Medicare Preventive Services: Most Beneficiaries Receive Some but Not All Recommended Services
Published: 2004-09-21T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Preventive care depends on identifying health risks and on taking steps to control these risks. In contrast, Medicare, the federal health program insuring almost 35 million beneficiaries age 65 or older, was established largely to help pay beneficiaries' health care costs when they became ill or injured. Congress has broadened Medicare coverage over time to include specific preventive services, such as flu shots and certain cancer-screening tests, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) added coverage for several preventive services, including a one-time preventive care examination for new enrollees, which will start in 2005. GAO's work, done before MMA, included analyzing data from four national health surveys to examine the extent to which Medicare beneficiaries received preventive services through physician visits. GAO also interviewed officials from the Centers for Medicare & Medicaid Services (CMS) and other experts and reviewed the results of past demonstrations and studies to assess expected benefits and limits of different delivery options for preventive care, including a one-time preventive care examination.
section_title: What GAO Found
paragraphs: Most Medicare beneficiaries receive some but not all recommended preventive services. Our analysis of year 2000 data shows that nearly 9 in 10 Medicare beneficiaries visited a physician at least once that year; beneficiaries made, on average, six visits or more within the year. Still, many did not receive recommended preventive services, such as flu or pneumonia vaccinations. Moreover, many are apparently unaware that they may have conditions, such as high cholesterol, that preventive services are meant to detect. In one 19992000 nationally representative survey where people were physically examined and asked a series of questions, nearly one-third of people age 65 or older whom the survey found to have high cholesterol measurements said they had not before been told by a physician or other health professional that they had high cholesterol. Projected nationally, this percentage translates into about 2.1 million people who may have had high cholesterol without knowing it. A one-time preventive care examination may help orient new beneficiaries to Medicare and provide further opportunity for beneficiaries to receive some preventive services. Covering a one-time preventive care examination does not ensure, however, that beneficiaries will receive the recommended preventive services they need over the long term or consistently improve health or lower costs. CMS is exploring an alternative that would provide beneficiaries with systematic health risk assessments by means other than visits to physicians. A key component of this early effort involves the coupling of risk assessments with follow-up interventions, such as referrals for follow-up care.

section_title: Letter
paragraphs: I am pleased to be here today as you discuss seniors’ health and the  preventive care benefits in the Medicare Prescription Drug, Improvement,  and Modernization Act of 2003 (MMA). Overall preventive care depends  heavily on identifying health risks associated with the onset or progression  of disease and on taking steps to reduce or mitigate these risks. The  Medicare program, in contrast, was established largely to help pay  beneficiaries’ health care costs when they became ill or injured. Over time,  however, Congress has broadened Medicare coverage to include specific  preventive services, such as immunizations for influenza and pneumonia  and screening tests for certain cancers, that aim to keep an illness or  condition from developing or becoming more serious. Most recently, in  passing the MMA, Congress added coverage, to start in 2005, for a one- time preventive care examination for new enrollees and for selected other  preventive services.
As these new benefits are implemented under MMA, you have inquired  about lessons learned from previous research on delivery options for  preventive services. Since 2002, we have done a series of reports for  Congress that examines the delivery of preventive care services to  Medicare beneficiaries. My statement today summarizes some relevant  findings from our work done before MMA, specifically:  the extent to which Medicare beneficiaries receive preventive services  through physician visits, and    some of the expected benefits and limitations of delivering services  through a one-time preventive care examination, including discussion of  another delivery option being explored by the Centers for Medicare &  Medicaid Services (CMS).
My testimony today is based on reports and testimony we have issued  since 2002. Our work for these products included a synthesis of  information on preventive care received by people age 65 or older from  four nationally representative health surveys; a review of the results of  past related research demonstrations and congressionally mandated  studies; and interviews with Department of Health and Human Services  (HHS) and CMS officials and other experts. This work allows us to discuss  the benefits and limitations of the delivery of preventive services through a  one-time examination. This body of work was conducted from August  2001 through August 2003 in accordance with generally accepted  government auditing standards. In July 2004, we updated information on  recommended preventive services and on the status of a CMS effort to  explore another delivery option.
In summary, although they typically visit a physician several times during a  year, most Medicare beneficiaries receive some but not all recommended  preventive services. Our analysis of year 2000 data shows that nearly 9 in  10 Medicare beneficiaries visited a physician at least once that year, and  beneficiaries made an average of six visits or more within the year.  Despite these opportunities, many beneficiaries did not receive  recommended preventive services. In 2000, for example, about 30 percent  of Medicare beneficiaries did not receive an influenza vaccination, and 37  percent had never had a pneumonia vaccination as recommended under  current guidelines for people age 65 or older. Moreover, many Medicare  beneficiaries are apparently unaware that they may have conditions that  preventive services are meant to detect. For example, in one 1999–2000  nationally representative survey during which people received physical  examinations, nearly one-third of people age 65 or older whom the survey  found to have high cholesterol measurements said they had not previously  been told by a physician or other health professional that they had high  cholesterol. Projected nationally, this percentage translates into 2.1 million  people age 65 or older who may have had high cholesterol without  knowing it.
A one-time preventive care examination may provide an opportunity for  beneficiaries to receive some preventive services while orienting new  beneficiaries to Medicare. But covering an initial examination does not  ensure that beneficiaries receive the recommended preventive services  they need. The results of a CMS demonstration conducted in the late 1980s  and early 1990s indicated that offering Medicare beneficiaries packages of  broad-based preventive services slightly improved the use of some  services, such as immunizations and cancer screenings, but did not  consistently improve health or lower costs. CMS is exploring an  alternative for Medicare preventive care that, by means other than a  physician’s examination, would provide systematic health risk  assessments to Medicare beneficiaries. A key component of this  demonstration, which is still in development, is to address concerns that  to be effective, risk assessments must be coupled with follow-up  interventions, such as referrals for follow-up care.
subsections: section_title: Background
paragraphs: Preventive health care can extend lives and promote well-being among our  nation’s seniors. Medicare now covers a number of preventive services,  including immunizations, such as hepatitis B and influenza, and cancer  screenings, such as Pap smears and colonoscopies. Not all beneficiaries,  however, avail themselves of covered preventive services. Some  beneficiaries may simply choose not to use these services, but others may  be unaware that the services are available or covered by Medicare.  Further, for some beneficiaries, certain services may not be warranted or  may be of limited value. Appropriate preventive care depends on an  individual’s age and particular health risks, not simply on the results of a  standard battery of tests.
To evaluate preventive care for different age and risk groups, HHS in 1984  established the U.S. Preventive Services Task Force, a panel of private- sector experts. The task force recommends certain screening,  immunization, and counseling services for people age 65 or older.  Medicare covers some, but not all, of these services (see table 1).
Medicare’s fee-for-service program does not cover regular periodic  examinations, where clinicians might assess an individual’s health risk and  provide needed preventive services. Beneficiaries could and still can,  however, receive some of these services during office visits for other  health issues.
In late 2003, MMA added coverage under Medicare for a one-time “initial  preventive physician evaluation” if performed within 6 months after an  individual’s enrollment under Part B of the program. Covered services  under the examination include measurement of height, weight, and blood  pressure; an electrocardiogram; and education, counseling, and referral  services for screenings and other preventive services covered by Medicare.  MMA also added coverage for various screening tests to identify  cardiovascular disease (and related abnormalities) in “elevated risk”  beneficiaries and diabetes in “at risk” beneficiaries. The new coverage  applies to services provided on or after January 1, 2005.
section_title: Most Beneficiaries Receive Some but Not All Recommended Preventive Services
paragraphs: Nationally representative survey data show that Medicare beneficiaries  visit physicians often and that most report receiving “routine checkups.”  These data do not show, however, which specific services were delivered  during those “checkups.” Despite the frequency of visits, many Medicare  beneficiaries do not receive the full range of recommended preventive  services. Data also show that many beneficiaries may not know about their  risk for health conditions that preventive care is meant to detect.
From 2000 survey data and U. S. Bureau of the Census estimates of people  age 65 or older, we estimated that beneficiaries visited a physician at least  six times that year, on average, mainly for illnesses or medical conditions.  Only about 1 in 10 visits occurred when beneficiaries were well (see   fig. 1).
Even though the majority of visits to physicians were to treat illness or  health conditions, most Medicare beneficiaries reported receiving what  they considered to be “routine checkups.” In CDC’s 2000 Behavioral Risk  Factor Surveillance System Survey, for example, 93 percent of  respondents age 65 or older reported that they had received a “routine  checkup” within the previous 2 years. This survey did not, however,  provide information on which specific services were delivered during  those checkups. Data from another survey, enumerating services provided  during office visits, indicated that Medicare beneficiaries do receive some  preventive services during visits when they are ill or being treated for a  health condition.
Despite how often Medicare beneficiaries visit physicians, relatively few  beneficiaries receive the full range of recommended preventive services  covered by Medicare. As we reported in 2002, for example, although 91  percent of female Medicare beneficiaries in our analysis received at least  one preventive service, only 10 percent were screened for cervical, breast,  and colon cancer and were also immunized against influenza and  pneumonia. Our analysis of additional data for our 2003 report showed  that many Medicare beneficiaries still did not receive certain  recommended preventive services. The task force recommends, for  example, that all people age 65 or older receive an annual influenza  vaccination and at least one pneumonia vaccination. According to data  from CMS’s Medicare Current Beneficiary Survey of 2000, however, about  30 percent of Medicare beneficiaries did not receive an influenza  vaccination, and 37 percent had never had a pneumonia vaccination.
Many Medicare beneficiaries may not know that they are at risk for health  conditions that preventive care could detect—strong evidence that they  may not be receiving the full range of recommended preventive services.  For example, data from CDC’s NHANES for 1999–2000 show that, of  beneficiaries participating in this nationally representative survey who, as  part of the survey, had a physical examination and were found to have  elevated blood pressure readings at that time, 32 percent reported that no  physician or other health professional had told them about the condition  before. On the basis of this survey, we estimate that, during the period  when the survey was conducted, 21 million Medicare beneficiaries may  have been at risk for high blood pressure, and an estimated 6.6 million of  them may have been unaware of this risk. Similarly, 32 percent of those  found by the survey to have a high cholesterol level reported that no one  had told them that they had high cholesterol. Projected nationally, this  percentage translates into 2.1 million Medicare beneficiaries who may  have had high cholesterol without knowing it (see fig. 2).
section_title: An Initial Examination May Improve Preventive Care, but Follow-up Is Also Key
paragraphs: A one-time initial preventive care examination covered by Medicare may  offer opportunity to deliver some preventive services but alone is not  enough to ensure better health among beneficiaries. Information from a  CMS demonstration and from other related studies shows that ensuring  receipt of follow-up care will be important to improving beneficiaries’  health. A proposed CMS demonstration, currently in design, will explore  another preventive care delivery option and examine the value of linking  beneficiaries to needed follow-up services.
As proponents of a one-time “Welcome to Medicare” examination told us,  such an examination could be a means to better ensure that health care  providers have enough time to identify individual Medicare beneficiaries’  health risks and provide preventive services appropriate for their risks. It  could be used to orient new beneficiaries to Medicare and encourage them  to make informed choices about providers and plans. Nevertheless, a one- time examination does not ensure delivery of the full range of preventive  services. Primary care physicians typically cannot provide services such as  mammography screenings for breast cancer or colonoscopies for colon  cancer, because these services usually require specialists.
It also is uncertain whether a one-time or periodic examination would be  an effective way to improve beneficiaries’ health. For example, one  previous CMS initiative that included preventive health care visits ended  with mixed results. In the late 1980s and early 1990s, the agency conducted  a congressionally mandated demonstration to test varied health promotion  and disease prevention services, such as free preventive visits, health risk  assessment, and behavior counseling, to see if they would increase use of  preventive services, improve health, or lower health care expenditures for  Medicare beneficiaries. The agency’s final report, published in 1998,  concluded that the demonstration services were marginally effective in  raising the use of some simple disease-prevention measures, such as  immunizations and cancer screenings, but did not consistently improve  beneficiary health or reduce the use of hospital or skilled nursing  services. The report tempered these results by pointing out that the  relatively brief period during which the services were provided (roughly 2  years) and the limited number of follow-ups and beneficiary contacts with  providers (one to two) may have been inadequate to achieve measurable  outcomes.
Determining how to better ensure adequate follow-up once health risks  are identified is a concern that a new CMS project aims to evaluate. CMS is  exploring an alternative for Medicare preventive care that would provide  systematic health risk assessments to fee-for-service beneficiaries through  a means other than examination by a physician. In the late 1990s, the  agency commissioned the RAND Corporation to evaluate the potential  effectiveness of health risk assessment programs. Such programs collect  information from individuals; identify their risk factors; and refer the  individuals to at least one intervention to promote health, sustain function,  or prevent disease. The study concluded that health risk assessment  programs have increased beneficial behavior (particularly exercise) and  improved physiological variables (particularly diastolic blood pressure and  weight) and general health. In addition, the study stated that to be  effective, risk assessment questionnaires must be coupled with follow-up  interventions, such as referrals to appropriate services. The study  recommended that CMS conduct a demonstration to test cost- effectiveness and other aspects of the health risk assessment approach for  Medicare beneficiaries.
Following through on the study’s findings, CMS has begun designing a  demonstration project focused on Medicare fee-for-service beneficiaries,  called the Medicare Senior Risk Reduction Program, to identify health  risks and follow up with preventive services provided by means other than  examinations by physicians. The program will use a beneficiary-focused  health risk assessment questionnaire to assess health risks, such as  lifestyle behaviors, and use of clinical preventive and screening services.  The program will test different approaches to administering health risk  assessments, creating feedback reports, and providing follow-up services,  such as referring beneficiaries to health-promoting community services  including physical activity and social support groups. According to project  researchers, the program will tailor preventive interventions to individual  risks; track patient risks and health over time; and provide beneficiaries  with self-management tools and information, health behavior advice, and  end-of-life counseling where appropriate. The design phase had not been  finalized as of last week and, according to a CMS official, still required  approval from HHS and the Office of Management and Budget.
section_title: Concluding Observations
paragraphs: Current data indicate that many opportunities exist for Medicare  beneficiaries to receive preventive care, but many beneficiaries  nonetheless fail to receive the full range of recommended services.  Although some beneficiaries may not choose to seek these services, others  may not be aware that these services are available and covered by  Medicare. Our work shows that more needs to be done to deliver  preventive services to those beneficiaries who need them, because many  people may have a health condition that preventive services can easily  diagnose, and yet they may not know that they have this condition.
A one-time preventive care examination will add a dedicated opportunity  for delivering preventive care and could help reduce the gap in the  preventive services that Medicare beneficiaries receive. At the same time,  it is not a panacea. Ensuring that beneficiaries receive needed services and  follow-up care is likely to remain a challenge.
Mr. Chairman, this concludes my prepared statement. I will be happy to  answer any questions that you or Members of this Committee may have.
section_title: Contact and Acknowledgments
paragraphs: For future contacts regarding this testimony, please call Janet Heinrich at  (202) 512-7119. Katherine Iritani, Matt Byer, Ellen W. Chu, Lisa Lusk, and  Behn Miller Kelly also made key contributions to this testimony.
This is a work of the U.S. government and is not subject to copyright protection in the  United States. It may be reproduced and distributed in its entirety without further  permission from GAO. However, because this work may contain copyrighted images or  other material, permission from the copyright holder may be necessary if you wish to  reproduce this material separately.