening as a 
preventive service under Medicare has never been clearer. In May of 
2001, two separate panels from the National Institutes of Health (NIH) 
and the Agency for Healthcare Research and Quality (AHRQ) concluded 
that elderly individuals of all age ranges can substantially lower 
their risk of heart attack by aggressively treating abnormal 
cholesterol and lipid blood levels. Previously, these agencies had 
established upper age limits within their federal cholesterol screening 
guidelines, but they changed these recommendations last year in the 
face of overwhelming scientific evidence. Nonetheless, although these 
federal recommendations highlight the importance of cholesterol 
screenings for elderly patients, many Medicare beneficiaries are not 
able to benefit from these simple tests under current Medicare coverage 
policy.
    Currently, Medicare beneficiaries are only covered for cholesterol 
and lipid testing if they already suffer from known illnesses such as 
heart disease, stroke, diabetes or other disorders associated with 
elevated cholesterol levels. In many cases, seniors eligible for these 
tests are already victims of a condition cholesterol screening might 
have caught and helped prevent. By adding cholesterol screening as a 
covered benefit for ALL seniors enrolled in the Medicare program, 
Congress will enable Medicare beneficiaries and their physicians to 
learn of otherwise silent problems and seek appropriate treatment in 
advance of a disabling or deadly event. This will help drastically 
reduce the number of cardiovascular disease and stroke deaths each year 
and will greatly reduce the number of individuals disabled by these 
conditions.
    With this in mind, the American Heart Association is leading an 
effort to enact H.R. 3278 and S. 1761--The Medicare Cholesterol 
Screening Coverage Act of 2001. We ask that your committee consider 
these bills as you investigate Medicare's preventive benefits. 
Congressmen Dave Camp (R-MI) and William Jefferson (D-LA) introduced 
this important bill in the United States House of Representatives late 
in 2001. Senators Byron Dorgan (D-ND), Ben Nighthorse Campbell (R-CO) 
and Jeff Bingaman (D-NM) introduced a companion bill in the United 
States Senate. This legislation will guarantee Medicare coverage of 
preventive screenings for cholesterol and other lipid levels.

                      SMOKING CESSATION COUNSELING

    As the nation's largest health care purchaser, the federal 
government has a vital role to play in promoting effective, affordable 
tobacco use cessation services. Research consistently has shown that 
smoking cessation saves lives, reduces smoking-related health care 
costs, and is one of the most cost-effective health interventions 
available. Unfortunately, some government financed health care 
programs, including Medicare and Medicaid, do not provide reimbursement 
for some of the most effective smoking cessation treatments recommended 
by the Department of Health and Human Services' Clinical Practice 
Guideline for treating nicotine addiction. The facts supporting 
expanded coverage of effective smoking cessation treatments are 
compelling.
    Tobacco use is our nation's number one cause of preventable death. 
Tobacco use causes more than 400,000 deaths each year among smokers and 
contributes to profound disability and pain in many others.1 
About half of all long-term smokers die prematurely of diseases caused 
by smoking.2 The U.S. Surgeon General has concluded that 
reducing tobacco use is the single most important action this nation 
can take to reduce death from heart disease and other chronic 
diseases.3
---------------------------------------------------------------------------
    \1\ U.S. Department of Health and Human Services. Reducing Tobacco 
Use: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department 
of Health and Human Services, Centers for Disease Control and 
Prevention, National Center for Chronic Disease Prevention and Health 
Promotion, Office on Smoking and Health, 2000.
    \2\ Peto R, et al. Mortality from Smoking in Developed Countries, 
1950-2000. New York, NY: Oxford University Press, 1994.
    \3\ U.S. Department of Health and Human Services. Reducing Tobacco 
Use: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department 
of Health and Human Services, Centers for Disease Control and 
Prevention, National Center for Chronic Disease Prevention and Health 
Promotion, Office on Smoking and Health, 2000.
---------------------------------------------------------------------------
    Tobacco users would like to quit but success rates are low. 
Approximately 50 million Americans are now addicted to tobacco 
products.\3\ More than 70 percent of all smokers report that they would 
like to break their addiction, but have not been able to do so.\3\
    Effective, therapies exist to double or triple successful quit-
rates but these life-saving measures are significantly 
underused.4 Research consistently demonstrates a sharp 
increase in successful tobacco cessation among smokers who seek 
assistance. In general, those who receive no assistance are about twice 
as likely to fail in their quit attempts. When optimal professional 
counseling and smoking cessation drugs (nicotine replacement therapy 
and/or Zyban) are combined, success rates can triple.\4\
---------------------------------------------------------------------------
    \4\ Fiore MC, Bailey WC, Cohen SJ et al. Treating Tobacco Use and 
Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department 
of Health and Human Services. Public Health Service. June 2000.
---------------------------------------------------------------------------
    Smoking cessation is extremely cost-effective compared to health 
interventions already covered by public and private health providers. 
Smoking cessation coverage has been found to be more cost effective 
than many widely accepted reimbursable medical interventions.\4\ For 
pregnant women, smoking cessation interventions result in fewer low 
birth weight babies and perinatal deaths, fewer physical, cognitive, 
and behavioral problems during infancy and childhood, and also yield 
important health benefits for the mother.\4\ Providing both counseling 
and smoking cessation drugs is significantly more cost-effective than 
providing either treatment alone because a much higher percentage of 
patients will successfully quit using the combined approach.\4\ Over a 
five to six year period, smokers experienced 30 to 45 percent more 
hospital admissions than former smokers.5
---------------------------------------------------------------------------
    \5\ Wagner, EH et al. ``The Impact of Smoking and Quitting on 
Health Care Use.'' Archives of Internal Medicine, 1995;155:1789-1795.
---------------------------------------------------------------------------
    Congress should act now to promote effective tobacco use cessation 
therapies. The American Heart Association favors reimbursement of 
tobacco use cessation treatments as part of all health care programs, 
including those financed by the federal government.
    Immediate priorities for congressional action include:

 Adding a smoking cessation counseling benefit for all Medicare 
        beneficiaries and ensuring that any prescription drug benefit 
        for Medicare beneficiaries includes coverage of smoking 
        cessation drugs. Smoking cessation provides significant health 
        benefits for smokers of all ages.\4\
 Providing prescription and non-prescription smoking cessation 
        drugs in the Medicaid program. Current Medicaid law allows 
        states to exclude FDA-approved smoking cessation therapies from 
        coverage. Moreover, less than half of the states provide 
        coverage for smoking cessation products in their Medicaid 
        program even though the states won $246 billion over the next 
        25 years from the tobacco industry in 1998 settlements of 
        Medicaid claims. Full coverage of smoking cessation is urgently 
        needed by the Medicaid population, which bears a 
        disproportionate burden of the death and disease caused by 
        tobacco. About 57 percent of Medicaid recipients are current or 
        former smokers.6
---------------------------------------------------------------------------
    \6\ Harris JE. Written Testimony Before the Senate Judiciary 
Committee Hearings on the ``Proposed Global Tobacco Settlement: Who 
Benefits?'' Washington, D.C., July 30, 1997.
---------------------------------------------------------------------------
 Clarifying that the maternity care benefit for pregnant women 
        in Medicaid covers smoking cessation counseling and services. 
        This is critically important for the health of the mother and 
        child. Women who stop smoking before becoming pregnant or 
        during the first trimester of pregnancy reduce their risk of 
        miscarriage or of having a low birth weight baby to that of 
        women who have never smoked.\4\ A counseling benefit is 
        essential because use of smoking cessation medications may not 
        be appropriate for this population.
 Ensuring that the Maternal and Child Health (MCH) Program 
        funds may be used for smoking cessation counseling and 
        medications, and that smoking cessation is considered part of 
        quality maternal and child health services.
    These proposals are based on the June 2000 clinical practice 
guideline for treating nicotine dependence, which represents the state 
of the art in tobacco use cessation.\4\ These proposals focus 
exclusively on improving delivery of effective tobacco use cessation 
through existing health programs and are contained wholly or in part in 
H.R. 3676, the Medicare, Medicaid, and MCH Tobacco Use Cessation 
Promotion Act of 2001, sponsored by Representatives Mary Bono and Diane 
DeGette. Companion legislation was introduced in the United States 
Senate (S. 622) by Senator Richard Durbin.
    Costs for these benefits would be modest. For instance, ensuring 
that Medicaid recipients have access to proven smoking cessation drugs 
would cost $200 million over 10 years, according to a 2000 estimate by 
the Office of Management and Budget.
    disease management as an approach to confronting chronic illness
    The incorporation of disease management benefits into the Medicare 
program may improve health care quality for Medicare beneficiaries as 
well as contain costs. Disease management is a promising and evolving 
approach to confronting the challenges represented by chronic illness. 
As government, health plans and clinicians have adopted disease 
management models to fit their own needs and goals, the various 
meanings of disease management have evolved and diversified. In 
practice, it can cover a range of potential activities, from 
distributing pamphlets to patients instructing them on self-management 
techniques related to their particular condition to relying on a case 
manager to develop patient-specific care plans.7 Although 
the term is widely and inconsistently used, all disease management 
programs share the common goal of improving quality of life and care 
outcomes for people with chronic illness.
---------------------------------------------------------------------------
    \7\ Jeff Tieman, Disease Management Making a Case for Itself 
Clinically and Financially, Modern Healthcare, July 9, 2001.
---------------------------------------------------------------------------
    Increasingly, disease management is being offered as an approach to 
health care management in the public and private sectors. Hundreds of 
so-called ``disease management programs'' exist for a wide array of 
chronic illnesses, including congestive heart failure, diabetes, asthma 
and depression. Federal agencies are currently evaluating the cost 
effectiveness and patient outcomes of programs that rely on disease 
management techniques to deliver patient care; a number of states are 
offering disease management services through their Medicaid programs; 
key members of Congress are introducing legislation to fund new disease 
management initiatives; and pharmaceutical benefit managers (PBMs) are 
contracting with states to provide disease management services through 
pharmaceutical assistance programs for seniors.
    The American Heart Association finds the concept of disease 
management promising, but also urges the Subcommittee to consider two 
issues--

(1) any quality standards or performance measures for cardiovascular 
        disease and stroke must be based on appropriate, objective and 
        scientifically-derived evidence-based guidelines; and
(2) quality of care must be prioritized over cost-containment or other 
        financial incentives in all disease management initiatives. 
        Disease management should be primarily about improving patient 
        outcomes and only secondarily about cost containment.
    For disease management to truly put patients first, clinical 
guidelines must rely on a template that emerges from medical community 
consensus. For example, appropriate clinical guidelines for some 
disease states may require minimum staffing levels. Additionally, 
appropriate disease-specific programs should reach low-risk patients as 
well as high-risk patients to best serve long-term health needs. In 
short, to focus on appropriate patient-centered clinical guidelines, 
medical community standards must serve as the fundamental framework for 
any disease management program that hopes to draw widespread approval 
and acceptance.
    In addition to the use of appropriate clinical guidelines, it is 
critical to ensure that disease management programs are driven by the 
clinical needs of patients rather than mere cost containment or 
financial profit. While we recognize the need for cost containment and 
careful allocation of health care resources, the improvement of quality 
care must be the primary goal of any disease management program.
    The American Heart Association is at the forefront of investigating 
ways to improve the quality of care for patients with cardiovascular 
disease and stroke. We have developed and are currently operating a 
number of patient-centered programs. In essence, our existing programs, 
when viewed together, represent a form of disease management. We are 
extremely proud of the process through which our guidelines are 
developed and place great emphasis on ensuring objectivity and sound 
science.
    Our work on disease management is ongoing. We are currently 
reviewing various models of disease management, particularly in the 
area of cardiovascular disease and stroke. We are analyzing the 
effectiveness of these models and hope to use this information to 
refine our current programs and efforts, if needed. The American Heart 
Association considers disease management an important and timely issue 
and looks forward to working with Congress as it continues to consider 
the appropriate integration of disease management into the Medicare 
program.
    The American Heart Association is eager to work with your 
subcommittee, with others in Congress, and with the Administration as 
you work on these and other health care reforms. We invite you to call 
upon our organization for any assistance you may need in these 
endeavors. The Association feels strongly that Congress should enact 
changes to Medicare and other federal programs that are based on sound 
science, honor good medical practices, and are meant to provide 
patients with the best possible care.
    Again, we commend the subcommittee for holding this hearing and 
greatly appreciate the opportunity to comment on a few of the items we 
feel will greatly improve the clinical preventive benefits received by 
the over 40 million seniors currently enrolled in the Medicare program.
                                 ______
                                 

       PREPARED STATEMENT OF THE COLLEGE OF AMERICAN PATHOLOGISTS

    The College of American Pathologists (CAP) is pleased to submit 
this statement for the record of the Subcommittee on Oversight and 
Investigation's hearing on issues associated with Medicare's Clinical 
Preventive Benefits. The College is a medical specialty society 
representing more than 16,000 board-certified physicians who practice 
clinical or anatomic pathology, or both, in community hospitals, 
independent clinical laboratories, academic medical centers and federal 
and state health facilities.
    The College is aware that much has been learned about providing a 
robust approach to quality health care for seniors since 1965, when 
Congress created the Medicare program and chose not to include coverage 
of preventive benefits. Preventive services have become a cornerstone 
of quality, cost-effective health care delivery and should be readily 
available to our nation's seniors. A specific example of where Medicare 
falls short on prevention is the need for all women who are or have 
been sexually active to have an annual Pap test and pelvic examination. 
Medicare lacks such coverage for many women in the program.
    Medicare provides annual screening Pap test coverage only for women 
defined by the program as being at ``high risk'' of cervical cancer. To 
help women understand Medicare coverage policies for the Pap test, the 
Centers for Medicare and Medicaid Services offers a 14-page brochure. 
But this well-intentioned document is complicated and confusing. Given 
this approach, it's not surprising that many Medicare beneficiaries are 
not utilizing this valuable service. Simply adopting an annual Pap test 
coverage policy for Medicare would go far toward clearing up this 
confusion. Physicians, in consultation with their patients, should 
decide how often to perform this test and not be restricted by anything 
less than annual Pap test coverage. Reasons for this are detailed 
below.
    No cancer screening test in medical history has proved as effective 
for early detection of cancer as the Pap test. Since the introduction 
of the Pap test shortly after World War II, death rates from cervical 
cancer have decreased 70 percent in the United States. But despite the 
test's unparalleled record of success, thousands of American women 
still fail to have an annual Pap examination. It is sad to note that of 
those women who die of cervical cancer, 80 percent had not had a Pap 
test in the five years preceding their deaths, studies show. The 
benefits of annual Pap tests are clear: A 1999 report from the Agency 
for Healthcare Research and Quality (AHRQ), titled ``Evaluation of 
Cervical Cytology,'' showed that the lifetime number of cervical cancer 
cases decreases from 506 to109 in a cohort of 100,000 women with annual 
Pap test screenings and cervical cancer deaths decrease from 116 to 21 
with annual Pap tests. The report concluded that annual Pap tests could 
result in 65 percent fewer cervical cancer deaths compared with 
screenings once every two years.
    Access to annual Pap tests is particularly important to women in 
the Medicare program. The 1999 AHRQ report revealed that 40 percent to 
50 percent of all women who die of cervical cancer are older than 65.
    Recognizing the limitations of Medicare's coverage policy and the 
importance of annual Pap tests, the College has called for annual 
screening Pap test coverage under Medicare. Congress responded by 
passing the ``Medicare, Medicaid and S-CHIP Benefits Improvement and 
Protection Act of 2000'' (BIPA), which, last year, improved Medicare's 
coverage of Pap tests and pelvic and clinical breast examinations from 
once every three years to once every two years for all women in the 
program. While BIPA did much to expand Medicare access to the Pap test, 
it fell short of ensuring that all women beneficiaries have access to 
the test on an annual basis.
    The College believes that lack of Medicare coverage for the annual 
screening Pap test often precludes early detection and diagnosis of 
disease and results in greater costs to the Medicare program for 
treating serious medical conditions that could have been prevented. The 
College is now supporting legislation that would provide annual 
coverage for the screening Pap test and pelvic examination. The 
``Providing Annual Pap Tests to Save Women's Lives Act of 2001'' (H.R. 
1202, S.258) would establish an annual Pap test benefit for all women 
in Medicare. Passage of the bill is crucial to preventing death and 
disability among America's elderly women.
    The College thanks the subcommittee for the opportunity to present 
its views on this important issue and offers its support and continued 
assistance as Congress works to improve women's health.
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