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.