MEDICARE

Use of Preventive 

Services Could Be 

Better Aligned with 

Clinical 

Recommendations

Report to Congressional Requesters

January 2012

GAO-12-81

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-81, a report to 

congressional requesters

January 2012

MEDICARE

Use of Preventive Services Could Be Better Aligned 

with Clinical Recommendations

Why GAO Did This Study

Preventive care services have the 

potential to improve health outcomes 

and lower health care expenditures.

This report examines (1) whether 

preventive service use by Medicare 

fee-for-service (FFS) beneficiaries 

aligns with recommendations from the 

U.S. Preventive Services Task Force 

and the Advisory Committee on 

Immunization Practices (ACIP), (2) use 

of the Welcome to Medicare (WTM) 

exam and its association with use of 

preventive services, (3) preventive 

service use in Medicare Advantage 

(MA) relative to FFS, and (4) service 

use among MA health maintenance 

organizations (HMO) and efforts by 

high-performing HMOs to encourage 

preventive care. To do this, GAO 

selected eight preventive services that 

had Task Force or ACIP guidelines for 

the general Medicare population. GAO 

analyzed the most recently available 

data from Medicare claims, a 

beneficiary survey, and MA plan 

ratings. GAO also interviewed 

representatives of selected HMOs.

What GAO Recommends

Congress should consider requiring 

beneficiaries to share the cost of a 

service if the Task Force recommends 

against use of that particular service 

for those beneficiaries. The 

Administrator of CMS should provide 

coverage for Task Force 

recommended services, as she 

determines is appropriate considering 

cost-effectiveness and other criteria. 

CMS agreed that preventive service 

use could be improved, but stated that 

GAO likely undercounted use of some 

preventive services. The agency also 

pointed out that it has recently added 

coverage for several new preventive 

services.

What GAO Found

Use of some preventive services—cardiovascular disease screening and cervical 

cancer screening—by FFS beneficiaries generally aligned with clinical 

recommendations, but use of other cancer screenings for certain age groups, 

osteoporosis screening, and immunizations did not. In particular, among women 

aged 65 to 74, for whom breast cancer screening is recommended biannually by 

the Task Force, only two out of three received a mammogram in 2008 or 2009. 

Among beneficiaries aged 65 to 75, about one out of four received any of the 

Task Force recommended regimens for colorectal cancer screening from 2005 

through 2009. Among men aged 75 or older, about two out of five received a 

Prostate-Specific Antigen test for prostate cancer—a test that required no cost 

sharing—from 2006 through 2009 even though the Task Force recommended 

against this service for that age group. Use of osteoporosis screening—for which 

Medicare coverage is limited—and influenza and pneumococcal immunizations 

was generally lower than recommended by the Task Force or ACIP. The 

Department of Health and Human Services has the authority to modify coverage 

of Medicare preventive services—such as osteoporosis screening—consistent 

with Task Force recommendations.

Fewer than 7 percent of FFS beneficiaries who became eligible for the WTM 

exam in 2008 received it. For FFS beneficiaries who became eligible in 2006 and 

received the exam, use rates for all of the selected preventive services GAO 

reviewed were higher than for beneficiaries who did not have the exam.

Specifically, use of selected preventive services from 2006 through 2009 was 

greater by about 3 to 20 percentage points for women and about 4 to 

17 percentage points for men. 

Compared to beneficiaries in FFS, those in MA HMOs reported greater use of 

immunizations and cholesterol tests but not cancer screenings, holding 

demographic and geographic factors constant. There was no discernable 

difference in use rates between FFS beneficiaries and those in MA non-HMO 

plans. Overall, Medicare beneficiaries who did not receive certain preventive 

services commonly reported that they had limited information on prevention; had 

concerns about discomfort, side effects, or efficacy; or their doctor did not 

recommend the services.

HMO performance data from the Centers for Medicare & Medicaid Services’ 

(CMS) Medicare Health Plan Compare ratings show that use varied substantially 

for the preventive services we examined. Representatives from higherperforming HMOs reported using tools such as clinical guidelines, performance 

monitoring and feedback, and financial incentives to encourage physicians to 

provide preventive services. HMO representatives also said they developed 

newsletters, phone messages, and websites to highlight the availability of 

preventive services and enhanced benefits to encourage enrollees’ use of 

preventive care.

View GAO-12-81. For more information, 

contact James C. Cosgrove at (202) 512-7114

or cosgrovej@gao.gov.
Page i GAO-12-81 Medicare Preventive Services

Letter 1 

Background 6

FFS Use of Tests for Cardiovascular Disease and Cervical Cancer 

Generally Aligned with Recommendations, but Use of Other 

Preventive Services Did Not 12

Few FFS Beneficiaries Had a Welcome to Medicare Exam; Its Use 

Was Associated with Greater Utilization of Preventive Services 25

Beneficiaries in MA HMOs Reported Higher Use of Immunizations 

and Cholesterol Tests than Those in FFS 29

Preventive Care Use Varied Widely among MA HMOs; HigherPerforming HMOs Provided Information and Offered Incentives 

to Promote Preventive Care 31

Conclusions 39

Matter for Congressional Consideration 39

Recommendation for Executive Action 40

Agency and Industry Comments and Our Evaluation 40

Appendix I Scope and Methodology 43

Appendix II Medicare Part B Coverage and Cost Sharing for Preventive 

Services as of September 2011 50

Appendix III Tables with Full Analysis of Preventive Service Use in Medicare 

FFS 53

Appendix IV Use of the Welcome to Medicare Exam by Medicare FFS 

Beneficiaries Who Reached Age 65 in 2008 63

Appendix V Comments from the Department of Health and Human Services 64

Appendix VI GAO Contact and Staff Acknowledgments 67

Contents
Page ii GAO-12-81 Medicare Preventive Services

Tables

Table 1: Medicare Part B Coverage and Cost Sharing for Selected 

Preventive Services, 2009 7

Table 2: Use of Cholesterol Tests by Male Medicare FFS 

Beneficiaries during the 5-year Period 2005 through 2009 13

Table 3: Use of Screening Pap Tests by Female Medicare FFS 

Beneficiaries during the 3-year Period 2007 through 2009 14

Table 4: Use of the Influenza Vaccination by Medicare FFS 

Beneficiaries for the July 2008 through June 2009 Flu 

Season 15

Table 5: Use of the Pneumococcal Vaccination during the 5-year 

Period 2005 through 2009 by Medicare FFS Beneficiaries 

Aged 65 as of January 1, 2005 16

Table 6: Use of Bone Mass Measurements by Female Medicare FFS 

Beneficiaries during the 5-year Period 2005 through 2009 18

Table 7: Use of Mammography by Female Medicare FFS 

Beneficiary Age during the 2-year Period 2008 through 

2009 20

Table 8: Use of Colorectal Cancer Screening and Diagnostic 

Services by Medicare FFS Beneficiaries Aged 65 to 75, 

2005 through 2009 21

Table 9: Use of Colorectal Cancer Screening Services by Medicare 

FFS Beneficiaries Aged 76 or Older, 2005 through 2009 22

Table 10: Use of PSA Tests by Male Medicare FFS Beneficiaries 

during the 4-year Period 2006 through 2009 23

Table 11: Use of Selected Preventive Service among Urban and 

Rural Medicare FFS Beneficiaries 24

Table 12: Use of Selected Preventive Service among Medicare FFS 

Beneficiaries Who Live in a HPSA and Those Who Do Not 25

Table 13: 2006 through 2009 Use of Selected Preventive Services by 

Female Medicare FFS Beneficiaries Who Became Eligible 

for a Welcome to Medicare (WTM) Exam in 2006 27

Table 14: 2006 through 2009 Use of Selected Preventive Services by 

Male Medicare FFS Beneficiaries Who Became Eligible for 

a Welcome to Medicare (WTM) Exam in 2006 28

Table 15: Common Reasons Medicare Beneficiaries Reported for 

Not Using Certain Preventive Services, 2009 31

Table 16: Use of Cholesterol Tests by Male Medicare FFS 

Beneficiaries during the 5-year Period 2005 through 2009 53

Table 17: Use of Screening Pap Tests by Female Medicare FFS 

Beneficiaries during the 3-year Period 2007 through 2009 54
Page iii GAO-12-81 Medicare Preventive Services

Table 18: Use of Influenza Vaccination by Medicare FFS 

Beneficiaries for the July 2008 through June 2009 Flu 

Season 55

Table 19: Use of the Pneumococcal Vaccination during the 5-year 

Period 2005 through 2009 by Medicare FFS Beneficiaries 

Aged 65 as of January 1, 2005 56

Table 20: Use of Bone Mass Measurements by Female Medicare 

FFS Beneficiaries during the 5-year Period 2005 through 

2009 57

Table 21: Use of Screening and Diagnostic Mammography by 

Female Medicare FFS Beneficiaries Aged 65 to 74 during 

the 2-year Period 2008 through 2009 58

Table 22: Use of Screening Mammography by Female Medicare 

FFS Beneficiaries Aged 75 or Older during the 2-year 

Period 2008 through 2009 59

Table 23: Use of Colorectal Cancer Screening and Diagnostic 

Services by Medicare FFS Beneficiaries Aged 65 to 75, 

2005 through 2009 60

Table 24: Use of Colorectal Cancer Screening Services by Medicare 

FFS Beneficiaries Aged 76 or Older, 2005 through 2009 61

Table 25: Use of PSA Tests by Male Medicare FFS Beneficiaries 

during the 4-year Period 2006 through 2009 62

Figures

Figure 1: Distribution of HMOs by Service and 2011 Medicare 

Compare Star Rating 33

Figure 2: Distribution of HMO Beneficiaries by Service and 2011 

Medicare Compare Star Rating 34
Page iv GAO-12-81 Medicare Preventive Services

Abbreviations

AAA Abdominal Aortic Aneurysm

ACIP Advisory Committee on Immunization Practices

AHIP America’s Health Insurance Plans

AHRQ Agency for Healthcare Research and Quality

AWV Annual Wellness Visit

CAHPS Consumer Assessment of Healthcare Providers and 

 Systems

CDC Centers for Disease Control and Prevention

CMS Centers for Medicare & Medicaid Services

EKG electrocardiogram

ESRD end-stage renal disease

FFS fee-for-service 

HCPCS Healthcare Common Procedure Coding System

HEDIS Healthcare Effectiveness Data and Information Set

HHS Department of Health and Human Services

HIV human immunodeficiency virus

HMO health maintenance organization

HPSA Health Professional Shortage Area

HRSA Health Resources and Services Administration 

ICD International Classification of Diseases

IPPE Initial Preventive Physical Examination

MA Medicare Advantage

MCBS Medicare Current Beneficiary Survey

MIPPA Medicare Improvements for Patients and Providers Act of 

 2008

NCQA National Committee on Quality Assurance

PFFS Private Fee-for-Service

PPACA Patient Protection and Affordable Care Act

PPO Preferred Provider Organization

PSA Prostate-Specific Antigen

Task Force U.S. Preventive Services Task Force

VIS Vaccine Information Statement

WTM exam Welcome to Medicare exam

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Page 1 GAO-12-81 Medicare Preventive Services

United States Government Accountability Office

Washington, DC 20548

January 18, 2012

The Honorable Max Baucus

Chairman

Committee on Finance

United States Senate

The Honorable Tom Harkin

Chairman

Committee on Health, Education, Labor and Pensions

United States Senate

The Honorable Sheldon Whitehouse

Untied States Senate

Over the past several years, preventive health care services have 

received increased attention for their potential to improve health 

outcomes and lower health care expenditures. Researchers have found 

that certain preventive services are effective in early diagnosis or reduced 

prevalence of diseases that contribute to the growth in Medicare 

spending. As of the end of 2011, Medicare covered 30 preventive 

services, including 3 types of immunizations, various screenings for a 

number of diseases, and several other types of preventive services under 

Part B.1 To encourage beneficiary use, the Patient Protection and 

Affordable Care Act (PPACA) removed beneficiary cost-sharing 

requirements for many Medicare-covered preventive services.2

 

1

Medicare Part B covers physician, outpatient hospital, home health care, and certain 

other services.

Additionally, PPACA created an annual wellness visit benefit—which 

allows Medicare beneficiaries a yearly examination without cost sharing—

in part to improve the identification of needed preventive services. Prior to 

this new benefit, the only coverage for a physical was the Welcome to 

Medicare exam, a one-time benefit for new beneficiaries.

2

Cost sharing can include coinsurance—a percentage of the cost—or a copayment—a 

fixed amount toward the cost. Although PPACA eliminated the deductible and coinsurance 

for certain preventive services, beneficiaries may still be required to pay coinsurance for 

the office visit during which the service takes place. Pub. L. No. 111-148, § 4103-04, 

10406, 124 Stat. 119, 553, 975 (2010).

 
 

Page 2 GAO-12-81 Medicare Preventive Services

These changes are important for the vast majority of the roughly 

36 million beneficiaries covered by fee-for-service (FFS) or “traditional” 

Medicare, and the nearly 12 million beneficiaries enrolled in Medicare 

Advantage (MA) plans as of 2010.3,4 Because MA organizations—which 

typically offer plans with a number of different benefit packages—bear a 

certain amount of financial risk and are assessed for quality, they may 

have an incentive to encourage preventive care use to better control 

expenditures and improve performance.5

Despite Medicare’s expanded coverage and the removal of financial 

barriers for certain preventive services, research suggests that use of 

some preventive services may not be optimal. Some researchers have 

raised concerns that the use of some preventives services is low—overall 

or for particular patient populations.

Given their organizational 

characteristics, health maintenance organizations (HMO) in particular 

may be able to employ strategies with both providers and beneficiaries to 

promote greater use of preventive services than is feasible in Medicare 

FFS.

6 Other researchers have noted the 

overuse and misuse of certain preventive services.7

 

3

MA organizations, which sponsor MA plans, are private health insurers that contract with 

the Centers for Medicare & Medicaid Services (CMS) to provide health care to Medicare 

beneficiaries. MA organizations must provide all Medicare-covered services (except 

hospice care) and may sponsor multiple plans with different benefits, cost-sharing 

requirements, and premiums. 

To enhance 

appropriate provision of preventive services by primary care clinicians 

and health systems, the Department of Health and Human Services’ 

4

Some FFS beneficiaries may be insulated from the reduction in cost sharing if they have 

supplemental insurance coverage, which pays expenses not covered by Medicare. 

5

A study of MA benefits found that most plans covered certain preventive services with no 

cost sharing. In 2009, the share of MA beneficiaries enrolled in plans that did not require 

cost sharing for eight preventive services ranged from 84 and 100 percent, depending on 

the service. See M. Gold and M.C. Hudson, Medicare Advantage Benefit Design: What 

Does It Provide, What Doesn’t It Provide, and Should Standards Apply? (prepared by 

Mathematica Policy Research, Inc. for AARP Public Policy Institute, March 2009).

6

M.V. Maciosek et al., “Priorities Among Effective Clinical Preventive Services,” American 

Journal of Preventive Medicine, 31, no. 1 (2006): 52-61. 

7

D. Steinwachs et al., “National Institutes of Health State-of-the-Science Conference 

Statement: Enhancing Use and Quality of Colorectal Cancer Screening,” Annals of 

Internal Medicine, vol. 152, no. 10 (2010):663-667. C. Sima et al., “Cancer Screening 

Among Patients With Advanced Cancer,” Journal of the American Medical Association, 

vol. 304, no. 14 (2010): 1584-1591.
 

Page 3 GAO-12-81 Medicare Preventive Services

(HHS) Agency for Healthcare Research and Quality (AHRQ) provides the 

U.S. Preventive Services Task Force—a group composed of 

independent, private-sector experts in prevention and evidence-based 

medicine—with research support. The Task Force reviews evidence from 

randomized control trials and other studies documenting the effectiveness 

of clinical preventive services. It then issues recommendations for 

providers and may include guidance on the sex and age groups most 

likely to benefit from the service, as well as the interval of the service. The 

Task Force does not make recommendations with regard to vaccines; 

rather, it defers to the Centers for Disease Control and Prevention’s 

(CDC) Advisory Committee on Immunization Practices (ACIP).8 The 

Centers for Medicare & Medicaid Services (CMS)—the agency within 

HHS that administers the Medicare program—relies on recommendations 

by the Task Force when considering coverage of a new preventive 

service. However, research has shown that Medicare coverage does not 

always correspond with the specifications of Task Force 

recommendations.9

You asked us about a range of issues concerning use of preventive 

services, particularly in the Medicare program. This report examines 

(1) the extent to which use of preventive services by FFS beneficiaries 

aligns with Task Force or ACIP recommendations, (2) the extent to which 

FFS beneficiaries use the Welcome to Medicare exam and whether use 

of that service is associated with higher use of preventive care services, 

(3) how preventive service use in MA compares to use in FFS, and (4) the 

extent to which use varies among MA HMOs and which practices the 

better performing HMOs find effective in promoting use of preventive 

services. 

To determine the extent to which preventive service use by FFS 

beneficiaries aligns with guidelines, we selected eight Medicare-covered 

preventive services that had related Task Force or ACIP usage 

recommendations for the general Medicare population. In making our 

selection, we excluded certain services for which the recommendations 

 

8

ACIP is a committee of 15 experts selected by the Secretary of HHS that provides 

recommendations for vaccination administration, including a schedule of recommended 

vaccines for adults and children.

9

L.I. Lesser et al., “Comparison Between US Preventive Services Task Force 

Recommendations and Medicare Coverage,” Annals of Family Medicine, 9, no. 1 (2011): 

44-49.
 

Page 4 GAO-12-81 Medicare Preventive Services

were primarily aimed at high-risk populations or populations with specific 

diagnoses. We analyzed a 5 percent sample of FFS claims from 2005 

through 2009 to determine use rates based on service-specific age 

groups and intervals outlined in Task Force or ACIP recommendations.10

To assess the use of the Welcome to Medicare exam, we analyzed a 

5 percent sample of 2008 and 2009 FFS claims for this service by eligible 

beneficiaries. To examine the association, if any, between the Welcome 

to Medicare exam and use of preventive services, we compared 

100 percent of claims for a selection of recommended preventive services 

from 2006 through 2009 for beneficiaries who became eligible for a 

Welcome to Medicare exam in 2006 and received it with those for 

beneficiaries who did not have that exam.

We excluded claims for beneficiaries who were under the age of 65 or 

were not continuously enrolled in Medicare Part B. We also excluded 

beneficiaries who resided in institutions, were qualified for Medicare due 

to end-stage renal disease (ESRD), and were enrolled at any time in MA 

during the period of study. We recognize that guidelines may not apply to 

all beneficiaries due to individual circumstances, and that 100 percent use 

of recommended services is unrealistic. We considered Medicare FFS 

use to be in alignment with the Task Force and ACIP if at least three in 

four beneficiaries overall received a recommended service. We also 

considered use to be in alignment if no more than one in four 

beneficiaries overall received a service that the Task Force 

recommended against having.

To compare preventive service use in MA to use in FFS Medicare, we 

analyzed beneficiary survey results because claims data for services 

provided to MA beneficiaries are not available from CMS. Using 2008 and 

2009 Medicare Current Beneficiary Survey (MCBS) data and plan 

enrollment data supplied by CMS, we examined the effect enrollment in 

MA HMO and MA non-HMO organizations had on reported use compared 

with FFS beneficiaries’ reported use. We analyzed these data using a 

logistic regression model that included the effects of contract type, age, 

dual-eligibility, education, race, income, marital status, health status, and 

 

10The Medicare 5 percent files contain claims and demographic information for 5 percent 

of the Medicare FFS population. Files are constructed such that results from this analysis 

are generalizable to the entire FFS Medicare population. 
 

Page 5 GAO-12-81 Medicare Preventive Services

geographic location.11

To examine differences in utilization of preventive services across HMOs, 

we reviewed information on relative utilization for five services posted on 

CMS’s Medicare Health Plan Compare website for 2011.

This analysis allowed us to isolate the effect of 

beneficiaries’ enrollment choice, holding other beneficiary characteristics 

constant.

12

We ensured the reliability of the Medicare claims data, MCBS data, and 

Plan Compare data used in this report by performing appropriate 

electronic data checks and by interviewing agency officials who were 

knowledgeable about the data. Analyzing claims data on preventive 

service use risks undercounting because some preventive services are 

available outside of Medicare (such as at community events), and would 

not be reflected in the claims data. Analyzing survey or self-reported data 

on preventive service use risks overcounting due to reasons such as 

interviewee recollection errors or inclination to give a socially desirable

response. However, we found the data were sufficiently reliable for the 

purpose of our analyses. Appendix I contains a more complete 

description of our methodology.

To learn about 

approaches for improving delivery of preventive services, we interviewed 

officials from six HMOs that ranked among the top performing for 

provision of selected preventive services and had enrollment of 37,000 or 

greater in January 2011.

We conducted this performance audit from September 2010 through 

January 2012, in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

 

11The MCBS is a survey of a nationally representative sample of the Medicare population, 

including both aged and disabled beneficiaries. The survey data are released annually 

and the results are contained in two data files, Access to Care and Cost and Use. The 

Access to Care file contained responses related to preventive care.

12We analyzed Plan Compare data on colorectal cancer screening, influenza vaccination, 

mammography, osteoporosis screening, and pneumococcal vaccination. The Plan 

Compare database contained use rate information for cholesterol testing but it was based 

on a subset of beneficiaries with certain diseases. The database did not include 

information on cervical cancer screening or PSA tests.
 

Page 6 GAO-12-81 Medicare Preventive Services

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives.

When the Medicare program was established in 1965, it covered health 

care services for the diagnosis or treatment of illness or injury, but did not 

cover preventive services. Since 1980, Congress has expanded coverage 

of preventive services for the Medicare population several times. For 

instance, the Balanced Budget Act of 1997 added coverage of prostate 

and colorectal cancer screening, among other things. Later, the Medicare 

Prescription Drug, Improvement, and Modernization Act of 2003 

mandated coverage of a one-time Initial Preventive Physical Examination 

(IPPE)—also known as the Welcome to Medicare (WTM) exam—for new 

Part B enrollees. The WTM exam includes a review of medical history, 

blood pressure, vision, height, as well as weight, and planning for 

patients’ preventive service needs. The WTM exam was initially available 

to beneficiaries within the first 6 months of enrollment beginning in 2005, 

but the Medicare Improvements for Patients and Providers Act of 2008 

(MIPPA) extended the period of eligibility to within the first 12 months of 

enrollment beginning in 2009. MIPPA also gave HHS authority to add 

coverage of new preventive services through its National Coverage 

Determination process when HHS determines services are reasonable 

and necessary for the prevention or early detection of an illness, 

recommended by the Task Force, and appropriate for beneficiaries. 

Medicare coverage and cost sharing for selected preventive services in 

2009—the year relevant to several of the findings in this report—is shown 

in table 1.

Background 

Medicare Coverage of 

Preventive Services
 

Page 7 GAO-12-81 Medicare Preventive Services

Table 1: Medicare Part B Coverage and Cost Sharing for Selected Preventive Services, 2009

Selected preventive service Medicare coverage Beneficiary cost sharing

Vaccinations

a

Influenza vaccination Covered once every influenza season in the fall or 

winter, for all beneficiaries

Noneb

Pneumococcal vaccination

 

Covered as needed, likely once in a lifetime for all 

beneficiaries

Noneb

Screening services

 

Breast cancer—mammography Covered annually for beneficiaries 40 or older 20 percent of approved amount c

Cardiovascular disease—

cholesterol test

Covered every 5 years for all beneficiaries None for the lab work, but may have required 

20 percent of the approved amount for the 

physician office visit

Cervical cancer—pap test Covered biannually for all female beneficiaries, 

annually for female beneficiaries at high risk

None for the lab work, but 20 percent of the 

approved amount for the administration 

Colorectal cancer—colonoscopy, 

fecal occult blood test, or flexible 

sigmoidoscopy

Fecal occult blood test and flexible sigmoidoscopy 

covered for beneficiaries aged 50 or older, and 

colonoscopy covered without minimum age; 

colonoscopy covered every 10 years or 4 years 

after a previous flexible sigmoidoscopy; fecal 

occult blood test covered annually; flexible 

sigmoidoscopy covered every 4 years, or 

10 years after a previous colonoscopy

d

e

20 percent of the approved amount for 

colonoscopy and flexible sigmoidoscopy; 

none for the fecal occult blood test lab work, 

but 20 percent of the approved amount for an 

office visit associated with it 

 

Osteoporosis—bone mass 

measurement

Covered biannually, or more often if medically 

necessary, for people with certain medical 

conditions or that meet certain criteria

20 percent of the approved amount for the 

test, and the deductible applied to this service

Prostate cancer—ProstateSpecific Antigen (PSA) testPSA test covered annually for men 50 or older f None for the lab work, but 20 percent of the 

approved amount for the physician office visit; 

the deductible applied for the physician office 

visit

Other

Initial Preventive Physical 

Examination (IPPE) or Welcome 

to Medicare (WTM) exam

Beginning in 2009, Medicare covered a WTM 

exam for all new beneficiaries within 12 months of 

enrollment

20 percent of the approved amount for the 

service

Source: GAO analysis of CMS information.

a

Cost sharing may have been different for several components of a preventive service, such as the 

administration of the service, any lab testing that may be involved with the service, and the physician 

office visit associated with the service. In addition, some services when provided in a hospital setting 

may have required cost sharing of a different amount.

b

If the provider did not accept assignment for providing the vaccination, the beneficiary may have had 

to pay for 100 percent of the vaccination up front and submit a claim to Medicare for reimbursement, 

and the provider may have charged more than the Medicare-approved payment.

c

Medicare also covered one baseline mammogram for women 35-39.

d

Medicare also covered a barium enema as a form of colorectal cancer screening, but because the 

Task Force does not recommend it, it was not included in our analysis.

e

Screening intervals for some of these tests were shortened for beneficiaries at high risk.

f

Medicare also covered an annual digital rectal exam as a form of prostate cancer screening, but 

because the Task Force does not endorse it, it was not included in our analysis.
 

Page 8 GAO-12-81 Medicare Preventive Services

PPACA created further incentives for Medicare beneficiaries to obtain 

preventive care. In addition to covering wellness visits annually, beginning 

January 1, 2011, PPACA eliminated cost sharing for the WTM exam and 

for covered preventive services that are appropriate for a beneficiary and 

recommended by the Task Force for any indication or population. Prior to 

the implementation of PPACA, influenza and pneumococcal 

immunizations and clinical lab testing for preventive services were 

available with no cost sharing, but many other preventive services had 

some cost-sharing requirements. Further, PPACA gave HHS the authority 

to modify or eliminate coverage of certain preventive services.13

In developing regulations implementing these provisions, CMS 

acknowledged that although the Task Force may find a service to 

produce net benefits for only certain patients, the services would be 

available to all beneficiaries without cost sharing.

(For 

specifics on Medicare preventive services coverage and cost sharing for 

2011, see app II.)

14

In addition, PPACA required HHS to implement a national public-private 

partnership for prevention and health promotion outreach and education. 

In June 2011, CMS announced the “Share the News. Share the Health.” 

campaign to educate Medicare providers, beneficiaries, and caregivers 

about new and expanded prevention-related benefits. The goal of the 

campaign is to encourage use of those preventive services that are now 

available to beneficiaries without cost sharing.

In instances where the 

Task Force recommends against the use of a service by a certain 

population, CMS expects providers to limit delivery to those beneficiaries 

for whom it is clinically appropriate on a case-by-case basis. CMS also 

noted that if, at a later date, concern is raised about the appropriateness 

of a service for a specific population, it may use its authority to adjust 

Medicare coverage for that service.

 

13HHS can (1) modify the coverage of most of the preventive services enumerated in the 

statutory provision on the WTM exam to the extent that the modification is consistent with 

Task Force recommendations, (2) modify which services are included in the WTM exam, 

and (3) eliminate payment for those services that the Task Force determines have no net 

benefit or that the harms outweigh the benefits. § 4105, 124 Stat. at 558 (adding 

42 U.S.C. § 1395m(n)).

14Medicare Program; Payment Policies Under the Physician Fee Schedule and Other 

Revisions to Part B for CY 2011. 75 Fed. Reg. 73,170, 73,415 (Nov. 29, 2010).
 

Page 9 GAO-12-81 Medicare Preventive Services

As of July 2011, roughly one in four Medicare beneficiaries were enrolled 

in approximately 3,700 MA plans sponsored by 667 parent MA 

organizations. Nearly two-thirds of MA enrollees were covered by HMOs. 

HMOs tend to limit utilization outside the organization’s network of 

providers to a greater degree than other MA organization types. They are 

also more likely to coordinate care across providers and provider types.

Other MA organization types, such as Preferred Provider Organizations 

or Private Fee-for-Service organizations, are more similar to Medicare 

FFS in that enrollees face fewer limitations on their choice of providers.

Each year CMS posts information on its website about MA organizations’ 

performance in delivering preventive services and other performance 

measures.15 The information is available in CMS’ Medicare Health Plan 

Compare database, which compiles information comparing MA 

organizations’ performance from survey and administrative data. CMS 

assigns ratings—ranging from one to five stars—for each measure, which 

are based on an MA organization’s performance compared to other 

organizations.16 The star ratings are designed to indicate meaningful 

differences between MA organizations and thus the cut points vary by 

service. For example, a mammography use rate of below 59 percent 

would yield one star, while a use rate of 82 percent or above would yield 

five stars. Conversely, for colorectal cancer screening, one star plans had 

use rates of less than 36 percent while five star plans had use rates equal 

to or above 70 percent. Better-scoring MA organizations may attract new 

enrollees and, beginning in 2012, may qualify for Medicare bonus 

payments.

 

15Some measures, such as breast cancer screening, are based on data for broad 

populations that may be limited only by age range or sex. Other measures, such as 

cholesterol screening for patients with diabetes, are based on groups of individuals who 

have displayed some risk of illness.

16Plan Compare data are compiled at the organization level and thus the star ratings are 

the same across each organization’s plans. Not all organizations in the database have 

information for every measure; some organizations are not required to report data for 

certain measures, others may be too new or too small, or there may not be enough data to 

calculate the measure. 

Public Reporting on the 

Use of Preventive Services 

in MA
 

Page 10 GAO-12-81 Medicare Preventive Services

When developing its recommendations for specific preventive services, 

the Task Force takes into account the medical evidence on benefits 

across a broad population; that is, whether the benefits across a broad 

population outweigh the harms. A commonly cited potential benefit is 

preventing the development of a condition through early diagnosis. For 

example, medication therapy as a result of cholesterol testing to detect 

lipid disorders may substantially decrease the incidence of coronary heart 

disease. Likewise, treatment as a result of the early detection of cancer 

may increase one’s odds of survival from cancer. The Task Force also 

takes into consideration any potential harms related to specific preventive 

services. These include pain or complications associated with the 

screening procedures themselves or with the procedures used as a 

follow-up to screening. For example, risks associated with colonoscopies 

include perforations and other complications that can arise from the 

invasive procedure. Similarly, treatment of conditions identified through 

screening can cause harms that may be viewed as worse than the 

underlying condition.

The Task Force reviews clinical research and issues a recommendation 

statement and evidence report giving each service a grade, as follows:

• An “A” grade means that the Task Force recommends the service 

because there is high certainty that the net benefit is substantial.

• A “B” grade means that the Task Force recommends the service 

because there is high certainty that the net benefit is moderate or 

there is moderate certainty that the net benefit is moderate to 

substantial.

• A “C” grade means that the Task Force recommends against routinely 

providing the service because, although there may be considerations 

that support providing the service in an individual patient, there is at 

least moderate certainty that the net benefit is small.17

 

17Prior to May 2007, a “C” grade meant that the Task Force made no recommendation for 

or against the provision of the service because it found at least fair evidence that the 

service could improve health outcomes but concluded that the balance of benefits and 

harms was too close to justify a general recommendation.

Development of Task 

Force and ACIP 

Recommendations 
 

Page 11 GAO-12-81 Medicare Preventive Services

• A “D” grade means that the Task Force recommends against the 

service because there is moderate or high certainty that the service 

has no net benefit or that the harms outweigh the benefits.

• An “I Statement” means that the Task Force concludes that the 

current evidence is insufficient to assess the balance of benefits and 

harms of the service.

AHRQ officials have noted that the Task Force’s recommendations are

designed as guidance for clinicians, not coverage policies for health 

insurers. They maintain that patients should have access to preventive 

services and that decisions to obtain a particular service should rest with 

patients, based on their values and preferences. For example, although 

colorectal cancer screening for people age 86 or older in the general 

population received a D grade, the service may be appropriate for certain 

older beneficiaries given their health status. At the same time, AHRQ 

officials noted that the Task Force position on “D” rated services is that 

physicians should discourage most patients from obtaining such services.

Similarly, ACIP takes into account benefits and risks of vaccines in 

developing its recommendations, and CDC publishes information on the 

benefits and risks of vaccines through its Vaccine Information Statements 

(VIS). ACIP experts review clinical research to obtain information related 

to disease morbidity and mortality, safety, efficacy, effectiveness, and 

cost-effectiveness of specific vaccines. Potential benefits may be shortterm protection from the disease, in the case of the influenza vaccine, or 

long term, in the case of the pneumococcal vaccine, as well as preventing 

the spread of infection. The VISs for influenza and pneumococcal 

immunizations generally report minimal risks with these vaccines.
 

Page 12 GAO-12-81 Medicare Preventive Services

While FFS beneficiaries’ use of cardiovascular and cervical cancer tests 

generally aligned with clinical recommendations, use of immunizations 

and osteoporosis screenings was low compared to recommendations, 

and tests for breast, colorectal, and prostate cancer were generally not 

aligned with recommendations for certain age groups. Alignment with 

recommendations was generally lower for beneficiaries living in rural and 

provider shortage areas.

We found that more than four out of five male FFS beneficiaries received 

a cholesterol test in the 5-year period 2005 through 2009, indicating that 

utilization generally aligned with Task Force recommendations. Because 

lipid disorders are a risk factor for cardiovascular disease and other heartrelated conditions, the Task Force strongly recommends cholesterol 

screening (grade A) for men aged 35 or older to detect lipid disorders.18,19

 

18Among available lipid screening tools, the Task Force endorses total cholesterol and 

high density lipoprotein-cholesterol testing samples as the preferred tests.

Although the Task Force states that the optimal screening interval is 

uncertain, it notes that a reasonable interval for cholesterol screening to 

detect a lipid disorder would be once every 5 years. Cholesterol testing 

may also be conducted for the purpose of monitoring cholesterol after a 

diagnosis of abnormal levels, and thus may be done more frequently than 

for screening to identify cardiovascular disease risk. From 2005 through 

2009, approximately 84 percent of male beneficiaries aged 65 or older 

19In 2008, the Task Force updated its recommendation statement to strongly recommend 

screening women aged 45 or older for lipid disorders only if they are at increased risk for 

heart disease. Because claims data are not sufficiently detailed to ascertain which female 

beneficiaries were at increased risk, we could not reliably analyze use of cholesterol 

screening in high-risk women.

FFS Use of Tests for 

Cardiovascular 

Disease and Cervical 

Cancer Generally 

Aligned with 

Recommendations, 

but Use of Other 

Preventive Services 

Did Not

Use of Cardiovascular and 

Cervical Cancer Tests 

Generally Aligned with 

Recommendations 

Cholesterol testing to detect 

lipid disorders
 

Page 13 GAO-12-81 Medicare Preventive Services

received at least one cholesterol test, with the majority receiving two or 

more such tests.20

Table 2: Use of Cholesterol Tests by Male Medicare FFS Beneficiaries during the 

5-year Period 2005 through 2009

Overall use of cholesterol testing was somewhat lower 

for male beneficiaries 85 or older, but remained relatively high. (See 

table 2.)

Numbers in percent

Male beneficiaries No services a One service Two or more services

All 16.2 8.3 75.5

65 to 74 16.4 7.9 75.8

75 to 84 15.2 8.6 76.2

85 or older 21.7 12.3 66.0

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Medicare Parts A and B during the 

period of study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries 

who were enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2005.

In general, female FFS beneficiaries’ use of cervical cytology, or Pap 

tests, was relatively low, which generally aligns with Task Force 

recommendations. For women 65 or older, the Task Force recommended 

against routine screening (grade D) if they have had a recent normal Pap 

test and are not otherwise at high risk for cervical cancer.21,22

 

20It was beyond of the scope of this report to determine the reason for which the 

cholesterol testing was administered. Additionally, claims data may undercount the actual 

use of cholesterol testing, as some beneficiaries may receive cholesterol testing outside of 

FFS Medicare, such as at a health fair.

After 

reviewing evidence, the Task Force concluded that screening women 

older than 65 is associated with an increased risk for potential harm, 

including false-positive results and invasive procedures. However, for 

women under age 65 who have been sexually active and have a cervix, 

the Task Force strongly recommended the use of Pap tests to detect 

21The Task Force also recommends against screening with Pap test in women who have 

had a total hysterectomy for benign disease.

22Prior to May 2007, a D grade indicated that the Task Force recommended against 

routinely providing the service to asymptomatic patients.

Pap testing to detect cervical 

cancer 
 

Page 14 GAO-12-81 Medicare Preventive Services

cervical cancer, and stated that annual screening achieves outcomes no 

better than screening every 3 years.23,24

Although claims data do not identify women who are at high risk for 

cervical cancer, use appears to align with recommendations.

Approximately 23 percent of female beneficiaries aged 65 or older 

received a screening Pap test from 2007 through 2009. Use was lower for 

older beneficiaries; approximately 17 percent of women 75 to 84 and 

6 percent of women 85 or older received one or more Pap tests. (See 

table 3.)

Table 3: Use of Screening Pap Tests by Female Medicare FFS Beneficiaries during 

the 3-year Period 2007 through 2009

Numbers in percent

Female beneficiaries No services a One service Two or more services

All 77.0 17.8 5.2

65 to 74 69.1 23.7 7.3

75 to 84 83.1 13.4 3.5

85 or older 93.9 5.1 1.0

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Medicare Parts A and B during the 

period of study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries 

who were enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2007.

 

23Because beneficiaries may have continued receiving Pap tests at the interval 

recommended for younger women, we used a 3-year period to assess use in the 

Medicare population.

24In October 2011, the Task Force submitted a draft update to its 2003 recommendation, 

proposing to issue an ‘A’ grade for Pap smear every 3 years in women ages 21 to 65, and 

proposing to issue a “D” grade for Pap smear in women younger than age 21. The draft 

recommendation still issues a “D” grade for Pap smear in women older than age 65 who 

have had adequate prior screening and are not otherwise at high risk for cervical cancer. 
 

Page 15 GAO-12-81 Medicare Preventive Services

Medicare claims data indicated that use of the influenza vaccination was 

low relative to the ACIP recommendation that it be received every year.

Despite the absence of cost sharing, only about half of all beneficiaries 65 

or older had a Medicare claim for the influenza vaccination during the 

2008-09 influenza season.25

Table 4: Use of the Influenza Vaccination by Medicare FFS Beneficiaries for the July 

2008 through June 2009 Flu Season

A higher proportion of women than men had 

a claim for the influenza vaccine, and older beneficiaries were more likely 

to have such claims than younger beneficiaries. (See table 4.)

Numbers in percent

Beneficiaries No vaccinations a One or more vaccinations

All

b

50.9 49.1

Female 49.2 50.9

Male 53.4 46.6

65 to 74 55.7 44.3

75 to 84 45.8 54.2

85 or older 45.3 54.7

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Medicare Parts A and B during the 

period of study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries 

who were enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of July 1, 2008.

b

Less than one half of 1 percent received two or more influenza vaccinations for the July 2008 

through June 2009 flu season.

Medicare claims data, however, may undercount the actual use of the 

influenza vaccine because some beneficiaries receive this service from 

nontraditional sources of care, such as a workplace or health fair. Survey 

data—which can capture use of clinical services outside of Medicare—

suggest that a substantially higher proportion of beneficiaries received 

 

25Some beneficiaries, such as those who are very ill, may not be appropriate candidates 

for the influenza vaccination. 

Use of Immunizations and 

Osteoporosis Screenings 

Was Lower than 

Recommended

Vaccination to prevent 

influenza virus
 

Page 16 GAO-12-81 Medicare Preventive Services

influenza vaccinations. In a 2009 CDC survey, more than 31 percent of 

older adults reported they had not received an influenza vaccination in the 

past year.26

Although ACIP recommends that beneficiaries 65 or older receive the 

pneumococcal vaccination, few newly enrolled FFS beneficiaries received 

one within 5 years of Medicare enrollment even though it was available 

without cost sharing.27,28

Table 5: Use of the Pneumococcal Vaccination during the 5-year Period 2005 

through 2009 by Medicare FFS Beneficiaries Aged 65 as of January 1, 2005

During the 5 years from 2005 through 2009, 

about 27 percent of beneficiaries aged 65 as of January 1, 2005, received 

a pneumococcal vaccination. Use did not vary substantially between 

women and men. (See table 5.)

Numbers in percent

Beneficiaries No vaccination One or more vaccinations

All 

a

72.7 27.3

Female 71.7 28.4

Male 73.9 26.1

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries who 

were not continuously enrolled in Medicare Parts A and B during the period of study, (2) beneficiaries 

residing in institutions, (3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in 

Medicare Advantage during the period of study.

a

Less than 2 percent of beneficiaries aged 65 at the beginning of the 5-year period 2005 through 

2009 received two or more pneumococcal vaccinations.

 

26Centers for Disease Control and Prevention, Administration on Aging, Agency for 

Healthcare Research and Quality, and Centers for Medicare & Medicaid Services, 

Enhancing Use of Clinical Preventive Services Among Older Adults (Washington, D.C.: 

AARP), 2011.

27We analyzed use of the pneumococcal vaccination for beneficiaries who were aged 65 

as of January 1, 2005, to determine whether they received it between 2005 and 2009—a 

period generally covering their first 5 years of enrollment in Medicare FFS.

28Pneumococcal vaccination is recommended for all adults aged 65 or older who were 

vaccinated over 5 years prior and were less than 65 years of age at the time of the prior 

vaccination. Pneumococcal vaccination is also recommended for adults aged 65 or older 

who lack documentation of vaccination. 

Vaccination to prevent 

pneumonia
 

Page 17 GAO-12-81 Medicare Preventive Services

Similar to measurement issues regarding influenza vaccination and 

cholesterol testing, these claims data may undercount the actual use of 

the pneumococcal vaccine because beneficiaries may receive this service 

from sources outside of Medicare. According to the 2009 CDC survey, 

more than 33 percent of older adults reported never having received a 

pneumococcal vaccination.29

Relative to Task Force recommendations, female FFS beneficiaries’ use 

of bone mass measurement was low. The Task Force recommends that 

women aged 65 or older be screened for osteoporosis with a bone mass 

measurement (grade B). Regarding the appropriate screening interval, 

the Task Force suggests that a minimum of 2 years between screenings 

may be necessary to discern notable differences in bone density, but that 

longer intervals may be necessary to improve the prediction of fracture 

risk. From 2005 through 2009, approximately 53 percent of female 

beneficiaries who were aged 65 or older at the beginning of 2005 

received at least one bone mass measurement screening. Older 

beneficiaries had lower use of this service; about 50 percent of 

beneficiaries aged 75 to 84 received at least one bone mass 

measurement, and about 30 percent of beneficiaries aged 85 or older 

received a bone mass measurement. (See table 6.)

 

29Centers for Disease Control and Prevention, Administration on Aging, Agency for 

Healthcare Research and Quality, and Centers for Medicare & Medicaid Services, 

Enhancing Use of Clinical Preventive Services Among Older Adults. (Washington, D.C.: 

AARP), 2011.

Bone mass measurement to 

detect osteoporosis
 

Page 18 GAO-12-81 Medicare Preventive Services

Table 6: Use of Bone Mass Measurements by Female Medicare FFS Beneficiaries 

during the 5-year Period 2005 through 2009

Numbers in percent

Female beneficiaries No services a One service Two or more services

All 47.4 29.3 23.3

65 to 74 42.2 31.2 26.6

75 to 84 50.3 28.5 21.2

85 or older 70.5 19.7 9.8

Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously 

enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions, 

(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage 

during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2005.

One factor that may have contributed to the relatively low use of bone 

mass measurement is that Medicare coverage is limited. Although the 

Task Force recommends the screening for all female beneficiaries aged 

65 or older, Medicare covers this service only for people who have certain 

medical conditions or meet certain criteria.30 To the degree that coverage 

for preventive care is a significant determinant of service use, not having 

coverage could explain why some beneficiaries have not received the 

service. In 2010, PPACA gave HHS the authority to modify coverage of 

Medicare preventive services—including bone mass measurement—

when the change is consistent with Task Force recommendations.

 

30Beneficiaries need to meet one of the following criteria to be eligible for bone mass 

measurement coverage: be estrogen deficient and at clinical risk for osteoporosis; have 

vertebral abnormalities; be receiving glucocorticoid therapy for more than 3 months; have 

primary hyperparathyroidism; or be in the process of monitoring to assess response to 

FDA-approved osteoporosis drug therapy.
 

Page 19 GAO-12-81 Medicare Preventive Services

Use of mammography is low relative to recommendations for younger 

Medicare FFS beneficiaries, indicating that use generally does not align 

with recommendations for that age group. The Task Force recommends 

that women aged 50 to 74 receive a screening mammogram every 

2 years (grade B). Because some high-risk women may receive a 

diagnostic mammogram in lieu of a screening mammogram, we included 

both types of claims in our analysis for younger beneficiaries.31 We found 

that, among women aged 65 to 74, roughly two out of three beneficiaries 

received either a screening or diagnostic mammogram in 2008 or 2009.32

For women 75 or older, the Task Force reported that evidence is 

insufficient to assess the additional benefits and harms of screening 

mammography (with a grade of I). About 41 percent of women in that age 

group received at least one screening mammogram in 2008 or 2009, and 

22 percent of women 85 or older received at least one screening 

mammogram. (See table 7.)

 

31Diagnostic mammograms are administered when evidence already exists that a 

beneficiary may have or be at risk to develop breast cancer—that is, when a beneficiary is 

symptomatic. However, some asymptomatic, high-risk women may be given a diagnostic 

mammogram instead of a screening mammogram.

32We included screening and diagnostic mammograms in the analysis for the younger 

population because diagnostic mammograms are sometimes given for the purpose of 

screening in high-risk women, and because beneficiaries who received diagnostic testing 

would not necessarily be expected to receive additional screening. 

Use of Breast, Colorectal, 

and Prostate Cancer Tests 

Generally Did Not Align 

with Recommendations for 

Certain Age Groups

Screening mammography to 

detect breast cancer 
 

Page 20 GAO-12-81 Medicare Preventive Services

Table 7: Use of Mammography by Female Medicare FFS Beneficiary Age during the 

2-year Period 2008 through 2009

Numbers in percent

Female beneficiaries Type of mammogram a No mammogram

One or more 

mammograms

65 to 74 Screening or diagnostic 35.5 64.5

75 or older Screening only 59.5 40.5

75 to 84 Screening only 52.9 47.1

85 or older Screening only 77.9 22.1

Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously 

enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions, 

(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage 

during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2008.

We found that use of colorectal cancer testing regimens was low relative 

to the recommendations for younger FFS beneficiaries. For beneficiaries 

aged 50 to 75, the Task Force recommends using one of three different 

regimens to screen for colorectal cancer (grade A): fecal occult blood 

testing once per year, a sigmoidoscopy every 5 years along with fecal 

occult blood testing every 3 years, or a colonoscopy every 10 years.33 For 

beneficiaries aged 65 to 75, we computed use rates using codes for 

screening and diagnostic services because it is likely that at least some 

services claimed as diagnostic were for screening purposes.34

Beneficiaries who satisfied one of the colorectal cancer screening 

regimens from 2005 through 2009 were deemed to have met the 

recommendation, and those who satisfied none of the regimens were 

considered to not have met the recommendation.35

 

33Screening colonoscopies and sigmoidoscopies are examples of multiple types of 

colorectal cancer testing. Diagnostic colonoscopies and sigmoidoscopies are administered 

when symptomatic evidence already exists that a beneficiary may have colorectal cancer 

or had it in the past.

From 2005 through 

34Also, because beneficiaries who received diagnostic testing would not necessarily be 

expected to receive additional screening, we included both screening and diagnostic 

services for the recommended population of beneficiaries aged 65 to 75. 

35Screening colonoscopy is recommended every 10 years. We reviewed data for 2005 

through 2009, which allowed us to maintain a robust sample. Not including colonoscopy 

services from 2000 through 2004 may have resulted in undercounting the share of 

beneficiaries who met the recommended regimens. 

Testing to detect colorectal 

cancer 
 

Page 21 GAO-12-81 Medicare Preventive Services

2009, about one quarter of Medicare FFS beneficiaries aged 65 to 75 

followed any of the recommended regimens. (See table 8.)

Table 8: Use of Colorectal Cancer Screening and Diagnostic Services by Medicare 

FFS Beneficiaries Aged 65 to 75, 2005 through 2009

Numbers in percent

Beneficiaries Followed a regimen a Did not follow a regimen

All aged 65 to 75 25.5 74.5

Female 27.0 73.0

Male 23.5 76.5

Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously 

enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions, 

(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage 

during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2005.

Among older Medicare FFS beneficiaries, use of colorectal cancer testing 

regimens generally aligned with recommendations. The Task Force 

recommends against routine screening in adults aged 76 to 85 (grade C), 

and recommends against any screening for adults aged 86 or older 

(grade D).36 Using only claims for services coded as screenings, we 

found that about 6 percent of beneficiaries aged 76 to 85 received a 

colorectal cancer screening regimen. Among beneficiaries aged 86 or 

older, 

2 percent met any of the regimens. Because routine screening of older 

beneficiaries is discouraged by the Task Force, these low rates indicate 

general alignment with recommended use. (See table 9.)

 

36According to AHRQ officials, the Task Force believes there are circumstances where 

individuals may benefit from a “D” grade service, but “D” services are not recommended 

for the general population.
 

Page 22 GAO-12-81 Medicare Preventive Services

Table 9: Use of Colorectal Cancer Screening Services by Medicare FFS 

Beneficiaries Aged 76 or Older, 2005 through 2009

Numbers in percent

Beneficiaries Followed a regimen a Did not follow a regimen

Female 5.4 94.6

Male 6.4 93.6

76 to 85 6.3 93.7

86 or older 2.0 98.0

Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously 

enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions, 

(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage 

during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2005.

We found that rates of PSA screening differed substantially from the Task 

Force recommendation for older FFS beneficiaries. In 2008, the Task 

Force recommended against screening for prostate cancer (grade D) for 

men aged 75 or older.37 The Task Force noted that treatment for prostate 

cancer as a result of screening can cause moderate to substantial harms, 

and some men who are treated would not have developed symptoms 

related to the cancer during their lifetime. Among beneficiaries aged 75 or 

older, more than 40 percent received a PSA test, with 35 percent of those 

at least 85 years old having the screening at least once. Approximately 

one in five beneficiaries aged 75 or older received two or more PSA tests 

in our 4-year study period. By statute, beneficiaries were not required to 

share the cost of the PSA test.38

For men younger than 75, the Task Force reported that current evidence 

was insufficient to assess the balance of benefits and harms of PSA 

testing for prostate cancer (with a grade of I). It further stated that PSA 

screening as infrequently as once every 4 years could yield as much 

benefit as annual screening. Among male beneficiaries aged 65 to 74, 

about half received at least one PSA test in our 4-year study period. (See 

table 10.)

 

37In October 2011, the Task Force submitted a draft update to its 2008 recommendation, 

proposing to issue a “D” grade for PSA testing in men of all ages. 

38Beneficiaries may have been required to pay coinsurance for the physician visit.

Prostate-Specific Antigen 

(PSA) testing to detect prostate 

cancer 
 

Page 23 GAO-12-81 Medicare Preventive Services

Table 10: Use of PSA Tests by Male Medicare FFS Beneficiaries during the 4-year 

Period 2006 through 2009

Numbers in percent

Male beneficiaries No services a One service Two or more services

All 50.9 23.6 25.6

65 to 74 48.0 23.5 28.5

75 or older 55.3 23.8 20.9

75 to 84 53.7 24.1 22.1

85 or older 65.0 21.5 13.6

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Medicare Parts A and B during the 

period of study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries 

who were enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2006.

For more detail on Medicare beneficiaries’ use of the eight selected 

preventive services, see appendix III.

For all of the recommended preventive services in our study where use 

did not align with recommendations, FFS beneficiaries living in rural areas 

or areas with provider shortages had consistently lower use rates than 

their counterparts in urban areas. Rural beneficiaries had slightly lower 

use rates than urban beneficiaries, ranging from about 1 percentage point 

lower for use of colorectal cancer screening to about 6 percentage points 

lower for bone mass measurement. (See table 11.)

Lack of Alignment with 

Recommendations Was 

Particularly Evident for 

Beneficiaries Who Live in 

Rural or Provider Shortage 

Areas
 

Page 24 GAO-12-81 Medicare Preventive Services

Table 11: Use of Selected Preventive Service among Urban and Rural Medicare FFS 

Beneficiaries

Numbers in percent

Urban Rural

Percentage 

point 

difference 

Use of influenza vaccination during 2008 to 2009 

flu season 50.2 45.6 -4.6

Use of pneumococcal vaccination within first 5 years

of enrollment beginning in 2005 28.4 a 24.2 -4.2

Use of bone mass measurement by women, 2005 

through 2009 54.0 47.7 -6.3

Up-to-date colorectal cancer screening by 

beneficiaries 65 to 75, 2005 through 2009 25.7 b 24.8 -0.9

Use of mammography by women 65-74 from 2008 

through 2009 65.3 c 62.0 -3.3

Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously 

enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions, 

(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage 

during the period of study.

a

These data include only beneficiaries who were aged 65 as of January 1, 2005.

b

Denotes the beneficiary’s age as of January 1, 2005.

c

Denotes the beneficiary’s age as of January 1, 2008.

Similarly, FFS beneficiaries living in Health Professional Shortage Areas 

(HPSA) had lower use rates than beneficiaries who did not live in 

HPSAs.39 For example, influenza immunization rates were about 

11 percentage points lower for HPSA beneficiaries than for non-HPSA 

beneficiaries, and bone mass measurement use rates for women living in 

a HPSA were about 8 percentage points lower than their counterparts.

(See table 12.)

 

39HPSAs are urban/rural areas, population groups, or medical facilities that have a 

shortage of primary medical care, dental, or mental health providers. CMS makes bonus 

payments to physicians who provide medical care in geographic areas designated as 

Primary Care HPSAs. Approximately 66 million Americans live in a Primary Care HPSA.
 

Page 25 GAO-12-81 Medicare Preventive Services

Table 12: Use of Selected Preventive Service among Medicare FFS Beneficiaries 

Who Live in a HPSA and Those Who Do Not

Numbers in percent

Not 

HPSA HPSA 

Percentage 

point 

difference

Use of influenza vaccination during 2008 

to 2009 flu season 49.9 39.4 -10.5

Use of pneumococcal vaccination within first 

5 years of enrollment beginning in 2005 27.8 a 22.5 -5.3

Use of bone mass measurement by women, 

2005 through 2009 53.2 44.8 -8.4

Up-to-date colorectal cancer screening by 

beneficiaries 65 to 75, 2005 through 2009 25.7 b 23.3 -2.4

Use of mammography by women 65 to 74, 

2008 through 2009 65.0 c 58.4 -6.6

Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously 

enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions, 

(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage 

during the period of study.

a

These data include only beneficiaries who were aged 65 as of January 1, 2005.

b

Denotes the beneficiary’s age as of January 1, 2005.

c

Denotes the beneficiary’s age as of January 1, 2008.

A small number of FFS beneficiaries received a Welcome to Medicare 

(WTM) exam. Among beneficiaries who became eligible for the WTM in 

2006 and subsequently received it, use of preventive services was higher.

Few FFS 

Beneficiaries Had a 

Welcome to Medicare 

Exam; Its Use Was 

Associated with 

Greater Utilization of 

Preventive Services
 

Page 26 GAO-12-81 Medicare Preventive Services

Very few FFS beneficiaries who reached age 65 during 2008, and were 

thus eligible for a WTM exam sometime in 2008 or 2009, received a WTM 

exam in either year.40

• about the same proportion of women and men had a WTM exam,

Overall, 6.6 percent of beneficiaries received the 

WTM exam after becoming eligible for it in 2008. Specifically,

• urban beneficiaries had similar use rates as rural beneficiaries, and

• a somewhat smaller share of beneficiaries who lived in a HPSA used 

the exam (4.2 percent) compared to beneficiaries who did not live in a 

HPSA (6.8 percent).

For more detail on Medicare beneficiaries’ use of the WTM exam, see 

appendix IV.

Use of selected preventive services was higher for FFS beneficiaries who 

had a WTM exam after becoming eligible for it in 2006 compared to those 

who did not receive the exam.41

Female beneficiaries who received the WTM exam had higher Medicare 

use rates than female beneficiaries who did not receive the exam for each 

of five services we reviewed. For example, use of bone mass 

measurement over the period 2006 through 2009 was about 20 

percentage points higher for female beneficiaries who received the WTM 

exam than for those who did not receive the WTM exam.42

 

40In 2008, beneficiaries were eligible for a WTM exam for up to 6 months after enrollment, 

and beginning January 1, 2009, new beneficiaries became eligible for a WTM exam within 

12 months of enrollment. 

Similarly, the 

rate at which female beneficiaries had at least three influenza 

vaccinations over the period was about 15 percentage points higher 

41It is possible that users of the WTM exam were generally more inclined to be users of 

other preventive services as well. Determining the cause of the higher use of preventive 

services was beyond the scope of our objective.

42In this analysis, we examined a cohort of beneficiaries who turned 65 in 2006—1 year 

after the WTM benefit became available—and was thus eligible for a WTM exam 

sometime in 2006 or 2007. We then examined preventive service use from 2006 through 

2009 in beneficiaries who received the WTM exam compared with beneficiaries who did 

not receive the WTM exam. 

Less than 7 Percent of FFS 

Beneficiaries Had the 

Welcome to Medicare 

Exam 

Among FFS Beneficiaries 

Who Received the 

Welcome to Medicare 

Exam, Use of Preventive 

Services Was Higher
 

Page 27 GAO-12-81 Medicare Preventive Services

among those who received the WTM exam compared to those who did 

not receive the exam.43

Table 13: 2006 through 2009 Use of Selected Preventive Services by Female 

Medicare FFS Beneficiaries Who Became Eligible for a Welcome to Medicare (WTM) 

Exam in 2006

(See table 13.)

Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries residing in institutions, 

(3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in Medicare Advantage 

during the period of study.

a

Influenza vaccinations are recommended annually. Because beneficiaries reached age 65 at some 

point during 2006, and thus may have been in Medicare for less than 4 years, this rate reflects 

beneficiaries who had claims for three or more influenza vaccinations.

Similarly, male beneficiaries who received the WTM exam had higher 

Medicare use rates of vaccinations and selected screenings than male 

beneficiaries who did not receive the exam. For example, the rate at 

which male beneficiaries had at least three influenza vaccinations was 

about 17 percentage points higher among those who received the WTM 

exam compared with those who did not receive the exam. Male 

beneficiaries who received the WTM exam had a colorectal cancer 

screening rate about 13 percentage points higher than male beneficiaries 

who did not receive the exam. (See table 14.)

 

43Because influenza vaccination is recommended annually, one would expect a 

beneficiary that was new to Medicare sometime in 2006 to have received at least three 

influenza vaccinations from 2006 through 2009.

Numbers in percent

Female 

beneficiaries 

who had a 

WTM exam

Female 

beneficiaries 

who did not have 

a WTM exam

Percentage point 

difference 

Influenza vaccinations 47.4 a 32.3 15.1

Pneumococcal vaccination 17.3 14.6 2.7

Colorectal cancer screening 44.7 34.3 10.4

Bone mass measurement 65.3 45.1 20.2

Mammogram 38.3 30.4 7.9
 

Page 28 GAO-12-81 Medicare Preventive Services

Table 14: 2006 through 2009 Use of Selected Preventive Services by Male Medicare 

FFS Beneficiaries Who Became Eligible for a Welcome to Medicare (WTM) Exam in 

2006

Numbers in percent

Male 

beneficiaries 

who had 

a WTM exam

Male 

beneficiaries 

who did not have 

a WTM exam

Percentage 

point 

difference 

Influenza vaccinations 42.0 a 25.2 16.8

Pneumococcal vaccination 16.7 12.3 4.4

Colorectal cancer screening 40.7 27.5 13.2

Cardiovascular disease screening 86.7 74.4 12.3

Source: GAO analysis of CMS Medicare data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries residing in institutions, 

(3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in Medicare Advantage 

during the period of study.

a

Influenza vaccinations are recommended annually. Because beneficiaries reached age 65 at some 

point during 2006, and thus may have been in Medicare for less than 4 years, this rate reflects 

beneficiaries who had claims for three or more influenza vaccinations.
 

Page 29 GAO-12-81 Medicare Preventive Services

Relative to beneficiaries in FFS, those enrolled in HMOs—the most 

popular type of MA plan—reported higher use rates for some preventive 

services.44 Specifically, survey data indicate that beneficiaries enrolled in 

MA HMOs in 2009 had slightly greater use of immunizations and 

cholesterol tests compared to beneficiaries in FFS, holding constant 

demographic and geographic factors.45 For HMO beneficiaries,46

• reported use of cholesterol screening in the preceding 12 months was 

3.6 percentage points higher,

• reported use of the influenza vaccine during the most recent flu 

season was 4.0 percentage points higher, and

• reported use of the pneumococcal vaccination at least once in the 

beneficiary’s lifetime was 3.0 percentage points higher.

However, the data did not indicate a difference between reported use of 

various cancer screening tests.47

 

44This is consistent with previous research on preventive service use in Medicare 

managed care. A study of survey data for 2001 found that, holding other factors constant, 

beneficiaries in Medicare+Choice—now known as MA—plans were slightly more likely to 

be high users of certain preventive services relative to those in Medicare FFS. See 

Ozminkowski et al., “Predictors of Preventive Service Use Among Medicare Beneficiaries,” 

Health Care Financing RevIew, Spring 2006, Volume 27, Number 3: 5-23.

For breast, cervical, colorectal, and 

prostate cancer screenings, we did not find a statistically significant 

difference in reported utilization between MA HMO and FFS beneficiaries, 

when holding other factors constant. This was equally true among 

younger beneficiaries and older beneficiaries for breast, colorectal, and 

45To account for other factors that may influence preventive service use, we used logistic 

regression to hold constant the impact of beneficiaries’ age, sex, dual-eligibility status, 

education level, marital status, income, race, Hispanic heritage, health status, and 

residence by state and metropolitan area.

46For enrollment status, we were able to classify 96 percent of survey respondents as 

enrolled in Medicare FFS, an MA HMO, or another type of MA organization (such as 

preferred provider organizations or private FFS organizations).

47The MCBS varies some questions from year to year. Although not asked in 2009, our 

analysis of the responses regarding osteoporosis tests in 2008 showed no statistically 

significant difference in reported use rates by type of enrollment.

Beneficiaries in MA 

HMOs Reported 

Higher Use of 

Immunizations and 

Cholesterol Tests than 

Those in FFS
 

Page 30 GAO-12-81 Medicare Preventive Services

prostate cancer screenings—services that have different Task Force 

recommendations for the different age groups.48

We were not able to discern a distinction in use rates between enrollees 

in FFS and enrollees in other types of MA organizations. Holding other 

factors constant, there was no statistically significant difference in 

reported use rates by FFS and MA non-HMO enrollees for any of the 

services we examined. This result may stem from the fact that non-HMO 

plans are structurally more similar to FFS than HMOs.

When asked why they did not have a particular preventive service, 

beneficiaries commonly indicated that they had limited information on 

prevention and relied on providers to initiate preventive care, regardless 

of whether the beneficiaries were enrolled in FFS, MA HMOs, or MA nonHMO organizations. Among the more common reasons beneficiaries 

gave for not having a preventive service were that they did not know it 

was needed; they had concerns about discomfort, side effects, or 

efficacy; or their provider did not recommend it to them. Table 15 shows 

the proportion of beneficiaries, regardless of their enrollment choice, who 

cited these reasons for not having one of three services where the use 

rates in our analysis of Medicare claims were generally lower than 

desired based on clinical guidelines—influenza vaccination, 

pneumococcal vaccination, and mammography for younger beneficiaries.

For example, about half of beneficiaries who reported never having 

received a pneumococcal vaccination said that they did not know it was

needed, and more than half of beneficiaries who reported not receiving an 

influenza vaccination in the previous winter said they were concerned 

about discomfort, side effects, or efficacy. Furthermore, a substantial 

share of surveyed beneficiaries for whom certain preventive services are 

recommended indicated that they were unaware that those services were 

Medicare-covered benefits.49

 

48For breast and prostate cancer screening, younger respondents were ages 65 to 74 and 

older respondents were age 75 and older. For colorectal cancer screening, the age groups 

were 65 to 75 and 76 and older, respectively.

49For instance, among beneficiaries age 65 to 75, about one in four reported that they did 

not know or thought Medicare did not cover colorectal cancer screening. 
 

Page 31 GAO-12-81 Medicare Preventive Services

Table 15: Common Reasons Medicare Beneficiaries Reported for Not Using Certain 

Preventive Services, 2009

Numbers in percent

Reason reported for not having service

Did not know it 

was needed

Concerned about 

discomfort, side 

effects, or efficacy a Doctor did not 

recommend it b

Pneumococcal vaccination 

ever

c

50.2 20.9 21.2

Influenza vaccination in 

the previous winter 16.3 51.9 9.7

Mammogram in the 

previous year (women 65 

to 74 years old) 20.5 14.1 10.1

Source: GAO analysis of MCBS data. 

Note: Survey respondents may have given multiple answers.

a

Data include responses for “wasn’t needed,” “didn’t know it was needed,” “no need,” or “nothing 

wrong.” 

b

Data include responses for “don’t like (shots/needles, mammograms);” “could have side effects;” 

“don’t think it prevents (flu, pneumonia, cancer);” or “could cause (flu, pneumonia, cancer).” 

c

Data include responses for “doctor did not recommend,” or “doctor recommended against getting 

shot/allergic to shot/medical reasons.” 

Among MA HMOs, use of preventive services varied widely and tended to 

be higher among HMOs with greater enrollment. Higher-performing 

HMOs told us they generally share guidelines, monitor work performance, 

and offer financial incentives to encourage the provision of preventive 

care by providers. These HMOs also reported using outreach and benefit 

incentives to encourage enrollees to obtain preventive care services.

Preventive Care Use 

Varied Widely among 

MA HMOs; HigherPerforming HMOs 

Provided Information 

and Offered 

Incentives to Promote 

Preventive Care
 

Page 32 GAO-12-81 Medicare Preventive Services

MA HMO performance data from CMS’s Medicare Health Plan Compare 

database show that use—based on star ratings—varied substantially for 

the five preventive services we examined: colorectal cancer screening, 

the influenza vaccine, mammography, osteoporosis testing, and the 

pneumococcal vaccine.50 In developing the star ratings for each service, 

CMS selected cut points from data on reported utilization rates.51

Although the average number of stars assigned to MA HMOs was similar 

across the selected services—ranging from a low of 2.7 for 

mammography to a high of 3.1 for colorectal cancer and osteoporosis 

testing—the distribution of HMO star ratings varied significantly by 

service. Notably,

The cut 

points produced a range in the average use rates for each star category.

For each of the five preventive services, the difference in average use 

rates between one-star and five-star MA HMOs was 30 percentage points 

or more in 2009. For example, the average mammography use rate for 

HMOs with five stars was 86 percent, while the average mammography 

use rate for HMOs with one star was 53 percent.

• For colorectal cancer screening, 34 percent of HMOs received either 

one or two stars while 41 percent of HMOs had four or five stars.

• For the influenza vaccinations, the same proportion of HMOs— 

20 percent—garnered one star as they did five stars.

• For mammography, nearly half of the HMOs had fewer than three 

stars and 10 percent achieved five stars.

• For pneumococcal vaccinations, HMOs were more evenly distributed, 

with roughly 20 percent of HMOs in each of the five star categories. 

(See fig 1.)

 

50Using enrollment data from January 2010, we were able to match 353 HMOs in the Plan 

Compare database with just under 7 million MA beneficiaries. Roughly one quarter of the 

HMOs did not have star ratings for at least one of the five preventive services we 

examined because they were too new, too small, unable to report, or not required to report 

data. However, those that did not have star ratings accounted for less than 2 percent of 

enrollees for any of the five services.

51The use rates for colorectal cancer screening and mammography were based on 

administrative data while the use rates for osteoporosis testing and the vaccines were 

based on survey data.

Preventive Service Use 

Ranged Widely among 

HMOs and Was Higher in 

HMOs with Greater 

Enrollment 
 

Page 33 GAO-12-81 Medicare Preventive Services

Figure 1: Distribution of HMOs by Service and 2011 Medicare Compare Star Rating

Note: Although MA organizations may sponsor a number of different plan benefit packages, star data 

are aggregated across plans to the organization level. Data are derived from a combination of 

administrative sources for 2009 and surveys for 2009 and 2010.

We also found that, for the preventive services we examined, larger 

HMOs generally had higher star ratings than smaller HMOs. When 

weighted by enrollment, the average HMO star rating ranged from 3.3 to 

3.9 across our study services. For colorectal cancer screening and 

pneumococcal vaccination, more than 6 in 10 HMO beneficiaries were 

enrolled in organizations with four- or five-star ratings. Roughly half of 

HMO beneficiaries were enrolled in organizations that had the top two 

ratings for mammography and osteoporosis screening. For influenza 

vaccinations, almost 4 in 10 HMO beneficiaries were enrolled in an 
 

Page 34 GAO-12-81 Medicare Preventive Services

organization with four or five stars and more than a third were enrolled in 

organizations with three stars. (See fig 2.)

Figure 2: Distribution of HMO Beneficiaries by Service and 2011 Medicare Compare 

Star Rating

Note: Percentages may not add to 100 due to rounding. Although MA organizations may sponsor a 

number of different plan benefit packages, star data are aggregated across plans to the organization 

level. Data are derived from a combination of administrative sources for 2009 and surveys for 2009 

and 2010. Organization ratings were weighted by January 2010 enrollment data from CMS.

A number of possible reasons could explain why HMOs with higher 

enrollment tend to have higher star ratings. A Medicare Payment Advisory 

Commission analysis of some of the measures used to determine star 
 

Page 35 GAO-12-81 Medicare Preventive Services

ratings found that older, more established HMOs had higher use rates—

which increase the chance of a higher star rating for the organization—

than newer HMOs.52 These organizations may benefit from a more 

extensive infrastructure and a more loyal enrollee base that may allow 

them to increase total enrollment over time. Also, CMS has been 

publishing plan ratings since 2006, and the ratings themselves may have 

helped drive beneficiary migration to better-rated organizations.

Representatives from higher-performing MA HMOs said they employed a 

number of tools at the organization level—such as clinical guidelines, 

performance monitoring and feedback, and financial incentives—to 

encourage physicians to provide preventive services.

To develop guidelines about preventive service use for their physicians, 

representatives from the HMOs said they relied on Task Force 

recommendations and, in some cases, recommendations of other entities 

as well. Some HMOs considered the Task Force recommendations a key 

source of information, while others said they also consulted a range of 

other sources, such as the American Cancer Society and specialty 

societies. Two HMOs told us they collaborated with other guideline 

sponsors in the states where they operate to develop sets of common 

clinical guidelines.

While recognizing the important role of clinical recommendations, HMOs 

used public reporting of performance data to set targets for high rates of 

preventive service use. They specifically cited the National Committee on 

Quality Assurance’s (NCQA) Healthcare Effectiveness Data and 

Information Set (HEDIS)53

 

52Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment 

Policy (Washington, D.C.: March 2011). 

measures and CMS’s Medicare Health Plan 

Compare measures. For example, HMOs used data on preventive service 

use specified in HEDIS—which includes use rates for services such as 

influenza immunization, breast cancer screening, and colorectal cancer 

screening—to establish utilization goals. Several HMOs said they set their 

53HEDIS consists of 75 measures that include preventive services and contains data from 

Medicare Advantage plans collected on behalf of CMS. Not all HEDIS measures align with 

Task Force recommendations; for example, HEDIS measures mammography use by 

women through age 69 while the Task Force recommends mammography for women up 

to age 75.

Higher-Performing HMOs 

Disseminated Guidelines, 

Monitored Performance, 

and Offered Financial 

Incentives to Encourage 

Physicians’ Provision of 

Preventive Services
 

Page 36 GAO-12-81 Medicare Preventive Services

annual utilization targets to the 90th percentile of the use rates reported in 

the NCQA Quality Compass—an online database that features up to 

3 years of performance data from HEDIS and the Consumer Assessment 

of Healthcare Providers and Systems (CAHPS).54 They explained that 

public reporting in Plan Compare is a way to compare their performance 

to the performance of their competitors and will be increasingly important 

in the future when Medicare bonus payments will be based on these 

data.55

Monitoring providers’ provision of care and giving feedback were 

important motivators to increase utilization. HMOs routinely monitor 

physicians’ delivery of preventive services by conducting retrospective 

reviews.56

 

54CAHPS is an annual CMS patient satisfaction survey of Medicare beneficiaries. 

Typically, they collect and evaluate data on use rates monthly 

or quarterly to determine whether individual practitioners are meeting 

performance targets or if additional efforts are needed. For example, one 

organization said it maintained an electronic registry of patient screenings 

and tests that was updated monthly; another reported it was about to 

implement a system that would compute utilization for the previous 

12 months on a quarterly basis. Several HMOs based their monitoring at 

the individual physician level, while one focused on physician group 

practices. The HMOs we contacted also commonly used provider 

feedback to encourage the provision of preventive services. The 

representatives stated that provider feedback was a significant motivator 

of physician behavior, particularly when their performance was compared 

to others in the network. Several HMOs stated that they either sent out 

reports on utilization to providers or made them available to providers 

55PPACA, as amended by the Health Care and Education Reconciliation Act of 2010, 

stipulated that organizations with a cumulative average of four stars out of a possible five 

would be eligible for bonus payments. However, in November 2010, CMS announced it 

would test an alternative approach that would provide bonuses to organizations with three 

stars or higher.

56Although representatives of some HMOs reported that they monitored preventive 

service use to identify potential overuse of services, in general, HMO representatives did 

not indicate that curbing inappropriate use of preventive services through referrals or prior 

approval was a high priority.
 

Page 37 GAO-12-81 Medicare Preventive Services

who wanted to see them. Representatives of one HMO said they followed 

up their reports by meeting with individual physicians.57

Representatives of some of the HMOs also reported using clinical 

reminders to support the delivery of preventive services. By integrating 

clinical reminders into their electronic medical records, the HMOs could 

prompt physicians at the point of service. Other HMOs said they notified 

physicians about needed screenings and vaccines for their patients.

However, representatives of some HMOs commented that they 

discontinued this practice because it appeared to be ineffective.

Another key strategy employed by HMOs is to reward the delivery of 

preventive services through provider financial incentives. Most of the 

organizations used some form of performance-based compensation that

included using preventive service measures. The staff of one of the six 

HMOs said future contracts will associate bonuses with HEDIS-based 

goals. Providers will be rewarded with incentive payments, but the 

amounts that will be paid were described as “small.” 

A representative of one MA HMO said emphasis on enrollees is more 

effective than emphasis on providers as it becomes a teachable moment 

for the enrollees. Ultimately, beneficiary action is an essential component 

of preventive care delivery, and several HMOs suggested that some 

beneficiaries are resistant to receiving preventive care. Representatives 

of one HMO noted that certain beneficiaries are skeptical of preventive 

services, such as vaccines, which can make delivery of preventive care 

difficult. This HMO suggested certain beneficiaries who are very ill may 

not benefit from all types of preventive care given their underlying medical 

condition. HMO representatives gave us examples of enrollee populations 

that have anxiety or ambivalence about preventive care.

Representatives of the HMOs described various initiatives directed at 

enrollees. Most commonly, they distributed enrollee education materials 

that outline preventive service recommendations. They developed 

 

57CMS is implementing a physician feedback reporting program. CMS plans to use 

information from the feedback program to adjust payments to physicians starting in 2015.

See GAO, Medicare Physician Feedback Program: CMS Faces Challenges with 

Methodology and Distribution of Physician Reports, GAO-11-720 (Washington, D.C.: 

Aug. 12, 2011).

HMOs Used Outreach and 

Benefit Incentives to 

Encourage Enrollees’ Use 

of Preventive Care
 

Page 38 GAO-12-81 Medicare Preventive Services

newsletters, phone messages, and websites to highlight the availability of 

preventive services. They also conducted health fairs and used their 

disease and care management programs to attempt to improve 

immunization and screening rates.

Several HMOs employed software programs that identified gaps in care 

to identify the enrollees who need specific preventive services. For 

example, one HMO reported that when an enrollee contacts its staff, the 

HMO’s data system provides the staff member with information 

concerning the enrollee’s preventive care status. Also, regardless of 

whether enrollees initiate contact, this HMO’s staff contact enrollees to 

alert them about the need for a preventive service. Several HMOs’ efforts 

also targeted specific populations. For example, some HMOs conducted 

outreach among high-risk enrollees to raise awareness and encourage 

screening and vaccinations.

The HMOs also offered incentives to enrollees directed at increasing the 

number that get vaccinations or screenings each year. To reduce 

financial barriers, some HMOs did not impose cost-sharing requirements 

for certain preventive services, such as screenings for cervical or 

colorectal cancer, even before PPACA required elimination of cost 

sharing for these services in FFS. In addition, all of the HMOs we 

interviewed had broader coverage of preventive services, such as 

covering an annual physical exam, before Medicare FFS implemented 

such coverage. One HMO reported that it also covered vaccinations by 

non-network providers to increase enrollees’ access and that this action 

had boosted utilization rates. Another HMO offered enrollees incentives, 

such as tote bags, when they visit a provider to obtain a mammogram.

These higher-performing HMOs also noted that their organizational 

structure contributed to their ability to encourage preventive care. One 

HMO said its new enrollees may have had long-standing relationships 

with network providers because they used these providers as members of 

the organization’s commercial HMO before they became eligible for 

Medicare. Additionally, unlike FFS Medicare, there is a primary care focus 

in HMOs. As an example of a benefit of that focus, one HMO 

representative said primary care providers have a more holistic view of a 

patient’s health status. Furthermore, HMOs suggested that if Medicare 

FFS could employ care coordination—a process in which an individual or 

group helps to arrange a patient’s primary and specialty health care 

services—it may be able to utilize measures HMOs now use to promote 

preventive care use.
 

Page 39 GAO-12-81 Medicare Preventive Services

Adherence to Task Force and ACIP recommendations is uneven among 

Medicare FFS beneficiaries, with use of a number of services falling short 

or exceeding age-specific clinical recommendations. Likewise, MA HMO 

performance data revealed wide variation in service use across 

organizations. This information indicates the considerable challenge in 

achieving closer alignment of patterns of use with evidence-based 

recommendations for preventive care. Even when beneficiaries were not 

required to share the cost of a service—as with immunizations—many 

were not receiving the recommended preventive services. Therefore, 

efforts may be needed that go beyond eliminating out-of-pocket costs for 

a core set of preventive services, as PPACA has done.

Use of preventive services could be improved to better align with Task 

Force and ACIP recommendations by providing more information to both 

beneficiaries and providers. For some services, beneficiaries may not be 

aware of the preventive services that they need or their physicians may 

not have discussed certain preventive services, resulting in lower than 

recommended use. For other services, use rates were substantial even 

though the Task Force recommended against their provision for certain 

subpopulations. Beneficiaries and providers may not be aware that some 

preventive services are recommended for specific age groups and not 

recommended for others.

Furthermore, better alignment of preventive service use with Task Force 

and ACIP recommendations is unlikely without appropriate Medicare 

coverage. Low use of some recommended services which have a 

recommendation grade of “A” or “B”—such as bone mass measurement 

for osteoporosis screening—may result, in part, from limitations on which 

beneficiaries are covered or how frequently the service is covered.

Conversely, the absence of cost sharing for services with a 

recommendation grade of “D”—such as the PSA test—may send an 

inappropriate signal to Medicare beneficiaries. Thus, Medicare coverage 

and cost-sharing policies do not always encourage the use of high-valued 

preventive services—those recommended by the Task Force—and 

discourage use of low-value services—those for which clinical evidence 

suggests that the risks generally outweigh the benefits.

To further align Medicare beneficiary use of preventive services with Task 

Force recommendations, Congress should consider requiring 

beneficiaries who receive services with a grade of “D” to share the cost, 

notwithstanding that cost sharing may not be required for other 

beneficiaries receiving the same services.

Conclusions 

Matter for 

Congressional 

Consideration 
 

Page 40 GAO-12-81 Medicare Preventive Services

The Administrator of CMS should take steps to better align Medicare 

beneficiary use of preventive services with Task Force recommendations, 

including providing coverage of services with an “A” or “B” grade for the 

recommended population and at the recommended frequency, as she 

determines is appropriate considering cost-effectiveness and other 

criteria.

We received written comments on a draft of this report from HHS and oral 

comments on a portion of the draft from representatives of America’s 

Health Insurance Plans (AHIP).58

HHS agreed that there is room for improvement in preventive service use 

by Medicare beneficiaries, but noted that FFS preventive service use 

rates are likely higher than we reported due to inherent difficulties in 

relying on claims data and the time frame of the analysis. Specifically, the 

agency stated that our claims-based analysis of vaccinations likely 

underestimated actual 2009 use rates because not all vaccine providers 

bill Medicare directly; it cited higher 2009 use rates derived from 

telephone survey responses. In the report, we acknowledge that FFS 

claims may not account for all utilization if beneficiaries obtain services 

from sources that do not bill Medicare. We further report that CDC survey 

data showed higher use rates for both influenza and pneumococcal 

vaccinations. At the same time, we note that self-reported data collected 

by surveys may overcount use of preventive services for various reasons. 

HHS’s general comments are included 

as appendix V. The agency also provided technical comments, which we 

incorporated as appropriate.

In addition, HHS commented that our use rates for colorectal cancer 

screening would have been more accurate if we had examined a 10-year 

period—the recommended time frame for a screening colonoscopy for 

those not at high risk; again, it cited higher use rates for a related 

colorectal cancer screening measure derived from survey data. For two of 

the three recommended regimens for detecting colorectal cancer, our 

review of 5 years of Medicare claims data corresponds to the 

recommended frequencies—fecal occult blood testing every year or a 

sigmoidoscopy every 5 years along with fecal occult blood testing every 

 

58AHIP is a national trade association representing health insurance companies, including

those participating in the Medicare Advantage program.

Recommendation for 

Executive Action

Agency and Industry 

Comments and Our 

Evaluation 
 

Page 41 GAO-12-81 Medicare Preventive Services

3 years. For the third regimen—a colonoscopy every 10 years—we note 

in the report that our decision to use a 5-year time frame for this service 

may have resulted in an undercount of the share of beneficiaries who met 

the recommendation. Because our methodology required continuous 

enrollment in Medicare FFS during the period of examination, we chose 

the shorter time frame in order to obtain a robust sample of beneficiaries, 

as well as to allow for the inclusion of younger beneficiaries in our 

analysis.

HHS also commented that, because the report examined service use as 

of 2009, it does not capture the influence of PPACA changes to 

beneficiary cost sharing, which it expects will increase use of certain 

preventive services over time. When we began our review, Medicare 

claims for 2009 were the most current data available. We describe the 

January 2011 changes in beneficiary cost sharing in the report, but 

measuring their effect on utilization—which may not be evident for some 

time—was not possible. Nevertheless, our analysis demonstrates that for 

certain services—such as immunizations—the absence of cost sharing 

has not been sufficient to align FFS beneficiary use with Task Force 

recommendations.

In response to our recommendation, HHS pointed out that it has recently 

used its authority to expand Part B benefits to cover several new 

preventive services. This additional coverage, however, does not address 

the misalignment that remains between Medicare coverage for certain 

services and the corresponding Task Force recommendations. As we 

noted in the report, for example, bone mass measurement for 

osteoporosis screening has a recommendation grade of “B” from the Task 

Force for all women over the age of 65. Yet, Medicare coverage for this 

service is limited to those who meet specific clinical criteria. As a result, 

not all women over the age of 65 are eligible for this benefit. We have 

altered the language of our recommendation to clarify that, in addition to 

covering new services recommended by the Task Force, CMS should 

ensure that all beneficiaries for whom a current recommendation applies 

have coverage for that service at the recommended frequency, as 

appropriate.

In their oral comments, AHIP representatives said the report 

demonstrated that, through the use of innovative tools such as 

performance feedback and incentives, MA plans are leaders in promoting 

greater use of preventive services. They also noted that, as it is currently 

structured, Medicare FFS cannot apply the kinds of management tools 

used by HMOs.
 

Page 42 GAO-12-81 Medicare Preventive Services

As we agreed with your offices, unless you publicly announce the 

contents of this report earlier, we plan no further distribution of it until 

30 days from its date. We are sending copies of this report to the 

Secretary of Health and Human Services. The report will also be available 

at no charge on our website at http://www.gao.gov. 

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made major contributions to 

this report are listed in appendix VI.

James C. Cosgrove

Director, Health Care
Appendix I: Scope and Methodology

Page 43 GAO-12-81 Medicare Preventive Services

This appendix describes our methodology for addressing the four 

objectives: (1) the extent to which use of preventive services by fee-forservice (FFS) beneficiaries aligns with U.S. Preventive Services Task 

Force or the Advisory Council on Immunization Practices (ACIP) 

recommendations, (2) the extent to which FFS beneficiaries use the 

Welcome to Medicare (WTM) exam and whether use of that service is 

associated with higher use of preventive care services, (3) how 

preventive service use in Medicare Advantage (MA) compares to use in 

FFS, and (4) the extent to which use varies among MA health 

maintenance organizations (HMO) and which practices the better 

performing HMOs find effective in promoting use of preventive services.

To address the objectives, we analyzed the most recently available data 

from Medicare claims, a beneficiary survey, and MA plan ratings. The 

appendix also describes our efforts to ensure the reliability of the data.

To determine the extent to which preventive service use aligns with 

guidelines, we selected certain Medicare-covered preventive services that 

had related Task Force or ACIP guidelines for the general Medicare 

population. We identified all Medicare-covered preventive services, but 

included only those that had an “A,” “B,” “C,” or “D” grade from the Task 

Force or an ACIP recommendation for some groups of beneficiaries.1

 

1

In some instances, services we reviewed had a grade of “I” for certain age groups, but all 

selected services at least had one “A,” “B,” “C,” or “D” grade recommendation.

We 

excluded preventive services for which the recommendations were 

primarily aimed at high-risk populations and populations with specific 

diagnoses because identifying the appropriate target population cannot 

be done reliably. Finally, we excluded preventive services that are only 

recommended by providers through the use of the WTM exam or billed 

through the WTM exam. We recognize that guidelines may not apply to 

all beneficiaries due to individual circumstances, and that 100 percent use 

of recommended services is unrealistic. We considered Medicare FFS 

use to be in alignment with the Task Force and ACIP if at least three in 

four beneficiaries overall received a recommended service. We also 

considered use to be in alignment if no more than one in four

beneficiaries overall received a service that the Task Force 

recommended against having.

Appendix I: Scope and Methodology

Preventive Service Use 

Alignment with Task Force 

Recommendations 
Appendix I: Scope and Methodology

Page 44 GAO-12-81 Medicare Preventive Services

To determine FFS beneficiaries’ use rates for the selected preventive 

services, we analyzed claims data from 2005 through 2009 from a 

5 percent sample of beneficiaries. Measurement intervals varied by 

service based on service-specific age and frequency parameters outlined 

in Task Force or ACIP guidelines. CMS provided a list of relevant 

Healthcare Common Procedure Coding System (HCPCS) codes and 

International Classification of Diseases (ICD) diagnosis and procedure 

codes for the services for which claims could be submitted. Using claims 

from Physician, Inpatient, Outpatient, and Skilled Nursing Facility 

5 Percent Standard Analytic Files and enrollment data from CMS’s 

Denominator file for the same 5 percent sample, we created an estimate 

of the use rates of the selected preventive services for service-specific 

time frames, based on Task Force and ACIP recommendations.

• Influenza Vaccine: Because it is recommended once a year, we 

examined claims from the 2008 to 2009 flu season.

• Pneumococcal Vaccine: Because it is recommended once for those 

65 or older, we examined beneficiaries who were 65 years old as of 

January 1, 2005, and examined claims from 2005 through 2009.

• Mammography: Because it is recommended once every 2 years, we 

examined claims in 2008 and 2009.

• Mammography is recommended for women 50 through 74. To 

account for all potential screenings, we included both screening 

and diagnostic HCPCS codes when analyzing use rates for 

women 65 through 74. When analyzing use for women aged 75 or 

older, we only included screening codes.

• Cervical Cancer Screening: Because the recommended interval was 

every 3 years, we examined claims from 2007 through 2009.

• Cholesterol Screening: Because the Task Force suggests that a 

reasonable interval may be every 5 years, we examined claims from 

2005 to 2009. Because it is recommended for all men aged 35 or 

older (but only high-risk women), we only examined claims for male 

beneficiaries.

• Colorectal Cancer Screening: Because the Task Force recommends 

most services annually or every 5 years, we examined colorectal 

cancer screening claims from 2005 through 2009.
Appendix I: Scope and Methodology

Page 45 GAO-12-81 Medicare Preventive Services

• Colorectal cancer screening is recommended for beneficiaries 

aged 50 through 75. To account for all potential screenings, we 

included both screening and diagnostic HCPCS codes when 

analyzing use rates for beneficiaries 65 through 75. When 

analyzing use for beneficiaries aged 76 or older, we only included 

screening codes.

• Osteoporosis Screening: Because the Task Force notes that a 

screening interval of a minimum of 2 years may be necessary to 

discern notable differences in bone density, but that longer intervals 

may also be necessary, we calculated bone mass measurement 

claims from 2005 through 2009.

• Prostate Cancer Screening: For men younger than 75, the Task Force 

concluded that evidence was insufficient to assess the balance of 

benefits and harms of PSA testing. Because it found that PSA 

screening as infrequently as once every 4 years could yield as much 

benefit as annual screening, we measured use of the PSA test over a 

4-year period 2006 through 2009.

The Medicare 5 percent files contain claims and demographic information 

for 5 percent of the Medicare FFS population. Files are constructed such 

that results from this analysis are generalizable to the entire FFS 

Medicare population.

We excluded the following beneficiaries from the denominator: 

beneficiaries under the age of 65, beneficiaries with MA enrollment, 

beneficiaries who had End Stage Renal Disease (ESRD), beneficiaries 

who were institutionalized, and beneficiaries who were only partially 

enrolled in Medicare part A or B during the interval of study. To analyze 

urban/rural beneficiary status, we used the CMS Core Based Statistical 

Area state and county code crosswalk to match with the state and county 

code information in the Denominator file. To analyze Health Professional 

Shortage Area (HPSA) beneficiary status, we used the Health Resources 

and Services Administration (HRSA) Primary Care HPSA zip code 

crosswalk to match with the zip code information in the Denominator file. 

We determined that the urban/rural status of beneficiaries in the 5 percent 

denominator file is proportionate to the 100 percent denominator file, and 

thus geographic weights were not necessary for our analysis.
Appendix I: Scope and Methodology

Page 46 GAO-12-81 Medicare Preventive Services

To assess FFS beneficiaries’ use of the Welcome to Medicare exam, we 

analyzed a 5 percent sample of 2008 and 2009 claims for eligible 

beneficiaries—that is, beneficiaries who became eligible for the Welcome 

to Medicare exam sometime in 2008. We excluded the following 

beneficiaries from the denominator: beneficiaries with MA enrollment, 

beneficiaries who had ESRD, beneficiaries who were institutionalized, 

and beneficiaries who were not simultaneously enrolled in both Medicare 

part A and B for at least 6 months in 2009.

To determine the association, if any, between the Welcome to Medicare 

exam and use of preventive services, we compared claims for a selection 

of recommended preventive services from 2006 through 2009 for 

beneficiaries who became eligible for a Welcome to Medicare exam in 

2006 and received it with those for beneficiaries who did not have that 

exam. We constructed a data set that consisted of 100 percent of the

beneficiaries who reached age 65 in 2006. We also excluded the 

following beneficiaries from the data set: beneficiaries with MA 

enrollment, beneficiaries who had ESRD, beneficiaries who were 

institutionalized, and beneficiaries who were only partially enrolled in 

Medicare part A or B anytime from 2007 through 2009. Looking 

separately at female and male beneficiaries, we counted claims for 

recommended preventive services between 2006 and 2009 using CMSprovided HCPCS and ICD codes from 100 percent of the Medicare 

claims. For female beneficiaries, we calculated the rate of having 

received at least three influenza vaccines, at least one pneumococcal 

vaccination, one bone mass measurement, one colorectal cancer 

screening, and one mammography. For male beneficiaries we calculated 

the rate of having received at least three influenza vaccines, at least one 

pneumococcal vaccination, one colorectal cancer screening, and one 

cholesterol test. For mammography and colorectal cancer screenings, we 

included both diagnostic and screening codes.

To compare preventive service use in MA to use in FFS, we analyzed 

beneficiary survey results, as claims data for services provided to MA 

beneficiaries are not available from CMS. Using 2009 Medicare Current 

Beneficiary Survey (MCBS) data and plan enrollment data supplied by 

CMS, we examined the effect that enrollment in MA HMO plans and nonWelcome to Medicare 

Exam Use

Medicare Advantage and 

Fee-for-Service Use
Appendix I: Scope and Methodology

Page 47 GAO-12-81 Medicare Preventive Services

HMO plans had on use compared with FFS.2

The 2009 MCBS contained survey questions for seven of our selected 

preventive services: cholesterol testing, mammography, pap testing, PSA 

testing, colorectal cancer testing, influenza vaccination, and 

pneumococcal vaccination. We constructed a measure for colorectal 

cancer screening using several survey variables. The survey question for 

pneumococcal vaccination asked if the respondents had ever had the 

service while the questions for the other services either asked about the 

most recent year—the question for influenza vaccination asked about the 

recent flu season—or asked about certain time intervals that allowed us 

to group answers in a way to measure utilization within the last year. The 

2008 MCBS contained a question on osteoporosis testing and we 

conducted the same analysis using the survey and enrollment data from 

2008.

The MCBS interview data 

contained responses from a sample of 14,695 MA and FFS beneficiaries 

as well as weights that can be used for making estimates for the 

population enrolled in Medicare during the year.

Our analysis accounted for the effects of contract type, age, dualeligibility, education, sex, race, Hispanic heritage, income, marital status, 

health status, and geographic location. We omitted beneficiaries in 

institutional settings or those under 65 as well as those who did not give a 

response on any of the included questions on beneficiary characteristics.

These filters yielded a dataset of 11,216 respondents representing 

34 million beneficiaries.

Although the MCBS contained an array of useful variables on beneficiary 

characteristics, the variable for MA enrollment was not particularly useful 

for our purposes as 95 to 96 percent of MA enrollees were classified as 

“risk HMO enrollees” for every month in 2009 while data from monthly 

CMS enrollment data showed a much different distribution. For example, 

the CMS enrollment file for February 2009 showed that 63 percent of MA 

enrollees were enrolled in HMO plans, 22 percent were enrolled in Private 

Fee-for-Service (PFFS) plans and another 12 percent were enrolled in 

Preferred Provider Organization (PPO) plans, with the remainder 

 

2

The MCBS is a survey of a nationally representative sample of the Medicare population, 

including both aged and disabled beneficiaries. The survey data are released annually 

and the results are contained in two data files, Access to Care and Cost and Use. The 

Access to Care file contained responses related to preventive care.
Appendix I: Scope and Methodology

Page 48 GAO-12-81 Medicare Preventive Services

scattered among some other plan categories. At our request, CMS 

supplied us with a crosswalk that allowed us to map respondents to MA 

organization contract number. As each organization contract number had 

a unique plan type, we were able to associate each contract number with 

its plan type using mapping available in CMS MA enrollment data. Based 

on this mapping, the resulting distribution approximated the CMSreported distribution of enrollees by plan type. Of this group, we were able 

to assign all but 4 percent of enrollees to one of three enrollment 

categories—FFS, MA HMO, and MA non-HMO (both PFFS and PPO 

enrollees). Beneficiaries were assigned to a category if they were enrolled 

no more than 1 month in a different plan type. Those who were enrolled 

at least 2 months in multiple categories were not assigned.

We used logistic regression to estimate the marginal effect of 

beneficiaries’ enrollment choice on the use of a selected preventive 

service, holding other beneficiary characteristics constant. We reported 

the differences if the results were statistically significant at the 95 percent 

confidence level.

To determine reasons beneficiaries report for not receiving preventive 

services, we examined MCBS follow-up questions for respondents who 

indicated they had not received a particular preventive service. For 

example, a respondent may indicate they did not know the test was 

needed or their doctor did not recommend it. We compared the 

distribution of reasons given by nonrecipients of those services by 

question and by enrollment category.

Because our analysis of MCBS data indicated that only MA HMOs 

displayed a statistically significant difference in use rates from FFS, we 

limited our examination of any differences in utilization of preventive 

services to MA HMOs. Using information on star ratings for 2011 posted 

on CMS’s Medicare Health Plan Compare website, we examined ratings 

for five of the eight selected preventive services: Colorectal cancer 

screening, influenza vaccination, mammography, osteoporosis testing, 

and pneumococcal vaccination.3

 

3

The Plan Compare database contained use rate information for cholesterol testing but it 

was based on a subset of beneficiaries with certain diseases. The database did not 

include information on cervical cancer screening or PSA tests.

The ratings are based on relative use 

rates across plans and, although they are displayed by plan, they are 

Comparison of MA HMO 

Use of Preventive Services
Appendix I: Scope and Methodology

Page 49 GAO-12-81 Medicare Preventive Services

actually determined at the contract organization level. In order to analyze 

the distribution of HMO beneficiaries as well as the distribution of HMO 

organizations, we associated each organization with enrollment data from 

January 2010 because it represented a midpoint in the range of dates of 

the source data.4 We identified HMO organizations using the plan type 

variable in the enrollment file. Of the 575 MA organizations in the 2011 

Plan Compare, 353 were HMOs with enrollment in January 2010. Of the 

353, between 262 and 288 had star rankings for the selected services, 

the remainder were either not required to report data, were too new or too 

small, or had insufficient data to calculate a particular measure.

To learn about approaches for improving delivery of preventive services, 

we interviewed officials from six HMOs that ranked among the top 

performing for provision of selected preventive services and had 

enrollment of 37,000 or greater in January 2011. The HMOs we selected 

had five stars on four of our selected services and at least four stars on 

the remaining service.

We ensured the reliability of the Medicare claims data, MCBS data, and 

Plan Compare data used in this report by performing appropriate 

electronic data checks and by interviewing agency officials who were 

knowledgeable about the data. We found the data were sufficiently 

reliable for the purpose of our analyses.

We conducted this performance audit from September 2010 through 

January 2012 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

 

4

The star ratings are based on use rates from administrative data from 2009 and survey 

data from 2009 and 2010.

Practices Considered 

Effective by MA 

Organizations

Data Reliability and Audit 

Standards 
Appendix II: Medicare Part B Coverage and 

Cost Sharing for Preventive Services as of 

September 2011

Page 50 GAO-12-81 Medicare Preventive Services

Service

Year first 

covered Groups covered Frequency of service

Beneficiary cost 

sharing

Vaccinations

a

Pneumococcal vaccination 1981 All beneficiaries As needed 

(likely once per lifetime)

Noneb

Hepatitis B vaccination

 

1984 Beneficiaries at intermediate or

high risk of contracting hepatitis B

Scheduled dosages are 

required

Noneb

Influenza vaccination

 

1993 All beneficiaries Once every flu season Noneb

Screening services

 

Cervical cancer—pap test 1990 All female beneficiaries Every 2 years None c b

Breast cancer—

mammography

 

1991 Female beneficiaries 40 or older Every year d Noneb

Vaginal cancer—pelvic 

exam

 

1998 All female beneficiaries Every 2 years None c b

Colorectal cancer—fecal 

occult blood test

 

1998 Beneficiaries 50 or older Every year None for screening; 

generally 20 percent of 

approved amount for visit

Colorectal cancer—barium 

enema

1998 Beneficiaries 50 or older when 

used instead of a flexible 

sigmoidoscopy or colonoscopy 

Every 4 years 20 percent of approved 

amount

e

Colorectal cancer—flexible 

sigmoidoscopy

1998 Beneficiaries 50 or older Every 4 years or 

10 years after a 

colonoscopy

None

e

b

Colorectal cancer—

colonoscopy

 

1998 All beneficiaries Every 10 years or 

4 years after a flexible 

sigmoidoscopy

None

e

b

Osteoporosis—bone mass 

measurement

 

1998 Estrogen-deficient female 

beneficiaries at clinical risk for 

osteoporosis as well as other 

qualified individuals

Every 2 years

f

None g b

Prostate cancer—ProstateSpecific Antigen test

 

2000 Male beneficiaries 50 or older Every year 20 percent of approved 

amount for visit and 

deductible for visit may 

applyh

Prostate cancer—digital 

rectal examination

 

2000 Male beneficiaries 50 or older Every year 20 percent of approved 

amount and deductible 

applies for visit

Glaucoma

h

2002 Beneficiaries determined to be at 

high risk for glaucoma

Every year i 20 percent of approved 

amount after annual 

deductible

Cardiovascular disease—

screening electrocardiogram 

(EKG) 

h

2004 For beneficiaries whose physician 

ordered as part of a Welcome to 

Medicare exam

One-time 20 percent of approved 

amount after annual 

deductible

Appendix II: Medicare Part B Coverage and 

Cost Sharing for Preventive Services as of 

September 2011

h
Appendix II: Medicare Part B Coverage and 

Cost Sharing for Preventive Services as of 

September 2011

Page 51 GAO-12-81 Medicare Preventive Services

Service

Year first 

covered Groups covered Frequency of service

Beneficiary cost 

sharing

Diabetes

a

2005 Beneficiaries with risk factors 

such as hypertension, history of 

dyslipidemia, obesity, a history of 

high blood sugar

Up to twice a year None for screening; 

generally 20 percent of 

approved amount for visit

Cardiovascular disease—

cholesterol test

2005 Beneficiaries with no signs or 

symptoms of cardiovascular 

disease

Every 5 years None for screening; 

generally 20 percent of 

approved amount for visit

Abdominal Aortic Aneurysm 

(AAA)—ultrasound

2007 Beneficiaries medically 

determined to be at risk for AAA 

and given a referral during the 

Welcome to Medicare exam

One-time Noneb

Human immunodeficiency 

virus (HIV)

 

2009 All beneficiaries who ask for the 

test, pregnant women, and 

beneficiaries at increased risk for 

infection 

Every year for 

beneficiaries at increased 

risk, or up to three times 

per pregnancy

None for screening; 

generally 20 percent of 

approved amount for visit

Other

Diabetes outpatient selfmanagement training1998 Diabetic beneficiaries with written 

order from provider

Up to 10 hours of training 

first year, up to 2 hours 

follow-up training 

subsequent years

20 percent of approved 

amount after annual 

deductible

Medical nutrition therapy

h

2002 Beneficiaries with diabetes, 

kidney disease, or who have 

had a kidney transplant within 

the past 3 years, and that are 

referred by a physician

Up to 3 hours of training 

first year, 2 hours training 

subsequent years

Noneb

Initial Preventive Physical 

Examination (IPPE) or 

Welcome to Medicare 

(WTM) exam

 

2005 All beneficiaries within 1 year 

of enrollment

One-time Noneb

Smoking and tobacco use 

cessation

 

2005 All beneficiaries who use tobacco Up to eight visits every 

year

None for beneficiaries 

who have not been 

diagnosed with related 

illness

Annual Wellness Visit 

(AWV) 

j

2011 All beneficiaries enrolled in Part B 

for at least 1 year who have not 

had an IPPE or AWV within the 

past year

Every year Noneb

Sources: CMS, GAO.

 

Note: In October 2011, CMS announced new coverage of alcohol misuse counseling and depression 

screening; CMS also announced in November 2011 new coverage of screening for Sexually 

Transmitted Infections, high-intensity behavioral counseling to prevent Sexually Transmitted 

Infections, and intensive behavioral therapy to reduce the risk of cardiovascular disease as well as 

obesity.

a

Cost sharing may be different for several components of a preventive service, such as the 

administration of the service, any lab testing that may be involved with the service, and the physician 

office visit associated with the service. Some services when provided in a hospital setting may require 

a separate copayment for the hospital visit.
Appendix II: Medicare Part B Coverage and 

Cost Sharing for Preventive Services as of 

September 2011

Page 52 GAO-12-81 Medicare Preventive Services

b

If the provider does not accept assignment for providing the service, the beneficiary may have to pay 

for 100 percent of the service up front and submit a claim to Medicare for reimbursement, and the 

provider may charge more than the Medicare-approved payment.

c

Medicare covers annual pap and pelvic exams for women who are at high risk for cervical or vaginal 

cancers and for women who are of childbearing age who have had an abnormal Pap test result within 

the past 3 years.

d

Medicare also covers one baseline mammogram for women 35-39.

e

Medicare-covered screening intervals for these tests are shortened for beneficiaries at high risk.

f

The statute defines “qualified individuals” to include also those who have vertebral abnormalities or 

primary hyperparathyroidism, or who are receiving long-term glucocorticoid steroid or osteoporosis 

drug therapy. See 42 U.S.C. § 1395x(rr)(2).

g

CMS permits coverage of a bone mass measurement more frequently if the service is medically 

necessary. 42 C.F.R. § 410.31(c) .

h

Each year, beneficiaries are responsible for 100 percent of the payment amount until those 

payments equal a specified deductible amount, $162 in 2011.

i

High-risk populations include those with diabetes, a family history of glaucoma, African Americans 

aged 50 or older, and Hispanics aged 65 or older. 42 C.F.R. § 410.23(a)(2).

j

Beneficiaries who have been diagnosed with an illness caused or complicated by tobacco use must 

still pay 20 percent of the approved amount after the annual deductible.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 53 GAO-12-81 Medicare Preventive Services

This appendix provides complete details of our analyses of the following 

Medicare preventive services: cholesterol tests, pap tests, influenza 

vaccinations, pneumococcal vaccinations, bone mass measurements, 

mammograms, colorectal cancer screenings, and PSA tests.

Table 16: Use of Cholesterol Tests by Male Medicare FFS Beneficiaries during the 5-

year Period 2005 through 2009

Numbers in percent

Male beneficiaries No services a,b One service Two or more services

All 16.2 8.3 75.5

65 to 74 16.4 7.9 75.8

75 to 84 15.2 8.6 76.2

85 or older 21.7 12.3 66.0

Not dual 16.0 8.2 75.9

Dual 19.9 10.0 70.1

White 15.6 8.2 76.3

Black 24.3 9.8 65.9

Hispanic 22.7 10.2 67.2

Asian 12.7 7.6 79.7

Other/Unknown 23.7 8.1 68.2

Urban 15.1 7.8 77.1

Rural 19.6 9.9 70.5

South 15.7 8.0 76.3

West 19.0 9.2 71.8

Midwest 16.7 9.2 74.1

Northeast 13.9 6.8 79.3

Other/Unknown 18.9 7.2 73.9

Not HPSA 15.8 8.2 76.0

HPSA 21.2 9.8 69.0

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of 

study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were 

enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2005.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.

Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 54 GAO-12-81 Medicare Preventive Services

Table 17: Use of Screening Pap Tests by Female Medicare FFS Beneficiaries during 

the 3-year Period 2007 through 2009

Numbers in percent

Female beneficiaries No services a,b One service Two or more services

All 77.0 17.8 5.2

65 to 74 69.1 23.7 7.3

75 to 84 83.1 13.4 3.5

85 or older 93.9 5.1 1.0

Not dual 75.7 18.7 5.6

Dual 86.3 11.5 2.1

White 76.3 18.3 5.4

Black 81.6 14.7 3.7

Hispanic 86.2 11.7 2.1

Asian 84.7 12.8 2.6

Other/Unknown 81.1 15.4 3.6

Urban 76.5 18.0 5.4

Rural 78.7 17.1 4.3

South 75.6 18.9 5.5

West 79.8 16.2 4.1

Midwest 78.6 16.9 4.5

Northeast 75.4 18.3 6.3

Other/Unknown 89.7 9.2 1.1

Not HPSA 76.8 18.0 5.3

HPSA 80.1 16.0 3.9

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of 

study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were 

enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2007.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 55 GAO-12-81 Medicare Preventive Services

Table 18: Use of Influenza Vaccination by Medicare FFS Beneficiaries for the July 

2008 through June 2009 Flu Season

Numbers in percent

Beneficiaries No vaccinations a,b One vaccination Two or more vaccinations

All 50.9 48.8 0.3

Female 49.2 50.6 0.3

Male 53.4 46.4 0.2

65 to 74 55.7 44.1 0.2

75 to 84 45.8 53.9 0.3

85 or older 45.3 54.4 0.3

Not dual 49.4 50.3 0.3

Dual 63.2 36.5 0.3

White 48.9 50.9 0.3

Black 70.2 29.6 0.1

Hispanic 73.1 26.7 0.2

Asian 52.4 47.2 0.4

Other/Unknown 59.1 40.6 0.3

Urban 49.8 49.9 0.3

Rural 54.4 45.4 0.2

South 51.5 48.3 0.3

West 55.2 44.6 0.2

Midwest 48.0 51.7 0.3

Northeast 48.9 50.7 0.4

Other/Unknown 93.1 6.9 0.0

Not HPSA 50.1 49.6 0.3

HPSA 60.6 39.2 0.2

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of 

study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were 

enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of July 1, 2008.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 56 GAO-12-81 Medicare Preventive Services

Table 19: Use of the Pneumococcal Vaccination during the 5-year Period 2005 

through 2009 by Medicare FFS Beneficiaries Aged 65 as of January 1, 2005

Numbers in percent

Beneficiaries No vaccinations a One vaccination Two or more vaccinations

All 72.7 25.8 1.5

Female 71.7 26.9 1.5

Male 73.9 24.5 1.6

Not dual 72.1 26.5 1.5

Dual 78.4 19.8 1.8

White 71.6 26.8 1.6

Black 82.4 16.5 1.1

Hispanic 84.7 13.9 1.3

Asian 75.7 22.8 1.6

Other/Unknown 76.3 22.7 1.1

Urban 71.6 26.7 1.7

Rural 75.8 23.1 1.1

South 73.2 25.2 1.6

West 74.4 24.3 1.3

Midwest 71.2 27.2 1.6

Northeast 71.4 27.1 1.6

Other/Unknown 97.1 2.9 0.0

Not HPSA 72.2 26.2 1.6

HPSA 77.6 21.2 1.3

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries who 

were not continuously enrolled in Parts A and B during the period of study, (2) beneficiaries residing 

in institutions, (3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in 

Medicare Advantage during the period of study.

a

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 57 GAO-12-81 Medicare Preventive Services

Table 20: Use of Bone Mass Measurements by Female Medicare FFS Beneficiaries 

during the 5-year Period 2005 through 2009

Numbers in percent

Female beneficiaries No services a,b One service Two or more services

All 47.4 29.3 23.3

65 to 74 42.2 31.2 26.6

75 to 84 50.3 28.5 21.2

85 or older 70.5 19.7 9.8

Not dual 45.7 29.8 24.6

Dual 59.8 25.8 14.4

White 46.0 29.8 24.2

Black 62.7 24.5 12.8

Hispanic 54.5 27.6 18.0

Asian 50.7 27.9 21.5

Other/Unknown 53.3 26.2 20.5

Urban 46.0 29.5 24.5

Rural 52.3 28.6 19.2

South 45.8 29.6 24.6

West 47.2 29.3 23.5

Midwest 49.9 29.6 20.5

Northeast 47.8 28.1 24.0

Other/Unknown 45.3 30.2 24.6

Not HPSA 46.8 29.5 23.7

HPSA 55.2 27.1 17.8

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of 

study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were 

enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2005.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 58 GAO-12-81 Medicare Preventive Services

Table 21: Use of Screening and Diagnostic Mammography by Female Medicare FFS 

Beneficiaries Aged 65 to 74 during the 2-year Period 2008 through 2009

Numbers in percent

Female beneficiaries No mammogram a,b One or more mammograms

All aged 65 to 74 35.5 64.5

Not dual 33.2 66.8

Dual 51.3 48.7

White 34.3 65.8

Black 40.9 59.1

Hispanic 51.6 48.4

Asian 51.7 48.3

Other/Unknown 45.6 54.4

Urban 34.7 65.3

Rural 38.0 62.0

South 35.8 64.3

West 37.8 62.2

Midwest 34.7 65.3

Northeast 33.7 66.3

Other/Unknown 44.5 55.5

Not HPSA 35.0 65.0

HPSA 41.6 58.4

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of 

study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were 

enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2008.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 59 GAO-12-81 Medicare Preventive Services

Table 22: Use of Screening Mammography by Female Medicare FFS Beneficiaries 

Aged 75 or Older during the 2-year Period 2008 through 2009

Numbers in percent

Female beneficiaries No mammogram a,b One or more mammograms

All aged 75 or older 59.5 40.5

75 to 84 52.9 47.1

85 or older 77.9 22.1

Not dual 57.3 42.7

Dual 73.8 26.2

White 58.4 41.6

Black 64.7 35.4

Hispanic 71.5 28.5

Asian 74.3 25.7

Other/Unknown 68.6 31.4

Urban 59.2 40.8

Rural 60.4 39.6

South 59.1 40.9

West 60.0 40.0

Midwest 58.6 41.4

Northeast 60.3 39.7

Other/Unknown 88.2 11.8

Not HPSA 59.1 40.9

HPSA 64.2 35.8

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of 

study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were 

enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2008.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 60 GAO-12-81 Medicare Preventive Services

Table 23: Use of Colorectal Cancer Screening and Diagnostic Services by Medicare 

FFS Beneficiaries Aged 65 to 75, 2005 through 2009

Numbers in percent

Beneficiaries Followed a regimen a,b Did not follow a regimen

All beneficiaries 65 to 75 25.5 74.5

Female 27.0 73.0

Male 23.5 76.5

Not dual 26.1 73.9

Dual 19.8 80.2

White 25.8 74.2

Black 24.8 75.2

Hispanic 19.2 80.8

Asian 19.3 80.7

Other/Unknown 21.8 78.2

Urban 25.7 74.3

Rural 24.8 75.2

South 26.1 73.9

West 23.2 76.8

Midwest 25.3 74.7

Northeast 26.6 73.4

Other/Unknown 24.3 75.7

Not HPSA 25.7 74.3

HPSA 23.3 76.7

Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously 

enrolled in Parts A and B during the period of study, (3) beneficiaries residing in institutions, (4) ESRD 

beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage during the 

period of study.

a

Denotes the beneficiary’s age as of January 1, 2005.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 61 GAO-12-81 Medicare Preventive Services

Table 24: Use of Colorectal Cancer Screening Services by Medicare FFS 

Beneficiaries Aged 76 or Older, 2005 through 2009

Numbers in percent

Beneficiaries Followed a regimen a,b Did not follow a regimen

All beneficiaries 76 or older 5.8 94.3

Female 5.4 94.6

Male 6.4 93.6

76 to 85 6.3 93.7

86 or older 2.0 98.0

Not dual 6.0 94.0

Dual 3.6 96.4

White 5.9 94.1

Black 5.3 94.7

Hispanic 3.5 96.5

Asian 4.3 95.7

Other/Unknown 3.9 96.1

Urban 5.7 94.3

Rural 5.8 94.2

South 5.8 94.2

West 5.4 94.6

Midwest 6.6 93.4

Northeast 4.9 95.1

Other/Unknown 0.6 99.4

Not HPSA 5.8 94.2

HPSA 5.3 94.7

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of 

study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were 

enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2005.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix III: Tables with Full Analysis of 

Preventive Service Use in Medicare FFS

Page 62 GAO-12-81 Medicare Preventive Services

Table 25: Use of PSA Tests by Male Medicare FFS Beneficiaries during the 4-year 

Period 2006 through 2009

Numbers in percent

Male beneficiaries No services a,b One service Two or more services

All 50.9 23.6 25.6

65 to 74 48.0 23.5 28.5

75 or older 55.3 23.8 20.9

75 to 84 53.7 24.1 22.1

85 or older 65.0 21.5 13.6

Not dual 50.1 23.6 26.3

Dual 60.6 23.1 16.3

White 49.5 23.9 26.6

Black 59.9 21.7 18.5

Hispanic 67.4 21.2 11.4

Asian 67.1 19.9 13.0

Other/Unknown 64.1 19.2 16.7

Urban 52.5 23.3 24.3

Rural 46.0 24.5 29.4

South 48.0 24.0 28.0

West 60.5 22.3 17.2

Midwest 44.1 24.8 31.1

Northeast 56.1 22.7 21.3

Other/Unknown 92.3 5.7 2.1

Not HPSA 51.1 23.6 25.4

HPSA 48.6 23.9 27.5

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under 

age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of 

study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were 

enrolled at any time in Medicare Advantage during the period of study.

a

Denotes the beneficiary’s age as of January 1, 2006.

b

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.
Appendix IV: Use of the Welcome to Medicare 

Exam by Medicare FFS Beneficiaries Who 

Reached Age 65 in 2008

Page 63 GAO-12-81 Medicare Preventive Services

Numbers in percent

Beneficiaries Received WTM exam a Did not receive WTM exam

All 6.6 93.4

Female 7.0 93.0

Male 6.1 93.9

Not dual 7.3 92.7

Dual 1.1 99.0

White 7.3 92.7

Black 1.7 98.3

Hispanic 0.7 99.3

Asian 3.4 96.6

Other/Unknown 3.7 96.3

Urban 6.7 93.3

Rural 6.3 93.7

South 6.1 93.9

West 6.4 93.6

Midwest 8.0 92.0

Northeast 6.4 93.7

Other/Unknown 0.0 100.0

Not HPSA 6.8 93.2

HPSA 4.2 95.8

Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries who 

were not continuously enrolled in Parts A and B during 2008 and half of 2009, (2) beneficiaries 

residing in institutions, (3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in 

Medicare Advantage during 2008.

a

Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in 

an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.

Appendix IV: Use of the Welcome to 

Medicare Exam by Medicare FFS 

Beneficiaries Who Reached Age 65 in 2008
Appendix V: Comments from the Department 

of Health and Human Services

Page 64 GAO-12-81 Medicare Preventive Services

Appendix V: Comments from the Department 

of Health and Human Services
Appendix V: Comments from the Department 

of Health and Human Services

Page 65 GAO-12-81 Medicare Preventive Services
Appendix V: Comments from the Department 

of Health and Human Services

Page 66 GAO-12-81 Medicare Preventive Services
Appendix VI: GAO Contact and Staff 

Acknowledgments

Page 67 GAO-12-81 Medicare Preventive Services

James C. Cosgrove, (202) 512-7114 or cosgrovej@gao.gov

In addition to the contact named above, individuals making key 

contributions to this report include Rosamond Katz, Assistant Director; 

Todd D. Anderson; and Kate Nast. Zhi Boon and Elizabeth T. Morrison 

also provided valuable assistance.

Appendix VI: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Acknowledgments 

(290889)
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