Medicare: Most Beneficiaries Receive Some but Not All Recommended Preventive Services
Published: 2003-09-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicare, the federal health program insuring almost 35 million beneficiaries age 65 and older, covers certain preventive services, such as flu shots and mammograms. Most beneficiaries receive care through Medicare's fee-for-service program, under which they generally receive these services as part of visits to the doctor for specific illnesses or conditions. Other beneficiaries receive services under Medicare's managed care program, called Medicare + Choice. GAO was asked to determine (1) the extent to which beneficiaries received recommended preventive services through existing visits, (2) whether approaches used by Medicare + Choice plans provide insight for improving delivery of preventive care services for fee-for-service beneficiaries, and (3) what the Centers for Medicare & Medicaid Services (CMS) is doing to explore suggested options for delivering preventive care to fee-for-service beneficiaries. GAO's work included analyzing data from four national health surveys and reviewing five Medicare + Choice plans considered to have innovative approaches to delivering preventive services. GAO also interviewed Department of Health and Human Services (HHS) and CMS officials and reviewed documents on CMS demonstrations related to preventive services.
section_title: What GAO Found
paragraphs: Most Medicare beneficiaries receive some preventive services through their visits to physicians, but relatively few receive the full range of preventive services available. Survey data showed, for example, that in 2000 about 30 percent of beneficiaries did not receive a flu shot, and 37 percent had never been vaccinated against pneumonia. Moreover, many Medicare beneficiaries are apparently unaware that they may have conditions that preventive services are meant to detect. For example, in a 1999-2000 nationally representative survey during which people received physical examinations, nearly one-third of those age 65 and older who were 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 could represent 2.1 million people. No clear "best practice" approach to delivering preventive care stands out among the innovative Medicare + Choice plans GAO studied. All five plans identify health risks, provide feedback on risks to patients or their physicians, and follow up to reduce those risks. But their follow-up programs, approaches, and priorities differ, and little is known about the effectiveness of these efforts for the Medicare-age population. CMS has begun the development work to design a project evaluating the use of individual assessments of health risks, followed by counseling and other services, as a way to improve preventive care delivery. Another suggested approach--adding a routine physical examination benefit to Medicare's fee-for-service program--could provide more opportunities, but at increased cost and without guarantee that preventive services would actually be provided to Medicare beneficiaries.

section_title: Letter
paragraphs: Medicare, the federal government’s health insurance program that covers  almost 35 million people age 65 and older, was created largely to help pay  beneficiaries’ health care costs once they become ill or injured. For the  most part, the federal government pays physicians and other health care  providers to treat Medicare beneficiaries for illnesses and health  conditions. In addition, the Congress has broadened Medicare coverage to include specific preventive services, aimed at either (1) keeping an illness  or condition from developing or (2) keeping it from becoming more  serious through early detection and subsequent management.  Immunization against influenza (a “flu shot”) is an example of the first type  of preventive service; a mammogram to detect breast cancer is an example  of the second. Overall preventive care depends heavily on identifying  health risks associated with the onset or progression of disease and taking  steps to reduce or mitigate these risks.
We previously reported to you that Medicare beneficiaries’ use of covered preventive services has increased over time but varies widely from service  to service. In response, you asked us to follow up on several issues. One  issue is the success of providing preventive services through a Medicare  service delivery system based primarily on treating existing illnesses and  health conditions. Under Medicare’s fee-for-service program, which enrolls  about 84 percent of Medicare beneficiaries, no specific provision exists for  a routine annual physical or checkup that could be a vehicle for delivering  preventive services. Unless beneficiaries in the fee-for-service program  have supplemental insurance that covers such a checkup, they may have  to depend on receiving preventive services during their visits for specific  illnesses or conditions, or during other visits for those specific preventive  services that Medicare does cover. A second issue is what can be learned  about the effectiveness of preventive service approaches put in place by  plans that contract with Medicare to offer health care on a managed care  basis. These plans, which enroll about 14 percent of all Medicare  beneficiaries under an option known as Medicare + Choice, generally offer  a benefit for periodic checkups. Some of these Medicare + Choice plans  are regarded as particularly innovative in assessing risk, providing  screening services, and conducting prevention programs. This report  addresses the following questions:
Do Medicare beneficiaries receive recommended preventive services  through existing physician visits?
What approaches for preventive care have been taken by selected  Medicare + Choice plans, and what is known about their effectiveness for  the Medicare beneficiaries they serve?
What delivery options for identifying and reducing health risks have been  suggested for Medicare fee-for-service beneficiaries, and are any of these  options being explored by the Centers for Medicare & Medicaid Services  (CMS), the agency administering the program?
Because no single source contained all the information we needed to  assess the extent to which Medicare beneficiaries receive preventive  services through existing physician visits, we analyzed data from four  nationally representative health surveys. The Centers for Disease Control  and Prevention’s (CDC) Behavioral Risk Factor Surveillance System asks a  range of health questions over the telephone, including if respondents  received a “routine checkup” within the past year. CMS’s Medicare Current  Beneficiary Survey collects self-reported data, including whether  respondents have received influenza or pneumonia immunizations. CDC’s  National Health and Nutrition Examination Survey (NHANES) collects  data on health conditions by means of both comprehensive health  examinations and interviews, where patients self-report information,  including whether a physician or other health professional has ever told  them that they have a given health condition. Unlike the other surveys,  which take a sample of the population, CDC’s National Ambulatory  Medical Care Survey samples physician practices, collecting detailed  information about office visits, including the major reason for the visit and  which preventive services were ordered or provided. In addition, this  survey captured information that allowed us to assess whether visits by  Medicare beneficiaries were on a fee-for-service basis. Unless otherwise  noted, however, the data we report generally included beneficiaries from  both systems.
To describe the approaches of selected Medicare + Choice plans in  delivering preventive services, we assessed literature and interviewed  national experts to identify plans that were considered innovative in  preventive care. We then obtained information from five such plans:  AvMed Health Plans, Group Health Cooperative, Highmark Blue Cross and  Blue Shield, Kaiser Permanente, and Oxford Health Plans. Collectively, an  estimated 1.2 million Medicare beneficiaries in 15 states plus the District  of Columbia receive their health care under these plans. To determine  suggested options for identifying and reducing health risks and what CMS  is doing to assess them, we reviewed the results of past related research  demonstrations and congressionally mandated studies and interviewed  Department of Health and Human Services (HHS) and CMS officials and  other experts. (App. I further describes our scope and methodology.) We  conducted our work from October 2002 through August 2003 in  accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: Many of the health conditions that people age 65 and older experience are  preventable and linked to specific health risks. Some health risks are  difficult to change, and some, such as a hereditary predisposition for a  given disease, cannot be changed. For these, preventive services such as  cancer screens can help identify disease in its early stages so that people  can be referred to other services that can help manage or treat the disease.  Other health risks, such as complications from influenza, can be  successfully reduced by targeted preventive services. For example, studies  show that immunizations against influenza can prevent thousands of  hospitalizations and deaths each year among those age 65 and older.  Health risks such as high blood pressure and high cholesterol are also  considered health conditions because, if left alone, they can develop into  potentially more significant conditions, such as cardiovascular disease, or  lead to stroke.
The term preventive care covers a wide spectrum of actions aimed at  reducing risks for deteriorating health and improving the detection and  management of disease. Generally, preventive care is intended for three  purposes:
To prevent a health condition from occurring at all. Vaccinations and  physical activity to reduce the risk of heart disease, for example, qualify as  this first type of preventive care (termed primary prevention).
To prevent or slow a condition’s progression to more significant health  conditions by detecting a disease in its early stages. Mammograms to  detect breast cancer and other screens to detect disease early are  examples of this second type of preventive care (termed secondary  prevention).
To prevent or slow a condition’s progression to more significant health  conditions by minimizing the consequences of a disease. Care  coordination and self-management of an existing disease, such as diabetes  or asthma, are examples of this third type of preventive care (termed  tertiary prevention).
Many people associate the idea of preventive care with annual physical  examinations, or “routine checkups,” by a family doctor, a practice first  proposed by the American Medical Association (AMA) in the early  twentieth century. In the early 1980s, however, the AMA determined that  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 a panel of experts called the U.S. Preventive Services Task  Force. At present, the task force recommends certain screening,  immunization, and counseling services for people age 65 and older (see  app. II).
Medicare covers some, but not all, of the task force-recommended  preventive services (see comparison in app. II). Medicare’s fee-for-service  program—which comprises approximately 84 percent of Medicare  beneficiaries—does not cover periodic checkups, where clinicians might  assess an individual’s health risk and provide needed preventive services.  These Medicare beneficiaries may, however, receive some of these  services during office visits for other health problems. Under Medicare +  Choice, which covers about 14 percent of Medicare beneficiaries, a benefit  for periodic checkups generally does exist.
section_title: Most Beneficiaries Receive Some Preventive Services, but Not All That Are Recommended
paragraphs: Medicare beneficiaries typically visit a physician several times during a  year and most receive some preventive services, but most do not receive  the full range of recommended services. Based on 2000 survey data and  U.S. Bureau of the Census estimates of people age 65 and older, we  estimate that beneficiaries visit a physician at least six times a year, on  average, mainly for illnesses or medical conditions. About 1 in 10 visits  occurred when beneficiaries were well, and most Medicare beneficiaries  reported having what they considered to be a “routine checkup” in the  previous year. The purposes of these routine checkups and the specific  services that are delivered during these visits, however, remain unknown.  Many Medicare beneficiaries did not receive recommended preventive  services, such as influenza and pneumonia immunizations. Moreover,  another national survey indicated that a substantial share of Medicare  beneficiaries who were at risk for a condition that preventive services are  meant to identify said that they had not been told by a health professional  that they might have that condition.
subsections: section_title: Medicare Beneficiaries Visit Physicians Often, and Most Report Receiving Routine Checkups
paragraphs: In 2000, 88 percent of Medicare beneficiaries reported that they visited a  physician at least once that year. On the basis of data from CDC’s  National Ambulatory Medical Care Survey, we estimate that, on average,  beneficiaries visit physicians at least six times a year. Almost 9 in 10 visits  made by beneficiaries in the fee-for-service program were to treat illnesses  or health conditions: more than half the visits targeted preexisting  (chronic) problems, more than one-fourth targeted illnesses of sudden or  recent onset (acute), and about 10 percent of visits took place pre- or  postsurgery or to follow up after injuries. Only about 10 percent of visits  dealt with nonillness care when the patient was considered healthy (see  fig. 1).
Even though the majority of visits to physicians are for treating illness or  health conditions, most Medicare beneficiaries reported receiving routine  checkups. In CDC’s 2000 Behavioral Risk Factor Surveillance System  Survey, for example, 93 percent of respondents age 65 and 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. Indeed, as the following  section shows, few beneficiaries receive all recommended services,  although they receive some preventive services during visits when they are  healthy as well as during visits to treat illnesses or health conditions.
section_title: Despite Frequency of Visits, Many Medicare Beneficiaries Do Not Receive the Full Range of Recommended Preventive Services
paragraphs: Despite how often Medicare beneficiaries visit physicians, many of them  do not receive a full complement of recommended preventive services,  including some recommended by the U.S. Preventive Services Task Force  and currently covered by Medicare. As we reported earlier, use of specific  preventive services varies widely by service. Although each preventive  service we reviewed was delivered to a majority of Medicare beneficiaries,  relatively few beneficiaries received the full range of preventive services.  For example, 91 percent of female Medicare beneficiaries received at least  one preventive service, but only 10 percent were screened for cervical,  breast, and colon cancer and also immunized against influenza and  pneumonia. Our analysis of additional data since our previous report  shows that many Medicare beneficiaries still do not receive certain  recommended preventive services. The task force recommends, for  example, that all people age 65 and older receive an annual influenza  vaccination and at least one pneumonia vaccination. In 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.
Survey data showing the services provided during office visits indicate  that Medicare beneficiaries do receive some preventive services during  visits when they are ill or being treated for a health condition, and services  are delivered at comparable rates during all types of visits, whether for  nonillness care or for treating acute or chronic conditions. Beneficiaries in  the fee-for-service program receive preventive services, such as  cholesterol and blood tests, during visits when they are healthy and during  visits to treat acute or chronic health conditions. Some tests are typically  provided or ordered slightly more often during visits for nonillness care. In  2000, for example, blood tests for anemia were provided in about 16  percent of visits for nonillness care, compared with 7 percent of visits for  chronic problems and 5 percent of visits for acute conditions. Other  preventive services were provided at similar rates during the different  types of visits. For example, we estimate that blood pressure  measurement, a clinical screen for conditions such as hypertension, was  done during 56 to 62 percent of visits, depending on the type of visit. Diet  counseling services were provided during 13 to 20 percent of visits,  depending on the type of visit.
section_title: Many Beneficiaries May Be Unaware of Their Risk for Health Conditions That Preventive Care Is Meant to Detect
paragraphs: 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 had  a physical examination and were found to have elevated blood pressure  readings at the time of the examination, 32 percent reported that no  physician or other health professional had ever told them about the  condition. 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 in the 1999–2000 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 (see fig. 2).
section_title: Medicare + Choice Plans Reviewed Assess Health Risks Using Varying Approaches
paragraphs: The Medicare + Choice plans we reviewed vary in their specific strategies  for delivering preventive services, but several common themes emerge  from their efforts. First, nearly all identify members’ health risks and  inform them or their providers about specific services that might be  needed. For example, some plans mail questionnaires to members, seeking  information, such as when certain screening tests were last performed;  other plans review claims and prescription data to identify at-risk  members who might need a screening test or other preventive service.  Second, all plans have follow-up strategies to help beneficiaries obtain  needed preventive services, although their strategies and priorities vary.  Third, while limited data provided by some plans suggest promising  results, most plans have not evaluated the degree to which their strategies  improve health outcomes or affect health care costs for Medicare  beneficiaries.
subsections: section_title: Plans Use a Combination of Ways to Identify Health Risks
paragraphs: Although all the Medicare + Choice plans we reviewed use questionnaires  to meet the requirement that they conduct health assessments for newly  enrolled Medicare beneficiaries, they use a combination of approaches to  identify health risks. The particular risks that plans seek to identify vary  from plan to plan. Risks include those associated with depression or lack  of physical activity; risks from not obtaining recommended immunizations  or screenings, such as mammography; and more general risk of short-term  hospitalization or illness. For example, Group Health Cooperative,  Highmark Blue Cross and Blue Shield, and Kaiser Permanente use  questionnaire information to calculate a risk score meant to represent  each enrollee’s probability of using health services heavily in the future.  From its questionnaire, Kaiser Permanente also calculates the probability  of 3-year survival for enrollees who have an existing advanced illness, as  well as the probability that they will become dependent on others for daily  care or need nursing home services during the next year (a condition  Kaiser Permanente officials refer to as frailty). Oxford Health Plan, on the  other hand, analyzes questionnaire data to assign enrollees a risk  classification of high, moderate, or low and assigns patients to health  management teams or programs appropriate for each risk level.
For existing members, plans use slightly different approaches to identify  health risks, including information from claims and pharmacy data, annual  risk assessment questionnaires, physician visits, and computer systems  (called registries) that indicate when patients require specific preventive  services. The specific approaches vary from plan to plan. For instance,  Group Health Cooperative officials reported that they review the health  risks, such as the immunization status, of their existing members through  health maintenance visits, which they encourage Medicare beneficiaries to  have every 2 years. During this visit, the provider reviews responses to a  completed questionnaire that each patient is asked to bring to the visit and  updates computer registry data, compiled from previous risk assessment  questionnaires and physician visits. AvMed conducts a health risk  assessment for each of its Medicare members and also uses claims and  pharmacy data to identify members with specific diseases, so as to target  preventive services. For example, using pharmacy and claims data to  identify people with diabetes, AvMed invites these members to a health  fair featuring services to prevent further progression of the disease. Paying  a single copayment to attend the health fair, members can receive a  number of services, such as a blood draw for laboratory work and vision  and glaucoma screening.
Finally, some plans report that they have increased the use of specific  preventive services through their participation in CMS-required national  performance improvement projects. For example, Highmark reported  that in 2002 the plan used medical claims data to identify female Medicare  beneficiaries who had not received a mammogram within the past 2 years  and notified the beneficiaries and their physicians. As a result, the officials  reported that 60 percent of contacted beneficiaries went on to receive  mammograms.
section_title: Plans Use a Variety of Follow-up Means to Reduce Identified Risks
paragraphs: After identifying the health risks of Medicare beneficiaries—whether new  enrollees or existing members—plans we contacted reported that they  also make efforts to follow up on that information by providing feedback  to enrollees about risks and referring them to specific, risk-related  preventive services. For example, all plans have approaches to prevent  disease progression for individuals identified as having chronic health  conditions. The plans sometimes differ in their types of follow-up and in  their emphasis on different types of preventive services. Some plans we  reviewed, for example, stress primary prevention activities, such as  exercise programs for all members, to a greater degree than others.
To provide feedback, many plans contact members directly through letters  or phone calls, encourage contact with primary care physicians, or  combine written or oral feedback with follow-up physician examinations  (see table 1).
Using data available on computer registry, health professionals can  review specific health risks with members. Health professionals also  monitor the computer registry to track services members use.
For new enrollees, physicians review a summary report and provide  feedback during an initial office visit. In San Diego, existing members  who visit health assessment centers receive a letter, based on a  completed questionnaire and tests estimating “health age,” that  discusses ways of decreasing specific health risks, and they receive a  second visit for a complete exam.
Various departments receive health risk reports based on risk  assessment questionnaires. Reports for high-risk members go to  teams of registered nurses, who contact the members and their  primary care physicians to coordinate care.
Plan sends results of health risk assessment to physicians to facilitate  discussion with patients. Members with risks related to smoking, heart  disease, or osteoporosis receive letters. New members identified as  at risk for being frail are referred to case managers, and members  identified with chronic disease are referred to a condition  management program for targeted interventions.
Physicians receive health risk information from risk assessment  questionnaires and pharmacy and claims data. Members identified as  having specific risks are contacted directly by the plan if health  promotion or disease management programs are available for them.
In addition to educating members about their health risks, some plans also  link members to specific preventive services to reduce or mitigate these  risks. For example, plans may send targeted health promotion materials;  offer 24-hour telephone access to a nurse to discuss health concerns; or  offer access to fitness programs, nutrition courses, immunizations, exams,  and disease management or care coordination programs. These care  coordination programs resolve health care issues through various means,  such as in-depth telephone evaluations, communication with primary care  physicians, in-home visits, or connections with community resources like  Meals on Wheels.
To refer Medicare members to preventive services, one plan we contacted  emphasized directing them to primary prevention services, such as  physical activity programs, while another plan emphasized connecting  members to tertiary prevention services, such as disease management  programs. For example, identifying physical activity and social isolation as  two important predictors of overall health outcomes for seniors, Group  Health Cooperative refers Medicare members to physical activity benefits  and other primary prevention services. In contrast, acknowledging that  most individuals age 65 or older have more than one chronic health  condition, AvMed focuses more on identifying members with existing  conditions and referring them to preventive services that can mitigate the  condition. AvMed has created eight disease management programs  covering conditions such as congestive heart failure, asthma, and diabetes.  The goal is to provide members having these conditions with a series of  condition-specific care interventions. For example, interventions for  AvMed enrollees in the congestive heart failure program include  prescribing specific drugs (such as ACE inhibitors, diuretics, and beta- blockers), providing self-directed care plans, and monitoring weight.
Some plans described how they track the success of their efforts to  provide people with specific preventive care interventions. Highmark, for  example, offers financial incentives to physicians who follow specific  clinical guidelines for a given condition. The plan also gives physicians  quarterly report cards, generated by a computer registry, that indicate  whether their patients have received all the care recommended by the  management programs in which the patients are enrolled. AvMed, on the  other hand, tracks the number of members identified as eligible for  specific disease management programs, whether the program was offered  to all eligible members, and the number who enrolled. AvMed also  reported setting, monitoring, and reporting on performance goals for the  percentage of members receiving specific care interventions. For example,  for enrollees in the congestive heart failure management program, AvMed  tracks the percentage receiving an ACE inhibitor drug.
section_title: Assessments of Health Outcomes or Cost Savings for Medicare Beneficiaries Are Limited
paragraphs: Few of the health plans we contacted had specifically evaluated whether  their approaches to risk identification and reduction lead either to  improved health outcomes for Medicare beneficiaries or to cost savings  for the plan. From those plans that have such information, the available  data suggest that offering disease management programs to people who  have existing health conditions may hold promise, but most plans lacked  evidence from controlled studies of a specific benefit to their Medicare  members.
AvMed and Oxford are among the plans that have evaluated whether their  approach improves health outcomes and saves money. For example,  AvMed plan officials observed that, in all AvMed plans, including its  Medicare + Choice plan, AvMed members with existing chronic conditions  spent fewer days in the hospital during the same period when more of  their members with existing conditions were enrolled in disease  management programs. According to AvMed officials, between 2001 and  2002, shorter hospital stays of Medicare congestive heart failure patients  led to total savings of $1 million, and shorter hospital stays of asthma  patients from all plans (not limited to Medicare beneficiaries) led to  savings of $400,000. Similarly, Oxford has estimated savings attributed to  various interventions, such as a mean savings of $219 per member per  month from Medicare beneficiaries who voluntarily participated in a self- management workshop for diabetes, as compared with a random group of  diabetic members who did not attend the workshop. Although these  findings show potential to improve health and decrease costs, it is unclear  from this information whether the decreased length of hospitalization and  cost savings resulted from disease management or from other factors. It is  also not clear what the long-term effects may be on Medicare beneficiaries  and whether these observations would also apply to beneficiaries in a fee- for-service environment.
Some plans are evaluating specific aspects of their approaches as a first  step in determining which approaches are effective. For example, Kaiser  Permanente officials provided data demonstrating their ability to identify a  certain type of health risk among Medicare beneficiaries, but they did not  provide data demonstrating that their overall approaches to risk  identification or risk reduction resulted in improved health outcomes or  cost savings. Specifically, they found that three questions on the risk  assessment questionnaire, along with the patient’s age, predicted with a  high degree of accuracy whether a person would need daily assistance  from another person during the following year. Kaiser identified these  people as at risk for frailty and through additional study found that, over  the next decade, frail people spent more days in nursing homes than  individuals who were not frail. Kaiser Permanente officials told us that  they have not identified interventions that decrease or prevent frailty from  developing but were instead focusing on identifying interventions to  improve outcomes for those people once they were identified as frail.
In addition to reviewing the efforts of contacted Medicare + Choice plans,  we reviewed several studies that evaluated the effectiveness of employer- sponsored approaches to providing preventive services, such as health  risk assessment and feedback, to both employees and retirees. Although  these studies conclude that employer-sponsored approaches hold promise  in terms of increasing preventive services, improving health outcomes, and  lowering cost, we found the results limited in how they might be  generalized to all Medicare beneficiaries. For example, General Motors  evaluated its companywide prevention program, which offered health risk  assessments, individualized health profiles, a quarterly newsletter, a self- care book, and a toll-free health information line. The company reported  that providing risk assessment and feedback helped participants lower  their health risk status and that nearly half of this benefit was realized  within the first of 5 years. Although General Motors provides a similar risk  appraisal program to retirees, this study did not include them, so the  study’s finding cannot be generalized to the Medicare population.
section_title: New Ways to Improve the Provision of Preventive Services within Medicare’s Fee-for-Service Program Are Promising but Untested
paragraphs: Several options have been suggested for improving the provision of  preventive services within Medicare’s fee-for-service program. They  include adding a new benefit for a nonillness-related examination, either a  one-time “welcome-to-Medicare” examination for new beneficiaries or an  examination available to all beneficiaries on a periodic basis. Although  covering a one-time or periodic nonillness examination could be easily  administered and could increase the receipt of some preventive services,  doing so could also increase Medicare costs without necessarily ensuring  that beneficiaries receive the full range of preventive services. CMS has  tested similar options in the past and found that they produced mixed  results. It is now examining an alternative that would essentially create a  different structure using nonphysician providers to assess health risks and  connect individuals with preventive services. The design work will be  completed at the end of 2003, and if the decision is made to conduct a  demonstration, results would not be available for several years after that.  Additional demonstrations also under way—such as one exploring  effective smoking cessation approaches and one giving physicians  incentives to coordinate and manage the overall health care needs of  beneficiaries—may provide additional insights into coordinating and  delivering appropriate preventive services within the Medicare fee-for- service program.
subsections: section_title: Two Proposed Options Center on Adding a Preventive Examination to the Medicare Fee-for- Service Program
paragraphs: A one-time “welcome-to-Medicare” examination for new beneficiaries has  been proposed as 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. Proponents assert  that a one-time benefit could combine a health evaluation with screenings  and immunizations, along with counseling about health promotion and  disease prevention. It could also orient new beneficiaries to Medicare and  encourage them to make informed choices about providers and plans.  Health risk assessment and behavior counseling could be provided by a  range of nonphysician professionals, including nurses, counselors, and  dietitians.
A similar option would have Medicare cover an annual or periodic  preventive visit available to all fee-for-service beneficiaries. In theory,  many of the advantages of a one-time preventive visit would also apply to  periodic examinations. For instance, dedicated preventive visits might  provide greater opportunities for health care providers to assess and  address health risks. Some evidence also suggests that a periodic health  examination may increase use of preventive cancer screening and  counseling services. For example, a National Cancer Institute-supported  study surveyed general internists and family physician practices and their  patients in 1992 and found that patients who had received a periodic  health examination within the previous year were substantially more likely  to have received appropriate cancer screening and counseling.
While these options have benefits, they also have potential drawbacks.  Adding a benefit for a one-time or periodic examination to the Medicare  fee-for-service package could increase the program’s costs without  necessarily ensuring that beneficiaries receive the full range of preventive  services. The Congressional Budget Office in June 2002 estimated that a  one-time physical examination benefit for new enrollees could cost as  much as $1.6 billion over the 2003–2012 period. According to a  Congressional Budget Office official, the agency has not recently  estimated the potential costs of a Medicare benefit for examinations  provided on a periodic basis. This cost, however, would likely be  substantially higher than that of a one-time visit for new beneficiaries. At  the same time, establishing such a benefit would not necessarily ensure  delivery of the full range of preventive services. In addition, primary care  physicians typically cannot provide services such as mammography  screenings for breast cancer and colonoscopies for colon cancer, because  these services usually require specialists.
It also remains uncertain whether covering a one-time or periodic  examination would be an effective means of improving beneficiary health  outcomes. A 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 outcomes,  and 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 outcomes  or reduce the use of hospital and skilled nursing services.
section_title: CMS Is Exploring an Alternative for Assessing Health Risks and Delivering Preventive Services
paragraphs: CMS is exploring one alternative for Medicare preventive care that would  provide systematic health risk assessments to fee-for-service beneficiaries  through a means other than physician visits. In the late 1990s, the agency  commissioned the RAND Corporation to evaluate the potential  effectiveness of health risk assessment programs. Similar to the  approaches taken by the Medicare + Choice plans we reviewed, 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 status. It also concluded  that more research would help clarify the programs’ effects on preventive  services such as clinical screening. 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 found  limited but encouraging evidence on the effectiveness of health risk  assessment programs but concluded that the evidence was insufficient to  accurately estimate the programs’ cost-effectiveness. 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 up on the study’s findings, CMS has begun designing a fee-for- service-focused demonstration project, called the Medicare Senior Risk  Reduction Program, to identify health risks and follow up with preventive  services provided by means other than physician visits. 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. Because the demonstration is still in its design phase,  the particular set of risk factors to be included is not yet final. Risk factors  that might be addressed include preventable accidents such as falls, lack  of exercise, high blood pressure, obesity, and use of preventive services.  The Medicare Senior Risk Reduction 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 is scheduled for completion in late 2003,  when CMS will decide whether to conduct a full demonstration.According to CMS officials, the potential demonstration’s final cost was  uncertain at the time our report was completed. CMS is spending  approximately $1 million on the developmental work.
Unlike some health risk assessment programs, CMS’s program will be  limited to questionnaires and follow-up contacts; it will not directly  provide clinical screening such as blood pressure or cholesterol  measurements. Instead, the program will concentrate on identifying,  through information provided by the beneficiary, any modifiable lifestyle  and behavioral risk factors and on referring beneficiaries to services for  reducing those risks. CMS officials and researchers did indicate, however,  that the program’s risk assessment tools will collect information on  needed immunizations and cancer screenings and alert beneficiaries and  their physicians to any needed services.
section_title: CMS Is Also Exploring Ways to Improve Care for Those with Identified Health Risks and Conditions
paragraphs: CMS has other initiatives under way that may help improve the delivery of  preventive services within the fee-for-service program. The first is the  Medicare Stop Smoking Program, a smoking cessation demonstration  project for fee-for-service beneficiaries. Recognizing that smoking is the  single most preventable cause of disease and death in the United States,  posing a significant health risk to the aged, CMS launched the  demonstration to identify the most effective service to help beneficiaries  stop smoking. The demonstration will evaluate the effectiveness of  different smoking cessation services. The four services being tested are:  (1) reimbursement for provider counseling, (2) reimbursement for  provider counseling and for smoking cessation drugs or nicotine  replacement therapy, (3) access to a telephone counseling quit-line plus  reimbursement for nicotine replacement therapy, and (4) provision of  written information on smoking cessation. Seven states are participating in  the demonstration: Alabama, Florida, Missouri, Ohio, Oklahoma,  Nebraska, and Wyoming. The study will be completed in 2004, with the  results published in 2005. CMS has budgeted approximately $14 million for  this project.
CMS is also developing a physician group-practice demonstration that was  required by the Medicare, Medicaid, and SCHIP Benefits Improvement and  Protection Act of 2000. The aim of this demonstration is to provide  incentives for physicians to coordinate and manage the overall health care  needs of Medicare fee-for-service beneficiaries, especially those with  chronic health conditions. Under the 3-year demonstration, physician  groups will be paid on a fee-for-service basis and may, in some  circumstances, earn a bonus from savings achieved if the average  Medicare expenditure for beneficiaries in their group of patients is below  an established target. Up to six physician group practices will be selected  to participate in the demonstration, which is expected to start during 2003.  Under the mandate, the aggregate expenditures for this demonstration  must be budget neutral. Any bonus payments made to physician groups  must therefore be taken from savings produced by the participating  organizations.
Finally, a 4-year coordinated-care demonstration is currently under way at  16 sites. Authorized by the Balanced Budget Act of 1997, this  demonstration examines private-sector best practices for coordinating the  care of patients with complex chronic conditions. These conditions  include congestive heart failure, other heart and lung diseases, liver  diseases, diabetes, psychiatric disorders, Alzheimer’s disease or other  dementia, and cancer. CMS is testing whether care coordination  programs—such as those that develop a plan of care after a complete  assessment of patient needs and offer patient education, health care  service arrangements, and coordination with providers—can, without  increasing program costs, improve the quality of care and reduce  avoidable hospital admissions among Medicare beneficiaries with chronic  diseases. The selected sites mix case management and disease  management models in their practices; operate in urban and rural  settings around the country; and include hospitals, retirement  communities, and academic medical centers. CMS is required to formally  evaluate the projects every 2 years after implementation and report to the  Congress on its findings. HHS officially announced the selected sites in  January 2001, and as of May 2003, the 16 sites had enrolled approximately  10,000 Medicare beneficiaries in the demonstration. CMS officials stated  that the demonstration could eventually enroll more than 36,000  beneficiaries, although half of these will serve as a control group who will  not receive coordinated care. CMS officials told us that they expect this  demonstration to also be budget neutral. That is, they anticipate that  overall costs to Medicare for providing the services will be offset by  savings achieved from providing the care coordination services.
section_title: Concluding Observations
paragraphs: Most Medicare beneficiaries receive some preventive services, but many  do not receive services that can help prevent and manage their health risks  and conditions early, before significant health problems occur. Services  recommended for all people in this age group are not delivered  consistently. Perhaps of most concern, nearly one-third of beneficiaries  who were screened and identified as having elevated blood pressure or  high cholesterol measures in a nationally representative survey had not  previously been told by their physicians or other health providers that they  had these conditions. Projected nationally, the survey results translate into  millions of people who could be unaware that they have a health condition  whose treatment could prevent or delay much more significant health  concerns.
The solutions to ensure that beneficiaries receive needed services are not  obvious. The experience of selected Medicare + Choice plans shows that  no single approach stands out. All plans we contacted had a means to  identify health risks, to provide feedback on risks to patients or their  physicians, and to follow up with interventions to reduce those risks. But  the follow-up programs, approaches, and priorities differed among the  plans we contacted, and few had evaluated their approaches in a manner  that would indicate whether these programs could, without significantly  increasing costs, improve health outcomes for Medicare beneficiaries.  Nevertheless, some current research shows promise for improving the  delivery of preventive services—particularly when there are follow-up  interventions, such as referrals to appropriate services.
section_title: Agency Comments
paragraphs: We obtained comments on our draft from HHS as well as from the health  plans we contacted. HHS generally concurred with our findings and  provided examples of CMS’s successes in promoting existing preventive  services and in identifying strategies that might be used in future health  promotion efforts. HHS also clarified the status of its program evaluating  the use of individual health risk assessments, which is in development, and  clarified its Medicare Stop Smoking Program, which will assess options for  a new benefit for smoking cessation but not necessarily lead to CMS  coverage for these benefits. HHS emphasized that only the Congress can  decide which preventive services or benefits Medicare covers. HHS also  updated its estimate of this program’s budget. We incorporated these  clarifications in the draft.
HHS also commented that without sufficient evidence, the report links  beneficiaries’ lack of knowledge that they may have certain conditions,  such as high blood pressure, with evidence that they are not receiving the  full range of preventive services. We did not intend to link these  statements, but we have independent evidence for each of them and have  added information to our summary of results to help clarify this evidence.  HHS’s comments are reproduced in appendix IV.
HHS and the health plans 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 issue date.  We are sending copies of this report to the Secretary of HHS, the  Administrator of CMS, the Director of CDC, and others who are interested.  We will make copies available to others on request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov.
If you or your staff have any questions, please contact me at (202) 512-7119 or Katherine Iritani, Assistant Director, at (206) 287-4820. Other individuals who made contributions to this report include Matthew Byer, Sophia Ku,  and Tina Schwien.
section_title: Appendix I: Scope and Methodology
paragraphs: Because no single source contained all the information we needed to  assess the extent to which Medicare beneficiaries receive preventive  services through existing physician visits, we used data from four national  health surveys: three conducted by the Centers for Disease Control and  Prevention (CDC) and one conducted by the Centers for Medicare &  Medicaid Services (CMS) (see table 2). For example, CMS’s Medicare  Current Beneficiary Survey samples Medicare beneficiaries, asking them  for detailed information on their demographic characteristics, insurance  coverage, and health status but asking only a few questions about specific  preventive services received during physician visits. In contrast, CDC’s  National Ambulatory Medical Care Survey samples physicians about office  visits, rather than the people who made those visits. The survey contains  information about reasons for office visits and about diagnostic and  preventive services provided during visits, but it cannot be used to  determine the extent to which Medicare beneficiaries received these  services.
For our analyses of these surveys, we extracted data for people age 65 and  older to represent Medicare beneficiaries, because almost 95 percent of  the population in this age group was enrolled in Medicare in 2000. Also,  because the National Ambulatory Medical Care Survey samples office  visits to physicians, not the people who made the visits, to estimate the  average number of physician visits made by Medicare beneficiaries, we  first estimated the number of visits made by patients age 65 and older  using this database, and then divided this number by the U.S. Bureau of  the Census estimates of the civilian noninstitutionalized population age 65  and older. To determine the major reasons for physician visits and the  specific types of preventive services provided to Medicare beneficiaries in  the fee-for-service program, we used visit data in this survey for patients  age 65 and older who did not belong to a health maintenance organization  and whose visits were not paid on a capitated basis. Tables 3 to 5 show  the estimates and standard errors in data from the National Ambulatory  Medical Care Survey 2000 on major reasons for physician visits and on the  preventive diet counseling services provided during those visits. We also  tested at the 95 percent confidence level the statistical significance of  differences we observed between nonillness and other types of visits in  the proportion of visits where preventive screening tests (e.g., cholesterol  and blood tests) were provided.
To estimate the proportion of Medicare beneficiaries who had health  conditions that they were not previously aware of—specifically, high  blood pressure or high cholesterol—we used data from both the interview  and the physical examination portions of CDC’s National Health and  Nutrition Examination Survey (see app. III for methodology and results  from this analysis).
To describe the preventive care approaches of Medicare + Choice plans,  we consulted with national experts and officials from the American  Association of Health Plans and chose five plans considered to have  innovative preventive care programs. Together, these five plans serve  more than 1.2 million Medicare beneficiaries in 15 states and the District  of Columbia (see table 6). We interviewed officials from each plan and  reviewed documents, including plan-provided studies or evaluations of  their preventive services programs. We reviewed the scope and  methodology of the studies done by some of the plans, but we did not  independently verify the accuracy of the data.
To examine the alternatives for identifying and reducing health risks and  CMS’s efforts in exploring them, we reviewed available literature,  including results of past demonstrations and congressionally mandated  studies, and interviewed experts in the field, including those conducting  studies and developing position papers for the Partnership for Prevention,  a nonprofit organization funded by the Robert Wood Johnson Foundation.  We also interviewed Department of Health and Human Services and CMS  officials and reviewed documents on planned and present CMS  demonstrations related to preventive services.
section_title: Appendix II: Preventive Services Recommended by the U.S. Preventive Services Task Force or Covered by Medicare
paragraphs: Recommends (women only)
N/A  The costs of the laboratory test portion of these services are not subject to copayment or deductible.  The beneficiary is subject to a deductible, copayment, or both for physician services only.
section_title: Appendix III: National Health and Nutrition Examination Survey Methodology and Results
subsections: section_title: Background
paragraphs: Conducted by the Centers for Disease Control and Prevention’s (CDC)  National Center for Health Statistics, the National Health and Nutrition  Examination Survey (NHANES) is a nationwide population-based survey  designed to estimate the health and nutrition of the noninstitutionalized  U.S. civilian population. Our analysis was based on data gathered during  NHANES 1999–2000, which represent the most recent information  available. This survey comprises two parts: an in-home interview and a  health examination. During the in-home interview, participants are asked  about their health status, disease history, and diet; during the health  examination, participants receive a number of tests, including blood  pressure readings and a blood test to determine total serum cholesterol.Details of the survey design, questionnaires, and examination components  are available at http://www.cdc.gov/nchs/nhanes.htm.
section_title: Scope, Methodology, and Results
paragraphs: For our analysis, we used the NHANES data described in table 7 to  determine if participants age 65 and older had high blood pressure or high total serum cholesterol. We used the same criteria for these conditions as  CDC and the National Heart Blood and Lung Institute use to estimate the  conditions’ prevalence.
To determine whether the participants age 65 and older found by  examination to have elevated measures of these health conditions were  previously unaware of having them, we used patients’ responses from the  NHANES interview. During the interview, participants were asked if they  had ever been told by a physician or health professional that they had  certain conditions, including high blood pressure and high cholesterol.
Tables 8 and 9 show the estimates and standard errors from 1999–2000  NHANES data for specific health conditions and level of awareness among  participants age 65 and older.
Estimated numbers, proportions, and standard errors were obtained using  SUDAAN, a computer program for analyzing data from complex sample  surveys, as suggested in the NHANES Analytic Guidelines.