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. 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. 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. 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.) 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. 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. 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. 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. 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. 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. Other major contributors to this report include Lacinda Ayers, Matthew Byer, Jennifer Cohen, Jennifer Major, Behn Miller, and Stan Stenersen.

Summary: 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. 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.