[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
KEEPING SENIORS HEALTHY: NEW PERSPECTIVE BENEFITS IN THE MEDICARE
MODERNIZATION ACT
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 21, 2004
__________
Serial No. 108-117
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
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------------------------------
COMMITTEE ON ENERGY AND COMMERCE
JOE BARTON, Texas, Chairman
W.J. ``BILLY'' TAUZIN, Louisiana JOHN D. DINGELL, Michigan
RALPH M. HALL, Texas Ranking Member
MICHAEL BILIRAKIS, Florida HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RICK BOUCHER, Virginia
PAUL E. GILLMOR, Ohio EDOLPHUS TOWNS, New York
JAMES C. GREENWOOD, Pennsylvania FRANK PALLONE, Jr., New Jersey
CHRISTOPHER COX, California SHERROD BROWN, Ohio
NATHAN DEAL, Georgia BART GORDON, Tennessee
RICHARD BURR, North Carolina PETER DEUTSCH, Florida
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
BARBARA CUBIN, Wyoming BART STUPAK, Michigan
JOHN SHIMKUS, Illinois ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico ALBERT R. WYNN, Maryland
JOHN B. SHADEGG, Arizona GENE GREEN, Texas
CHARLES W. ``CHIP'' PICKERING, KAREN McCARTHY, Missouri
Mississippi, Vice Chairman TED STRICKLAND, Ohio
VITO FOSSELLA, New York DIANA DeGETTE, Colorado
STEVE BUYER, Indiana LOIS CAPPS, California
GEORGE RADANOVICH, California MICHAEL F. DOYLE, Pennsylvania
CHARLES F. BASS, New Hampshire CHRISTOPHER JOHN, Louisiana
JOSEPH R. PITTS, Pennsylvania TOM ALLEN, Maine
MARY BONO, California JIM DAVIS, Florida
GREG WALDEN, Oregon JANICE D. SCHAKOWSKY, Illinois
LEE TERRY, Nebraska HILDA L. SOLIS, California
MIKE FERGUSON, New Jersey CHARLES A. GONZALEZ, Texas
MIKE ROGERS, Michigan
DARRELL E. ISSA, California
C.L. ``BUTCH'' OTTER, Idaho
JOHN SULLIVAN, Oklahoma
Bud Albright, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Health
MICHAEL BILIRAKIS, Florida, Chairman
RALPH M. HALL, Texas SHERROD BROWN, Ohio
FRED UPTON, Michigan Ranking Member
JAMES C. GREENWOOD, Pennsylvania HENRY A. WAXMAN, California
NATHAN DEAL, Georgia EDOLPHUS TOWNS, New York
RICHARD BURR, North Carolina FRANK PALLONE, Jr., New Jersey
ED WHITFIELD, Kentucky BART GORDON, Tennessee
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
Vice Chairman BART STUPAK, Michigan
BARBARA CUBIN, Wyoming ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois GENE GREEN, Texas
HEATHER WILSON, New Mexico TED STRICKLAND, Ohio
JOHN B. SHADEGG, Arizona DIANA DeGETTE, Colorado
CHARLES W. ``CHIP'' PICKERING, LOIS CAPPS, California
Mississippi CHRIS JOHN, Louisiana
STEVE BUYER, Indiana BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania JOHN D. DINGELL, Michigan,
MIKE FERGUSON, New Jersey (Ex Officio)
MIKE ROGERS, Michigan
JOE BARTON, Texas,
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Clancy, Carolyn, Director, Agency for Healthcare Research and
Quality, U.S. Department of Health and Human Services...... 10
Heinrich, Janet, Director, Healthcare/Public Health Issues,
U.S. Government Accountability Office...................... 17
Woolf, Steven H., Executive Vice President for Policy
Development, Partnership for Prevention.................... 19
Material submitted for the record by:
American Cancer Society, prepared statement of............... 52
American Occupational Therapy Association, prepared statement
of......................................................... 70
(iii)
KEEPING SENIORS HEALTHY: NEW PERSPECTIVE BENEFITS IN THE MEDICARE
MODERNIZATION ACT
----------
TUESDAY, SEPTEMBER 21, 2004
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Health,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:13 p.m., in
room 2123, Rayburn House Office Building, Hon. Michael
Bilirakis (chairman) presiding.
Members present: Representatives Bilirakis, Hall, Norwood,
Shimkus, Brown, Stupak, and Green.
Staff present: Ryan Long, majority professional staff;
Melissa Bartlett, majority counsel; Chuck Clapton, majority
counsel; Eugenia Edwards, legislative clerk; and Amy Hall,
minority professional staff.
Mr. Bilirakis. Good afternoon. This hearing will now come
to order.
Today the Health Subcommittee will be focusing on a very
important issue, the new preventive benefits now being offered
by the Medicare program. Coverage of these new preventive
benefits, which were authorized by the Medicare Prescription
Drug Improvement and Modernization Act of 2003, MMA, is a
serious initiative to make Medicare a modern prevention-focused
program.
I would like to thank the witnesses who are here before us
today:
Carolyn Clancy, Dr. Clancy, is Director of the Agency for
Health Care Research and Quality, and she will discuss the
findings of the United States Preventive Services Task Force.
We also have Ms. Janet Heinrich, Director of Health Care,
Public Health Issues, at the U.S. Government Accountability
Office, GAO. And Dr. Steven Woolf, who I understand is a former
resident of the Tampa area--welcome to Washington, Dr. Woolf--
who is Executive Vice President for Policy, Development at
Partnership for Prevention.
I look forward to hearing from all of you today. I am sure
we all do.
Since the program's inception in the mid-1960's, in 1965,
Medicare has paid the health care costs for beneficiaries when
they are sick. In 1965, this was an appropriate approach to
health care.
Today, with rapidly increasing technology, health care is
changing from diagnostic to preventive care. However, while the
climate has changed, the Medicare program, I think we all would
agree, has drug its feet. Over the past few years, Medicare has
been incrementally changing to add preventive services to the
program. In the 1980's, Medicare began coverage of certain
vaccinations. In 1984, Medicare established the U.S. Preventive
Services Task Force to make evidence-based recommendations on
the appropriateness of preventive services. In 1991, Medicare
began coverage for mammography screenings, and the Balanced
Budget Act of 1997, BBA, expanded coverage to include
colorectal and prostate cancer screenings, pelvic exams, and
osteoporosis tests.
With the implementation of MMA beginning in 2005,
beneficiaries' access to preventive benefits has been brought
to a whole new level. One of the most important new benefits is
what we call the ``Welcome to Medicare Physical,'' a complete
preventive examination for all new Medicare beneficiaries
entering the program. I am particularly proud of this new
benefit because I fought for its inclusion from the beginning.
My good friend, a gentleman who has been a geriatric physician
who retired to Florida many years ago because he had a health
problem--thank God he has been with us for a long time down
there--came up with this idea. He told it to me years ago and
how important it was for beneficiaries to have a complete
physical so that their health can be carefully evaluated and
any potential problems can be realized. And I am referring to a
Dr. William Hale.
Under this new physical, Medicare will now cover influenza
and hepatitis B vaccines, mammograms, Pap smears, and pelvic
examinations and screening tests for prostate cancer, colon
cancer, glaucoma, and osteoporosis. As part of the exam,
Medicare will pay for an electrocardiogram, an assessment of a
person's risk of depression, hearing and vision tests, and a
review of a person's agility to perform routine activities such
as bathing, eating, and getting in and out of bed.
Additionally, education and counseling for any problems
discovered in exams will also be covered.
Other preventive benefit provisions in MMA include Medicare
coverage of blood tests for the screening and detection of
cardiovascular disease for any individual, and coverage of two
diabetes screening tests each year for at-risk beneficiaries.
Over 64 million Americans live with cardiovascular disease,
and it is the leading cause of death in this country, and most
of those people are over the age of 65. The economic impact of
cardiovascular disease in our health care system continues to
grow, and according to CDC will reach $368 billion in 2004,
including health care expenditures and lost productivity from
death and disability.
What makes this even more atrocious is that cardiovascular
disease is largely preventable. Expanding Medicare coverage for
cardiovascular disease will help seniors who may believe that
they are healthy realize potential problems early rather than
later. This will increase the health of the individual and
reduce the overall cost of health care.
This hearing is, I think, especially timely right now. The
Centers for Medicare and Medicaid Services released their
Physician Fee Schedule Proposed Rule which contains their
proposed guidelines for these preventive benefits in early
August, and comments, I guess--were they completed last week?
This Friday. Comments are due by this Friday.
Again, thank you for being here today. And I very gladly
yield to--I say ``gladly,'' I may be sorry that I used that
word--to the ranking member of the subcommittee, the gentleman
from Ohio, for an opening statement.
Mr. Brown. I am never that, Mr. Chairman. Thank you. Thank
you for holding the hearing today, and thank you, all three
panelists, for joining us, some of you as repeats. Thank you
for that.
I appreciate the opportunity to be recognized for an
opening statement. The opportunity to make opening statements,
which we all took for granted, has long been recognized in this
committee as a member's right, was unilaterally and improperly
usurped by Chairman Barton last Wednesday, September 15. I
suggest in the future that any attempt to gag Democratic
members of the subcommittee, which Mr. Bilirakis has never done
and I would never expect someone of his integrity to do, but I
would hope that any attempt to gag members of the full
committee will be counterproductive, and I urge the committee
precedent tradition be respected in the future.
Along these lines, Mr. Chairman, I would like to address
colleagues on the other side of the aisle who will invariably
criticize my opening statement today as a partisan attack. If
the Republican majority would dispassionately consider the
problems with its new prescription drug law as readily as it
promotes the bill's benefits, with tens and tens and tens of
millions of taxpayer dollars on television and mailings and all
other ways, then our concerns wouldn't be called partisan, they
would be called germane. We have been given no such opportunity
when it comes to making the most sweeping changes ever to
Medicare. American seniors and other American taxpayers don't
want an air-brushed sale; they want the truth.
The truth is, the drug law establishes several important
preventive benefits, to be sure. It is also true that Congress
should not have to mandate coverage of new preventive benefits.
Medicare is authorized to cover new diagnosis and treatment
benefits without waiting for congressional approval or mandate.
Preventive benefits should be treated the same way.
I have sponsored legislation which will enable CMS to
approve new preventive benefits through the national coverage
process. I hope colleagues on both sides of the aisle will
consider cosponsoring this commonsense bill.
Nonetheless, the new preventive benefits are a positive
addition to Medicare. Had they been offered as a stand-alone
bill, I am sure the bill would have passed with overwhelmingly
bipartisan support. But lacing last year's prescription drug
law with a couple of new preventive benefits, no matter how
attractive, doesn't begin to compensate for the dollars wasted
lining the pockets of the insurance industry and the drug
companies, or the opportunity wasted, the opportunity to work
on a bipartisan basis and add a real drug benefit to Medicare.
It doesn't compensate for the time wasted on red-herring
discount cards, on HMO experiments, all because the Republican
majority and the Republican President don't much like Medicare
the way it is, or at least the way it was, and do really like
the drug industry and the insurance industry and the way that
they both operate; because in the new drug law, Medicare
premiums are going to increase by more than 17 percent next
year, the highest increase in Medicare history. Seniors will
receive a cost-of-living in their Social Security benefits of
less than 3 percent. Premiums increase 17 percent.
It didn't have to be that way. The new law, as we know,
hands HMOs bonus payments of over $23 billion. Last March, HMOs
got their first checks from Federal taxpayers totaling $229
million. In April they got another $229 million. In May they
got another $229 million. Yet there was no prescription drug
benefit yet. In June, $229 million; July, August, September,
all the way through next year, yet still no prescription drug
benefit, but plenty of dollars for Medicare HMOs. And,
remember, even before these new payments, the Bush
administration itself admitted that HMOs were being overpaid.
They already said they were overpaid, but now we are giving
them $229 million a month. Not that it would have anything to
do with political contributions to the President from the
insurance industry or to Republican leadership. This bill
forces private HMOs regardless of--forces them on seniors
regardless of what seniors want and despite the fact that HMOs
add billions to Medicare's price tag. The new law prohibits the
Federal Government from negotiating volume discounts on RX
drugs, as the VA does, a concept that no one I have ever met in
Ohio understands, except to be explained away by drug company
contributions to George Bush.
Drug industry profits will increase by $182 billion thanks
to this new law, with seniors and taxpayers footing the bill.
The new law would never have passed if the administration had
not lied about the cost of Medicare, had not threatened the
Medicare functionary, did not threaten his job if he sang to
Congress or the American people about the cost. And--
undoubtedly. But we got a bill because we--we got that bill
because some people didn't tell the truth. It never would have
passed if seniors knew they would be paying dramatically higher
Medicare premiums, 17 percent higher, so that the Medicare--
that the Republican majority and the President could privatize
Medicare, boost the profits of the drug industry, and line the
pockets of the HMOs. There are beneficial preventive benefits
and a shameful Medicare drug law. That is not a partisan
attack, it is simply the truth.
I yield back.
Mr. Bilirakis. The Chair would now yield to Dr. Norwood for
an opening statement.
Mr. Norwood. Thank you very much, Mr. Chairman. I wasn't
going to say anything, but I am stimulated to have a remark or
two.
First of all, thank you for this hearing. It is very
important, I believe, that we continue to point out prevention.
In my profession, we have been into that a long, long time. It
is high time that we got into that with Medicare.
A couple of points I would make, so Mr. Brown would know.
The premium increase that was set out was to help stop the 4.5
percent reduction in fees to our providers, which, had that not
been done, access to health care would have drastically been
cut. So the Democrats who supported that, we appreciate that,
and it is time to bring out at this hearing that that was a
good thing.
The Democratic substitute called for increased payments to
HMOs. You know, their substitute wasn't any different. So it
would be better, just quit being partisan about this bill.
There are a lot of good things in this Medicare bill, and I
guess to start with, prevention would be at the top of my list.
Second, I am on a number of committees, as we all are, and
many of our committees, Mr. Chairman, don't have opening
statements other than the chairman and the ranking member. And
I don't know about tradition in the Commerce Committee, but
that is not a bad rule, particularly 2 months before an
election when people aren't really trying to dig into the sense
of the problem but are playing politics. And, you know, for me
to encourage you to do that on this subcommittee means I don't
get to make an opening statement too. But I do want to say that
sometimes it is real appropriate not to have an opening
statement and listen to the people we have asked to come to
Washington to help us learn.
With that, Mr. Chairman, I will----
Mr. Bilirakis. Would you yield?
Mr. Norwood. I would yield.
Mr. Bilirakis. I would just like to say, none of us are
happy about the premium increase. We should remember, of
course, when Medicare was first devised back in the mid-1960's,
it was supposed to be a 50/50 situation; all of the costs would
be shared 50 percent by the beneficiaries, 50 percent by the
taxpayers, by the government, if you will. And as time went on,
that was reduced to something like 75/25. And we passed the law
some time back that said that 25 percent would be the share
that would be paid by the beneficiaries, and that is a formula
type of thing.
And regardless of who might be in the White House and
regardless of which party will be in charge this year, it would
come out to this dollar figure because it is a flat-out 75/25.
And my colleagues know this. And I would hope that they would
not play basically political games with that particular point.
I mean, was I distressed when I saw that happening? Of
course I was. But it came out to--it is a formula type of a
thing.
Having said that----
Mr. Norwood. Mr. Chairman, if I could, one last sentence on
my time.
Mr. Bilirakis. One last sentence.
Mr. Norwood. The premium increase also is part of why we
can afford to have the preventive benefits. Preventive benefits
are lifesaving benefits. It was the right thing to do.
Mr. Bilirakis. And I daresay that Mr. Brown's ideas of
additional preventive benefits, which I don't think my good
friend has directly made me aware of, but if he has, you know,
it was at a time maybe when it didn't stick. But that is
certainly something that I generally would support, and we just
haven't sat down and talked about them specifically. But that
would probably also increase the Part B premium in the future
with additional preventive benefits added therein.
Anyhow. Mr. Green, for an opening statement.
Mr. Green. Thank you, Mr. Chairman. I wasn't planning to
enter in on that, but part of that increase that we had in the
Medicare bill and was widely reported a few minutes ago, that
part of the increase, that we are paying more dollars for the
Medicare+Choice, that actually costs more than regular Medicare
for our constituents. But, again, I think that came from CMS
when they talked about it.
Mr. Chairman, I just wanted to thank you for the hearing,
because there were new preventive benefits in the bill. At the
end of the day I voted against the bill because of its
incomplete prescription benefit, and in general I believe it
does more harm than good to the Medicare program and the
beneficiaries who depend on the program for their health care.
And I think the proof is in the fewer number of people than
expected to take up that benefit.
That being said, the new law does provide three extremely
new important preventive benefits: a physical upon enrollment
in Medicare; a cardiovascular screening blood test; and a
diabetes screening test. Each of these preventive benefits will
help save lives, and it is worth noting that in the long run
these new benefits will save significant costs for Medicare
because we will be able to catch many of these debilitating
illnesses in the early stages instead of treating them in
advanced stages where costs are skyrocketing.
Without a doubt, an ounce of prevention is worth a pound of
cure, and I am pleased that Congress took that message to heart
in that bill. Diabetes is a major health problem in my State of
Texas, and more than 1 million adult Texans have diabetes. The
State estimates that another 500,000 are living with
undiagnosed diabetes. The State of Texas, and the district I
represent in particular, has a large Hispanic population which
studies have shown is at higher risk. That is why I offered the
amendment, along with now-Governor Fletcher of Kentucky, to
include diabetes screening in the Medicare bill.
And I would like to take this opportunity to once again
thank my colleagues for including it at the committee level.
And if I had my druthers, Medicare would also include
screenings for abdominal aortic aneurysms, known as the
``silent killer.'' Abdominal aortic aneurysms can occur without
any symptoms or warnings, and less than 15 percent of the
patients with a ruptured abdominal aortic aneurysm survive, and
two out of three victims die before they ever reach the
hospital. With effective screenings, however, AAA can easily be
detected and repaired with a fairly noninvasive procedure. That
is why a AAA screening benefit is an excellent candidate for a
new Medicare preventive benefit.
My friend Jim Greenwood and I have introduced a bill to
cover AAA screenings under Medicare, and I am sure he agrees
and will welcome the support of the subcommittee in this
effort.
And while we are here today to discuss the implementation
and effectiveness of these three preventive benefits, we must
realize that there are great additions to Medicare that cannot
be examined in a vacuum. There are serious problems with the
Medicare program; and as more seniors take advantage of the
program's preventive benefits, they are sure to come up against
the several roadblocks making these benefits work for them.
Physicals don't help seniors if the result is a diagnosis of a
disease that must be treated with a prescription drug regimen
so expensive that it forces Medicare beneficiaries into a
doughnut hole where drugs aren't paid for. And, at the end of
the day, a preventive benefit isn't worth the paper it is
written on if the program doesn't provide seniors with the
resources to deal with the diagnosis.
I am certainly interested in hearing our witnesses' views
on the issues, and I know they will provide us with important
insight on the steps we need to take to ensure that new
preventive benefits are added to Medicare in a timely manner.
And, again, Mr. Chairman, I appreciate you holding this
hearing. And I know for a number of years we have had these
hearings on Medicare, not only for the bill that passed last
year, but on issues dealing with Medicare. And so I appreciate
the opportunity.
Mr. Bilirakis. I thank you, Mr. Green. I oftentimes wonder
why we can't in a bipartisan manner get together and do
something about the method that CBO uses to score, which is
something we run into all the time when we talk about things
such as preventive health care.
Mr. Green. Mr. Chairman, you and I have talked about that,
and it sure would be nice if we could set that so we could take
advantage of the savings from preventive care. And I know we
share that.
Mr. Bilirakis. It is crazy, isn't it? They call it the
Congressional Budget Office, and yet we don't seem to have any
control over them.
In any case, Mr. Hall for an opening statement.
Mr. Hall. Thank you, Mr. Chairman.
I would like to start with--and I have admiration and
respect for both the gentlemen present from the minority, but I
feel constrained to say that this committee and the chairman of
this committee ought to always gag anyone that is politicking
at the expense of this committee's very valuable time at this
particular time. And as Dr. Norwood has said, and as Mr. Brown
and Mr. Green both agreed, the increased payments are not
anything that we would enter into but for some reason. And the
very reason is that these preventive payments and these
preventive benefits save money, considerable money, later. The
savings, not today--it looks like a 17 percent increase today,
but it is a huge savings down the line. By the time these
senior citizens get to that stage, they would have a better
life if they had the prevention now. So it is not only saving
them money, but it saves in the health of people and the care
of people and the love of these senior citizens, these folks
that are the treasure that this program benefits.
I was in the Texas Senate in 1963 when Medicare and
Medicaid showed its face, and the Members of Congress came down
to all the legislators, they came to the Texas legislature and
told us about these two great programs that they were going to
initiate. One was called Medicare and one called Medicaid. They
said if we are not careful, the Medicaid could cost almost a
billion dollars a year. Imagine that. And Medicare could cost
as much as up to $7 billion a year. I think that was their
testimony before our little committee down in Texas.
Well, you know, last year it was $50, $60 billion, and $150
or $160 billion or so. I don't know if those figures are
correct, but I think the comparisons are. But for 2005, the
Part B premium is going to be more. I don't like that, but I
understand it. But, you know, there is a saving grace there.
While it is more--and it consists of outpatient hospital
services, of home health services, of durable medical
equipment--still about three quarters of the 2005 premium
increase is due to additional costs for Part B.
And I think the record indicates I believe that all the
members of the minority voted for that, in favor of increased
physician payments and reimbursements to Medicare Advantage
plans, where the major provision that led to the increase in
Medicare premium costs, either on the Democrats' substitute,
their own substitute for H.R. 1, our own final passage of H.R.
1 conference. So we are not all that far apart.
I think we all realize a lot of this is politics, and I
guess it is a political time, but I just think that we need to
remember that we, probably most of us, voted for that. And we
also need to remember that the beauty of the entire price
increase is more than 6 million low-income beneficiaries will
see absolutely no premium increase, because they already have
their entire premium paid by Medicaid. And the real saving
grace to all of it is they can opt out of it. They are not
forced into anything. So I don't think we ought to be trying to
sell that here 6 weeks before the general election.
I yield back my time.
Mr. Bilirakis. I thank the gentleman.
Mr. Stupak for an opening statement.
Mr. Stupak. Mr. Chairman, while I appreciate the topic of
today's hearing, the preventive benefits of the new Medicare
law, I believe there are many more important, more urgent
topics of concern for American seniors and American taxpayers
regarding the new law. Let me list a few.
Topics like cost. Why won't the administration just tell
American taxpayers the truth about the cost of this new law? It
seems like every day a new cost estimate comes out. The
committee deserves a straight answer. Let us face it, the
administration did not tell the truth to the American people
and Congress when they said the legislation would cost no more
than $400 billion over 10 years. Earlier this year, the
administration admitted the new law would cost 534 billion over
10 years. This week, a new estimate by the administration says
$576 billion. What is the true cost of this bill? And how much
of that cost is going to be to big insurance and HMOs as
overpayments?
According to a MEDPAC report that was released to Congress
last week, Medicare HMOs will get paid 107 percent of what it
would cost to care for the same seniors under traditional
Medicare. I thought HMOs are supposed to lower our costs. In
fact, Medicare spending could be reduced by $50 billion over
the next decade by paying private plans 100 percent of what it
pays for fee-for-service coverage. The HMOs and CMS need to
come before Congress and justify these overpayments. I don't
think they can be justified, but I am willing to listen to
their explanations. How much is this giveaway to HMOs and
prescription drug companies costing American seniors?
We know that Part B premiums are going up, are going to
increase by 17.5 percent next year. Seniors deserve to know why
they are going to be forced to pay the largest dollar increase
in the history of Medicare. We should be discussing how seniors
will afford a 17.5 percent increase next year on top of a 13.5
percent increase this year. We know they can't rely on Social
Security.
According to a recent administration analysis, which was
hidden until USA Today recently uncovered it--and I am quoting
now--a typical 65-year-old can expect to spend 37 percent of
his or her Social Security income on Medicare premiums,
copayments, and out-of-pocket expenses in 2006. That share is
projected to grow to almost 40 percent in 2011, and nearly 50
percent by 2021.
How are seniors supposed to make due? Congress should not
go home until the premium issue increase is addressed.
Mr. Chairman, there are a lot of questions that need to be
asked about the true cost of this law to both the taxpayers and
the seniors and about the quality of benefits. We need to know
why 3 million low-income seniors who qualify for the $600
credit under the drug card program have not signed up. We need
to know why the administration is not automatically enrolling
the only group of seniors I believe may benefit from this
otherwise lousy drug card program. And we need to know why,
when the Secretary of Human Services, Health and Human
Services, is going to use his authority granted to him under
the new law to allow the safe importation of prescription drugs
by our seniors.
This committee has a lot of questions to ask of the
administration on issues of great importance and urgency to our
seniors and taxpayers. I hope you allow us an opportunity to
ask those questions.
I yield back the balance of my time.
Mr. Bilirakis. The Chair recognizes the gentleman from
Illinois, Mr. Shimkus.
Mr. Shimkus. Thank you, Mr. Chairman. I will be brief.
Thank you for this hearing. You know, it is about time that
we started moving Medicare into the modern era, and we are
doing that and I think we will find out more with this hearing
with the ``Welcome to Medicare Physical'' as well as the
cardiovascular and the diabetes screening that is very
important. This is educational. It is educational for us so
that we can talk to our seniors, it is educational for the
public who will be watching over C-SPAN. The more we learn
about it, the better we are all going to be.
And I thank you for coming, Mr. Chairman. I yield back my
time.
Mr. Bilirakis. I thank the gentleman.
[Additional statement submitted for the record follows:]
Prepared Statement of Hon. Joe Barton, Chairman, Committee on Energy
and Commerce
Thank you Chairman Bilirakis for holding this important hearing. I
would also like to thank our witnesses for coming to testify before the
Subcommittee today. I look forward to hearing your testimony, and your
views on the new preventive services available to Medicare
beneficiaries.
The landmark Medicare legislation passed last year truly deserves
the name the Medicare Modernization Act. Medicare is too often behind
the curve in responding to changes in the practice of medicine. In
1965, prescription drugs were an afterthought in providing quality
medical care. The same was true for preventive benefits. The MMA
recognized the changes that have revolutionized health care since 1965,
and provided beneficiaries with access to both prescription drugs and
preventive benefits.
At its inception, Medicare was designed to treat acute conditions
after patients became symptomatic. Since that time quantum leaps have
been made in our understanding of diseases. Although we don't have a
cure for cancer, we do know that when detected early, patients can beat
this otherwise fatal disease.
Thirty-nine years ago, too many diabetics faced living with painful
diabetic ulcers or having to undergo life-changing amputations. Those
dangers still exist, but with early recognition of diabetes and proper
management of the disease, most diabetics can avoid serious
complications. According to the American Diabetes Association, over 18
percent of Americans age 60 and older have diabetes. With the
increasing prevalence of Type II, adult onset, diabetes it is
imperative for the quality of life of our seniors that we do a better
job of early detection and treatment of this disease. The Medicare
Modernization Act will provide seniors at risk for diabetes the
appropriate screenings for the disease.
In addition, thanks to the tireless efforts of Subcommittee
Chairman Bilirakis, seniors for the first time will receive a ``Welcome
to Medicare'' physical upon their enrollment in the program. The
importance of this initial exam cannot be overstated. These
examinations will allow seniors to better understand their current
health status and take steps to mitigate potential health risks.
Seniors will now also receive regular cardiovascular screenings.
According to the American Heart Association, in 2001, over four million
seniors were discharged from short-stay hospitals with a first listed
diagnosis of cardiovascular disease. Many of those could have avoided
hospitalization by early detection of their cardiovascular disease
risks.
The new preventive benefits provided by the MMA hold the promise to
dramatically improve patient outcomes. They also hold the potential to
reduce Medicare spending by identifying and treating conditions before
they require expensive acute care.
This year Medicare celebrated its 39th birthday. Thanks to the new
benefits provided for in the MMA, seniors will begin to see a Medicare
program that is based on the medicine of the 21st century, not an
outdated benefits package based on the medicine of decades gone by.
Thank you again Mr. Chairman for holding this important hearing.
Mr. Bilirakis. Let us go right into the witnesses. Our
gratitude for your taking time to be here. I am glad that we
have shortened our opening statements, so to speak, so that we
can hear from you.
Your written statements, of course, are a part of the
record, and hopefully you will complement and supplement them.
I will set the clock at 5 minutes, but by all means don't let
it rush you. In other words, we want to hear what you have to
say. And hopefully, of course, that doesn't mean you double the
time, But in any case, whatever. Please help us to better
understand what we have accomplished, what we hope to have
accomplished regarding preventive health care in this
legislation.
Dr. Clancy, please proceed.
STATEMENTS OF CAROLYN CLANCY, DIRECTOR, AGENCY FOR HEALTHCARE
RESEARCH AND QUALITY, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES; JANET HEINRICH, DIRECTOR, HEALTHCARE/PUBLIC HEALTH
ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; AND STEVEN H.
WOOLF, EXECUTIVE VICE PRESIDENT FOR POLICY DEVELOPMENT,
PARTNERSHIP FOR PREVENTION
Ms. Clancy. Mr. Chairman and members of the subcommittee, I
am really delighted to have the opportunity today to testify
about the role of the U.S. Preventive Services Task Force in
assessing the effectiveness of preventive health care services.
This year marks the 20th anniversary of the Task Force.
Composed of 16 private sector experts, the Task Force conducts
rigorous impartial assessments of the scientific evidence for a
broad range of clinical preventive services. Indeed, its
recommendations are considered the gold standard, if you will,
for preventive services provided in a clinical setting. The
work of the Task Force complements the important work of CDC's
Task Force on Community Preventive Services, which, by its
name, as it implies, examines preventive services delivered in
community or public health settings.
Before turning to how the Task Force does its work, I want
to just make three points to put its work in context:
First, the Task Force focuses on primary and secondary
preventive health care services that are delivered in primary
care clinical settings. So primary prevention is defined as
interventions that reduce the risk of disease in otherwise
healthy people. For example, flu shots. Secondary prevention is
defined as screening to identify risk factors for disease or to
identify disease before it appears, such as cancer or heart
disease.
The second point is that the role of the Task Force is to
identify those preventive services for which there is good-
quality evidence of effectiveness. In medicine, all of us are
taught that the first cardinal rule is do no harm. The role of
the Task Force is to identify those preventive services for
which there is evidence of effectiveness. In other words, that
the potential benefits outweigh the potential harms.
The third point is that the Task Force does not speak for
AHRQ or for HHS. While the director of AHRQ is statutorily
required to appoint its members and support its work, the Task
Force is not a Federal advisory body under law. So to date, the
Task Force has reviewed over 70 topics in the area of primary
and secondary clinical prevention, ranging from taking aspirin
to preventing a first heart attack to screening for obesity to
screening patients for potential problems with depression.
To determine which topics to review, the Task Force
solicits inputs from its members, Federal agencies,
professional organizations, and the public. The Task Force then
ranks the topics based on the magnitude of the problem as
defined by the number of people affected, and they work with
outside experts to identify the fundamental questions that
should be answered. For example, is a clinical preventive
service, whether it is screening, counseling, or chemo
prevention, associated with reduced morbidity and mortality?
Does early identification of the disease lead to an improved
outcome compared to the result that would occur if the disease
were not detected early? And so forth.
So this decision framework also takes into account
potential harms of these services, such as the possibility of
false-positive tests that require further and sometimes
invasive and potentially risky follow-up tests.
To rate the quality of the evidence, the Task Force relies
on AHRQ to coordinate systematic reviews of the evidence
through our Evidence-based Practice Centers program. The
Centers first identify all relevant studies, and then they
assess the quality of those studies to figure out whether they
are of good, fair, or poor quality. They then synthesize the
findings. Consistent with our policy and our authorizing
legislation, the Centers make no recommendations. That role is
left to the Task Force, which establishes recommendation by a
formal vote, and how they do this is they assign letter grades.
An A grade means a very strong recommendation; that there
is good evidence that the benefits of providing this service
substantially outweigh the harms.
A B grade, similar to report cards, means that the Task
Force recommends a service if there is at least fair evidence
and the benefits outweigh the harms.
A C grade means that the Task Force makes no
recommendations for or against if there is at least fair
evidence and there is a close balance between the benefits and
the harms.
A D grade means that the Task Force recommends against
routine use of a service that is ineffective or that the harms
outweigh the potential benefits.
And an I grade means that the Task Force finds insufficient
evidence to recommend for or against, since the balance of
benefits and harms is not known. This I recommendation
sometimes causes confusion. The I letter simply reflects that
there is insufficient evidence to make a formal recommendation.
It is neither a recommendation for nor against providing the
service on a routine basis. It may mean that few studies have
been conducted or that the existing studies are flawed or
contradictory or are not powerful enough statistically to
provide conclusive evidence.
Mr. Chairman, supporting the work of the Task Force is just
one aspect of AHRQ'S much broader prevention agenda. We have
come to appreciate that there is a large gap between what is
known and what is actually done in practice, and our work can
help in three ways:
First, before we can improve care, we need to understand
what is known or the state of the science. AHRQ plays an
increasingly important role in synthesizing that knowledge. We
now have a formal arrangement to develop such syntheses before
each consensus conference sponsored by the National Institutes
of Health, and the MMA directs AHRQ to expand its synthesis
role. The goal of MMA Section 1013 is to help those who manage
and are served by the Medicare, Medicaid, and SCHIP programs to
benefit faster from existing knowledge. In addition, we are
finalizing three reports related to obesity in the elderly,
geriatric surgery, and weight loss programs which we hope will
be very useful to public and private sector policymakers.
Second, recent experience demonstrates that knowing the
right thing to do is only the first step. The real challenge is
ensuring that our broad range of health care delivery systems
supports rather than frustrates the effort of harried
caregivers to provide state-of-the-art care; that is, to do the
right thing. The Institute of Medicine report ``To Err is
Human,'' which focused on medical errors and patient safety
made it very clear: It takes a dual focus on effective services
in effective and efficient ways to organize, manage, and
deliver those services.
Third, AHRQ can play a unique role in what is sometimes
called tertiary prevention or preventing complications in those
with diseases. From my experience as a practicing physician and
also from published studies, I can tell you that the critical
challenge is not developing management strategies for
individual diseases, it is understanding how to reconcile
competing recommendations for patients with multiple chronic
illnesses. For example, 82 percent of people with diabetes have
at least one other chronic illness. Twenty percent of Medicare
beneficiaries have five or more chronic conditions. The
perspective that we bring to chronic care management is
patient-centered, not disease-specific, and increasingly we are
shifting our work to ensure that patients and their caregivers
have better information for assessing these critical tradeoffs.
This concludes my prepared remarks, and I would be happy to
take any questions.
[The prepared statement of Carolyn Clancy follows:]
Prepared Statement of Carolyn Clancy, Director, Agency for Healthcare
Research and Quality, U.S. Department of Health and Human Services
INTRODUCTION
Mr. Chairman, I welcome this opportunity to testify about the role
of the United States Preventive Services Task Force in assessing the
effectiveness of preventive health care services. In fact, this year
marks the twentieth anniversary of the Task Force. Now in its third
incarnation, the Task Force is widely viewed by primary care clinicians
as providing the ``gold standard'' regarding those preventive services
for which there is good quality scientific evidence of effectiveness.
I will also comment briefly on the research and synthesis work
undertaken by the Agency for Healthcare Research and Quality (AHRQ). We
support the work of the Task Force, a statutory requirement since our
1999 reauthorization, but we also develop new information regarding the
effectiveness of preventive health care; synthesize ``state of the
art'' information regarding preventive health care services for
patients and their caregivers, and identify approaches for increasing
the rates at which effective clinical preventive services are delivered
and used.
AHRQ's work provides an important complement to the community-
based, public health strategies and interventions that are developed
and promoted under the leadership of the Centers for Disease Control
and Prevention (CDC). Both CDC and AHRQ also benefit from the work of
the National Institutes of Health in developing the basic building
blocks that underpin public health and clinical preventive services
interventions. Prevention research is a good example of how the
Department of Health and Human Services (HHS) is increasingly
functioning as ``one Department.''
As requested, my testimony will provide background information on
how the Task Force and AHRQ approach their work in prevention. However,
I want to stress that AHRQ maintains a focus on effective preventive
services for the elderly. In that capacity, each year we submit to the
Congress a report on the latest recommendations of the Task Force. I
welcome the opportunity to address any substantive issue following the
conclusion of my statement.
THE UNITED STATES PREVENTIVE SERVICES TASK FORCE
Context and Scope
Before turning to how the Preventive Services Task Force undertakes
its work, there are 3 points that need to be made regarding the context
and scope of its work.
First, the Task Force focuses on primary and secondary prevention.
Since the Office of the Secretary established the first Preventive
Services Task Force 20 years ago, the Task Force's mandate has focused
on the delivery in primary care settings of primary or secondary
prevention services. The Task Force was originally created to provide
guidance for primary care clinicians in the area of preventive care for
apparently healthy individuals. Primary prevention is defined as
interventions that reduce the risk of disease occurrence in otherwise
healthy individuals. Counseling patients not to smoke and prescribing
fluoride to children to prevent cavities are examples of primary
prevention. Secondary prevention can be defined as screening to
identify risk factors for disease or the detection of disease among
individuals who are at risk for that disease. Evaluating blood pressure
in adults is an effective way to identify individuals at risk for heart
disease and provides an opportunity to intervene before the disease
occurs. Screening for colon cancer using colonoscopy to detect pre-
cancerous polyps is another example of secondary prevention. The bottom
line is that individuals who receive primary or secondary prevention
services have no obvious signs of illness; in clinical terms, they are
asymptomatic. Consistent with the longstanding commitment by physicians
and other health care professionals to ``first do no harm,'' providing
services to individuals who are apparently free of disease requires a
careful approach to balancing benefits and harms.
By contrast, the Task Force does not address the category of
services known as tertiary prevention. Tertiary prevention services are
provided to individuals who clearly have a disease and the goal is to
prevent them from developing further complications. For example,
diabetes care would be considered tertiary prevention in that the care
provided is focused on limiting the complications of a disease that is
already present. Tertiary prevention interventions are a focus of
research by AHRQ and an important component of prevention public
policy, but they are not within the purview of the Task Force. Unlike
primary and secondary prevention, there are numerous groups who review
the literature on medical treatment in order to advise clinicians on
the optimal way to treat chronic illnesses. Therefore, it remains
critical for a group such as the Task Force to remain focused on the
types of preventive service decisions for which most primary care
clinicians have limited evidence-based guidance.
Second, the role of the Task Force is to identify those preventive
services for which there is good quality evidence of effectiveness.
This is a high standard to meet and has implications for interpreting
the work of the Task Force and determining what to do in the absence of
evidence. The first point to recognize is that good quality scientific
evidence takes time. Thus, when the Task Force concludes that there is
insufficient evidence upon which to make a recommendation, the Task
Force is not concluding that a service is ineffective. It may simply
reflect the fact that few studies have been conducted, or that existing
studies are flawed, contradictory, or simply not powerful enough
statistically to provide good quality evidence. Should a finding of
insufficient evidence preclude guidance from Federal agencies, medical
societies, or action by policymakers? Not necessarily. Patients and
their caregivers often need advice or assistance in the absence of
perfect information and there may be an important public health
rationale for action before good quality evidence is available. In such
cases, guidance from Federal agencies or medical societies or action by
policymakers may be appropriate.
Third, the Task Force does not speak for AHRQ or HHS. While the
Director of AHRQ is statutorily required to appoint its members, the
Task Force is not a Federal advisory body under the law. The Task Force
is a body of private sector primary care experts and methodologists. It
is configured to provide expertise in the area of primary and secondary
clinical prevention to a broad patient population and their primary
caregivers. I have included at the end of my testimony, a roster of the
current Task Force membership, which includes a mix of internists,
family physicians, pediatricians, obstetrician/gynecologists, nurses,
and methodologists with expertise in issues of screening, counseling,
and prescribing drugs for reducing the risk of disease in the primary
care setting.
How the Task Force Operates
To date the current Task Force has reviewed numerous topics in the
area of primary and secondary clinical preventions, ranging from
childhood vision screening to obesity counseling to postmenopausal
hormone replacement therapy. This range of topic areas and population
age groups reflects the breadth of such interventions encountered in
primary care settings. The process that the Task Force uses is as
follows:
Topic Selection: To determine which clinical preventive topics to
review, the Task Force solicits topics from its members, Federal
agencies, professional organizations and the public. The Task Force
then prioritizes these topics based on the magnitude of the problem as
defined by the number of people affected or the severity of the
problem, evolving evidence, and potential impact of the recommendation
on primary care practice.
The Framework for Evidence-Based Reviews: For each topic, the Task
Force establishes the scope of the review by identifying the specific
populations for which evidence will be evaluated. This decision
reflects the prevalence of the disease and its manifestation among
different groups, expressed in terms of age, gender, and risk status.
The analysis of the scientific literature is guided by the
ultimate outcomes on which the Task Force focuses. Is a clinical
preventive service--screening, counseling or prescribing drugs to
reduce the risk of disease--associated with reduced morbidity and
mortality? Does earlier identification of disease lead to an improved
outcome compared to the result that would occur if the disease was not
detected and treated early? The Task Force then works with external
experts to develop the specific key questions for each point in the
analytic framework that will illuminate the effectiveness of screening,
counseling or treatment on reducing mortality and morbidity. As the
graphic below demonstrates, the framework also takes into account
potential harms associated with these activities such as false
positives, increased anxiety, or adverse effects.
[GRAPHIC] [TIFF OMITTED] T6096.001
Rating the quality of the evidence: The Task Force relies on AHRQ
to coordinate the systematic reviews of the evidence through the
Evidence-based Practice Centers (EPCs) supported by the Agency. Before
an EPC can synthesize the scientific literature, it must first assess
the methodological rigor of each study, asking questions such as:
Did the investigators use an appropriate research design for the
question being asked?
Did they control for other factors that might affect the outcome
(what researchers call ``threats to validity'')?
Did they use the right statistical tests and calculate them properly?
Did the study address services provided in the primary care setting?
After evaluating the relevance and rigor of each individual study,
the EPC also considers the consistency of evidence across the entire
body of studies. Based on these components the strength of the evidence
is categorized as good, fair, or poor and then synthesized. Consistent
with its approach in other areas, AHRQ directs its EPCs to identify
strengths and limitations of the existing knowledge base, but these
evidence reports make no recommendations.
Developing a recommendation: After reviewing the EPC report and
considering the overall strength of the evidence and estimates the
magnitude of the net benefits (based on the balance of benefits and
harms), the Task Force then establishes recommendations by a formal
vote. To guide interpretation of its recommendations, it assigns a
letter grade to each recommendation, reflecting the strength of the
evidence and the magnitude of benefit. The letter grades include:
A--The Task Force strongly recommends a service, there is good
evidence, and benefits substantially outweigh the harms.
B--The Task Force recommends a service if there is at least fair
evidence, and the benefits outweigh the harms.
C--The Task Force makes no recommendations for or against a service if
there is at least fair evidence, and the benefits and harms are
closely balanced.
D--The Task Force recommends against routine use of a service that is
ineffective or if the harms outweigh the potential benefits.
I--The Task Force found insufficient evidence to recommend for or
against a service since the balance of benefits and harms is
not known.
The ``I'' letter grade simply reflects the lack of adequate
evidence to make a recommendation; it is neither a recommendation for
nor a recommendation against providing the service on a routine basis.
A preventive service could receive an ``I'' letter grade for several
reasons: Studies may be lacking, existing studies may be of poor
quality, or good-quality studies may have conflicting results.
Therefore, an ``I'' recommendation is a call for additional research
that would provide the appropriate evidence base for the USPSTF to make
either a positive or negative recommendation.
Two Methodological Issues now under Consideration
Mr. Chairman, there are two methodological issues under
consideration by the Task Force that may be of interest to the
Committee, and we would welcome your input. The first relates to
special populations. The Task Force addresses recommendations across
all age groups from birth to death. While the majority of
recommendations focus on the adult population, the current Task Force
has addressed 13 topics relating to children and adolescents.
Challenges exist in making recommendation for these populations for
multiple reasons. Defining the clinical endpoint can be difficult in
children because the reduction of morbidity and mortality may not be
realized until they reach adulthood. The potential benefits or harms of
clinical preventive services need to be considered for the child and
adolescent as well as their family. Finally, youth often receive
services in the school or community setting. To address these
challenges the Task Force established the Child Health Workgroup which
is currently discussing these issues and is planning a child health
expert conference.
The second issue relates to the consideration of costs and cost-
effectiveness. With the convening of the current Task Force, members
recognized that cost-effectiveness and value are important issues to
users of the Task Force recommendations. The Task Force convened a work
group to assess approaches for addressing cost and cost-effectiveness.
That assessment is still under way. At this point, the Task Force does
not consider cost or cost effectiveness as a primary determinate in
making its recommendations but rather in selected cases summarizes the
cost data for users in the discussion section of its recommendation
statement.
THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)
Mr. Chairman, supporting the work of the Task Force is but one
aspect of AHRQ's much broader prevention agenda. Unlike the Task Force,
our agenda includes tertiary prevention interventions in addition to
primary and secondary activities. Rather than provide a laundry list of
those activities, I would like to highlight three unique strengths that
AHRQ brings to all of its work, including the Department's prevention
initiatives
In recent years we have come to appreciate that there is a large
gap between what is known and what is done in practice. It is reflected
in the unacceptably long time line between the funding of pioneering
research and the point at which most Americans benefit from that
research investment; at least one analyst estimates that it takes 17
years. Our work suggests that there are a number of challenges we must
overcome if we are to ensure that Americans benefit more rapidly from
our past research investments. Let me highlight just three.
First, it is hard for physicians and their patients to keep abreast
of the latest scientific knowledge. The increased pace of publication
of new scientific findings also enhances this difficulty. As a
practicing physician, I know how difficult it is to determine whether
to change my practice on the basis of the latest finding about one of
many clinical issues I face. Unless research findings are put into
context, my colleagues and I cannot answer for our patients that vital
but deceptively simple question: what is known? I am increasingly
convinced that AHRQ's role in the synthesis of evidence--which we
undertake for (among others) the Task Force, CMS, FDA, and even NIH as
a prelude to its consensus conferences--is a vital first step to
reducing lag time. We need to understand what is known--the ``state of
the art''--before we can improve. In the area of prevention, for
example, we have completed three important evidence reports on obesity.
I expect these reports will be as useful to policymakers as they will
be for patients and their caregivers.
CMS commissioned a technology assessment from us to review and
analyze the scientific literature on treatments for obesity in
the elderly, including behavioral therapies and dietary
counseling.
At the request of Congress, we developed a report on a cost
effectiveness analysis of weight loss programs in the elderly.
One of our Evidence-based Practice Centers recently completed an
evidence report on pharmacological and surgical management of
obesity. This report was requested by primary care specialty
societies. It will be released in the next few days.
The Medicare Modernization Act (MMA) requires AHRQ to undertake
more of this type of work so that those who manage and are served by
the Medicare, Medicaid and SCHIP programs can benefit faster from
existing knowledge. The MMA also challenges AHRQ to see that physicians
and patients can access the information on ``what is known'' when they
need it. We already have an innovative arrangement with the vendor,
ePocrates, to provide physicians with fast access on their PDAs to the
bottom line of recommendations from the Task Force. Since a growing
number of clinicians rely on their PDAs to help keep them current with
the latest science, AHRQ has developed a free Interactive Preventive
Services Selector Program for PDAs. Since we made the software
available for downloading, the web site has been accessed 7,847 times
and the software has been installed on 1,837 Palm-based PDAs and 775
Pocket PC PDAs.
Second, recent experience demonstrates that knowing the right thing
to do is only the first step. The real challenge is ensuring that our
broad range of health care delivery systems supports, rather than
frustrates, the efforts of harried caregivers to do the right thing.
AHRQ has a unique dual focus on effective services and effective and
efficient ways to organize, manage, and deliver those services. We
pioneered the use of preventive services reminder systems and some
concepts for workflow redesign to improve the rates at which preventive
services were delivered and used. As my colleagues and I work to make
AHRQ more of a ``problem solving'' agency, we will focus increasing
attention on options for overcoming those system, organization, and
behavioral barriers to increased use of effective clinical services.
In addition, we will soon be announcing a series of grant and
contract awards to increase the deployment and use of health
information technology--precisely because health information technology
can make the right thing to do the easy thing to do. The awards we will
be announcing will advance the President's and Secretary's commitment
to improve the safety and quality of health care and increase the
utilization of preventive services.
Third, as the ``baby boomer'' generation ages, the ranks of chronic
care patients are swelling. AHRQ has and will continue to contribute to
efforts to develop and assess specific disease management strategies.
But the unique perspective we bring to chronic care management is a
patient-centered, not disease-centered, focus. For example, 82% of
patients with diabetes have another chronic condition and 20% of
Medicare beneficiaries have 5 or more chronic conditions. In our view,
the challenge of developing effective individual disease management
strategies is easily matched, if not exceeded, by the need to reconcile
disparate disease management programs for patients with multiple
chronic diseases. Increasingly, our work is shifting to meet this need.
The number of multiple chronic care patients will only continue to grow
in the years ahead and we need tertiary prevention strategies that can
be reconciled at the level of the primary carergiver.
CONCLUSION
Mr. Chairman, this concludes my prepared testimony. I would be
happy to answer questions.
Mr. Bilirakis. Thank you very much.
Director Heinrich.
STATEMENT OF JANET HEINRICH
Ms. Heinrich. Mr. Chairman and members of the subcommittee,
I too am pleased to be here today as you discuss preventive
care benefits for the Medicare population. As you stated, the
Medicare program was originally conceived to help pay for
people 65 and over who were ill or injured. But over time,
Congress has broadened coverage to include specific preventive
services such as immunizations or screenings for different
types of cancers. Most recently, Congress added coverage for a
one-time preventive care examination for new enrollees and
other selected preventive services.
As these new benefits are implemented, you have asked about
lessons learned from previous research on delivery options. My
statement today focuses on the extent to which beneficiaries
receive preventive services through physician visits and some
of the expected benefits and limitations of delivering services
through a one-time prevention examination.
You have just heard about the Preventive Services Task
Force and the excellent work that they do. It is clear that
Medicare does not cover all of the services that the Task Force
recommends. Under the traditional fee-for-service program,
there has not been coverage of a regular periodic examination
where clinicians might assess an individual's health risk and
provide needed services. Beneficiaries can receive some of
these services through office visits for other health problems.
For example, we examined survey data that showed Medicare
beneficiaries visited a physician at least six times a year, on
average, mainly for illness and medical conditions. Only about
10 percent of the visits occurred when a person is well.
Despite how often beneficiaries visit physicians, few people
received the full range of recommended preventive services. As
we reported, although 91 percent of females in our analysis
received at least one preventive service, only 10 percent
received screening for cervical, breast, colon cancer, and were
also immunized against influenza and pneumonia.
Many beneficiaries may not know that they are at risk of a
particular health condition. For example, data from a CDC
survey that includes a physical exam showed that 32 percent of
persons with an elevated blood pressure were unaware that they
might have this condition. This translates into about 6.6
million people who may not have known that they were at risk
for high blood pressure.
The new Welcome to Medicare examination may offer an
opportunity to correct some of these problems. It could be a
means to ensure that health care providers take the time to
identify individual beneficiaries' health risks and provide the
services appropriate for those risks.
The initial preventive physical exam described in the draft
regulations is comprehensive, and provides for a physical exam
as well as education, counseling, and referral for separately
covered preventive services. Questions remain, however, about
how follow-up to beneficiaries will be provided and how they
will be encouraged to make informed choices about screening
services, immunizations, and avoidance of risky behavior.
It also is unclear if a one-time examination will actually
improve beneficiaries' health. For example, one previous CMS
demonstration tested health promotion and disease prevention
services, such as preventive visits, health risk assessments,
and behavioral counseling, to see if this would increase
beneficiaries' health or lower health care expenditures. The
results showed some increased utilization of preventive
measures such as immunizations and cancer screenings, but did
not consistently improve beneficiary health or reduce the use
of hospital or skilled nursing services.
CMS is exploring an alternative for delivering preventive
care that would provide systematic health risk assessments to
fee-for-service beneficiaries through a means other than a
physician visit. The Medicare Senior Risk Reduction program
currently under design will use a beneficiary-focused health
risk assessment questionnaire to identify risks. The program
will test different approaches to provide feedback and follow-
up services, such as referring beneficiaries to community
services, including physical activity and social support in
changing risk behavior.
In conclusion, current data indicate that many
opportunities exist for Medicare beneficiaries to receive
preventive care. Our work shows that we also have more to do to
deliver preventive services to those beneficiaries who most
need them. A one-time preventive care examination is a good
start to reduce the gap in preventive services that
beneficiaries receive.
Mr. Chairman, this ends my prepared statement. I am happy
to answer questions.
[The prepared statement of Janet Heinrich appears at the
end of the hearing.]
Mr. Bilirakis. Thank you, Ms. Heinrich.
Dr. Woolf.
STATEMENT OF STEVEN H. WOOLF
Mr. Woolf. Good afternoon, Mr. Chairman, Mr. Brown, and
members of the subcommittee. My name is Steven Woolf. I am a
practicing family physician, a specialist in preventive
medicine and public health, and a professor at Virginia
Commonwealth University.
I am here this afternoon representing Partnership for
Prevention where I serve as Executive Vice President.
Partnership for Prevention is a national nonprofit, nonpartisan
policy research organization committed to helping Americans
prevent diseases. We have issued reports and convened national
meetings about preventive services under Medicare, have held
congressional briefings on the subject, and are now working
with CMS on strategies to improve the delivery of preventive
care to America's seniors.
Mr. Chairman, you and your colleagues are to be commended
for holding today's hearing on the power of prevention to
improve the health of America's seniors and to strengthen
Medicare.
The inherent logic behind prevention is obvious: The major
diseases that claim the lives of Americans and that contribute
mightily to the rising cost of health care are caused largely
by our health habits, such as smoking, physical inactivity, and
poor diet. Preventive services, in which doctors help patients
change these behaviors, give vaccines to prevent infectious
diseases, and use screening tests to catch them in their early
stages, deserve greater attention from policymakers. This was
always true, but especially now, a time when Americans are
growing older and falling victim to chronic diseases that could
have been prevented or made less severe through preventive
measures.
It is a mistake to think that seniors are too old to
benefit from prevention. Research indicates that seniors will
live longer and live healthier if they abandon unhealthy
behaviors, get recommended vaccines, and receive certain
screening tests.
It is in the interest of our Nation for America's seniors
to be healthy instead of infirm, active instead of
hospitalized, productive instead of costly, and independent
instead of dependent. Prevention makes sense not only for the
fundamental reason that it improves health but also for
economic reasons. The cost of treating the complications of
diseases are enormous. It is better to pay for prevention than
to pay for intensive care. As the Governor of Arkansas, Mike
Huckabee, has stated: Our health care system should build a
fence at the top of the cliff so we can stop sending ambulances
to the bottom.
Although prevention was excluded in the law that created
the Medicare program 40 years ago, Congress has done much in
the past decade to expand coverage for preventive services.
Medicare now covers many of the screening tests and
immunizations that medical organizations recommend for seniors,
including some of urgent public health importance, such as
screening tests for colon cancer and the vaccine that prevents
pneumonia.
The Medicare Modernization Act furthered this effort by
expanding coverage for cardiovascular and diabetes screening,
but also by including coverage for the ``Welcome to Medicare''
visit. Offering all new beneficiaries a clinical evaluation by
their primary care provider is an ideal opportunity to
determine the individual needs of patients, remind them about
the importance of prevention, and make arrangements for them to
receive the counseling, screening, and immunizations that they
are due. The visit can help set them off on the right foot.
Partnership for Prevention commends Congress for adding
these provisions, but there is far more to be done. Preventive
services under Medicare remain deficient. In particular, I will
highlight four issues which, in the interest of time, I will
state briefly. I expand on these points in my written
testimony, and, on request, can provide the subcommittee with
our publications on the topic.
First, the very fact that Medicare coverage of preventive
service is managed by Congress is itself an issue. When it
comes to diagnosing and treating disease, Congress allows CMS
to decide what to cover in consultation with the leading
experts of the Nation. The same should be true for preventing
disease, as the Institute of Medicine recommended in 2000.
Requiring an act of Congress to cover each preventive service
is not only inconsistent but also inefficient. It slows the
delivery of preventive care to America's seniors, compromising
their health and costing the system money. The machinery of
Congress is not designed for scientific deliberation and is
less nimble than CMS in keeping pace with rapid changes in
science and technology. Coverage policies that Congress
established years ago have become outdated, advocating
preventive services that medical groups no longer recommend;
yet CMS is compelled by congressional statute to continue
offering and paying for them. Partnership for Prevention
encourages Congress to direct CMS to make coverage decisions
for preventive services, just as it does for diagnostic and
treatment services.
Second, although Medicare now covers screening testing and
immunizations, it offers little support for clinicians to help
patients adopt the behaviors that will prevent disease, a
strategy much more likely to save lives. Help with stopping
smoking, controlling weight, and eating well, the most
effective strategies for improving health and reducing costs
for the Medicare program, is not covered under Medicare. The
recent decision by CMS to cover obesity treatment is welcomed,
but Congress should authorize Medicare to cover counseling for
tobacco cessation, physical activity, and healthy diet.
Third, although in theory the ``Welcome to Medicare'' visit
provides an opportunity to deliver or arrange for recommended
preventive services, greater structure is needed to ensure that
the visit is used to promote evidence-based preventive services
that improve health and it is not exploited to use Medicare
dollars for services of unproven benefit or potential harm. Not
all screening tests are good for you. Some may do more harm
than good, which is why expert bodies such as the U.S.
Preventive Services Task Force and most medical organizations
recommend only a dozen of the hundreds of screening tests that
are in existence. Promoting too many screening tests is not
only an expensive proposition but one that is likely to harm
the intended beneficiaries.
In draft regulations issued this summer, CMS proposed to
configure the ``Welcome to Medicare'' visit as a comprehensive
history and physical examination in which patients would be
given a battery of questions and examination procedures. Such
comprehensiveness has good intentions but is worthy of further
thought. For one thing, the opportunity for Medicare
beneficiaries to get comprehensive physicals is already
available. It is the opportunity for prevention that the MMA
sought to provide. Second, comprehensive evaluations often set
off a cascade of diagnostic workups that are of dubious health
benefit to patients.
Finally, and most importantly, the distractions introduced
by a comprehensive physical can lead physicians and patients
into diverse health complaints and crowd out the focus on
prevention that the MMA intended. The MMA sought to give
beneficiaries an opportunity, at least once during their tenure
with Medicare, to focus on prevention; and that worthy goal
could be lost if the visit turns into yet another comprehensive
physical.
Partnership for Prevention is concerned about
overutilization and recommends that the ``Welcome to Medicare''
visit be designed as a focused prevention visit, not as a
comprehensive physical, aimed at promoting a defined set of
services that are known to improve health outcomes.
Fourth, and finally, it is not enough to simply add
coverage for preventive services. Steps must also be taken to
ensure that they are delivered and delivered well. If what
Congress has done to expand coverage is to realize its full
potential benefits, both beneficiaries and providers must be
educated about the importance of prevention and how to make use
of the services that Medicare covers, reminder systems for
doctors and patients, and modern ideas for quality improvement
such as the Medicare Web site that patients can use at home to
manage their prevention program, help ensure that patients
receive services on time. These tools put patients in charge of
their health.
The Medicare program is plagued by racial and ethnic
disparities in who receives covered services. And research
shows that a systems approach to delivery can do much to reduce
such disparities. We therefore encourage data collection
activities at CMS to track outcomes and evaluate the
performance of preventive care.
Partnership for Prevention seeks to better educate
beneficiaries and clinicians about the ``Welcome to Medicare''
visit and preventive care, and it urges Medicare to encourage,
certainly not to impede, the introduction of systems within
practices and health care organizations that improve the
delivery of preventive care.
Once again, we thank the subcommittee for its commendable
efforts to promote prevention, and we look forward to working
with you to make Medicare better. I would be happy to answer
your questions.
[The prepared statement of Steven H. Woolf follows:]
Prepared Statement of Steven H. Woolf, Executive Vice President for
Policy Development Partnership for Prevention and Professor of Family
Medicine, Preventive Medicine and Community Health, Virginia
Commonwealth University
The inherent logic behind prevention is obvious. The major diseases
that claim the lives of Americans and that contribute mightily to the
rising costs of health care are caused largely by our health habits,
such as smoking, physical inactivity, and poor diet. Fully 35% of
deaths in the United States are caused by three behaviors: tobacco use,
poor diet, and physical inactivity.1
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\1\ Mokdad et al. Acutal causes of death in the United States,
2000. JAMA 2004;291:1238-45.
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Preventive services--in which doctors help patients change these
behaviors, give vaccines to prevent infectious diseases, and use
screening tests to catch diseases in their early stages--deserve
greater attention from policymakers. Our healthcare system expends most
of its resources on treating existing disease, but paying for
prevention could be much more effective. For example, treatments for
cardiovascular disease, once it has already developed, can save 4,000-
10,000 lives per year, but helping Americans to stop smoking would
prevent more than 400,000 deaths per year.2
---------------------------------------------------------------------------
\2\ Woolf. The need for perspective in evidence-based medicine.
JAMA 1999;282:2358-65.
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This was always true but especially now, a time when Americans are
growing older and in greater numbers are falling victim to chronic
diseases that could have been prevented or made less severe through
preventive measures. It is a mistake to think that seniors are too old
to benefit from prevention. Research indicates that seniors will live
longer and live healthier if they abandon unhealthy behaviors, obtain
recommended vaccines, and receive certain screening tests. For example,
lifelong smokers who stop smoking at age 50 live an average of 6 years
longer than those who continue smoking beyond that age.3
Prevention can improve function, postpone chronic disease and
disability, and avoid premature death.
---------------------------------------------------------------------------
\3\ Doll et al. Mortality in relation to smoking: 50 years'
observations on male British doctors. BMJ 2004;328:1519.
---------------------------------------------------------------------------
Prevention makes sense not only for the fundamental reason that it
improves health, but also for economic reasons. The costs of treating
the complications of diseases are enormous; it is wiser to pay for
prevention than to pay for intensive care. In Appendix 1 we outline the
cost savings associated with certain screening tests. As the Governor
of Arkansas, Mike Huckabee, recently stated, our health care system
should build a fence at the top of the cliff so we can stop sending
ambulances to the bottom.
Although prevention was excluded in the law that created the
Medicare program 40 years ago, Congress has done much in the past
decade to expand coverage for preventive services. Medicare now covers
many of the screening tests and immunizations that medical
organizations recommend for seniors, including some of urgent public
health importance such as screening tests for colon cancer and
pneumococcal vaccine, which helps prevent pneumonia.
Our nation's leaders have turned the corner in recognizing the need
to make Medicare a program that emphasizes prevention. President Bush,
speaking in the State of the Union address, said that ``Medicare is the
binding commitment of a caring society. We must renew that commitment
by giving seniors access to preventive medicine.'' 4 In
other speeches, the President has said that Medicare should be as much
about keeping seniors healthy as treating them after they become sick.
The current Administrator of CMS, Dr. Mark McClellan, said in July
that, ``we mean it when we say we're shifting the focus of the Medicare
program from treating conditions to preventing them.''
---------------------------------------------------------------------------
\4\ President George W. Bush, State of the Union Address, January
28, 2003. http://www.white
house.gov/news/releases/2003/01/20030128-19.html
---------------------------------------------------------------------------
The Medicare Prescription Drug and Modernization Act of 2003 (P.L.
108-173) affirmed this commitment by expanding coverage for
cardiovascular and diabetes screening but also by including coverage
for a ``Welcome to Medicare'' visit. Offering all new beneficiaries a
clinical evaluation by their primary care provider is an ideal
opportunity to determine the individual needs of patients; remind them
about the importance of prevention; and make arrangements for them to
receive the counseling, screening, and immunizations to get them up-to-
date on preventive care. If properly designed, the visit can start
patients off on the right foot and set expectations for an ongoing,
comprehensive approach to preventive services. It is an opportunity to
encourage patients to be active participants in managing their health
and health care needs. Not everything can be done in just one visit,
but the clinician and patient can leverage the opportunity to develop a
plan for obtaining recommended services, to arrange follow-up, and to
remind patients at a later date when repeat screening or immunizations
are due.
Partnership for Prevention commends Congress for adding these
provisions. But there is far more to be done; preventive services under
Medicare remain deficient. In particular, four issues deserve
attention:
1. The mechanism for determining coverage of preventive services
It is problematic that decisions about coverage of prevention under
Medicare are determined by Congress, service by service. This is not
the way that Medicare decides coverage for diagnostic tests and
treatments: for those services, Congress directs CMS to decide what to
cover, in consultation with the nation's leading medical experts. The
same should be true for preventive services, as many experts have
recommended. An Institute of Medicine study recommended just such a
change in its 2000 report, Extending Medicare Coverage for Preventive
and Other Services.5
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\5\ Institute of Medicine. Extending Medicare Coverage for
Preventive and Other Services. Washington, DC: National Academy Press,
2000.
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The existing model is failing. Requiring an ``act of Congress'' to
cover each preventive service is inefficient and slows the delivery of
preventive care to America's seniors--compromising their health and
costing the system money. A bill to introduce coverage of Pap smears
was introduced annually for 15 years before this benefit was added in
1989. The machinery of Congress is not designed for analyzing science
and producing medical guidelines, whereas mechanisms in place at CMS
are designed to more nimbly keep pace with the rapid changes that occur
in science and technology. The Medicare Coverage Advisory Committee
(MCAC), which evaluates effectiveness for CMS, is adept at critically
appraising the quality of evidence for new technologies and is quite
capable of giving similar advice on the effectiveness of preventive
services. As new preventive technologies emerge and as guidelines
change, CMS can update coverage policy much faster and with greater
scientific rigor than can a legislative body charged with
responsibilities for the economy, national security, and other diverse
issues.
The legislative mechanism used by Congress to cover preventive
services has not performed well in keeping coverage policies current.
The provisions written into law are time capsules, reflecting the
advice of the time, but many have now become outdated. For example, in
1991, Congress authorized Medicare to cover ``baseline mammograms'' to
be performed on all women at age 35, a practice advocated at the time
by the American Cancer Society. But today, no major medical group
(including the American Cancer Society) advocates baseline
mammograms.6 In 1998, Congress authorized Medicare to cover
colonoscopy screening as often as every 2 years, presumably because of
testimony received at the time. But in 2004, no scientific evidence and
no major gastroenterological organization supports performing the test
this frequently, even for patients at high risk for colon
cancer.7 In 1998 coverage was extended to osteoporosis
screening for high-risk women, the group that seemed most likely to
benefit. By 2002 the U.S. Preventive Services Task Force had begun
recommending screening for all women over age 65, but in 2004 Medicare
coverage remains restricted to women at high risk.
---------------------------------------------------------------------------
\6\ Smith et al. American Cancer Society guidelines for the
detection of cancer, 2004. CA Cancer J Clin 2004;54:41-52.
\7\ Winawer et al. Colorectal cancer screening and surveillance:
clinical guidelines and rationale-Update based on new evidence.
Gastroenterology. 2003;124:544-60.
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Although staff at CMS is aware of these discrepancies, as long as
the Congressional statute remains in place, the agency is legally
obliged to continue offering and paying for these unnecessary services.
CMS publications must inform beneficiaries that these services are
covered, thereby disseminating the implicit encouragement that
beneficiaries obtain preventive services at a greater frequency--and at
greater cost to Medicare--than any medical organization currently
recommends.
Experience has therefore taught us that relying on Congressional
mandate to cover preventive services under Medicare delays the
establishment of coverage for preventive services that are recommended
and the elimination of coverage for services that are not recommended.
America's seniors deserve a better system.
In a 2003 report, Partnership for Prevention issued a study, A
Better Medicare for Healthier Seniors 8, which laid out 6
options for Medicare coverage of preventive services:
---------------------------------------------------------------------------
\8\ Partnership for Prevention. A Better Medicare for Healthier
Seniors: Recommendations to Modernize Medicare's Prevention Policies.
Washington, DC: Partnership for Prevention, 2003.
Retain the status quo
Tie coverage to an outside group (e.g., U.S. Preventive Services Task
Force)
Create a Congressional ``fast track''
Use the regular coverage process
Introduce a rulemaking change for screening
Create preventive care accounts
The study concluded that: Congress should direct CMS to make
coverage decisions for preventive services, just as it does for
diagnostic and treatment services. We believe that the ideal option is
for decisions about Medicare coverage for preventive services to be
incorporated into the current decision-making process at CMS, based on
rigorous analysis of scientific evidence. As with other services, CMS
could use the MCAC model, obtaining expert advice about coverage from
an MCAC panel on preventive care.
We also recommended that CMS be given flexibility to determine
which providers and suppliers can be reimbursed for preventive
services; that HHS should require greater collaboration on preventive
care among all Federal agencies and with state and local agencies; that
Congress should support development of evidence-based recommendations
for clinical preventive services, health system interventions,
community programs, and public and private sector policies; that HHS
should maximize data and related analysis to better track and
understand beneficiaries' access to and use of preventive services; and
that Federal agencies sponsor new research to protect and improve
beneficiaries' health.
Our recommendations were supported by all seven living former
Secretaries of Health and Human Services (or Health, Education, and
Welfare); see Appendices 2-3. Interest in our recommendations has grown
in Congress. In May 2003, Representatives DeWine, Leach, and Moran and
Senators Graham and DeWine invited Partnership for Prevention to
conduct a Congressional briefing. Our recommendations received the
attention of Representatives Nancy Johnson, Jim Leach, and Jim Ramstad
and of Senator Bill Frist. They were also discussed with the head of
the Congressional Budget Office and the staff of Secretary of Health
and Human Services Tommy Thompson. We are gratified that these
discussions, along with the diligent work of other organizations that
share a commitment to prevention, facilitated the expanded focus on
preventive services that emerged in the Medicare Modernization Act. We
are also pleased that current legislation under consideration in the
House and Senate carries forward these recommendations.9
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\9\ Medicare Preventive Services Coverage Act of 2004 (S. 2535 and
H.R. 4898).
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2. Lack of coverage for counseling about health behaviors
Preventive services include not only screening tests and
immunizations, many of which Medicare now covers, but also the work
clinicians do to counsel patients to adopt healthy behaviors, such as
stopping smoking, controlling weight, staying physically active, and
eating well. Although screening tests can be beneficial in reducing
morbidity and mortality from diseases, the benefits of early detection
are limited because, by definition, the disease process is already
underway. Screening seeks to identify the disease at an early stage,
but by then the pathology is already in place and achieving a cure is
often an uphill battle.
A more effective strategy than waiting for diseases to develop and
attempting to catch them early is to prevent them from occurring in the
first place. Helping patients to change the behaviors that account for
half of all deaths in the United States is thus an urgent public health
priority and a prudent economic policy to control the spiraling costs
of health care. Accordingly, the Surgeon General and major task forces
in the Federal government have urged doctors to make such counseling a
routine part of primary care. For example, it is the recommendation of
the Department of Health and Human Services and the Surgeon General
that all doctors ask all patients, at every visit, whether they smoke;
advise them about the importance of quitting; and make arrangements to
help them in their quit attempts.10
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\10\ Fiore et al. Treating Tobacco Use and Dependence. Rockville,
MD: US Department of Health and Human Services, 2000.
---------------------------------------------------------------------------
It is therefore problematic that Medicare offers little
reimbursement for clinicians to provide such counseling to their
patients. The recent decision by CMS to cover obesity treatment is
welcome, but tobacco use remains the leading cause of death in the
United States.11 Physical inactivity and unhealthy diets
cause cancer and other diseases, even in people who are not obese, and
they are essential to prevent obesity. Counseling about tobacco use,
regular physical activity, and healthy diet are therefore urgent public
health priorities, but Medicare does not provide coverage.
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\11\ Mokdad et al. Acutal causes of death in the United States,
2000. JAMA 2004;291:1238-45.
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The absence of adequate reimbursement discourages physicians from
carving out the time they need with their patients to identify the
health behaviors that need attention, provide the information and
motivation on which patients rely to make lifestyle changes, arrange
for services within the community to facilitate patients' efforts, and
conduct follow-up calls and visits to provide the encouragement that
patients need to maintain changes over time. Neither their efforts, nor
the services within the community that can help them, are covered under
Medicare, even though these activities pose the most effective strategy
to improve the health of the Medicare population and to control
spiraling health care costs. Counseling about health behaviors costs
far less than the intensive care required for heart disease, cancer,
and the others diseases that these behavior changes can avert.
Congress should authorize Medicare to cover counseling for tobacco
cessation, physical activity, and healthy diet.
3. The need to control the content of the Welcome to Medicare visit
Although in theory the Welcome to Medicare visit provides an
opportunity to deliver or arrange for recommended preventive services,
greater structure is needed to ensure that the visit maintains its
focus on prevention and is used to promote evidence-based services.
Preventive services that are not evidence-based may result in more
harm than good. For example, it seems self-evident that screening for
diseases and catching them early must be beneficial, but this is not
always the case. Due to the inaccuracies of some screening tests and
the rarity of diseases in the general population, the number of people
who receive false-positive results may exceed the number of people who
have true disease. In some cases the tests used to investigate false-
positive results are potentially dangerous. If screening 100,000 people
for brain tumors finds two people with the disease but causes 1,000
people to have unnecessary brain surgery or brain biopsies for false-
positive test results, the screening program is likely to result in
more harm than good. Exposing 1,000 people to the complications of
brain surgery for the sake of two people with brain tumors raises
daunting ethical questions.
Thus, although hundreds of screening tests are in existence, expert
panels that issue guidelines for screening recommend only a handful of
screening tests. They refrain not so much out of concerns for costs--
these guideline panels are composed largely of health professionals who
focus on health outcomes and not economics--but out of a public duty
and ethical imperative to ensure that screening is for the good of the
population. Promoting too many screening tests is not only an expensive
proposition, but one that is likely to harm Americans.
The large consumer market introduced by the millions of seniors who
will be entitled to the Welcome to Medicare visit could entice
commercial entities and certain specialists to promote services at the
expense of the Medicare program. Encouraging clinicians to use the
visit for comprehensive assessments is likely to identify issues that
prompt further investigations, some involving expensive testing, for
which there is little scientific evidence of benefit. To avert the
emergence of a Welcome to Medicare ``industry'' and the exploitation of
Medicare dollars for services of dubious value or potential harm, it is
important to narrow the scope of the benefit around well-defined
services that have been proven to enhance health outcomes.
Below we array the preventive services that the U.S. Preventive
Services Task Force recommends for seniors and those covered under
Medicare.
[GRAPHIC] [TIFF OMITTED] T6096.002
While the Partnership for Prevention welcomes the entry of services
into box A, we believe that the services listed in box B should also be
covered under Medicare. Some services in box B, such as counseling
about tobacco use, have greater public health urgency than others, such
as diphtheria-tetanus vaccination, but all are supported by strong
scientific evidence that recipients have improved health
outcomes.12 Such evidence is lacking for the services listed
in box C, for which Congress has authorized coverage under Medicare. We
believe the resources expended on these services could go farther in
improving the health of beneficiaries if applied to the services listed
in box B. Box D is empty but represents the hundreds of preventive
services for which there is little evidence of benefit.
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\12\ See U.S. Preventive Services Task Force at http://
www.ahrq.gov/clinic/uspstfix.htm
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In draft regulations issued in July 2004, CMS proposed to configure
the Welcome to Medicare visit as a comprehensive history and physical
examination. Physicians are expected to ask about past hospital stays,
operations, allergies, injuries and treatments; to determine current
medications and vitamin supplements; to catalogue the patient's family
history; to review the patient's travel and work history; and to
discuss social activities. They must review the patient's functional
ability and level of safety, such as hearing ability, activities of
daily living, fall risk, and home safety. For any abnormality
identified by these assessments, physicians are to provide physical
examination measures, education, counseling, and referrals.
We are concerned about this broad focus for three reasons. First,
it is unnecessary. The elements outlined in the regulations are
standard components of a ``complete physical,'' for which Medicare
beneficiaries were eligible even before the Medicare Modernization Act
was passed. At most practices in the United States, new patients
complete enrollment forms that ask about past hospitalizations, drug
allergies, and the other items listed above, and established patients
are often asked to update the information at regular intervals.
Second, a comprehensive battery of questions and examination
procedures is likely to set off a cascade of diagnostic workups of
dubious health benefit to patients. Many studies have documented that
the putative health benefit of such comprehensive assessments is often
offset by the harms that result from complications of diagnostic
procedures and by the considerable costs induced by follow-up testing
and referrals.
Third, the focus on prevention is lost amid the comprehensiveness.
The Welcome to Medicare visit is a unique opportunity for a
``prevention'' visit: to help patients focus on the health behaviors
that prevent disease and to identify the screening tests and
immunizations for which they are due. A visit preoccupied with
comprehensive questions loses this focus on prevention. In the Welcome
to Medicare visit, physicians should be asking about tobacco use, not
compiling a list of drugs to which patients are allergic. In this
visit, physicians should be asking when patients were last screened for
breast cancer or immunized against influenza, not learning when an
appendectomy was performed. In this visit, patients should be counseled
about the importance of physical activity and healthy diet, not
arranging referrals for headaches, acid reflux, and other abnormalities
that will come to light in a comprehensive history.
We encourage Congress and CMS to authorize coverage of preventive
services that are recommended by the U.S. Preventive Services Task
Force or other evidence-based bodies. Coverage policies under Medicare,
and the content of the Welcome to Medicare visit, should be designed to
promote a defined set of services that are known to improve health
outcomes. The aims of the Welcome to Medicare visit should focus
squarely on prevention, not on offering a ``comprehensive physical.''
4. Addressing quality, along with coverage, of preventive services
It is not enough to expand coverage for preventive services. Steps
must also be taken to ensure that they are delivered, and delivered
well. As of 2001, only 60% of beneficiaries over age 65 had received
pneumococcal vaccinations, and only 44% had received sigmoidoscopy
screening for colorectal cancer. Only 10% of older women were up-to-
date on cervical, breast, and colorectal cancer screening. If what
Congress has done to expand coverage is to realize its full benefits,
both beneficiaries and providers must be educated about the importance
of prevention and how to make use of the services that Medicare covers,
and systems must be in place to expedite the delivery of these
services.
CMS communications to beneficiaries currently focus on describing
coverage benefits and little more. To be motivated to take full
advantage of the preventive services covered under Medicare,
beneficiaries first need to know why prevention matters. They need
encouragement to live healthy lifestyles, with messages that remind
them about the importance of stopping smoking, staying active, eating
well, and controlling their weight. They need to understand why
preventive services from their clinician are important, which ones are
recommended, and the importance of being ``activated consumers'' who
know what to ask and expect of their doctors.
The Department of Health and Human Services has developed excellent
lay resources to answer these questions for consumers, but because they
have been developed in ``silos'' other than CMS (e.g., Centers for
Disease Control and Prevention, National Cancer Institute, Agency for
Healthcare Research and Quality) CMS staff know little about them, and
the CMS website and publications do not mention them to beneficiaries.
We believe that CMS communications should be integrated with the work
of other components of HHS to disseminate a coordinated health message
that encompasses health advice, recommended services to obtain, as well
as the details of coverage policy. Partnership for Prevention is
currently working with CMS to address these gaps in beneficiary
communications.
Communications to providers about the Welcome to Medicare visit
should extend beyond traditional correspondence from CMS, which focuses
on billing codes and the technical provisions of coverage. To reach and
persuade providers, information about the Welcome to Medicare visit
should be channeled through their organizations and specialty
societies, using their medical journals, newsletters, and annual
meetings to discuss the provisions of the new law. The new law provides
an opportunity to introduce a ``culture shift'' toward excellence in
the preventive care of seniors, but this will not happen without an
organized educational campaign that involves physician organizations.
The aims should be to help providers understand how to use the visit to
enhance the delivery of recommended preventive services and avoid over-
utilization of services that are not recommended. Partnership is
convening medical specialty societies to carry forward these goals.
The full benefits of the Welcome to Medicare visit cannot be
realized without incorporating system solutions within health plans and
practice to improve the quality with which preventive services are
delivered. Effective measures include standing orders, financial
incentives and first-dollar coverage for patients, and feedback reports
to providers.13 Impediments to delivery must be removed, or
else reminders will accomplish little in improving care. Obstacles that
patients and providers face in obtaining tests, counseling, and
referrals must be addressed. Creative strategies, such as using health
coaches, social support, and other non-physician outreach workers, can
facilitate the delivery of preventive care. Finally, the Welcome to
Medicare visit is a moment in time, but preventive care is a continuum.
Mechanisms must be in place to connect patients with resources in the
community and to reinforce the initial steps taken during the visit
with follow-up visits over time.
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\13\ Southern California Evidence-Based Practice Center.
Interventions that Increase Utilization of Medicare-Funded Preventive
Services for Persons Age 65 and Older. Baltimore: Health Care Financing
Administration, 1999.
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Reminder systems, both those designed for doctors and reminders
sent to patients, are an important reinforcement tool that has been
proven to enhance uptake of preventive services. Electronic medical
records facilitate such reminders and provide useful tools for tracking
adherence to a health maintenance plan, and greater attention is now
turning to electronic health systems that give patients greater control
over their health. For example, a website service for patients that we
wish to test in a demonstration project would be accessed by patients
before their Welcome to Medicare visit. After obtaining information
from the patient, the website would list the preventive services that
are recommended, offer hyperlinks to web pages that explain the meaning
of medical terms (e.g., what is a ``colonoscopy''?), and direct
patients to decision aids to help with complex choices. Patients could
print summaries to bring to their appointment, thereby giving doctors a
convenient reminder of which services are due. The website would later
send patients follow-up emails to remind them to obtain follow-up
screening tests or, for example, to contact them in the Fall about
obtaining influenza vaccination.
As in other health systems, the Medicare program is plagued by
racial and ethnic disparities in patterns of care. For example, in 2002
pneumococcal vaccine was received by 66% of white Medicare
beneficiaries above age 65 but by only 51% of African Americans in the
same age group.14 Research has shown that such disparities
can be reduced by adopting reminder systems and other ``systems
approaches'' that make delivery of services more uniform.
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\14\ Bonito et al. Disparities in immunizations among elderly
Medicare beneficiaries, 2000 to 2002. Am J Prev Med 2004;27:153-60.
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Finally, the visit provides an opportunity for collecting data that
can be used for measuring the effectiveness of services and the
performance of plans and providers and tracking utilization over time.
These data can be used for research, such as studying the outcomes of
different mixes of services for specific subpopulations, based on risk
factors, disease, age, gender, race, and ethnicity. The data can also
be used to monitor quality and to apply performance metrics and quality
initiatives, such as ``pay for performance'' programs.
Partnership for Prevention seeks to better educate beneficiaries
and clinicians about the Welcome to Medicare visit and preventive care,
and it urges Medicare to encourage--certainly not to impede--the
introduction of systems within practices and healthcare organizations
that improve the delivery and quality of preventive care.
Summary: The Medicare Prescription Drug and Modernization Act
updated a program that has served the medical needs of seniors for
nearly 40 years, but Medicare is in need of further modernization.
There have been tremendous advances in medical science, including
knowledge about how to prevent disease and keep people in good health.
It is time to make Medicare a program that is as much about helping
beneficiaries stay healthy as about treating them when they get sick
and need hospitalization.
Partnership for Prevention is a partnership of public and private
sector organizations committed to finding solutions to health issues in
a nonpartisan and rigorously scientific manner. Our membership includes
national employers, nonprofit policy and research organizations,
professional and trade associations, voluntary health organizations,
health plans, and state health departments. See www.prevent.org for
more details.
Appendix 1. Cost-benefit of analysis of selected screening tests
Partnership for Prevention conducted an analysis, using methods
employed by the Congressional Budget Office, that assume fee-for-
service payment and 2002 dollars:
Over the first 10 years of coverage, vision screening would result in
net savings to Medicare of $148 million. The average net cost
per year over the first 10 years would be $18 million.
Vision screening would prevent 21,000 hip fractures and 4400
forearm fractures.
Cholesterol screening would result in net savings of $436 million
over 7-10 years of coverage. The average net cost per year over
the first 10 years of coverage would be $82 million.
Cholesterol screening would prevent 62,362 heart attacks and
44,912 strokes
Tobacco cessation counseling would begin producing a small net
savings to Medicare in the 9th and 10th years of coverage as
the savings from long-term quitters in prior years accumulate.
The average net cost per year over the first years of coverage
would be $19.5 million.
Tobacco cessation counseling would save 95,000 life years.
The average cost per year over 10 years for the Welcome to Medicare
visit would be $137 million.
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Appendix 3. Letter from Seven Living Former Health Secretaries
June 25, 2003
The Honorable Mike DeWine
Co-Chair
Congressional Prevention Coalition
United States Senate
Washington, DC 20510
Dear Chairman DeWine, as former Secretaries of Health and Human
Services (or Health, Education and Welfare), we write to encourage you
to include disease prevention in discussions about Medicare
modernization.
Congress created Medicare in 1965 based on the knowledge of health
and medicine at that time. Thus, Medicare came into being as a national
insurance system to cover hospitalization and visits to clinicians'
office for diagnoses and treatment.
In the nearly four decades since Medicare's creation, considerable
research and practice have yielded proven ways to not just diagnose and
treat disease, but to prevent it and promote longer, healthier life.
Today we know that postponing disability, maintaining social function,
and sustaining independence are achievable for seniors through
evidence-based health promotion and disease prevention services. It is
nearly always preferable, both for the individual and for society, to
prevent disease instead of waiting to treat it.
Congress has added selected preventive services to Medicare but has
not included other services that are proven effective, nor has it
encouraged Medicare to take a comprehensive approach to disease
prevention and health promotion for America's seniors.
A recent Harris Poll found that nine in ten American adults want
Medicare to be modernized and to put as much emphasis on disease
prevention as it does on disease treatment.
The roadmap for this Medicare modernization is laid out in a new
Partnership for Prevention (Partnership) report, A Better Medicare for
Healthier Seniors: Recommendations to Modernize Medicare's Prevention
Policies, which you already have received. These recommendations would
move the U.S. toward realization of our nation's two overarching
national health goals: increasing life expectancy and improving quality
of life, and reducing disparities in health among different segments of
the population.
Respectfully yours,
Joseph A. Calafano, Jr., Richard S. Schweiker,
Margaret M. Heckler, David Mathews, MD, Louis W. Sullivan, MD,
Donna E. Shalala, PhD, and Otis R. Bowen, MD
Mr. Bilirakis. Thank you, Dr. Woolf.
Isn't it a revelation, really, that we are at least talking
about this subject? Only a few years ago we were just concerned
about caring for the sick and whatnot, but now we are going
well past that, trying to prevent them from getting sick. And I
think that in itself is terrific.
Dr. Woolf, if my son who is an internist were sitting there
giving your testimony, he would probably say basically the same
thing that you have. But that, again, is the ideal and we would
hope that we would strive toward that, but obviously we can't
do everything that we might think is the right thing to do.
I guess maybe one question to ask is, will seniors utilize
these benefits, what they are now and what they may turn out to
be? I think Mr. Brown's bill--I haven't studied it, but
basically we are thinking preventive health care. And that is
good, but we also have to be sure that delivery of these
benefits will be available and will be done in the right
manner. We have to hope that of course people will take
advantage of it.
Dr. Clancy.
Ms. Clancy. Sure. I think that is about the most important
question you could ask. Coverage is the first step. You can't
get there without coverage. But as the GAO reports and many
other studies have noted, many of the covered services are
underused. This has been a big focus for CMS, trying to figure
out how to encourage more of that. And a lot of it does come
down to the systems and the settings where people get care.
For example, when I am--a scenario that happens a lot when
I see patients, I am sorry to say, is I am seeing a woman and
we both agree that it is time for a mammogram, and then we move
on to other things, and then she leaves and I forget to give
her the piece of paper that she needs to actually get the
mammogram, because where I see patients we don't have an idiot-
proof system to make sure that it automatically happens.
Eventually she gets the service, but it is a distraction, and
some people don't come back for the piece of paper and so
forth.
So it is that kind of systems approach that is necessary
not only in getting the services but also in following up and
making sure that people who have abnormal results are correctly
identified and referred on when needed, and so forth.
I think a lot of physicians and patients are increasingly
aware of this. We clearly have a lot more to do, and it is a
big focus of the Agency's work.
Mr. Bilirakis. Ms. Heinrich.
Ms. Heinrich. One question I have is about participation of
physicians. When you read through the draft regulations, you
see that this physical--comprehensive physical exam and battery
of preventive services will be reimbursed at the same rate as a
standard new patient evaluation and management fee. And a
comprehensive exam like this and the battery of preventive
services would take a lot of time. So I think that is a
question that has to be asked.
The second, of course, is will the beneficiaries themselves
say this is something that I need, that I want, and seek it.
And as we have said in our previous studies, the utilization
rate is highly variable, and it does depend on race. Minorities
utilize these services considerably less than white
populations.
Mr. Bilirakis. Why is that?
Ms. Heinrich. I don't think we know the reason
specifically. It could be an issue of access, it could be a
matter of really knowing and understanding that the benefit
exists. And some people, quite honestly, are concerned about
even accessing the flu vaccines because they are afraid that
they are going to get sick from the flu vaccine. So they are
afraid that the intervention will make them sick.
Mr. Bilirakis. Dr. Woolf, anything further?
Mr. Woolf. I think you have asked an excellent question. I
think the Welcome to Medicare visit provides a very good
leveraging opportunity to try to address this problem by making
patients aware of the need for preventive services. The visit
could help induce demand.
Many times, clinicians don't deliver preventive services
for innocent reasons. Sometimes they forget that a patient is
due for them, and there is ample experience in published
research suggesting that that kind of demand can be helpful.
Having said that, the agency, CMS, has an uphill battle in
organizing an educational campaign to make patients aware of
preventive services and the importance of prevention, because
this is something that hasn't been done in the past. We are
working with CMS--and Dr. McClellan is very enthusiastically
supporting this--to try to change the way communications go out
to beneficiaries, to make them more aware of the importance of
prevention as a basic concept and then, more specifically, to
make them aware of preventive services that are recommended.
Materials and patient education materials that they have
not yet developed have been developed by AHRQ and other Federal
agencies that they are less familiar with because of the silos
in the Federal Government. And we are working to try to link
the various agencies together to try to bring out the best-
quality information for beneficiaries.
Providers also need education about what this new visit
provision means. Without that type of education, it just
becomes another billing code and not an opportunity, as we feel
it could be, to change the culture of how preventive care is
offered to seniors; and with proper education, that can occur.
All that said, the points that have just been made are
fundamental. Paying for preventive services is just the
starting point, and without the infrastructure for delivering
it and following up on the abnormalities that are identified,
the great good that could come from this will not be realized.
Mr. Bilirakis. Do you all see a good level of cooperation--
maybe it is not the right word, but interest, dedication and
cooperation on the part of CMS to take into consideration all
the advice that you have given; the work that you are
volunteering, your group is volunteering, to get this done
right; and the education portion, of course, being very
significant?
Ms. Clancy. Without question, since my glass is half full,
I thought I would offer a slightly more positive view of this.
A lot of studies have found that doctors and patients are
very enthusiastic about prevention. They forget they don't have
good systems in place and so forth. But the one nice thing
about this Welcome to Medicare visit is, most studies have
found that doctors tend to do a much better job in the context
of something called a checkup, whether it is a comprehensive
physical, whether it is called a health maintenance visit or so
forth. So I think I would reiterate Dr. Woolf's point that this
gets people off on the right foot.
The other area we are working on closely with CMS is in
trying to deploy some of the power of information technology to
give people reminders. Ultimately, I think this is going to be
powerful for patients, as well. But a lot of times, doctors
don't do this because they forget or don't realize the time
sequence has come when it is time for someone's next service.
And that is fairly easy to correct and reminders make a huge
difference.
So I think there are some exciting developments in place
Mr. Bilirakis. Ms. Heinrich, you would anticipate that the
reimbursement to physicians who would conduct this Welcome to
Medicare physical would be what, insufficient? Any feeling on
that?
Ms. Heinrich. The observation I make is that you have busy
physicians, and the fact that they would not be reimbursed at a
rate higher than a regular evaluation, management, first-time
visit is not a large incentive. Now there are other incentives
at play.
Mr. Bilirakis. And that is what you see coming down the
pike that they probably would not be reimbursed higher?
Ms. Heinrich. That is the way the regulation reads now.
Mr. Bilirakis. Mr. Brown to inquire.
Mr. Brown. Thank you, Mr. Chairman.
Dr. Woolf, evidence shows that people with coverage for
preventive service logically use those services more than those
who don't have coverage. There has been a lot of attention
recently to consumer-directed health plans, things such as
medical health savings accounts and the like, which have a high
deductible and are supposed to encourage consumers/patients to
make wiser choices.
Comment, if you will, on what these kinds of plans, these
consumer-directed health plans would do to people's utilization
of preventive services.
Mr. Woolf. It is a very interesting question given what
appears to be an increasing trend among employers to pursue
that kind of product. Frankly, the jury is still out on what
impact they would have on preventive services. Most of the
experts that are working on this field feel that it is perhaps
2, 3 years before we will have enough high-quality data to know
what impact they might have.
The concern is, we have a large body of research going back
20 years to suggest that patients who face deductibles or
copayments are less likely to utilize preventive services. And
a phenomenon that we used to call ``reverse targeting'' occurs
where the patients most in need of preventive care, who have
the greatest risk factors for disease, are often, for
socioeconomic reasons, more adversely impacted by the added
costs. To the extent that a consumer-driven health plans mimic
that phenomenon, they could be at a disincentive to receiving
preventive care and adversely affect outcomes.
But there is a counterargument that giving people choices
would enable them to concentrate their resources on prevention
and thereby prevent disease. A concern that many have is
whether patients would have the background and information base
to make good choices about how to select preventive services
that are a proven value and not be encouraged to invest the
resources they have in their accounts on glitzy technologies
that promise a lot, but haven't been proven to better their
health.
Mr. Brown. Have you seen--understanding the body of
evidence has not accumulated to the degree that you would need
to analyze this as thoroughly as you would want, do you see--in
these consumer-directed health plans, have you seen special
attention paid by the health plan itself to encourage people--
to spend from their pot, if you will, their discretionary money
to really take advantage of preventive care? Is that something
these health plans have pushed effectively or pushed at all?
Mr. Woolf. I am pleased to see several examples of some of
the major vendors of these products offering first-dollar
coverage for preventive services and providing a safe harbor,
if you will, for preventive services under their plans. I don't
know whether that is generalizable and whether all plans in
that category are as careful to protect preventive services in
that way.
Mr. Brown. Ms. Heinrich and Dr. Woolf, as the chairman was
talking earlier, I introduced legislation to give CMS authority
to add preventive benefits to Medicare. We already--Medicare
has broad discretion to add new and promising treatments to
Medicare coverage, but doesn't have the discretion to go
further and offer preventive benefits.
Ms. Heinrich, would you support giving the Secretary more
flexibility to add preventive services?
And, Dr. Woolf, I know your organization has spoken on
that.
Would you both just address that issue?
Ms. Heinrich. We really haven't focused on where the
decision for covering preventive services is made, but we have
said that it really needs to be science-based. And, certainly,
depending on the U.S. Preventive Services Task Force would be a
good start.
Mr. Brown. Dr. Woolf?
Mr. Woolf. We issued a report last year that outlines
detailed recommendations on this issue and looked at a number
of different options, and we are trying to address this problem
and ultimately concluded that authority for covering preventive
services should be transferred from Congress to CMS, just as it
is for diagnostic and treatment services.
Mr. Brown. Thank you, Mr. Chairman.
Mr. Bilirakis. I would like to, without objection, offer a
document into the record by the Alzheimer's Foundation of
America basically making the case that Alzheimer's should be
included as part of the Welcome to Medicare preventive health
program. And I have reviewed this with Mr. Brown. Without
objection, it will be made part of the record.
[The information referred to follows:]
Prepared Statement of Eric J. Hall, CEO, Alzheimer's Foundation of
America
Chairman Bilirakis, Ranking Member Brown, and distinguished
Subcommittee members: On behalf of the Alzheimer's Foundation of
America (AFA), thank you for holding this important hearing on
preventive benefits enacted as part of the Medicare Modernization Act
of 2003 (MMA).
AFA believes the preventive benefits enacted under the MMA
represent an important step forward in improving the health of our
nation's Medicare beneficiaries. In particular, Mr. Chairman, we
support and applaud your efforts to establish an initial preventive
screening examination under Medicare.
AFA'S MISSION
An estimated five million Americans currently suffer from
Alzheimer's disease, and the number is expected to rise to 16 million
by mid-century. It is therefore critical that we all stand together for
care as the incidence of this devastating disease continues to rise.
AFA was founded as a nonprofit 501(c)(3) organization to fill a gap
that existed on the national front for advocacy of ``care . . . in
addition to cure'' for individuals affected by Alzheimer's disease and
related dementias. AFA and its members provide direct services to
millions of Americans living with Alzheimer's disease and related
disorders nationwide, as well as their caregivers and families. Our
goals include improving quality of life for all those affected and
raising standards for quality of care.
AFA operates a national resource and referral network with a toll-
free hotline, develops and replicates cutting-edge programs, hosts
educational conferences and training for caregivers and professionals,
provides grants to member organizations for hands-on support services
in their local areas, and advocates for funding for social services. It
annually sponsors two national initiatives, National Memory Screening
Day and National Commemorative Candle Lighting. AFA is also working to
promote healthy aging through prevention and wellness education and to
expand screening for memory impairment as a tool to facilitate early
diagnosis and treatment.
THE IMPORTANCE OF MEMORY SCREENING
Early recognition of Alzheimer's disease and related dementias is
essential to maximize the therapeutic effects of available and evolving
treatments, and screening for memory impairment is the only way to
systematically find treatable cases. Diagnosis in the early stages of
the disease is vital, providing multiple benefits to individuals with
the disease, families and society. Screening can also be beneficial for
individuals who do not present a diagnosis of Alzheimer's disease by
allaying fears and providing an opportunity for prevention and wellness
education.
Memory screening is a cost-effective, safe and simple intervention
that can direct individuals to appropriate care, improve their quality
of life, and provide cognitive wellness information. With no ``silver
bullet'' for dementia in the immediate future, it is essential to fully
use all preventive measures and early interventions. AFA supports a
comprehensive strategy that involves both research for a cure, as well
as a national system of care that includes cognitive wellness, early
detection and intervention, and disability compression.
To advance that objective, AFA launched National Memory Screening
Day in 2003 as a collaborative effort by organizations and health care
professionals across the country. AFA initiated this effort in direct
response to breakthroughs in Alzheimer's research that show the
benefits of early medical treatment for individuals with Alzheimer's
disease, as well as the benefits of counseling and other support
services for their caregivers.
AFA's annual National Memory Screening Day underscores the
importance of early diagnosis, so that individuals can obtain proper
medical treatment, social services and other resources related to their
condition. With no cure currently available for Alzheimer's disease, it
is essential to provide individuals with these types of interventions
that can improve their quality of life while suffering with the
disease.
During National Memory Screening Day, healthcare professionals
administer free memory screenings at hundreds of sites throughout the
United States. A memory screening is used as an indicator of whether a
person might benefit from more extensive testing to determine whether a
memory and/or cognitive impairment may exist. While a memory screening
is helpful in identifying people who can benefit from medical
attention, it is not used to diagnose any illness and in no way
replaces examination by a qualified physician.
Our goal is for individuals to follow up with the next steps--
further medical testing and consultation with a physician, if the
testing raises concerns. The latest research shows that several
medications can slow the symptoms of Alzheimer's disease and that
individuals begin to benefit most when they are taken in the early
stages of memory disorder. This intervention may extend the time that
individuals can be cared for at home, thereby dramatically reducing the
costs of institutional care.
With early diagnosis, individuals and their families can also take
advantage of support services, such as those offered by AFA member
organizations, which can lighten the burden of the disease. According
to several research studies, such care and support can reduce caregiver
depression and other health problems, and delay institutionalization of
their loved one--again reducing the economic burden of this disease on
society.
In addition, with early diagnosis, individuals can participate in
their care by letting family members and caregivers know their wishes.
Thus, memory screenings are an important tool to empower people with
knowledge and support. Just as importantly, the screenings should help
allay fears of those who do not have a problem.
AFA holds National Memory Screening Day on the third Tuesday of
November in recognition of National Alzheimer's Disease Month.
Broadcast personality Leeza Gibbons is the national advocate for this
event. Ms. Gibbons founded The Leeza Gibbons Memory Foundation in
response to her own family's trial with Alzheimer's. She lost her
grandmother to the disease, and her mother now battles with the final
stages of Alzheimer's.
This year, National Memory Screening Day will be held on November
16, 2004. Individuals concerned about memory problems will be able to
take advantage of free, confidential screenings at hundreds of sites
across the country with the goal of early diagnosis of Alzheimer's
disease or related dementias. Early diagnosis is critical, because as
Ms. Gibbons has noted, ``This is not a disease that will wait for you
to be ready.''
THE NEED FOR FEDERAL LEADERSHIP
As promising research continues in the search for a cure,
additional resources are also needed in support of efforts to delay the
progression of Alzheimer's disease and related dementias. The federal
government can play a critical role in that regard by providing
resources for a public health campaign designed to increase awareness
of the importance of memory screening and to promote screening
initiatives.
Federal support is essential to expand the scope of ongoing efforts
in the private sector. Working in partnership with AFA and other
participating organizations, the federal government can leverage its
resources cost-effectively to help overcome fear and misunderstanding
about Alzheimer's disease and related dementias, to promote public
awareness of the importance of memory screening, to expand options for
screening nationwide, and to direct Americans to the support services
and care available in their local communities.
To that end, AFA is urging the Centers for Medicare and Medicaid
Services (CMS) to provide screening for memory impairment as part of
the Medicare initial preventive screening examination. CMS included a
specific request for public comments on the scope of the exam in its
proposed rules; therefore, AFA is recommending that CMS include
screening for memory impairment within the proposed definition of a
``review of the individual's functional ability, and level of safety,
based on the use of an appropriate screening instrument.'' The proposed
rules also state that review of an individual's functional ability and
level of safety must address activities of daily living and home
safety.
In that context, unrecognized dementia can increase the likelihood
of avoidable complications such as delirium, adverse drug reactions,
noncompliance, etc. These complications reduce the autonomy of affected
individuals, thereby impeding their ability to perform activities of
daily living and compromising their safety. In addition, about one-
third of elders live by themselves, and these individuals are at
greater risks for accidents, injuries, exploitation, and other adverse
outcomes. Early identification allows safeguards and home assistance to
assure continued maximization of home placement.
For the affected individual, identification of early stage dementia
allows early aggressive use of available treatments. Early
identification allows optimal therapy with available and emerging
medications. Most FDA-approved medications can help slow the
progression of symptoms of Alzheimer's disease and related dementias
when presented in early stages of dementia.
Once dementia is identified, health care management can be adjusted
to incorporate treatment strategies that accommodate a person with
cognitive impairment. Issues such as patient education, self-
medication, compliance, and hospital care can be adjusted to meet the
needs of a mildly demented person who is at risk for common
complications such as delirium and depression. Home-based support
systems can be adjusted to maximize home placement for these
individuals. Safeguards can be taken to prevent avoidable complications
such as delirium during hospitalization.
Further, the early identification of dementia supports individual
patient rights and self-determination. Mildly impaired individuals are
capable of charting the future course of their care and making
substantial decisions on issues like end-of-life care, resuscitation,
disposition of wealth, etc. Advanced directives can be initiated that
incorporate the wishes of individuals with dementia, thereby reducing
the burden on the family of surrogate decision-making. Individuals with
the disease can also take advantage of social services and other
support that can improve quality of life. These include counseling,
verbal support groups and cognitive stimulation therapies. These
strategies may prolong activities of daily living, and promote a sense
of dignity.
Separately, family caregivers also benefit from early
identification at several levels. As noted above, early identification
reduces the family burden with regard to decision-making, because
families can follow the instructions of their loved ones. This process
allows family caregivers to benefit early on from support groups,
education and other interventions that address their unique and
pressing needs. Such knowledge and support can empower them to be
better caregivers and can reduce their incidence of depression and
other mental and physical health problems. Intervention can also help
on an economic front: lightening the burden on primary caregivers, who
are also in the workforce, could help reduce employee absenteeism and
lost productivity.
Finally, screening can be beneficial for those individuals who do
not present a diagnosis of Alzheimer's disease. These negative results
can allay fears and provide reassurance. Just as importantly,
physicians can take this opportunity to present individuals with
prevention and wellness education--a strategy that promotes successful
aging.
We would note that use of available screening instruments to
identify memory impairment during the Medicare initial preventive
physical examination is consistent with current clinical practice
guidelines. Individuals with mild cognitive impairment are at higher
risk for subsequent development of Alzheimer's disease and related
dementias. General cognitive screening instruments are available and
are useful in detecting dementia in patient populations with a higher
incidence of cognitive impairment (e.g., due to age or memory
dysfunction). Attached for Subcommittee Members' reference is a summary
of the relevant American Academy of Neurology practice guidelines for
physicians.
Inclusion of screening for memory impairment is also consistent
with the recent CMS National Coverage Decision expanding Medicare
coverage of Positron Emission Tomography (PET) for beneficiaries who
meet certain diagnostic criteria for Alzheimer's disease and fronto-
temporal dementia.
AFA believes PET and other neuroimaging devices will be a valuable
tool in predicting disease and in steering those with a diagnosis of
Alzheimer's or related illnesses to the appropriate clinical and social
service resources. Expanded reimbursement for PET studies will drive
early intervention for the increasing--and alarming--number of
Americans with Alzheimer's disease. Utilization of this technology will
become even more critical in the future, as the number of Americans
with dementia is projected to triple by mid-century.
CONCLUSION
Expanded screening to facilitate the early identification of memory
impairment will produce tangible benefits to society by protecting
individuals, improving quality of life, and reducing the costs of
health care. Enhancing compliance and protecting individuals with
dementia also produces tangible financial benefits to the health care
system. Intervention can enable individuals to remain independent
longer and can reduce the costs of insurance, absenteeism and lost
productivity at work for primary caregivers--currently estimated at $60
billion annually.
AFA commends the Subcommittee's leadership in striving to improve
preventive care for our nation's Medicare beneficiaries. We would
likewise welcome the opportunity to work collaboratively to improve the
quality of life for Alzheimer's patients, their families and
caregivers. Please feel free to contact me at 866-232-8484 or Todd
Tuten at 202-457-5215 if you have questions or would like additional
information.
Thank you for the opportunity to share our views.
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Mr. Bilirakis. Mr. Green, you weren't here a moment ago,
but you are now, so the Chair will recognize you to inquire.
Mr. Green. Thank you, Mr. Chairman. I appreciate the chance
and I appreciate your having the committee hearing.
Dr. Clancy, it is my understanding that the U.S. Preventive
Services Task Force is currently working on a new
recommendation for the abdominal aortic aneurysm screens.
Are you aware of a timeframe for delivering that
recommendation?
Ms. Clancy. November of this year. And we will make sure as
soon as it is released, you will get a copy and your staff.
Mr. Green. In your testimony, it details two main questions
that the task force recommendation process seeks to answer:
first, that the task force seeks to determine if the preventive
services screening indicates that AAA is associated with
reduced risk of morbidity or mortality. The statistics we have
on AAA indicate it is a condition that has no symptoms or
warning signs, and that less than 15 percent with a ruptured
abdominal aortic aneurysm actually survive. It seems to me that
preventive services isn't just associated with a reduced risk
of morbidity or mortality, that about the only way to reduce
that is if you have a preventive test.
And second, in your testimony, the task force determines
whether the early identification of the condition leads to an
improved outcome compared to the result if these are not
detected and treated early. And I think most vascular surgeons
would agree that early detection and treatment of AAA would
mean catching it before the aneurysm ruptures. And again the
relevant statistics that we have are that 85 percent of
individuals with a ruptured AAA die. And when caught before the
rupture, AAA, it is curable up to 95 percent of the
individuals. And, you know, to me, it seems a slam dunk that
the task force would understand the need for a screening
benefit.
Ms. Clancy. Let me say I agree with your points. When the
official recommendation and specific language is released, you
will get a copy, and just also add that I have an uncle who was
one of the lucky ones who ruptured his aortic aneurysm a couple
of years ago and lives close enough to a major medical center
that he made it through, but it was a pretty humbling reminder
of what a terrible disease that is.
Mr. Green. I have a constituent near the Texas Medical
Center who made it there, but it took her 4 weeks of intensive
care in the hospital to be able to deal with it, and the cost
was outrageous. And they were Medicare beneficiaries, both she
and her husband.
I am one of the cochairs of the Congressional Vision
Caucus. I am real interested in preventive benefits regarding
common vision problems, and I know Medicare typically doesn't
deal with it. A preventive benefit to screen for glaucoma is
extremely important since approximately half of the individuals
aren't aware that they have the disease. And since January
2002, at-risk Medicare beneficiaries have been able to receive
these screenings.
Can you give us any information on the statistics or any
analysis on the effectiveness of that benefit? If you don't
have them today----
Ms. Clancy. We can look into it and follow up on that.
Mr. Green. I appreciate it, one for the caucus but also for
our health subcommittee.
Dr. Woolf, cost-sharing deductibles in Medicare can act as
a barrier to accessing preventive services. As I understand it,
the initial Welcome to Medicare exam is still subject to the
deductible, which will soon be increasing by 10 percent and the
20 percent coinsurance.
On top of that, seniors will have the burden, as we
discussed in our opening statement, of paying premiums which
are increasing by 17 percent. Given that half of all seniors
have incomes under 200 percent of poverty, don't you think, for
some beneficiaries, such out-of-pocket expense would deter them
from seeking this preventive benefit? And do you support
eliminating the cost sharing and the deductible for preventive
services?
Mr. Woolf. The evidence indicates Congressman, that the
presence of copayments and deductibles does act as a
disincentive for the uptake of preventive services. So the
science would tell us that that is going to pose a problem,
especially for disadvantaged populations.
I can't resist, though, using your earlier questions as a
way of responding to Mr. Brown's earlier question, and that is
your analysis of the effectiveness of screening for abdominal
aortic aneurysms and for glaucoma. I think you are identifying
some important analytic arguments. But again, our view as an
organization is that the scientific details of how to evaluate
the effectiveness of these screening modalities center on
issues that experts around the country normally deal with
through the process that CMS currently uses for diagnostic and
treatment services.
The issue of whether to screen for abdominal aortic
aneurysms, for example, turns very much on the likelihood of
progression of small aneurysms into large ones and on the
performance characteristics of the available screening
modalities. Deliberating on these fine technical details in
this environment at the same time that you must contend with
national security, economy, tax policy and so forth strikes me
as inefficient, especially when, in Baltimore, regularly
experts convened by CMS deal with much more complex technical
issues as they determine whether to cover diagnostic and
treatment services.
While I agree with the direction of your intention to cover
these preventive services and think many of the scientific
arguments have merit, we would encourage the notion of
transferring the authority for this type of scientific analysis
to CMS.
Mr. Green. And if I could follow up, I agree Congress and
our country have a lot of concerns, but having had some
constituents and family members who--I don't know if we are
going to worry about our tax policy or terrorism--but depending
on whether my great uncle bleeds from an aneurysm or not, that
is our job and our subcommittee here, and we will deal with
that. And maybe if we had a different tax policy we would have
more resources to deal with it.
Mr. Bilirakis. Dr. Clancy's response to you regarding
triple-A, now you are in the process of preparing a report in
that regard, so you can't tell us where that might be in terms
of that particular area?
Ms. Clancy. Not today, but again, it is just a few weeks
off, and because it gets down to debating and being very
specific about the details, what size of aneurysm would make a
difference and so forth in how often people should get a
screening.
Mr. Green. And, Mr. Chairman, having talked with vascular
surgeons, there are people, when it is discovered, it is not a
threat immediately, but by knowing it, they can continue to
have it monitored instead of waiting until it bursts and you
bleed out.
Mr. Bilirakis. Well, there aren't any other members.
Anything further, Mr. Brown?
That being the case, again our gratitude. Your written
statements, of course, your testimony here today will be
nothing but helpful. But again, keep in mind, we are always
open to suggestions.
Dr. Woolf, we sort of have to keep our feet on the ground.
We have to be concerned, of course, about accountability and
the dollars and things of that nature. So, you know, we can't
do everything, as we much as many of us would like to. But any
suggestions you may have in addition to what you have made here
today that might be helpful to us, fine.
And, you know, the CMS argument, they are making these
decisions, that is an interesting point. I don't know, I guess
the Secretary decided that obesity should be a covered area,
and he has decided that it is a disease, which means apparently
he has some control or power in that regard. How far that might
go or should go is another question.
Thank you very much. The hearing is adjourned.
[Whereupon, at 3:25 p.m., the subcommittee was adjourned.]
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