Medicare: Beneficiary Use of Clinical Preventive Services
Published: 2002-04-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Preventive medicine, including immunizations for many diseases and screening for some types of cancer, holds the promise to extend and improve the quality of life for millions of Americans. Medicare now covers three preventive services for immunizations and three for screenings, and the Centers for Medicare and Medicaid Services (CMS) sponsors "interventions" to increase the use of preventive services.
section_title: What GAO Found
paragraphs: GAO found that the use of preventive services varies widely by service, state, ethnic group, income, and education. The greatest differences among ethnic groups were for immunization rates. Cancer screening rates tended to differ according to income and education level. CMS pays for interventions that promote breast cancer screenings and pneumonia and flu shots. Most of the techniques being used, such as reminder systems that medical offices can use to alert doctors and patients to needed cancer screenings, have been effective. CMS is evaluating what its current efforts have accomplished and expects the results later this year.

section_title: Letter
paragraphs: Preventive health care services can extend lives and promote well-being  among our nation’s seniors. For example, immunizations against the flu  can prevent thousands of hospitalizations and deaths each year among  those age 65 and older. Screening for some types of cancer may extend  and improve the quality of life through early detection and treatment. Such  preventive services are a growing part of Medicare, the federal  government’s health insurance program for some 34 million Americans age  65 and older, as well as 6 million younger disabled persons. Medicare,  administered by the Centers for Medicare and Medicaid Services (CMS),  now covers 10 preventive services—3 types of immunizations and 7 types  of screening.
Although Medicare provides coverage for these preventive services, some  beneficiaries do not receive them. These beneficiaries may, for example,  face barriers in obtaining the services or simply choose not to use them.  To help ensure that preventive services are being delivered to those  beneficiaries who need them, CMS sponsors efforts—called  “interventions”—aimed at increasing preventive service usage rates.
You asked us to examine two questions regarding preventive services for  older Americans:    To what extent are Medicare beneficiaries using covered preventive  services?
What action has CMS taken to increase use of preventive services among  the Medicare population?
To answer these questions, we estimated Medicare beneficiaries’ use of  services from a nationwide, state-based survey conducted by the Centers  for Disease Control and Prevention (CDC). We obtained information  about effective techniques to increase use of preventive services from  published reports and discussions with program officials at the federal and  state levels who are responsible for implementing projects intended to  increase the use of preventive services. For both questions, we conducted  interviews with officials from the Department of Health and Human  Services, CDC, the National Institutes of Health, CMS, and the Agency for  Health Care Research and Quality. We also spoke with representatives  from the Partnership for Prevention, a nonprofit association involved in  the research and promotion of preventive services. We conducted our  work from August through February 2002 in accordance with generally  accepted government auditing standards.
subsections: section_title: Background
paragraphs: When the Medicare program was established in 1965, it only covered  health care services for the diagnosis or treatment of illness or injury.  Preventive services did not fall into either of these categories and,  consequently, were not covered. Since 1980, the Congress has amended  Medicare law several times to add coverage for certain preventive services  for different age and risk groups within the Medicare population. (See  table 1.) For most of these services, Medicare requires some degree of  cost-sharing by beneficiaries, although most beneficiaries have additional  insurance, which may cover most, if not all, of these cost-sharing  requirements. Some services, such as pneumonia and flu shots and the  fecal-occult blood test for colorectal cancer, have no cost-sharing  requirements.
Many other preventive services exist besides those specifically covered as  preventive services under Medicare, such as blood pressure screening and  cholesterol screening. Although Medicare does not explicitly provide  coverage for these other services, Medicare beneficiaries may receive  some of them during office visits for other medical problems. Data from  surveys of Medicare beneficiaries indicate that the receipt of such services  is common. For example, in 1999, nearly 98 percent of seniors reported  that they had had their blood pressure checked within the last 2 years, and  more than 88 percent of seniors reported having their cholesterol checked  within the prior 5 years. At least a portion of these services were likely  ordered by physicians in order to diagnose the causes of medical  problems, and were paid for by Medicare as such.
To identify how best to increase use of preventive services needed by the  Medicare population, CMS sponsors reviews of studies that examine  various kinds of interventions that have been used in the past for  populations age 65 and older. CMS also takes action to implement  interventions in each state through its Peer Review Organization (PRO)  program. Under this program, CMS contracts with 37 organizations  responsible for each state, U.S. territory, and the District of Columbia. The  PRO program, which is designed to monitor and improve quality of care  for Medicare beneficiaries, currently includes the goal of increasing the  use of flu and pneumonia immunizations, as well as breast cancer  screening, in each state. These organizations collaborate with hospitals  and health care professionals, suggesting systemic changes to improve  how preventive services are provided. CMS also conducts a variety of  health promotion activities to educate beneficiaries about the benefits of  preventive services and to encourage their use. These include the  publication of brochures on certain covered services and media  campaigns.
section_title: Use of Preventive Services Is Growing but Varies Widely
paragraphs: Use of preventive services offered under Medicare has increased over  time. Some services are used more extensively than others, and use of  individual services varies by state and, to a lesser extent, by demographic  characteristics such as ethnicity, income, and education. Although  opportunities remain to increase the use of preventive services within  Medicare, there are limits to the extent some beneficiaries would be  expected to use certain services.
subsections: section_title: The Use of Individual Preventive Services Has Increased over Time but a Minority Receive Multiple Services
paragraphs: Information on usage for 4 of the 10 preventive services covered under  Medicare is available in the data we used—immunizations against  pneumonia and flu and screening for cervical and breast cancer. This  information shows that beneficiaries age 65 and older are increasing their  use of all 4 services. (See table 2.) For example, 68 percent of beneficiaries  received flu shots in 1999, compared with 60 percent in 1995.
In 1999, although each preventive service was used by the majority of  Medicare beneficiaries, fewer receive multiple preventive services. For  example, 1999 data show that while 91 percent of female Medicare  beneficiaries received at least 1 preventive service, only 10 percent of  these beneficiaries were screened for cervical, breast, and colon cancer,  as well as immunized against flu and pneumonia. These data also show  that 44 percent of male beneficiaries were immunized against both flu and  pneumonia. When colorectal screening is included in this set of services,  the proportion of men who had received all 3 services falls to less than 27  percent.
section_title: Use of Services Varies by State and Other Demographic Characteristics
paragraphs: While national rates provide an overall picture of current use, they mask  substantial differences in how seniors living in different states use some  services. For example, the national breast cancer screening rate for  Medicare beneficiaries was 75 percent in 1999, but rates for individual  states ranged from a low of 66 percent to a high of 86 percent. In table 3,  we show the range over which state estimates of preventive service usage  rates vary from lowest to highest for selected states.
While usage rates for each service varied from state to state, the services  with the highest rates in each state were generally the same. For example,  in most states, screening rates for breast and cervical cancer were higher  than rates for colorectal screens.
Usage rates for Medicare beneficiaries also varied based on ethnicity, and  on socioeconomic status, as defined by income and education. By  ethnicity, the biggest differences occurred in use of immunization services.  For example, 1999 data show that about 57 percent of whites and 54  percent of “other” ethnic groups were immunized against pneumonia,  compared to about 37 percent of African Americans and Hispanics.  Similarly, about 70 percent of whites and “other” ethnic groups received  flu shots during the year compared to 49 percent of African Americans.  The only other statistically significant difference between ethnic groups  was for the fecal-occult blood test for colon cancer, for which 26 percent  of whites received screenings within the past year compared to 16 percent  of Hispanics and “other” ethnic groups. For income and education, in  general, as income and education rose, the rates at which individuals used  preventive services also increased. (See table 4.)
section_title: Opportunities and Limitations Exist to Increase the Use of Preventive Services
paragraphs: Various studies have identified a variety of factors affecting beneficiary  decisions to seek preventive care, including low patient awareness of the  benefits of the services as well as the need for service. Some factors, such  as those involving patient awareness of the benefits, may represent  opportunities to increase the use of preventive services. For example, see  the following.
In a 1997 report, the Agency for Healthcare Research and Quality found  that, although patients may be unaware of the risks or symptoms of  colorectal cancer, they are more likely to participate in screening once  they understand the nature and risks of the disease.
Data from CMS’s 1999 Medicare Current Beneficiary Survey show that,  while about one-fourth of beneficiaries who did not receive flu shots were  unaware of the benefits of obtaining this immunization, about half of the  people who were not immunized avoided getting the shot for reasons such  as concerns about side effects and whether doing so would effectively  prevent illness.
On the other hand, usage rates alone may not provide a clear picture of  success, and may mask inherent limitations to increasing usage rates. For  example, survey data show that 44 percent of women age 65 and over have  had hysterectomies—an operation that usually includes removing the  cervix. For these women, researchers state that cervical cancer screening  may not be necessary unless they have a prior history of cervical cancer.  Also, according to officials in charge of research on preventive services at  the National Institutes of Health, it is reasonable for beneficiaries, their  families, or their providers to decide to forgo services because of the  limited benefits they would offer patients with terminal illnesses or of  advanced age. These officials explained that research has shown, for  example, that the benefits of cancer screening services, such as for  prostate, breast, and colon cancer, can take 10 years or more to  materialize, a time frame that could exceed the life expectancy of as much  as half of the Medicare population.
CMS officials also pointed out that the controversy over the effectiveness  of some services, such as mammography and prostate cancer screening,  may add to the difficulty in further improving screening rates for these  services. The benefit of mammography has recently been challenged by  two Danish researchers and an independent group of experts on the  National Cancer Institute’s (NCI) advisory panel citing serious flaws in 6 of  the 8 clinical trials that showed benefits. However, subsequent to the  Danish report and the NCI panel’s statement, both the NCI and the U.S.  Preventive Services Task Force reiterated their recommendation for  regular mammography screening. While acknowledging the  methodological limitations in these trials, the U.S. Preventive Services  Task Force concluded that the flaws in these studies were unlikely to  negate the reasonable, consistent, and significant mortality reductions  observed in these trials. Routine screening for prostate cancer is also a  matter of controversy. For example, the American Cancer Society and the  American Urological Association support routine prostate cancer  screening, while the U.S. Preventive Services Task Force and others state  that there is insufficient evidence to support it.
section_title: Efforts Under Way to Increase Use of Some Preventive Services
paragraphs: CMS has studied various types of interventions to increase the use of  preventive services among seniors. These studies show that many types of  interventions can potentially be effective, but also that interventions must  be tailored to the circumstances of specific situations. CMS is funding  efforts in every state to implement interventions for three preventive  services that Medicare covers. CMS also has efforts under way aimed at  increasing the use of preventive services among minority and low-income  seniors.
subsections: section_title: Studies Identify Effective Methods to Increase Use of Services
paragraphs: CMS has sponsored reviews of studies looking at the effectiveness of  interventions to increase use of preventive services among people age 65  and older. One of these reviews evaluated the effectiveness of  interventions targeting people over age 65 for five services covered by  Medicare—immunizations for flu and pneumonia and screenings for  breast, cervical, and colon cancer. The report evaluated 218 separate  studies on interventions designed to increase use of preventive services.  The studies were performed in both academic and nonacademic settings  in various geographic areas, and in a mixture of reimbursement systems.  Most of the interventions studied that involved pneumococcal and  influenza immunizations were targeted toward persons over 65 years of  age, while cancer screening interventions were targeted at adults, but not  necessarily those 65 years of age.
This evaluation concluded that no specific intervention was consistently  most effective for all services and settings, and that success depended on  how closely the intervention addressed the unique circumstances in each  state and for different populations within each state, while also taking into  account the cost and difficulty of implementation. Obstacles to improved  screening rates can differ across states thus requiring different  approaches. For example, officials responsible for improving the use of  preventive services in Idaho and Washington explained that while a  significant barrier in Idaho was beneficiary access to Medicare providers,  this was not a barrier in Washington. The CMS evaluation also showed that  using multiple interventions generally provided greater success than using  a single approach.
The types of interventions evaluated in the CMS-sponsored review  included a variety of efforts targeting health delivery systems, providers,  and patients. The key conclusion the report drew from the literature was  that organizational and system change, such as the use of standing orders  and the use of financial incentives, were the most consistent at producing  the largest increase in the use of preventive services. These and other  interventions found to be effective follow.
System Change. These interventions change the way a health system  operates so that patients are more likely to receive services. For example,  medical or administrative staff may be given responsibility to ensure that  patients receive services, or standing orders may be implemented in  nursing homes to allow nonphysician personnel to administer  immunizations without a physician’s order.  Incentives. These interventions include gifts or vouchers to patients for  free services. Medicare allows this type of approach only in limited  circumstances.
Reminders. These interventions include computer-generated or other  approaches by which medical offices (1) reminded physicians to provide  the preventive service as part of services performed during a medical visit  or (2) generated notices to patients that it was time to make an  appointment for the service. Studies show that reminders to either  patients or physicians can effectively improve rates for cancer screening.  However, a computerized provider reminder is consistently more cost  effective than notifying the patient directly when a computerized  information system is already available in a physician’s medical office.  Patient reminders that are personalized or signed by the patient’s  physician are more effective than generic reminders.
Education. These interventions include pamphlets, classes, or public  events providing information for physicians or beneficiaries on coverage,  benefits, and time frames for services. The study found that while the  effect of patient education is significant, it is consistently less effective  than system change, incentives, or reminders.
section_title: CMS Is Sponsoring Interventions to Increase Use of Three Services
paragraphs: CMS is implementing interventions in all states through its PRO program.  Under this program, CMS contracts with 37 PROs, each responsible for  monitoring and improving the quality of care for Medicare beneficiaries in  one or more states, in U.S. territories, or in the District of Columbia. These  efforts are currently aimed at three preventive services offered under  Medicare—immunizations against flu and pneumonia and screening for  breast cancer. CMS chose these topics based on their public health  importance and other factors. CMS also contracts with select PROs to  provide support and assistance to all PROs for each area of focus. For  example, CMS has contracted with two of the existing PROs, one for flu  and pneumonia immunizations and one for breast cancer screening, to  provide support and share information among the PROs regarding their  efforts to improve usage rates for these services. Our discussions with the  officials from these two PROs indicate that, for immunizations, most PROs  are focusing on ways to better educate patients and providers on the  importance of getting flu and pneumonia shots. For breast cancer  screening, efforts are focusing on developing integrated reminder systems,  such as chart stickers or computer-based alerts that physicians’ offices can  use to contact patients on a timely basis.
Officials for the two PROs providing support indicated that most PROs  were implementing multiple interventions. For example, in a newsletter  intended to help PROs share information, officials at one PRO reported  that they have developed concurrent breast cancer screening interventions  for their state, which are targeted at physicians and their staffs, nurses,  and beneficiaries. Officials for this PRO report the following.
For physicians and their staffs, they (1) host seminars to teach them about  reminder and billing systems, (2) provide toolkits that include reminder  systems, checklists, and other materials, and (3) conduct on-site  consultations to encourage providers to implement system changes.
For nurses, they are conducting a campaign intended to increase  awareness and encourage nurses and student nurses to identify female  friends and family members who are overdue for mammograms. The  campaign includes information packets, a newsletter, and information  booths at nursing organization meetings.
For beneficiaries, the PRO publishes a periodic newsletter on the subject  of preventive medicine. This newsletter includes articles on the  importance of mammography for early detection of breast cancer.
CMS has taken steps to evaluate the success of PRO efforts. CMS officials  explained that the contracts with the PRO organizations are “performance  based” and provide financial incentives as a reward for superior outcomes.  The contracts include a methodology in which the performance of the  PRO for each state, U.S. territory, and the District of Columbia is scored  based on 22 indicators, including flu and pneumonia vaccination rates and  mammography rates. The performance of the PRO in each state will then  be ranked against all other states in order to identify the higher and lower  performing PROs. CMS intends to automatically renew the contracts with  the top 75 percent of the PROs for the next contract cycle, which begins in  2002. The PRO contracts also contain financial performance incentives  allowing each PRO to receive up to an additional 2 percent payment based  on the positive outcomes of their interventions. CMS officials expect  information on the results by the summer of 2002. Consequently, we have  not assessed the outcome of PRO efforts or CMS’s methodology for  measuring PRO performance.
While the current efforts include 3 of the 10 preventive services covered by  Medicare, CMS is also developing indicators and performance measures  necessary for interventions to increase use of screening services for  osteoporosis and colorectal and prostate cancer. CMS officials stated that  such interventions would be implemented in future contracts with PROs.  CMS is not currently developing indicators for the remaining preventive  services covered by Medicare—hepatitis B immunizations or screenings  for glaucoma and vaginal cancer.
section_title: CMS Is Also Sponsoring Interventions to Increase Use of Services among Minorities and Low- Income Seniors
paragraphs: CMS is also sponsoring PRO interventions and projects in each state to  increase use of preventive services by minorities and low-income  Medicare beneficiaries. CMS-funded research on successful interventions  for the general Medicare population 65 and older concluded that evidence  was insufficient to determine how best to increase use of services by  minorities and low-income seniors across various geographic settings.  Differences in how populations use preventive services are sometimes  found even when the populations have similar geographic settings or  delivery systems. For example, a study showed that although use of flu  shots among white and African American seniors is higher under managed  care than fee-for-service, the significant disparities in levels of use  between these ethnic groups persist in both these environments.
To begin addressing these information gaps, CMS requires that each PRO  conduct a project focusing on one of several specified Medicare  populations. This population can be low-income seniors enrolled in both  Medicare and Medicaid or one of several minority groups: American  Indians, Alaska Natives, Asian Americans and Pacific Islanders, African  Americans, or Hispanics. For the population chosen, the PRO is to target  interventions for one service. The projects in most states are focusing on  increasing breast cancer screening or flu and pneumonia immunization  among African American or low-income seniors. PROs are required to  identify the barriers that exist for the selected population and service, and  to implement interventions specifically designed to address these barriers  for patients and providers. A summary of PRO efforts to increase services  for minorities and low-income seniors is expected to be published  sometime after the spring of 2002.
Other studies or projects under way by CMS also aim to identify barriers  and increase use of services by certain Medicare populations. For  example, the Congress directed CMS to conduct a demonstration project  to, among other things, develop and evaluate methods to eliminate  disparities in cancer prevention screening measures. The law specifies a  total of nine demonstration projects to include two state-level  demonstrations for each of four minority groups (American Indians,  including Alaska Natives, Eskimos, and Aleuts; Asian Americans and  Pacific Islanders; African Americans; and Hispanics) and one project in  the Pacific Islands. In addition, one of the projects must have a rural focus  and one must have an urban focus for each group. CMS expects to  produce a report by December 2002, after the project’s first phase is  completed, identifying best practices and models to be tested in  demonstration projects. The second phase, which is to start around  December 2002, is to test these models by implementing them in actual  demonstration projects intended to determine which methods are most  effective in reducing the incidence of cancer and improving minority  health by overcoming barriers to the use of preventive services in the  target populations. A report evaluating the cost effectiveness of the  demonstration projects, the quality of preventive services provided, and  beneficiary and health care provider satisfaction is due to the Congress in  2004.
section_title: Agency Comments and Our Evaluation
paragraphs: We obtained comments on our draft report from CMS. CMS commented  that the draft report focused on the activities of its PROs and did not  consider all of CMS’s health promotion activities. CMS provided details on  its publication and educational campaigns to inform Medicare  beneficiaries about preventive service benefits and to encourage their use.  CMS’s comments are reproduced in appendix I.
We acknowledge that our report does not describe all of CMS’s health  promotion/education activities underway that relate to increasing the use  of preventive services among the Medicare population. While beneficiary  education activities are worthwhile, CMS studies have shown that other  interventions, such as those that are directed at changing the way a health  delivery system operates so that patients are more likely to receive  services, are more effective. Because PROs and CMS demonstration  projects are accountable for facilitating the implementation of these types  of interventions, we focused our efforts in describing these activities and  the status of their evaluations. We have revised the report to make it clear  that PRO activities are in addition to other CMS beneficiary education  efforts.
CMS also provided technical comments that we considered and  incorporated where appropriate.
As arranged with your office, unless you release its contents earlier, we  plan no further distribution of this report until 30 days after its issuance  date. At that time we will send copies of this report to the secretary of  health and human services, the administrator of the Centers for Medicare  and Medicaid Services, the director of the Centers for Disease Control and  Prevention, and others who are interested. We will also make copies  available to others on request.
If you or your staff have any questions, please contact me at (202) 512- 7119, or Frank Pasquier at (206) 287-4861. Other major contributors are  included in appendix II.
section_title: Appendix I: Comments from the Centers for Medicare and Medicaid Services
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: Other major contributors to this report include Lacinda Ayers, Matthew  Byer, Jennifer Cohen, Jennifer Major, Behn Miller, and Stan Stenersen.