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. 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). 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. 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. 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.

Summary: 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. 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.