Medicare: Beneficiary Use of Clinical Preventive Services	 
(10-APR-02, GAO-02-422).					 
                                                                 
Preventive medicine, including immunizations for many diseases	 
and screening for some types of cancer, holds the promise of	 
extending and improving the quality of life for millions of	 
Americans. Medicare now covers three preventive services for	 
immunizations and three for screenings. To ensure that preventive
services are available to beneficiaries who need them, the	 
Centers for Medicare and Medicaid Services (CMS) sponsors	 
"interventions" to increase the use of preventive services. GAO  
found that the use of preventive services varies widely by	 
service, by state, by ethnic group, by income, and by education. 
The greatest differences among ethnic groups were for		 
immunization rates. Cancer screening rates tended to differ	 
according to income and education level. CMS pays for		 
interventions that promote breast cancer screenings and pneumonia
and flu shots. Most of the techniques being sued, such as	 
reminder systems that medical offices can use to alert doctors	 
and patients to needed cancer screenings, have been effective.	 
CMS is evaluating what its current efforts have accomplished and 
expects the results later this year.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-422 					        
    ACCNO:   A03022						        
  TITLE:     Medicare: Beneficiary Use of Clinical Preventive Services
     DATE:   04/10/2002 
  SUBJECT:   Aid for the elderly				 
	     Health care programs				 
	     Health care services				 
	     Health insurance					 
	     Aid for the disabled				 
	     Immunization services				 
	     Disease detection or diagnosis			 
	     Medicare Program					 
	     Medicare Current Beneficiary Survey		 
	     CMS Peer Review Organization Program		 


******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-02-422
     
Report to the Chairman, Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce, House of Representatives

United States General Accounting Office GAO

April 2002 MEDICARE Beneficiary Use of Clinical Preventive Services

GAO- 02- 422

Page i GAO- 02- 422 Medicare Clinical Preventive Services Letter 1 Results
in Brief 2 Background 3 Use of Preventive Services Is Growing but Varies
Widely 6 Efforts Under Way to Increase Use of Some Preventive Services 11
Agency Comments and Our Evaluation 16 Appendix I Comments from the Centers
for Medicare and

Medicaid Services 18

Appendix II GAO Contact and Staff Acknowledgments 26

Tables

Table 1: Preventive Services Covered by the Medicare Program as of January
2002 4 Table 2: Percentage of Medicare Beneficiaries Age 65 and Older

Using Preventive Services in 1995, 1997, and 1999 7 Table 3: Variation in
State Usage Rates for Preventive Services by Medicare Beneficiaries 65 and
Older, 1999 8 Table 4: Percentages of Medicare Beneficiaries 65 and Older
Using Preventive Services by Income and Education, 1999 9 Abbreviations

BRFSS Behavior Risk Factor Surveillance Survey CDC Centers for Disease
Control and Prevention CMS Centers for Medicare and Medicaid Services NCI
National Cancer Institute PRO Peer Review Organization Contents

Page 1 GAO- 02- 422 Medicare Clinical Preventive Services

April 12, 2002 The Honorable Jim Greenwood Chairman Subcommittee on
Oversight and Investigations Committee on Energy and Commerce House of
Representatives

Dear Mr. Chairman: Preventive health care services can extend lives and
promote well- being among our nation?s seniors. For example, immunizations
against the flu can prevent thousands of hospitalizations and deaths each
year among those age 65 and older. Screening for some types of cancer may
extend and improve the quality of life through early detection and
treatment. Such preventive services are a growing part of Medicare, the
federal government?s health insurance program for some 34 million Americans
age 65 and older, as well as 6 million younger disabled persons. Medicare,

administered by the Centers for Medicare and Medicaid Services (CMS), now
covers 10 preventive services- 3 types of immunizations and 7 types of
screening. 1 Although Medicare provides coverage for these preventive
services, some

beneficiaries do not receive them. These beneficiaries may, for example,
face barriers in obtaining the services or simply choose not to use them. To
help ensure that preventive services are being delivered to those
beneficiaries who need them, CMS sponsors efforts- called ?interventions?-
aimed at increasing preventive service usage rates.

You asked us to examine two questions regarding preventive services for
older Americans:

 To what extent are Medicare beneficiaries using covered preventive
services?  What action has CMS taken to increase use of preventive services
among

the Medicare population? 1 A recent bill proposes adding visual acuity,
hearing impairment, cholesterol, and hypertension screenings as well as
expanding the eligibility of individuals for bone density screenings. See H.
R. 2058, 107th Cong. sect. 203 (2001).

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 02- 422 Medicare Clinical Preventive Services

To answer these questions, we estimated Medicare beneficiaries? use of
services from a nationwide, state- based survey conducted by the Centers for
Disease Control and Prevention (CDC). 2 We obtained information about
effective techniques to increase use of preventive services from published
reports and discussions with program officials at the federal and

state levels 3 who are responsible for implementing projects intended to
increase the use of preventive services. For both questions, we conducted
interviews with officials from the Department of Health and Human Services,
CDC, the National Institutes of Health, CMS, and the Agency for Health Care
Research and Quality. We also spoke with representatives from the
Partnership for Prevention, a nonprofit association involved in the research
and promotion of preventive services. We conducted our work from August
through February 2002 in accordance with generally accepted government
auditing standards.

While the use of preventive services offered under Medicare has increased
over time, use of these services varies widely by service and state. It also
varies by ethnic group, income, and education. From 1995 through 1999,

the proportion of all Medicare beneficiaries immunized against flu and
pneumonia, as well as the proportion of women who received screens for
cervical and breast cancer, increased steadily. Nevertheless, in 1999, usage
rates varied considerably among individual services. For example, the 75
percent usage rate for breast cancer screening was considerably higher than
the 55 percent rate for pneumonia immunizations. However, even for widely
used preventive services such as breast cancer screening, state- bystate
usage rates ranged from 66 to 86 percent. Among ethnic groups, differences
were greatest for immunizations. About 70 percent of whites reported
receiving flu shots within the past year compared to 49 percent of African
Americans. The disparities between income and educational

groups were greatest for cancer screening. While most Medicare 2 The
Behavioral Risk Factor Surveillance System (BRFSS), the survey we used, is
an ongoing, state- based, random- digit- dialed telephone survey of U. S.
civilian, noninstitutionalized adults 18 years or older. We used data from
1995, 1997, and 1999. Data from this survey are self- reported.

3 These included peer review organizations (PROs) under CMS contract to
improve quality of Medicare services. We talked to the two lead PROs
responsible for supporting PRO efforts to increase flu and pneumococcal
immunizations and breast cancer screening services, as well as to the PRO
leading efforts to reduce disparities in the use of preventive services
among disadvantaged populations. We also talked to three PROs responsible
for increasing use of services in states with the lowest, median, and
highest utilization rates. These six PROs were geographically dispersed
across the nation. Results in Brief

Page 3 GAO- 02- 422 Medicare Clinical Preventive Services

beneficiaries received at least one covered preventive service, a much
smaller number received additional preventive services covered under
Medicare. For example, 1999 data showed that while 91 percent of female
Medicare beneficiaries received at least one preventive service, only 10
percent of these beneficiaries were screened for cervical, breast, and

colon cancer, as well as immunized against flu and pneumonia. CMS pays for
interventions aimed at increasing the use of three services- breast cancer
screening and immunizations against flu and pneumonia- in each state. CMS
also pays for interventions that focus on increasing use of

services by ethnic groups and income groups with low usage rates. The
majority of techniques being used in these interventions, such as developing
reminder systems medical offices can use to alert providers

and patients when breast cancer screenings are needed, have been found
effective in the past. CMS is evaluating what the current efforts are
accomplishing and expects the results later in 2002.

In commenting on a draft of this report, CMS stated that the report did not
consider many of CMS?s publication and education campaigns that were either
completed or underway to increase use of Medicare covered preventive
services. We chose to focus mainly on those types of interventions that
studies showed to be the most effective in ensuring that patients obtain
services. When the Medicare program was established in 1965, it only covered
health care services for the diagnosis or treatment of illness or injury.

Preventive services did not fall into either of these categories and,
consequently, were not covered. Since 1980, the Congress has amended
Medicare law several times to add coverage for certain preventive services
for different age and risk groups within the Medicare population. (See table
1.) For most of these services, Medicare requires some degree of cost-
sharing by beneficiaries, although most beneficiaries have additional
insurance, which may cover most, if not all, of these cost- sharing
requirements. 4 Some services, such as pneumonia and flu shots and the
fecal- occult blood test for colorectal cancer, have no cost- sharing

requirements. 4 U. S. General Accounting Office, Medigap Insurance: Plans
Are Widely Available but Have Limited Benefits and May Have High Costs, GAO-
01- 941 (Washington, D. C.: July 31, 2001). Background

Page 4 GAO- 02- 422 Medicare Clinical Preventive Services

Table 1: Preventive Services Covered by the Medicare Program as of January
2002 Service Year first

covered Groups covered Frequency of service Cost- sharing requirements a
Immunizations

Pneumococcal 1981 All beneficiaries As needed (probably once per lifetime)

None Hepatitis B 1984 Beneficiaries at

intermediate or high risk of contracting hepatitis B

As needed (probably once per lifetime)

Copayment after deductible

Influenza 1993 All beneficiaries Every year None

Screening services

Cervical cancer- pap smear 1990 All female beneficiaries Every 2 years
Copayment with no deductible b Breast cancer- mammography 1991 Female
beneficiaries

35 to 39 Female beneficiaries 40 and older

One baseline mammogram for this period Every year Copayment with no

deductible Vaginal cancer- pelvic exam 1998 All female beneficiaries Every 2
years c Copayment with no

deductible b Colorectal cancer- fecal- occult blood test 1998 Beneficiaries
50 and older Every year No copayment or deductible Colorectal cancer-
sigmoidoscopy d 1998 Beneficiaries 50 and older Every 4 years Copayment
after

deductible e Colorectal cancer- colonoscopy d 1998 All beneficiaries Every
10 years f Copayment after deductible e Osteoporosis- bone mass measurement
1998 Estrogen- deficient female beneficiaries at clinical risk for
osteoporosis as well as other qualified

individuals g Every 2 years h Copayment after deductible

Prostate cancer- prostate- specific antigen test and/ or digital rectal
examination 2000 Men 50 and older Every year Copayment after

deductible b Glaucoma 2002 Beneficiaries medically determined to be at high
risk for glaucoma Every year Copayment after

deductible a Applicable Medicare cost- sharing requirements generally
include a 20 percent copayment after a $100 per year deductible. Each year,
beneficiaries are responsible for 100 percent of the payment amount until
those payments equal a specified deductible amount, $100 in 2002.
Thereafter, beneficiaries are responsible for a copayment that is usually 20
percent of the Medicare approved amount. For certain tests, the copayment
may be higher. See 42 U. S. C. sect. 1395( a)( 1). b The costs of the laboratory
test portion of these services are not subject to copayment or deductible.
The beneficiary is subject to a deductible and/ or copayment for physician
services only. c The exam is covered once every 12 months if the beneficiary
has had an abnormality within the prior 3 years or is otherwise determined
to be a high- risk candidate for cervical cancer.

Page 5 GAO- 02- 422 Medicare Clinical Preventive Services

d The doctor can decide to use a barium enema instead of a sigmoidoscopy or
colonoscopy for beneficiaries 50 and older. The frequency of service is the
same as the sigmoidoscopy or colonoscopy it substitutes for. e The copayment
is increased from 20 to 25 percent for services rendered in an ambulatory
surgical center. f Beneficiaries medically determined to be at high risk may
receive a colonoscopy every 2 years. g The statute defines ?other qualified
individuals? as those who have vertebral abnormalities or primary

hyperparathyroidism, or who are receiving long- term glucocorticoid steroid
or osteoporosis drug therapy. See 42 U. S. C. sect. 1395x( rr)( 2). h CMS
permits coverage of a bone mass measurement at any time- sooner than 2
years- if the

service is medically necessary. See 42 CFR sect. 410.31( c). Many other
preventive services exist besides those specifically covered as preventive
services under Medicare, such as blood pressure screening and cholesterol
screening. Although Medicare does not explicitly provide coverage for these
other services, Medicare beneficiaries may receive some of them during
office visits for other medical problems. Data from surveys of Medicare
beneficiaries indicate that the receipt of such services

is common. 5 For example, in 1999, nearly 98 percent of seniors reported
that they had had their blood pressure checked within the last 2 years, and
more than 88 percent of seniors reported having their cholesterol checked
within the prior 5 years. At least a portion of these services were likely
ordered by physicians in order to diagnose the causes of medical problems,
and were paid for by Medicare as such. To identify how best to increase use
of preventive services needed by the

Medicare population, CMS sponsors reviews of studies that examine various
kinds of interventions that have been used in the past for populations age
65 and older. CMS also takes action to implement interventions in each state
through its Peer Review Organization (PRO)

program. 6 Under this program, CMS contracts with 37 organizations
responsible for each state, U. S. territory, and the District of Columbia.
The PRO program, which is designed to monitor and improve quality of care
for Medicare beneficiaries, currently includes the goal of increasing the
use of flu and pneumonia immunizations, as well as breast cancer screening,
in each state. These organizations collaborate with hospitals and health
care professionals, suggesting systemic changes to improve

5 Survey data are from the CDC?s BRFSS 1999. 6 During the course of our
review CMS began referring to these entities as Quality Improvement
Organizations. CMS officials told us that CMS plans to formalize the name
change in a future Federal Register notice.

Page 6 GAO- 02- 422 Medicare Clinical Preventive Services

how preventive services are provided. CMS also conducts a variety of health
promotion activities to educate beneficiaries about the benefits of
preventive services and to encourage their use. These include the
publication of brochures on certain covered services and media campaigns.

Use of preventive services offered under Medicare has increased over time.
Some services are used more extensively than others, and use of individual
services varies by state and, to a lesser extent, by demographic
characteristics such as ethnicity, income, and education. Although
opportunities remain to increase the use of preventive services within
Medicare, there are limits to the extent some beneficiaries would be

expected to use certain services. Information on usage for 4 of the 10
preventive services covered under Medicare is available in the data we used
7 -immunizations against pneumonia and flu and screening for cervical and
breast cancer. 8 This information shows that beneficiaries age 65 and older
are increasing their

use of all 4 services. (See table 2.) For example, 68 percent of
beneficiaries received flu shots in 1999, compared with 60 percent in 1995.

7 The data were from the CDC?s BRFSS for 50 states and the District of
Columbia. BRFSS does not contain data for colorectal cancer screening for
1995 and 1997. 8 Although Medicare has covered immunizations for hepatitis B
since 1984, usage data are not available. Use of Preventive Services Is
Growing

but Varies Widely The Use of Individual Preventive Services Has Increased
over Time but a Minority Receive Multiple Services

Page 7 GAO- 02- 422 Medicare Clinical Preventive Services

Table 2: Percentage of Medicare Beneficiaries Age 65 and Older Using
Preventive Services in 1995, 1997, and 1999

National usage rate Service and frequency

Year first covered under

Medicare 1995 a 1997 1999 Immunizations

Pneumococcal- ever 1981 38 46 55 Influenza- within previous year 1993 60 66
68

Screening services

Cervical cancer- pap smear within previous 3 years 1990 70 71 72 Breast
cancer- mammogram within previous 2 years 1991 66 72 75

a For 1995 only, values obtained from CDC?s BRFSS web site data. These 1995
data includes Puerto Rico, and may include some survey respondents not
enrolled in Medicare. Source: CDC?s BRFSS for 50 states and the District of
Columbia. In 1999, although each preventive service was used by the majority
of Medicare beneficiaries, fewer receive multiple preventive services. For
example, 1999 data show that while 91 percent of female Medicare
beneficiaries received at least 1 preventive service, only 10 percent of
these beneficiaries were screened for cervical, 9 breast, and colon cancer,
10 as well as immunized against flu and pneumonia. These data also show that
44 percent of male beneficiaries were immunized against both flu and
pneumonia. When colorectal screening is included in this set of services,

the proportion of men who had received all 3 services falls to less than 27
percent.

While national rates provide an overall picture of current use, they mask
substantial differences in how seniors living in different states use some
services. For example, the national breast cancer screening rate for
Medicare beneficiaries was 75 percent in 1999, but rates for individual
states ranged from a low of 66 percent to a high of 86 percent. In table 3,

9 We excluded women who reported having had hysterectomies before
calculating the usage rate for the cervical cancer screen. 10 Sigmoidoscopy
or colonoscopy in past 5 years or fecal- occult blood test in past year. Use
of Services Varies by State and Other

Demographic Characteristics

Page 8 GAO- 02- 422 Medicare Clinical Preventive Services

we show the range over which state estimates of preventive service usage
rates vary from lowest to highest for selected states. 11 Table 3: Variation
in State Usage Rates for Preventive Services by Medicare

Beneficiaries 65 and Older, 1999 Preventive service a National

usage rate percentage b Usage rate range among states percentage

Number of states included

in range c Immunizations Pneumococcal- ever 55 51 to 62 24 Influenza- within
previous year 68 63 to 77 30

Screening services Breast cancer- mammogram within previous 2 years 75 66 to
86 21 Colorectal cancer- fecal- occult blood test in past year 25 14 to 37
34 Colorectal cancer- colonoscopy or sigmoidoscopy within previous 5 years
40 27 to 46 24

a Data were unavailable for Medicare population use of hepatitis B
immunization and screening services for osteoporosis. b National usage rate
includes all states and the District of Columbia. c This includes the number
of states whose 95 percent confidence intervals for the respective
preventive services were narrower than 10 percentage points. State specific
data were not included

for cervical cancer screening because none met this level of precision.
Source: CDC?s BRFSS for 50 states and the District of Columbia. While usage
rates for each service varied from state to state, the services with the
highest rates in each state were generally the same. For example, in most
states, screening rates for breast and cervical cancer were higher than
rates for colorectal screens. Usage rates for Medicare beneficiaries also
varied based on ethnicity, and on socioeconomic status, as defined by income
and education. By ethnicity, the biggest differences occurred in use of
immunization services. For example, 1999 data show that about 57 percent of
whites and 54 percent of ?other? 12 ethnic groups were immunized against
pneumonia,

11 We excluded states whose 95 percent confidence intervals for that service
were wider than 10 percentage points. 12 ?Other? ethnic groups include
survey respondents who reported an ethnicity other than African American,
Hispanic, or white.

Page 9 GAO- 02- 422 Medicare Clinical Preventive Services

compared to about 37 percent of African Americans and Hispanics. Similarly,
about 70 percent of whites and ?other? ethnic groups received flu shots
during the year compared to 49 percent of African Americans. The only other
statistically significant difference between ethnic groups

was for the fecal- occult blood test for colon cancer, for which 26 percent
of whites received screenings within the past year compared to 16 percent of
Hispanics and ?other? ethnic groups. 13 For income and education, in
general, as income and education rose, the rates at which individuals used
preventive services also increased. (See table 4.)

Table 4: Percentages of Medicare Beneficiaries 65 and Older Using Preventive
Services by Income and Education, 1999 Income Education Screening service a
Less than

$25,000 $25,000 and over Less than

high school High school

and some college

College graduate and postgraduate Immunizations

Pneumococcal- ever 53.7 57.5 47.9 56.4 60.1 Influenza- within previous year
65.2 71.0 61.7 68.6 72.6

Preventive services

Cervical cancer- pap smear within previous 3 years 66.1 81.5 62.0 74.8 b
78.6 b Breast cancer- mammogram within previous 2 years 69.7 84.2 65.3 76.9
84.0 Colorectal cancer- fecal- occult blood test in previous year 21.3 28.1
19.7 25.3 29.7 Colorectal cancer- colonoscopy or sigmoidoscopy within
previous 5 years 36.8 46.1 33.3 40.2 48.3

a Data were unavailable for Medicare population utilization of Hepatitis B
immunization and screening services for osteoporosis. b All differences
between income and education groups are statistically significant except for
cervical cancer screening services for high school graduates and above.
Source: CDC?s BRFSS for 50 states and the District of Columbia. 13 There was
no statistically significant difference between the rate at which the ethnic
groups used cervical and breast cancer screening or the sigmoidoscopy/
colonoscopy colorectal cancer screenings. Likewise, there was no
statistically significant difference between the rates that African
Americans and Hispanics were immunized against pneumonia or that whites and
?other? ethnic groups were immunized for either pneumonia or the flu.

Page 10 GAO- 02- 422 Medicare Clinical Preventive Services

Various studies have identified a variety of factors affecting beneficiary
decisions to seek preventive care, including low patient awareness of the
benefits of the services as well as the need for service. Some factors, such
as those involving patient awareness of the benefits, may represent
opportunities to increase the use of preventive services. For example, see
the following.

 In a 1997 report, the Agency for Healthcare Research and Quality found
that, although patients may be unaware of the risks or symptoms of
colorectal cancer, they are more likely to participate in screening once
they understand the nature and risks of the disease.

 Data from CMS?s 1999 Medicare Current Beneficiary Survey show that, while
about one- fourth of beneficiaries who did not receive flu shots were
unaware of the benefits of obtaining this immunization, about half of the
people who were not immunized avoided getting the shot for reasons such as
concerns about side effects and whether doing so would effectively

prevent illness. On the other hand, usage rates alone may not provide a
clear picture of success, and may mask inherent limitations to increasing
usage rates. For example, survey data show that 44 percent of women age 65
and over have had hysterectomies 14 -an operation that usually includes
removing the cervix. For these women, researchers state that cervical cancer
screening may not be necessary unless they have a prior history of cervical
cancer. 15 Also, according to officials in charge of research on preventive
services at

the National Institutes of Health, it is reasonable for beneficiaries, their
families, or their providers to decide to forgo services because of the
limited benefits they would offer patients with terminal illnesses or of
advanced age. These officials explained that research has shown, for

example, that the benefits of cancer screening services, such as for
prostate, breast, and colon cancer, can take 10 years or more to
materialize, a time frame that could exceed the life expectancy of as much
as half of the Medicare population. 16 14 Data are from the CDC?s BRFSS,
2000. 15 CDC researchers report that among the general population, over 80
percent of hysterectomies are performed for noncancerous conditions such as
fibroids and

endometriosis. 16 One half of the Medicare population is age 75 and older,
and in 1997, the life expectancy for 75 year olds was about 86. 2 years.
Opportunities and Limitations Exist to Increase the Use of Preventive
Services

Page 11 GAO- 02- 422 Medicare Clinical Preventive Services

CMS officials also pointed out that the controversy over the effectiveness
of some services, such as mammography and prostate cancer screening, may add
to the difficulty in further improving screening rates for these services.
The benefit of mammography has recently been challenged by two Danish
researchers and an independent group of experts on the National Cancer
Institute?s (NCI) advisory panel citing serious flaws in 6 of the 8 clinical
trials that showed benefits. However, subsequent to the

Danish report and the NCI panel?s statement, both the NCI and the U. S.
Preventive Services Task Force 17 reiterated their recommendation for
regular mammography screening. While acknowledging the methodological
limitations in these trials, the U. S. Preventive Services Task Force
concluded that the flaws in these studies were unlikely to negate the
reasonable, consistent, and significant mortality reductions observed in
these trials. Routine screening for prostate cancer is also a

matter of controversy. For example, the American Cancer Society and the
American Urological Association support routine prostate cancer screening,
while the U. S. Preventive Services Task Force and others 18 state that
there is insufficient evidence to support it.

CMS has studied various types of interventions to increase the use of
preventive services among seniors. These studies show that many types of
interventions can potentially be effective, but also that interventions must
be tailored to the circumstances of specific situations. CMS is funding
efforts in every state to implement interventions for three preventive
services that Medicare covers. CMS also has efforts under way aimed at
increasing the use of preventive services among minority and low- income
seniors.

CMS has sponsored reviews of studies looking at the effectiveness of
interventions to increase use of preventive services among people age 65 and
older. One of these reviews evaluated the effectiveness of interventions
targeting people over age 65 for five services covered by 17 The U. S.
Preventive Services Task Force is a committee of medical experts convened by
the Department of Health and Human Services to evaluate evidence and make
recommendations for clinical preventive services such as mammography and
prostate cancer screening.

18 These organizations include the American College of Physicians, the
National Cancer Institute, and the American College of Preventive Medicine.
Efforts Under Way to

Increase Use of Some Preventive Services

Studies Identify Effective Methods to Increase Use of Services

Page 12 GAO- 02- 422 Medicare Clinical Preventive Services

Medicare- immunizations for flu and pneumonia and screenings for breast,
cervical, and colon cancer. 19 The report evaluated 218 separate studies on
interventions designed to increase use of preventive services. The studies
were performed in both academic and nonacademic settings in various
geographic areas, and in a mixture of reimbursement systems.

Most of the interventions studied that involved pneumococcal and influenza
immunizations were targeted toward persons over 65 years of age, while
cancer screening interventions were targeted at adults, but not

necessarily those 65 years of age. This evaluation concluded that no
specific intervention was consistently most effective for all services and
settings, and that success depended on how closely the intervention
addressed the unique circumstances in each state and for different
populations within each state, while also taking into account the cost and
difficulty of implementation. Obstacles to improved screening rates can
differ across states thus requiring different approaches. For example,
officials responsible for improving the use of

preventive services in Idaho and Washington explained that while a
significant barrier in Idaho was beneficiary access to Medicare providers,
this was not a barrier in Washington. The CMS evaluation also showed that
using multiple interventions generally provided greater success than using

a single approach. The types of interventions evaluated in the CMS-
sponsored review 20 included a variety of efforts targeting health delivery
systems, providers, and patients. The key conclusion the report drew from
the literature was that organizational and system change, such as the use of
standing orders 21 and the use of financial incentives, were the most
consistent at producing

the largest increase in the use of preventive services. These and other
interventions found to be effective follow. 19 Health Care Financing
Administration, Evidence Report and Evidence- Based Recommendations:
Interventions that Increase the Utilization of Medicare- Funded

Preventive Services for Persons Age 65 and Older, Publication No. HCFA-
02151 (Prepared by Southern California Evidence- based Practice Center/
RAND, 1999).

20 Health Care Financing Administration, Evidence Report and Evidence- Based
Recommendations: Interventions that Increase the Utilization of Medicare-
Funded Preventive Services for Persons Age 65 and Older. 21 CMS is
conducting a standing orders pilot through its PRO program in nine states
(using five additional states as control states) to test organizational and
system change in nursing

homes.

Page 13 GAO- 02- 422 Medicare Clinical Preventive Services

 System Change. These interventions change the way a health system operates
so that patients are more likely to receive services. For example, medical
or administrative staff may be given responsibility to ensure that

patients receive services, or standing orders may be implemented in nursing
homes to allow nonphysician personnel to administer immunizations without a
physician?s order.

 Incentives. These interventions include gifts or vouchers to patients for
free services. Medicare allows this type of approach only in limited
circumstances. 22  Reminders. These interventions include computer-
generated or other

approaches by which medical offices (1) reminded physicians to provide the
preventive service as part of services performed during a medical visit or
(2) generated notices to patients that it was time to make an appointment
for the service. Studies show that reminders to either patients or
physicians can effectively improve rates for cancer screening. However, a
computerized provider reminder is consistently more cost

effective than notifying the patient directly when a computerized
information system is already available in a physician?s medical office.
Patient reminders that are personalized or signed by the patient?s physician
are more effective than generic reminders.

 Education. These interventions include pamphlets, classes, or public
events providing information for physicians or beneficiaries on coverage,
benefits, and time frames for services. The study found that while the
effect of patient education is significant, it is consistently less
effective than system change, incentives, or reminders.

CMS is implementing interventions in all states through its PRO program.
Under this program, CMS contracts with 37 PROs, each responsible for
monitoring and improving the quality of care for Medicare beneficiaries in
one or more states, in U. S. territories, or in the District of Columbia.
These efforts are currently aimed at three preventive services offered under

Medicare- immunizations against flu and pneumonia and screening for breast
cancer. CMS chose these topics based on their public health

22 Under certain circumstances, Medicare providers may offer incentives for
preventive services. Specifically, under regulations which became effective
April 26, 2000, providers may forgo some compensation by waiving coinsurance
and deductible payments for medical services, including Medicare preventive
services. In addition, other types of incentives- such as free
transportation or gift certificates- are also allowed so long as the

incentive is not disproportionately large in relationship to the value of
the preventive service. Under no circumstances may cash or instruments
convertible to cash be used. See 42 CFR sect. 1003. 101. CMS Is Sponsoring

Interventions to Increase Use of Three Services

Page 14 GAO- 02- 422 Medicare Clinical Preventive Services

importance and other factors. CMS also contracts with select PROs to provide
support and assistance to all PROs for each area of focus. For example, CMS
has contracted with two of the existing PROs, one for flu and pneumonia
immunizations and one for breast cancer screening, to provide support and
share information among the PROs regarding their

efforts to improve usage rates for these services. Our discussions with the
officials from these two PROs indicate that, for immunizations, most PROs
are focusing on ways to better educate patients and providers on the

importance of getting flu and pneumonia shots. For breast cancer screening,
efforts are focusing on developing integrated reminder systems, such as
chart stickers or computer- based alerts that physicians? offices can use to
contact patients on a timely basis.

Officials for the two PROs providing support indicated that most PROs were
implementing multiple interventions. For example, in a newsletter intended
to help PROs share information, officials at one PRO reported that they have
developed concurrent breast cancer screening interventions for their state,
which are targeted at physicians and their staffs, nurses, and
beneficiaries. Officials for this PRO report the following.

 For physicians and their staffs, they (1) host seminars to teach them
about reminder and billing systems, (2) provide toolkits that include
reminder systems, checklists, and other materials, and (3) conduct on- site
consultations to encourage providers to implement system changes.

 For nurses, they are conducting a campaign intended to increase awareness
and encourage nurses and student nurses to identify female friends and
family members who are overdue for mammograms. The campaign includes
information packets, a newsletter, and information booths at nursing
organization meetings.

 For beneficiaries, the PRO publishes a periodic newsletter on the subject
of preventive medicine. This newsletter includes articles on the importance
of mammography for early detection of breast cancer. CMS has taken steps to
evaluate the success of PRO efforts. CMS officials explained that the
contracts with the PRO organizations are ?performance

based? and provide financial incentives as a reward for superior outcomes.
The contracts include a methodology in which the performance of the PRO for
each state, U. S. territory, and the District of Columbia is scored based on
22 indicators, including flu and pneumonia vaccination rates and mammography
rates. The performance of the PRO in each state will then

be ranked against all other states in order to identify the higher and lower
performing PROs. CMS intends to automatically renew the contracts with the
top 75 percent of the PROs for the next contract cycle, which begins in

Page 15 GAO- 02- 422 Medicare Clinical Preventive Services

2002. The PRO contracts also contain financial performance incentives
allowing each PRO to receive up to an additional 2 percent payment based on
the positive outcomes of their interventions. CMS officials expect
information on the results by the summer of 2002. Consequently, we have not
assessed the outcome of PRO efforts or CMS?s methodology for

measuring PRO performance. While the current efforts include 3 of the 10
preventive services covered by Medicare, CMS is also developing indicators
and performance measures necessary for interventions to increase use of
screening services for

osteoporosis and colorectal and prostate cancer. CMS officials stated that
such interventions would be implemented in future contracts with PROs. CMS
is not currently developing indicators for the remaining preventive services
covered by Medicare- hepatitis B immunizations or screenings for glaucoma
and vaginal cancer.

CMS is also sponsoring PRO interventions and projects in each state to
increase use of preventive services by minorities and low- income Medicare
beneficiaries. CMS- funded research on successful interventions for the
general Medicare population 65 and older concluded that evidence was
insufficient to determine how best to increase use of services by minorities
and low- income seniors across various geographic settings. Differences in
how populations use preventive services are sometimes found even when the
populations have similar geographic settings or delivery systems. For
example, a study showed that although use of flu shots among white and
African American seniors is higher under managed care than fee- for-
service, the significant disparities in levels of use between these ethnic
groups persist in both these environments. 23 To begin addressing these
information gaps, CMS requires that each PRO

conduct a project focusing on one of several specified Medicare populations.
This population can be low- income seniors enrolled in both Medicare and
Medicaid or one of several minority groups: American

Indians, Alaska Natives, Asian Americans and Pacific Islanders, African
Americans, or Hispanics. For the population chosen, the PRO is to target
interventions for one service. The projects in most states are focusing on

23 E. C. Schneider, MD, MSc, et al, ?Racial Disparity in Influenza
Vaccination: Does Managed Care Narrow the Gap Between African Americans and
Whites?? JAMA, Volume 286, Number 12, (September 26, 2001). CMS Is Also
Sponsoring Interventions to Increase

Use of Services among Minorities and LowIncome Seniors

Page 16 GAO- 02- 422 Medicare Clinical Preventive Services

increasing breast cancer screening or flu and pneumonia immunization among
African American or low- income seniors. PROs are required to identify the
barriers that exist for the selected population and service, and to
implement interventions specifically designed to address these barriers for
patients and providers. A summary of PRO efforts to increase services for
minorities and low- income seniors is expected to be published sometime
after the spring of 2002.

Other studies or projects under way by CMS also aim to identify barriers and
increase use of services by certain Medicare populations. For example, the
Congress directed CMS to conduct a demonstration project to, among other
things, develop and evaluate methods to eliminate disparities in cancer
prevention screening measures. 24 The law specifies a total of nine
demonstration projects to include two state- level demonstrations for each
of four minority groups (American Indians, including Alaska Natives,
Eskimos, and Aleuts; Asian Americans and

Pacific Islanders; African Americans; and Hispanics) and one project in the
Pacific Islands. In addition, one of the projects must have a rural focus
and one must have an urban focus for each group. CMS expects to produce a
report by December 2002, after the project?s first phase is completed,
identifying best practices and models to be tested in

demonstration projects. The second phase, which is to start around December
2002, is to test these models by implementing them in actual demonstration
projects intended to determine which methods are most effective in reducing
the incidence of cancer and improving minority

health by overcoming barriers to the use of preventive services in the
target populations. A report evaluating the cost effectiveness of the
demonstration projects, the quality of preventive services provided, and
beneficiary and health care provider satisfaction is due to the Congress in
2004.

We obtained comments on our draft report from CMS. CMS commented that the
draft report focused on the activities of its PROs and did not consider all
of CMS?s health promotion activities. CMS provided details on

its publication and educational campaigns to inform Medicare 24 See the
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of
2000, Public Law 106- 554, Appendix F, sect. 122, 114 Stat. 2763, 2763A- 476
classified to 42 U. S. C. sect. 1395b- 1 nt. Agency Comments

and Our Evaluation

Page 17 GAO- 02- 422 Medicare Clinical Preventive Services

beneficiaries about preventive service benefits and to encourage their use.
CMS?s comments are reproduced in appendix I.

We acknowledge that our report does not describe all of CMS?s health
promotion/ education activities underway that relate to increasing the use
of preventive services among the Medicare population. While beneficiary
education activities are worthwhile, CMS studies have shown that other
interventions, such as those that are directed at changing the way a health
delivery system operates so that patients are more likely to receive
services, are more effective. Because PROs and CMS demonstration projects
are accountable for facilitating the implementation of these types of
interventions, we focused our efforts in describing these activities and the
status of their evaluations. We have revised the report to make it clear
that PRO activities are in addition to other CMS beneficiary education
efforts.

CMS also provided technical comments that we considered and incorporated
where appropriate.

As arranged with your office, unless you release its contents earlier, we
plan no further distribution of this report until 30 days after its issuance
date. At that time we will send copies of this report to the secretary of
health and human services, the administrator of the Centers for Medicare

and Medicaid Services, the director of the Centers for Disease Control and
Prevention, and others who are interested. We will also make copies
available to others on request. If you or your staff have any questions,
please contact me at (202) 512- 7119, or Frank Pasquier at (206) 287- 4861.
Other major contributors are included in appendix II. Sincerely yours,

Janet Heinrich Director, Health Care- Public Health Issues

Appendix I: Comments from the Centers for Medicare and Medicaid Services
Page 18 GAO- 02- 422 Medicare Clinical Preventive Services

Appendix I: Comments from the Centers for Medicare and Medicaid Services

Appendix I: Comments from the Centers for Medicare and Medicaid Services
Page 19 GAO- 02- 422 Medicare Clinical Preventive Services

Appendix I: Comments from the Centers for Medicare and Medicaid Services
Page 20 GAO- 02- 422 Medicare Clinical Preventive Services

Appendix I: Comments from the Centers for Medicare and Medicaid Services
Page 21 GAO- 02- 422 Medicare Clinical Preventive Services

Appendix I: Comments from the Centers for Medicare and Medicaid Services
Page 22 GAO- 02- 422 Medicare Clinical Preventive Services

Appendix I: Comments from the Centers for Medicare and Medicaid Services
Page 23 GAO- 02- 422 Medicare Clinical Preventive Services

Appendix I: Comments from the Centers for Medicare and Medicaid Services
Page 24 GAO- 02- 422 Medicare Clinical Preventive Services

Appendix I: Comments from the Centers for Medicare and Medicaid Services
Page 25 GAO- 02- 422 Medicare Clinical Preventive Services

Appendix II: GAO Contact and Staff Acknowledgments Page 26 GAO- 02- 422
Medicare Clinical Preventive Services

Frank Pasquier (206) 287- 4861 Other major contributors to this report
include Lacinda Ayers, Matthew Byer, Jennifer Cohen, Jennifer Major, Behn
Miller, and Stan Stenersen. Appendix II: GAO Contact and Staff

Acknowledgments GAO Contact Acknowledgments (290133)

The General Accounting Office, the investigative arm of Congress, exists to
support Congress in meeting its constitutional responsibilities and to help
improve the performance and accountability of the federal government for the
American people. GAO examines the use of public funds; evaluates federal
programs and policies; and provides analyses, recommendations, and other

assistance to help Congress make informed oversight, policy, and funding
decisions. GAO?s commitment to good government is reflected in its core
values of accountability, integrity, and reliability. The fastest and
easiest way to obtain copies of GAO documents is through the Internet. GAO?s
Web site (www. gao. gov) contains abstracts and full- text files of current
reports and testimony and an expanding archive of older products. The Web
site features a search engine to help you locate documents using key words

and phrases. You can print these documents in their entirety, including
charts and other graphics. Each day, GAO issues a list of newly released
reports, testimony, and correspondence. GAO posts this list, known as
?Today?s Reports,? on its Web site daily. The list contains links to the
full- text document files. To have GAO e- mail this list to you every
afternoon, go to www. gao. gov and select ?Subscribe to daily E- mail alert
for newly released products? under the GAO Reports heading. The first copy
of each printed report is free. Additional copies are $2 each. A check or
money order should be made out to the Superintendent of Documents.

GAO also accepts VISA and Mastercard. Orders for 100 or more copies mailed
to a single address are discounted 25 percent. Orders should be sent to:

U. S. General Accounting Office 441 G Street NW, Room LM Washington, D. C.
20548 To order by Phone: Voice: (202) 512- 6000 TDD: (202) 512- 2537

Fax: (202) 512- 6061 Contact: Web site: www. gao. gov/ fraudnet/ fraudnet.
htm E- mail: fraudnet@ gao. gov Automated answering system: (800) 424- 5454
or (202) 512- 7470

Jeff Nelligan, managing director, NelliganJ@ gao. gov (202) 512- 4800 U. S.
General Accounting Office, 441 G Street NW, Room 7149 Washington, D. C.
20548 GAO?s Mission

Obtaining Copies of GAO Reports and Testimony

Order by Mail or Phone To Report Fraud, Waste, and Abuse in Federal Programs
Public Affairs
*** End of document. ***