Medicare: Most Beneficiaries Receive Some but Not All Recommended
Preventive Services (08-SEP-03, GAO-03-958).			 
                                                                 
Medicare, the federal health program insuring almost 35 million  
beneficiaries age 65 and older, covers certain preventive	 
services, such as flu shots and mammograms. Most beneficiaries	 
receive care through Medicare's fee-for-service program, under	 
which they generally receive these services as part of visits to 
the doctor for specific illnesses or conditions. Other		 
beneficiaries receive services under Medicare's managed care	 
program, called Medicare + Choice. GAO was asked to determine (1)
the extent to which beneficiaries received recommended preventive
services through existing visits, (2) whether approaches used by 
Medicare + Choice plans provide insight for improving delivery of
preventive care services for fee-for-service beneficiaries, and  
(3) what the Centers for Medicare & Medicaid Services (CMS) is	 
doing to explore suggested options for delivering preventive care
to fee-for-service beneficiaries. GAO's work included analyzing  
data from four national health surveys and reviewing five	 
Medicare + Choice plans considered to have innovative approaches 
to delivering preventive services. GAO also interviewed 	 
Department of Health and Human Services (HHS) and CMS officials  
and reviewed documents on CMS demonstrations related to 	 
preventive services.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-958 					        
    ACCNO:   A08328						        
  TITLE:     Medicare: Most Beneficiaries Receive Some but Not All    
Recommended Preventive Services 				 
     DATE:   09/08/2003 
  SUBJECT:   Beneficiaries					 
	     Health care planning				 
	     Health care programs				 
	     Health care services				 
	     Health surveys					 
	     Managed health care				 
	     Disease detection or diagnosis			 
	     Medicare Program					 

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GAO-03-958

United States General Accounting Office

GAO 	Report to the Chairman, Subcommittee on Oversight and Investigations,
           Committee on Energy and Commerce, House of Representatives

September 2003

MEDICARE

  Most Beneficiaries Receive Some but Not All Recommended Preventive Services

GAO-03-958

Highlights of GAO-03-958, a report to the Chairman, Subcommittee on
Oversight and Investigations, Committee on Energy and Commerce, House of
Representatives

Medicare, the federal health program insuring almost 35 million
beneficiaries age 65 and older, covers certain preventive services, such
as flu shots and mammograms. Most beneficiaries receive care through
Medicare's fee-for-service program, under which they generally receive
these services as part of visits to the doctor for specific illnesses or
conditions. Other beneficiaries receive services under Medicare's managed
care program, called Medicare + Choice. GAO was asked to determine (1) the
extent to which beneficiaries received recommended preventive services
through existing visits, (2) whether approaches used by Medicare + Choice
plans provide insight for improving delivery of preventive care services
for fee-for-service beneficiaries, and (3) what the Centers for Medicare &
Medicaid Services (CMS) is doing to explore suggested options for
delivering preventive care to fee-for-service beneficiaries.

GAO's work included analyzing data from four national health surveys and
reviewing five Medicare + Choice plans considered to have innovative
approaches to delivering preventive services. GAO also interviewed
Department of Health and Human Services (HHS) and CMS officials and
reviewed documents on CMS demonstrations related to preventive services.

www.gao.gov/cgi-bin/getrpt?GAO-03-958.

To view the full report, including the scope and methodology, click on the
link above. For more information, contact Janet Heinrich on 202-512-7250.

September 2003

MEDICARE

Most Beneficiaries Receive Some but Not All Recommended Preventive Services

Most Medicare beneficiaries receive some preventive services through their
visits to physicians, but relatively few receive the full range of
preventive services available. Survey data showed, for example, that in
2000 about 30 percent of beneficiaries did not receive a flu shot, and 37
percent had never been vaccinated against pneumonia. Moreover, many
Medicare beneficiaries are apparently unaware that they may have
conditions that preventive services are meant to detect. For example, in a
1999-2000 nationally representative survey during which people received
physical examinations, nearly one-third of those age 65 and older who were
found to have high cholesterol measurements said they had not previously
been told by a physician or other health professional that they had high
cholesterol. Projected nationally, this percentage could represent 2.1
million people.

Estimated Number of Medicare Beneficiaries Age 65 and Older Who Were Aware
or Unaware That They Might Have High Blood Pressure or High Cholesterol,
1999-2000

Note: About one-third of Medicare beneficiaries examined and found to have
high cholesterol or elevated blood pressure measurements were previously
unaware that they might have the condition, representing millions
nationwide.

No clear "best practice" approach to delivering preventive care stands out
among the innovative Medicare + Choice plans GAO studied. All five plans
identify health risks, provide feedback on risks to patients or their
physicians, and follow up to reduce those risks. But their follow-up
programs, approaches, and priorities differ, and little is known about the
effectiveness of these efforts for the Medicare-age population.

CMS has begun the development work to design a project evaluating the use
of individual assessments of health risks, followed by counseling and
other services, as a way to improve preventive care delivery. Another
suggested approach-adding a routine physical examination benefit to
Medicare's fee-for-service program-could provide more opportunities, but
at increased cost and without guarantee that preventive services would
actually be provided to Medicare beneficiaries.

HHS generally concurred with the findings of this report.

Contents

  Letter

Results in Brief
Background
Most Beneficiaries Receive Some Preventive Services, but Not All

That Are Recommended Medicare + Choice Plans Reviewed Assess Health Risks
Using Varying Approaches New Ways to Improve the Provision of Preventive
Services within

Medicare's Fee-for-Service Program Are Promising but Untested Concluding
Observations Agency Comments

                                       1

                                      3 5

                                       7

11

17 24 24

Appendix I Scope and Methodology

Appendix II 	Preventive Services Recommended by the U.S. Preventive
Services Task Force or Covered by Medicare

Appendix III 	National Health and Nutrition Examination Survey Methodology
and Results

Appendix IV 	Comments from the Department of Health and Human Services

  Tables

Table 1. Feedback Processes Described by Medicare + Choice Plans 14 Table
2: Four National Health Surveys with Preventive Services Data, 1999-2000
26 Table 3: Estimated Proportion of Fee-for-Service Physician Visits

Made by People Age 65 and Older, by Major Reason for the

Visits, 2000 27

Table 4: Estimated Proportion of Fee-for-Service Physician Visits in Which
Diet Counseling Services Were Provided or Ordered, by Major Reason for the
Visits, 2000 28

Table 5: Estimated Proportion of Fee-for-Service Physician Visits in Which
Blood Pressure Measurements Were Provided or Ordered, by Major Reason for
the Visits, 2000 28

Table 6: Medicare + Choice Plans Included in GAO's Study 29 Table 7:
NHANES Data GAO Used to Determine if Participants Had Measures of Specific
Health Conditions 32

Table 8: People Age 65 and Older in the United States Found to Have
Measures of Specific Health Conditions, NHANES 1999-2000 33

Table 9: People Age 65 and Older in the United States Found to Have
Measures of Specific Health Conditions and Who Reported They Had Not
Previously Been Told They Might Have the Condition, NHANES 1999-2000 33

  Figures

Figure 1: Major Reasons for Physician Visits by Medicare

Beneficiaries in the Fee-for-Service Program, 2000 8 Figure 2: Estimated
Number of Medicare Beneficiaries Age 65 and Older Who Were Aware and
Unaware That They Might Have High Blood Pressure or High Cholesterol,
1999-2000 11

Abbreviations

AMA American Medical Association
ACE Inhibitor Angiotensin-converting enzyme inhibitor
BRFSS Behavior Risk Factor Surveillance Survey
CDC Centers for Disease Control and Prevention
CMS Centers for Medicare & Medicaid Services
HHS Department of Health and Human Services
NHANES National Health and Nutrition Examination Survey
Td Tetanus-diphtheria

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separately.

United States General Accounting Office Washington, DC 20548

September 8, 2003

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

Dear Mr. Chairman:

Medicare, the federal government's health insurance program that covers
almost 35 million people age 65 and older, was created largely to help pay
beneficiaries' health care costs once they become ill or injured.1 For the
most part, the federal government pays physicians and other health care
providers to treat Medicare beneficiaries for illnesses and health
conditions. In addition, the Congress has broadened Medicare coverage to
include specific preventive services, aimed at either (1) keeping an
illness
or condition from developing or (2) keeping it from becoming more
serious through early detection and subsequent management.
Immunization against influenza (a "flu shot") is an example of the first
type
of preventive service; a mammogram to detect breast cancer is an example
of the second. Overall preventive care depends heavily on identifying
health risks associated with the onset or progression of disease and
taking
steps to reduce or mitigate these risks.

We previously reported to you that Medicare beneficiaries' use of covered
preventive services has increased over time but varies widely from service
to service.2 In response, you asked us to follow up on several issues. One
issue is the success of providing preventive services through a Medicare
service delivery system based primarily on treating existing illnesses and
health conditions. Under Medicare's fee-for-service program, which enrolls
about 84 percent of Medicare beneficiaries, no specific provision exists
for

1 We focused our work on the people covered by Medicare who are 65 and
older-about 86 percent of the entire Medicare population. Besides this age
group, Medicare also covers about 5.8 million disabled persons younger
than age 65. Throughout this report, except where otherwise noted, we use
the term "Medicare beneficiaries" to refer only to those beneficiaries age
65 and older.

2 U.S. General Accounting Office, Medicare: Beneficiary Use of Clinical
Preventive Services, GAO-02-422 (Washington, D.C.: April 2002).

a routine annual physical or checkup that could be a vehicle for
delivering preventive services.3 Unless beneficiaries in the
fee-for-service program have supplemental insurance that covers such a
checkup, they may have to depend on receiving preventive services during
their visits for specific illnesses or conditions, or during other visits
for those specific preventive services that Medicare does cover. A second
issue is what can be learned about the effectiveness of preventive service
approaches put in place by plans that contract with Medicare to offer
health care on a managed care basis.4 These plans, which enroll about 14
percent of all Medicare beneficiaries under an option known as Medicare +
Choice, generally offer a benefit for periodic checkups.5 Some of these
Medicare + Choice plans are regarded as particularly innovative in
assessing risk, providing screening services, and conducting prevention
programs. This report addresses the following questions:

o  	Do Medicare beneficiaries receive recommended preventive services
through existing physician visits?

o  	What approaches for preventive care have been taken by selected
Medicare + Choice plans, and what is known about their effectiveness for
the Medicare beneficiaries they serve?

o  	What delivery options for identifying and reducing health risks have
been suggested for Medicare fee-for-service beneficiaries, and are any of
these options being explored by the Centers for Medicare & Medicaid
Services (CMS), the agency administering the program?

Because no single source contained all the information we needed to assess
the extent to which Medicare beneficiaries receive preventive services
through existing physician visits, we analyzed data from four

3 "Fee-for-service" is the Medicare arrangement sometimes referred to as
the original Medicare plan. Under this option, Medicare pays a health care
practitioner for each visit or procedure received by a patient, and a
beneficiary can visit any hospital, physician, or health care provider who
accepts Medicare patients. Medicare pays a set percentage of the expenses,
and the beneficiary is responsible for certain deductibles and coinsurance
payments-the portion of the bill that Medicare does not pay.

4 These are health care options (like health maintenance organizations) in
some areas of the country. In most programs, the beneficiary can go only
to doctors, specialists, or hospitals on the program's list. Programs must
cover all Medicare part A and part B health care but can also cover
extras, like prescription drugs and periodic checkups.

5 Besides the 84 percent of Medicare beneficiaries in fee-for-service and
the 14 percent in Medicare + Choice (2002 data), a small percentage of
Medicare beneficiaries receive services through such arrangements as
prepaid group practice plans or Medicare demonstrations.

nationally representative health surveys. The Centers for Disease Control
and Prevention's (CDC) Behavioral Risk Factor Surveillance System asks a
range of health questions over the telephone, including if respondents
received a "routine checkup" within the past year. CMS's Medicare Current
Beneficiary Survey collects self-reported data, including whether
respondents have received influenza or pneumonia immunizations. CDC's
National Health and Nutrition Examination Survey (NHANES) collects data on
health conditions by means of both comprehensive health examinations and
interviews, where patients self-report information, including whether a
physician or other health professional has ever told them that they have a
given health condition. Unlike the other surveys, which take a sample of
the population, CDC's National Ambulatory Medical Care Survey samples
physician practices, collecting detailed information about office visits,
including the major reason for the visit and which preventive services
were ordered or provided. In addition, this survey captured information
that allowed us to assess whether visits by Medicare beneficiaries were on
a fee-for-service basis. Unless otherwise noted, however, the data we
report generally included beneficiaries from both systems.

To describe the approaches of selected Medicare + Choice plans in
delivering preventive services, we assessed literature and interviewed
national experts to identify plans that were considered innovative in
preventive care. We then obtained information from five such plans: AvMed
Health Plans, Group Health Cooperative, Highmark Blue Cross and Blue
Shield, Kaiser Permanente, and Oxford Health Plans. Collectively, an
estimated 1.2 million Medicare beneficiaries in 15 states plus the
District of Columbia receive their health care under these plans. To
determine suggested options for identifying and reducing health risks and
what CMS is doing to assess them, we reviewed the results of past related
research demonstrations and congressionally mandated studies and
interviewed Department of Health and Human Services (HHS) and CMS
officials and other experts. (App. I further describes our scope and
methodology.) We conducted our work from October 2002 through August 2003
in accordance with generally accepted government auditing standards.

Results in Brief 	Most Medicare beneficiaries receive some but not all
recommended preventive services, although they typically visit a physician
several times during a year. Our analysis of year 2000 data shows that
nearly 9 in 10 Medicare beneficiaries visited a physician at least once
that year, with a beneficiary making an average of six visits or more
within the year. Preventive services are delivered during all types of
visits-whether for

illnesses, health conditions, or nonillness care. Regardless of the reason
for a visit, however, many beneficiaries did not receive recommended
preventive services. In 2000, for example, about 30 percent of Medicare
beneficiaries did not receive an influenza vaccination and 37 percent had
never had a pneumonia vaccination, as recommended under current guidelines
for people age 65 and older. Moreover, many Medicare beneficiaries may
have conditions of potential concern that they are unaware of. For
example, among the Medicare beneficiaries who participated in a nationally
representative survey and were found through physical examinations to have
high cholesterol, about one-third said they had not previously been told
by a physician or other health professional that they might have this
condition. Projected nationally, this percentage translates into about 2.1
million people age 65 and older.

Although they differ from one another in approach and emphasis, the
preventive care approaches of the Medicare + Choice plans we reviewed
share common elements. In particular, their approaches screen enrollees to
identify health risks and then provide a number of follow-up activities
designed to reduce those risks. The plans generally use combinations of
methods to ascertain needed preventive services, including periodic
preventive visits, health risk questionnaires, and periodic assessments of
medical claims and pharmacy data. All plans also have follow-up strategies
to help beneficiaries obtain needed preventive services, although their
strategies and priorities vary. Follow-up interventions include counseling
programs to encourage behavioral change, cancer screening for early
detection of disease, and programs to coordinate and manage chronic
conditions such as diabetes and cardiovascular disease. Although some
plans furnished us with data suggesting that their approaches hold
promise, few had conducted a systematic evaluation of whether the
approaches improved health outcomes or lowered health care costs. Those
studies that do show a relationship between greater use of preventive
services and improved health outcomes or cost savings are limited in terms
of how their findings might be generalized to Medicare beneficiaries.

Several options have been suggested for improving the provision of
preventive services under Medicare's fee-for-service program, each with
its own advantages and disadvantages. Two options center on adding a new
benefit for a nonillness-related examination, specifically either (1) a
one-time "welcome-to-Medicare" examination for new beneficiaries or (2) a
periodic examination benefit for all beneficiaries. Coverage of a one-time
or periodic wellness examination could be easily administered, and the
examination could provide an opportunity for beneficiaries to receive

some preventive services. Adding such a benefit, however, could increase
Medicare costs and still not guarantee that beneficiaries receive the
preventive services they need. The results of a past CMS demonstration
indicate that offering Medicare beneficiaries packages of broad-based
preventive services has not consistently improved health or lowered
hospital and other costs. As a result, CMS has recently considered an
alternative option that would essentially create a different structure
using nonphysician providers to assess health risks and ensure the
delivery of preventive services within the fee-for-service program. The
agency has started the development work to design a project to examine
whether assessments of individual health risks, combined with continued
counseling and follow-up services provided by nonphysicians, will improve
delivery of preventive services and beneficiary health. CMS also has under
way several other demonstration projects related to preventive care in the
fee-for-service program, such as a smoking cessation program tailored to
Medicare beneficiaries. Results from these demonstration efforts are not
expected for several years.

HHS reviewed a draft of this report and generally concurred with the
findings.

Many of the health conditions that people age 65 and older experience are
preventable and linked to specific health risks. Some health risks are
difficult to change, and some, such as a hereditary predisposition for a
given disease, cannot be changed. For these, preventive services such as
cancer screens can help identify disease in its early stages so that
people can be referred to other services that can help manage or treat the
disease. Other health risks, such as complications from influenza, can be
successfully reduced by targeted preventive services. For example, studies
show that immunizations against influenza can prevent thousands of
hospitalizations and deaths each year among those age 65 and older. Health
risks such as high blood pressure and high cholesterol are also considered
health conditions because, if left alone, they can develop into
potentially more significant conditions, such as cardiovascular disease,
or lead to stroke.

The term preventive care covers a wide spectrum of actions aimed at
reducing risks for deteriorating health and improving the detection and
management of disease. Generally, preventive care is intended for three
purposes:

  Background

o  	To prevent a health condition from occurring at all. Vaccinations and
physical activity to reduce the risk of heart disease, for example,
qualify as this first type of preventive care (termed primary prevention).

o  	To prevent or slow a condition's progression to more significant
health conditions by detecting a disease in its early stages. Mammograms
to detect breast cancer and other screens to detect disease early are
examples of this second type of preventive care (termed secondary
prevention).

o  	To prevent or slow a condition's progression to more significant
health conditions by minimizing the consequences of a disease. Care
coordination and self-management of an existing disease, such as diabetes
or asthma, are examples of this third type of preventive care (termed
tertiary prevention).

Many people associate the idea of preventive care with annual physical
examinations, or "routine checkups," by a family doctor, a practice first
proposed by the American Medical Association (AMA) in the early twentieth
century. In the early 1980s, however, the AMA determined that appropriate
preventive care depends on an individual's age and particular health
risks, not simply on the results of a standard battery of tests.6 To
evaluate preventive care for different age and risk groups, HHS in 1984
established a panel of experts called the U.S. Preventive Services Task
Force. At present, the task force recommends certain screening,
immunization, and counseling services for people age 65 and older (see
app. II).

Medicare covers some, but not all, of the task force-recommended
preventive services (see comparison in app. II). Medicare's
fee-for-service program-which comprises approximately 84 percent of
Medicare beneficiaries-does not cover periodic checkups, where clinicians
might assess an individual's health risk and provide needed preventive
services. These Medicare beneficiaries may, however, receive some of these
services during office visits for other health problems. Under Medicare +
Choice, which covers about 14 percent of Medicare beneficiaries, a benefit
for periodic checkups generally does exist.

6 The annual physical examination of healthy persons, in which a standard
set of tests and procedures is performed, was first proposed by the AMA in
1922. For many years afterward, health professionals recommended routine
physicals and comprehensive laboratory testing as effective preventive
medicine. But in 1983, the AMA withdrew its support for a standard annual
examination. Instead, the organization supported periodic visits in which
patients receive preventive services depending upon the individual's
unique combination of age, sex, and health risk.

  Most Beneficiaries Receive Some Preventive Services, but Not All That Are
  Recommended

Medicare beneficiaries typically visit a physician several times during a
year and most receive some preventive services, but most do not receive
the full range of recommended services. Based on 2000 survey data and U.S.
Bureau of the Census estimates of people age 65 and older, we estimate
that beneficiaries visit a physician at least six times a year, on
average, mainly for illnesses or medical conditions.7 About 1 in 10 visits
occurred when beneficiaries were well, and most Medicare beneficiaries
reported having what they considered to be a "routine checkup" in the
previous year. The purposes of these routine checkups and the specific
services that are delivered during these visits, however, remain unknown.
Many Medicare beneficiaries did not receive recommended preventive
services, such as influenza and pneumonia immunizations. Moreover, another
national survey indicated that a substantial share of Medicare
beneficiaries who were at risk for a condition that preventive services
are meant to identify said that they had not been told by a health
professional that they might have that condition.

    Medicare Beneficiaries Visit Physicians Often, and Most Report Receiving
    Routine Checkups

In 2000, 88 percent of Medicare beneficiaries reported that they visited a
physician at least once that year.8 On the basis of data from CDC's
National Ambulatory Medical Care Survey, we estimate that, on average,
beneficiaries visit physicians at least six times a year.9 Almost 9 in 10
visits made by beneficiaries in the fee-for-service program were to treat
illnesses or health conditions: more than half the visits targeted
preexisting (chronic) problems, more than one-fourth targeted illnesses of
sudden or recent onset (acute), and about 10 percent of visits took place
pre- or postsurgery or to follow up after injuries. Only about 10 percent
of visits

7 The surveys and other data sources from which we developed our
information generally did not disaggregate the information into
beneficiaries receiving care through fee-for-service and beneficiaries
receiving care through Medicare + Choice programs. As a result, unless
otherwise noted, the data reported include beneficiaries from both groups.

8 CMS's Medicare Current Beneficiary Survey, 2000.

9 To estimate the average number of physician visits, we used data from
the National Ambulatory Medical Care Survey and the U.S. Bureau of the
Census. See app. I for a description of our methodology. We believe that
the result is a conservative estimate of the average number of physician
visits, since the segment of the survey that we analyzed excluded visits
made in hospital outpatient and emergency departments or other
institutional settings and also excluded physicians in the specialties of
anesthesiology, pathology, and radiology.

dealt with nonillness care when the patient was considered healthy (see
fig. 1).10

Figure 1: Major Reasons for Physician Visits by Medicare Beneficiaries in
the Fee-for-Service Program, 2000

Chronic problem (Routine and flare-up)

Acute problem

Pre- and postsurgery or injury follow-up

Nonillness care

                                    Unknown

Care for specific conditions

         Source: CDC's National Ambulatory Medicare Care Survey, 2000.

Note: Numbers do not add to 100 percent due to rounding. The survey
defined an "acute problem" as a condition or illness of sudden or recent
onset, a "chronic problem" as a preexisting long-term or recurring
condition or illness, and "nonillness care" as a general health
maintenance examination or routine periodic examination of a presumably
healthy person. For chronic problems, the survey reported results
separately for "routine chronic problems" and for "chronic problem
flare-ups." We combined these results in this figure. The separate results
are found in app. I.

Even though the majority of visits to physicians are for treating illness
or health conditions, most Medicare beneficiaries reported receiving
routine checkups. In CDC's 2000 Behavioral Risk Factor Surveillance System
Survey, for example, 93 percent of respondents age 65 and older reported
that they had received a "routine checkup" within the previous 2 years.

10 Because Medicare's fee-for-service program does not cover routine
physical examinations but does cover some preventive services, such as
immunizations and certain cancer screening tests, it is possible that some
of the nonillness visits in 2000 were to obtain such services. In
addition, some fee-for-service beneficiaries may be paying for nonillness
examinations through other means, such as employer-provided or other
supplemental insurance. According to CMS's Medicare Current Beneficiary
Survey, in the year 2000 about 41 percent of Medicare fee-for-service
beneficiaries had insurance from former employers to supplement their
basic Medicare benefit.

This survey did not, however, provide information on which specific
services were delivered during those checkups. Indeed, as the following
section shows, few beneficiaries receive all recommended services,
although they receive some preventive services during visits when they are
healthy as well as during visits to treat illnesses or health conditions.

    Despite Frequency of Visits, Many Medicare Beneficiaries Do Not Receive the
    Full Range of Recommended Preventive Services

Despite how often Medicare beneficiaries visit physicians, many of them do
not receive a full complement of recommended preventive services,
including some recommended by the U.S. Preventive Services Task Force and
currently covered by Medicare. As we reported earlier, use of specific
preventive services varies widely by service.11 Although each preventive
service we reviewed was delivered to a majority of Medicare beneficiaries,
relatively few beneficiaries received the full range of preventive
services. For example, 91 percent of female Medicare beneficiaries
received at least one preventive service, but only 10 percent were
screened for cervical, breast, and colon cancer and also immunized against
influenza and pneumonia.12 Our analysis of additional data since our
previous report shows that many Medicare beneficiaries still do not
receive certain recommended preventive services. The task force
recommends, for example, that all people age 65 and older receive an
annual influenza vaccination and at least one pneumonia vaccination. In
CMS's Medicare Current Beneficiary Survey of 2000, however, about 30
percent of Medicare beneficiaries did not receive an influenza
vaccination, and 37 percent had never had a pneumonia vaccination.

Survey data showing the services provided during office visits indicate
that Medicare beneficiaries do receive some preventive services during
visits when they are ill or being treated for a health condition, and
services are delivered at comparable rates during all types of visits,
whether for nonillness care or for treating acute or chronic conditions.
Beneficiaries in the fee-for-service program receive preventive services,
such as cholesterol and blood tests, during visits when they are healthy
and during visits to treat acute or chronic health conditions. Some tests
are typically provided or ordered slightly more often during visits for
nonillness care. In

11 GAO-02-422.

12 In January 2003, the U.S. Preventive Services Task Force released new
recommendations for the use of pap smears to screen for cervical cancer.
The task force now "recommends against screening women 65 and older who
have had adequate recent screenings with normal Pap smears and are not
otherwise at increased risk for cervical cancer."

2000, for example, blood tests for anemia13 were provided in about 16
percent of visits for nonillness care, compared with 7 percent of visits
for chronic problems and 5 percent of visits for acute conditions. Other
preventive services were provided at similar rates during the different
types of visits. For example, we estimate that blood pressure measurement,
a clinical screen for conditions such as hypertension, was done during 56
to 62 percent of visits, depending on the type of visit. Diet counseling
services were provided during 13 to 20 percent of visits, depending on the
type of visit.14

    Many Beneficiaries May Be Unaware of Their Risk for Health Conditions That
    Preventive Care Is Meant to Detect

Many Medicare beneficiaries may not know that they are at risk for health
conditions that preventive care could detect-strong evidence that they may
not be receiving the full range of recommended preventive services.15 For
example, data from CDC's NHANES for 1999-2000 show that, of beneficiaries
participating in this nationally representative survey who had a physical
examination and were found to have elevated blood pressure readings at the
time of the examination, 32 percent reported that no physician or other
health professional had ever told them about the condition. On the basis
of this survey, we estimate that, during the period when the survey was
conducted, 21 million Medicare beneficiaries may have been at risk for
high blood pressure, and an estimated 6.6 million of them may have been
unaware of this risk. Similarly, 32 percent of those found in the
1999-2000 survey to have a high cholesterol level reported

13 Anemia is a condition in which the blood is deficient in red blood
cells, hemoglobin, or total volume. The hematocrit/hemoglobin test is used
to test for anemia and to measure the concentration of packed red blood
cells and hemoglobin in the blood. Hemoglobin is an iron-containing
respiratory pigment in red blood cells that helps transport oxygen from
the lungs to the body tissues.

14 Specifically, blood pressure measurements were provided at 56 percent
of visits for acute problems, 59 percent of visits for chronic problems,
and 62 percent of nonillness visits. Diet counseling services were
provided at 13 percent of visits for acute problems, 20 percent of visits
for chronic problems, and 18 percent of nonillness visits. For both blood
pressure measurement and diet counseling service estimates, the
differences in these percentages were not statistically significant at the
95 percent confidence level. See app. I for a discussion of the
methodology and specific results. Source: CDC's National Ambulatory
Medical Care Survey, 2000.

15 The source of data for this statement was CDC's National Health and
Nutrition Examination Survey of 1999-2000. This survey oversampled-that
is, included a larger number of persons age 60 and older in the sample,
providing for a sample size that enabled us to focus our analysis
specifically on the Medicare-age population for selected conditions. App.
III contains a description of this survey and the specific results of our
analyses.

that no one had told them that they had high cholesterol. Projected
nationally, this percentage translates into 2.1 million Medicare
beneficiaries (see fig. 2).

Figure 2: Estimated Number of Medicare Beneficiaries Age 65 and Older Who
Were Aware and Unaware That They Might Have High Blood Pressure or High
Cholesterol, 1999-2000

                              High blood pressure

High cholesterol

                                      14.4

0 2 4 6 8 10121416 Estimated number of Medicare beneficiaries (in
millions)

Told by physician or health professional

Not told by physician or health professional

Source: CDC's National Health and Nutrition Examination survey.

Note: CDC's NHANES measured blood pressure three or four times during its
1-day physical examination. For our analysis, we calculated the average of
the blood pressure measurements and applied CDC's definition of high blood
pressure: that is, a patient's having an average systolic blood pressure
equal to or greater than 140, or an average diastolic blood pressure equal
to or greater than 90, or a patient who reported taking hypertension
medication. CDC defined high cholesterol as a total cholesterol level
equal to or greater than 240.

The Medicare + Choice plans we reviewed vary in their specific strategies
for delivering preventive services, but several common themes emerge from
their efforts. First, nearly all identify members' health risks and inform
them or their providers about specific services that might be needed. For
example, some plans mail questionnaires to members, seeking information,
such as when certain screening tests were last performed; other plans
review claims and prescription data to identify at-risk members who might
need a screening test or other preventive service. Second, all plans have
follow-up strategies to help beneficiaries obtain needed preventive
services, although their strategies and priorities vary. Third, while
limited data provided by some plans suggest promising results, most plans
have not evaluated the degree to which their strategies improve health
outcomes or affect health care costs for Medicare beneficiaries.

Medicare + Choice Plans Reviewed Assess Health Risks Using Varying
Approaches

    Plans Use a Combination of Ways to Identify Health Risks

Although all the Medicare + Choice plans we reviewed use questionnaires to
meet the requirement that they conduct health assessments for newly
enrolled Medicare beneficiaries,16 they use a combination of approaches to
identify health risks. The particular risks that plans seek to identify
vary from plan to plan. Risks include those associated with depression or
lack of physical activity; risks from not obtaining recommended
immunizations or screenings, such as mammography; and more general risk of
short-term hospitalization or illness.17 For example, Group Health
Cooperative, Highmark Blue Cross and Blue Shield, and Kaiser Permanente
use questionnaire information to calculate a risk score meant to represent
each enrollee's probability of using health services heavily in the
future. From its questionnaire, Kaiser Permanente also calculates the
probability of 3-year survival for enrollees who have an existing advanced
illness, as well as the probability that they will become dependent on
others for daily care or need nursing home services during the next year
(a condition Kaiser Permanente officials refer to as frailty). Oxford
Health Plan, on the other hand, analyzes questionnaire data to assign
enrollees a risk classification of high, moderate, or low and assigns
patients to health management teams or programs appropriate for each risk
level.

For existing members, plans use slightly different approaches to identify
health risks, including information from claims and pharmacy data, annual
risk assessment questionnaires, physician visits, and computer systems
(called registries) that indicate when patients require specific
preventive services. The specific approaches vary from plan to plan. For
instance, Group Health Cooperative officials reported that they review the
health risks, such as the immunization status, of their existing members
through health maintenance visits, which they encourage Medicare
beneficiaries to have every 2 years. During this visit, the provider
reviews responses to a completed questionnaire that each patient is asked
to bring to the visit and updates computer registry data, compiled from
previous risk assessment questionnaires and physician visits. AvMed
conducts a health risk

16 Medicare + Choice plans are required to make a "best effort attempt" to
assess newly enrolled Medicare beneficiaries. 42 C.F.R. S:
422.122(b)(4)(i) (2002).

17 The risk assessment questionnaires for some plans are as brief as a
one-page form, while others are as long as eight pages. A number of
questions focus on identifying functional status, such as the ability to
bathe independently; immunization status; current use of prescription
medications; the history of screening tests, such as mammography; past
health care use, such as the number of times enrollees saw their primary
care physician in the preceding 6 months; behavior risks, such as smoking;
and past illnesses or existing health conditions.

assessment for each of its Medicare members and also uses claims and
pharmacy data to identify members with specific diseases, so as to target
preventive services. For example, using pharmacy and claims data to
identify people with diabetes, AvMed invites these members to a health
fair featuring services to prevent further progression of the disease.
Paying a single copayment to attend the health fair, members can receive a
number of services, such as a blood draw for laboratory work and vision
and glaucoma screening.

Finally, some plans report that they have increased the use of specific
preventive services through their participation in CMS-required national
performance improvement projects.18 For example, Highmark reported that in
2002 the plan used medical claims data to identify female Medicare
beneficiaries who had not received a mammogram within the past 2 years and
notified the beneficiaries and their physicians. As a result, the
officials reported that 60 percent of contacted beneficiaries went on to
receive mammograms.

    Plans Use a Variety of Follow-up Means to Reduce Identified Risks

After identifying the health risks of Medicare beneficiaries-whether new
enrollees or existing members-plans we contacted reported that they also
make efforts to follow up on that information by providing feedback to
enrollees about risks and referring them to specific, risk-related
preventive services. For example, all plans have approaches to prevent
disease progression for individuals identified as having chronic health
conditions. The plans sometimes differ in their types of follow-up and in
their emphasis on different types of preventive services. Some plans we
reviewed, for example, stress primary prevention activities, such as
exercise programs for all members, to a greater degree than others.

To provide feedback, many plans contact members directly through letters
or phone calls, encourage contact with primary care physicians, or combine
written or oral feedback with follow-up physician examinations (see table
1).

18 CMS generally requires each Medicare + Choice plan to undertake one
national quality assessment and performance improvement project per year
to measure and improve its own performance in a CMS-defined national focus
area. Past national focus areas include improving diabetes care and
increasing vaccination rates for influenza and pneumonia.

Table 1. Feedback Processes Described by Medicare + Choice Plans

Health plan Feedback process

Group Health Using data available on computer registry, health
professionals can

Cooperative review specific health risks with members. Health
professionals also monitor the computer registry to track services members
use. Kaiser

       For new enrollees, physicians review a summary report and provide

Permanente feedback during an initial office visit. In San Diego, existing
members who visit health assessment centers receive a letter, based on a
completed questionnaire and tests estimating "health age," that discusses
ways of decreasing specific health risks, and they receive a second visit
for a complete exam.

Oxford Health Various departments receive health risk reports based on
risk

Plans 	assessment questionnaires. Reports for high-risk members go to
teams of registered nurses, who contact the members and their primary care
physicians to coordinate care.

Highmark Blue Plan sends results of health risk assessment to physicians
to facilitate Cross and Blue discussion with patients. Members with risks
related to smoking, heart Shield disease, or osteoporosis receive letters.
New members identified as

at risk for being frail are referred to case managers, and members
identified with chronic disease are referred to a condition management
program for targeted interventions.

AvMed Health Physicians receive health risk information from risk
assessment

Plans 	questionnaires and pharmacy and claims data. Members identified as
having specific risks are contacted directly by the plan if health
promotion or disease management programs are available for them.

Source: Plan officials and plan documents.

In addition to educating members about their health risks, some plans also
link members to specific preventive services to reduce or mitigate these
risks. For example, plans may send targeted health promotion materials;
offer 24-hour telephone access to a nurse to discuss health concerns; or
offer access to fitness programs, nutrition courses, immunizations, exams,
and disease management or care coordination programs. These care
coordination programs resolve health care issues through various means,
such as in-depth telephone evaluations, communication with primary care
physicians, in-home visits, or connections with community resources like
Meals on Wheels.

To refer Medicare members to preventive services, one plan we contacted
emphasized directing them to primary prevention services, such as physical
activity programs, while another plan emphasized connecting members to
tertiary prevention services, such as disease management programs. For
example, identifying physical activity and social isolation as two
important predictors of overall health outcomes for seniors, Group Health
Cooperative refers Medicare members to physical activity benefits

and other primary prevention services. In contrast, acknowledging that
most individuals age 65 or older have more than one chronic health
condition, AvMed focuses more on identifying members with existing
conditions and referring them to preventive services that can mitigate the
condition. AvMed has created eight disease management programs covering
conditions such as congestive heart failure, asthma, and diabetes. The
goal is to provide members having these conditions with a series of
condition-specific care interventions. For example, interventions for
AvMed enrollees in the congestive heart failure program include
prescribing specific drugs (such as ACE19 inhibitors, diuretics, and
beta-blockers), providing self-directed care plans, and monitoring weight.

Some plans described how they track the success of their efforts to
provide people with specific preventive care interventions. Highmark, for
example, offers financial incentives to physicians who follow specific
clinical guidelines for a given condition. The plan also gives physicians
quarterly report cards, generated by a computer registry, that indicate
whether their patients have received all the care recommended by the
management programs in which the patients are enrolled. AvMed, on the
other hand, tracks the number of members identified as eligible for
specific disease management programs, whether the program was offered to
all eligible members, and the number who enrolled. AvMed also reported
setting, monitoring, and reporting on performance goals for the percentage
of members receiving specific care interventions. For example, for
enrollees in the congestive heart failure management program, AvMed tracks
the percentage receiving an ACE inhibitor drug.

    Assessments of Health Outcomes or Cost Savings for Medicare Beneficiaries
    Are Limited

Few of the health plans we contacted had specifically evaluated whether
their approaches to risk identification and reduction lead either to
improved health outcomes for Medicare beneficiaries or to cost savings for
the plan. From those plans that have such information, the available data
suggest that offering disease management programs to people who have
existing health conditions may hold promise, but most plans lacked
evidence from controlled studies of a specific benefit to their Medicare
members.

AvMed and Oxford are among the plans that have evaluated whether their
approach improves health outcomes and saves money. For example,

19 Angiotensin-converting enzyme.

AvMed plan officials observed that, in all AvMed plans, including its
Medicare + Choice plan, AvMed members with existing chronic conditions
spent fewer days in the hospital during the same period when more of their
members with existing conditions were enrolled in disease management
programs. According to AvMed officials, between 2001 and 2002, shorter
hospital stays of Medicare congestive heart failure patients led to total
savings of $1 million, and shorter hospital stays of asthma patients from
all plans (not limited to Medicare beneficiaries) led to savings of
$400,000. Similarly, Oxford has estimated savings attributed to various
interventions, such as a mean savings of $219 per member per month from
Medicare beneficiaries who voluntarily participated in a self-management
workshop for diabetes, as compared with a random group of diabetic members
who did not attend the workshop. Although these findings show potential to
improve health and decrease costs, it is unclear from this information
whether the decreased length of hospitalization and cost savings resulted
from disease management or from other factors. It is also not clear what
the long-term effects may be on Medicare beneficiaries and whether these
observations would also apply to beneficiaries in a fee-for-service
environment.

Some plans are evaluating specific aspects of their approaches as a first
step in determining which approaches are effective. For example, Kaiser
Permanente officials provided data demonstrating their ability to identify
a certain type of health risk among Medicare beneficiaries, but they did
not provide data demonstrating that their overall approaches to risk
identification or risk reduction resulted in improved health outcomes or
cost savings.20 Specifically, they found that three questions on the risk
assessment questionnaire, along with the patient's age, predicted with a
high degree of accuracy whether a person would need daily assistance from
another person during the following year. Kaiser identified these people
as at risk for frailty and through additional study found that, over the
next decade, frail people spent more days in nursing homes than
individuals who were not frail.21 Kaiser Permanente officials told us that
they have not identified interventions that decrease or prevent frailty
from

20 Specifically, over the next decade, people designated as "frail" spent
800 percent more days in nursing homes than individuals who were not
frail. K.K. Brody, R.E. Johnson, and L.D. Ried, "Evaluation of a
Self-Report Screening Instrument to Predict Frailty Outcomes in Aging
Populations," The Gerontologist, 37 (1997): 182-191.

21 K.K. Brody et al., "A Comparison of Two Methods for Identifying Frail
Medicare-Aged Persons," Journal of American Geriatrics Society, 50 (2002):
562-569.

developing but were instead focusing on identifying interventions to
improve outcomes for those people once they were identified as frail.22

In addition to reviewing the efforts of contacted Medicare + Choice plans,
we reviewed several studies that evaluated the effectiveness of
employer-sponsored approaches to providing preventive services, such as
health risk assessment and feedback, to both employees and retirees.
Although these studies conclude that employer-sponsored approaches hold
promise in terms of increasing preventive services, improving health
outcomes, and lowering cost, we found the results limited in how they
might be generalized to all Medicare beneficiaries. For example, General
Motors evaluated its companywide prevention program, which offered health
risk assessments, individualized health profiles, a quarterly newsletter,
a self-care book, and a toll-free health information line. The company
reported that providing risk assessment and feedback helped participants
lower their health risk status and that nearly half of this benefit was
realized within the first of 5 years. Although General Motors provides a
similar risk appraisal program to retirees, this study did not include
them, so the study's finding cannot be generalized to the Medicare
population.

  New Ways to Improve the Provision of Preventive Services within Medicare's
  Fee-for-Service Program Are Promising but Untested

Several options have been suggested for improving the provision of
preventive services within Medicare's fee-for-service program. They
include adding a new benefit for a nonillness-related examination, either
a one-time "welcome-to-Medicare" examination for new beneficiaries or an
examination available to all beneficiaries on a periodic basis. Although
covering a one-time or periodic nonillness examination could be easily
administered and could increase the receipt of some preventive services,
doing so could also increase Medicare costs without necessarily ensuring
that beneficiaries receive the full range of preventive services. CMS has
tested similar options in the past and found that they produced mixed
results. It is now examining an alternative that would essentially create
a different structure using nonphysician providers to assess health risks
and connect individuals with preventive services. The design work will be
completed at the end of 2003, and if the decision is made to conduct a
demonstration, results would not be available for several years after
that. Additional demonstrations also under way-such as one exploring

22 Once frail people are identified, for example, Kaiser encourages
medical providers to follow guidelines intended to detect conditions such
as depression and to prevent outcomes such as injuries from falls.

effective smoking cessation approaches and one giving physicians
incentives to coordinate and manage the overall health care needs of
beneficiaries-may provide additional insights into coordinating and
delivering appropriate preventive services within the Medicare
fee-for-service program.

    Two Proposed Options Center on Adding a Preventive Examination to the
    Medicare Fee-for-Service Program

A one-time "welcome-to-Medicare" examination for new beneficiaries has
been proposed as a means to better ensure that health care providers have
enough time to identify individual Medicare beneficiaries' health risks
and provide preventive services appropriate for their risks.23 Proponents
assert that a one-time benefit could combine a health evaluation with
screenings and immunizations, along with counseling about health promotion
and disease prevention. It could also orient new beneficiaries to Medicare
and encourage them to make informed choices about providers and plans.
Health risk assessment and behavior counseling could be provided by a
range of nonphysician professionals, including nurses, counselors, and
dietitians.

A similar option would have Medicare cover an annual or periodic
preventive visit available to all fee-for-service beneficiaries. In
theory, many of the advantages of a one-time preventive visit would also
apply to periodic examinations. For instance, dedicated preventive visits
might provide greater opportunities for health care providers to assess
and address health risks. Some evidence also suggests that a periodic
health examination may increase use of preventive cancer screening and
counseling services. For example, a National Cancer Institute-supported
study surveyed general internists and family physician practices and their
patients in 1992 and found that patients who had received a periodic

23 Partnership for Prevention, A Better Medicare for Healthier Seniors:
Recommendations to Modernize Medicare's Prevention Policies (Washington,
D.C.: Partnership for Prevention, 2003), and Gilbert S. Omenn, "Historical
and Current Policy Issues in Establishing Coverage for Clinical Preventive
Services under Medicare," cited in the Partnership for Prevention's
report.

health examination within the previous year were substantially more likely
to have received appropriate cancer screening and counseling.24

While these options have benefits, they also have potential drawbacks.
Adding a benefit for a one-time or periodic examination to the Medicare
fee-for-service package could increase the program's costs without
necessarily ensuring that beneficiaries receive the full range of
preventive services. The Congressional Budget Office in June 2002
estimated that a one-time physical examination benefit for new enrollees
could cost as much as $1.6 billion over the 2003-2012 period.25 According
to a Congressional Budget Office official, the agency has not recently
estimated the potential costs of a Medicare benefit for examinations
provided on a periodic basis. This cost, however, would likely be
substantially higher than that of a one-time visit for new beneficiaries.
At the same time, establishing such a benefit would not necessarily ensure
delivery of the full range of preventive services. In addition, primary
care physicians typically cannot provide services such as mammography
screenings for breast cancer and colonoscopies for colon cancer, because
these services usually require specialists.

It also remains uncertain whether covering a one-time or periodic
examination would be an effective means of improving beneficiary health
outcomes. A previous CMS initiative that included preventive health care
visits ended with mixed results. In the late 1980s and early 1990s, the
agency conducted a congressionally mandated demonstration to test varied
health promotion and disease prevention services, such as free preventive
visits, health risk assessment, and behavior counseling, to see if they
would increase use of preventive services, improve health outcomes,

24 C.H. Sox et al., "Periodic Health Examinations and the Provision of
Cancer Prevention Services," Archives of Family Medicine, 6 (1997):
223-230. This study reviewed a random selection of community general
internists and family physician practices in New Hampshire and Vermont.
Care was assessed for those who were patients of the study physicians for
at least 1 year, were age 42 or older, had no life-threatening illness,
and had recently visited the physician.

25 See Congressional Budget Office cost estimate, H. R. Rep. 107-539, pt.
1, at 238. Beginning in 2004, the bill would have required Medicare to pay
for a routine physical examination and associated services when furnished
within 6 months of a beneficiary's enrollment in part B. Beneficiaries
already enrolled would not have been eligible for this benefit. H.R. 4954,
107th Cong. (2d Sess. 2002).

and lower health care expenditures for Medicare beneficiaries.26 The
agency's final report, published in 1998, concluded that the demonstration
services were marginally effective in raising the use of some simple
disease prevention measures, such as immunizations and cancer screenings,
but did not consistently improve beneficiary health outcomes or reduce the
use of hospital and skilled nursing services.27

    CMS Is Exploring an Alternative for Assessing Health Risks and Delivering
    Preventive Services

CMS is exploring one alternative for Medicare preventive care that would
provide systematic health risk assessments to fee-for-service
beneficiaries through a means other than physician visits. In the late
1990s, the agency commissioned the RAND Corporation to evaluate the
potential effectiveness of health risk assessment programs. Similar to the
approaches taken by the Medicare + Choice plans we reviewed, such programs
collect information from individuals; identify their risk factors; and
refer the individuals to at least one intervention to promote health,
sustain function, or prevent disease.28 The study concluded that health
risk assessment programs have increased beneficial behavior (particularly
exercise) and improved physiological variables (particularly diastolic
blood pressure and weight) and general health status. It also concluded
that more research would help clarify the programs' effects on preventive
services such as clinical screening.29 In addition, the study stated that
to be

26 A 4-year demonstration was mandated in the Consolidated Omnibus Budget
Reconciliation Act of 1985, Pub. L. No. 99-272, S: 9314, 100 Stat. 82, 194
(1986), and extended for 1 year by the Omnibus Budget Reconciliation Act
of 1990, Pub. L. No. 101-508, S: 4164, 104 Stat. 1388, 1388-100. At the
time, CMS was known as the Health Care Financing Administration.

27 Donna E. Shalala, Medicare Prevention Demonstration: Final Report, RC
87-172 (Washington, D.C.: Department of Health and Human Services, 1998).
The report tempered these results by pointing out that the relatively
brief period during which the services were provided (roughly 2 years) and
the limited number of provider contacts and follow-ups (one to two) may
have been inadequate to achieve measurable outcomes. In addition, the
grouping of the health risk assessment and preventive services into a
preventive package may have obscured the relative effects of individual
components of the package.

28 A typical health risk assessment obtains information on demographic
characteristics (e.g., sex, age), lifestyle (e.g., smoking, exercise,
alcohol consumption, diet), personal health history, and family health
history. In some cases, physiological data (e.g., height, weight, blood
pressure, cholesterol levels) are also obtained, as well as a patient's
status regarding cancer screens and immunizations.

29 Southern California Evidence-Based Practice Center/RAND, Health Risk
Appraisals and Medicare (Baltimore: Centers for Medicare & Medicaid
Services, 2001). RAND identified 267 articles, unpublished reports, and
conference presentations, of which 27 contained data that project staff
deemed necessary to be included as evidence of the effectiveness of health
risk assessments.

effective, risk assessment questionnaires must be coupled with follow-up
interventions such as referrals to appropriate services. The study found
limited but encouraging evidence on the effectiveness of health risk
assessment programs but concluded that the evidence was insufficient to
accurately estimate the programs' cost-effectiveness. The study
recommended that CMS conduct a demonstration to test cost-effectiveness
and other aspects of the health risk assessment approach for Medicare
beneficiaries.

Following up on the study's findings, CMS has begun designing a
fee-for-service-focused demonstration project, called the Medicare Senior
Risk Reduction Program, to identify health risks and follow up with
preventive services provided by means other than physician visits. The
program will use a beneficiary-focused health risk assessment
questionnaire to assess health risks, such as lifestyle behaviors, and use
of clinical preventive and screening services. Because the demonstration
is still in its design phase, the particular set of risk factors to be
included is not yet final. Risk factors that might be addressed include
preventable accidents such as falls, lack of exercise, high blood
pressure, obesity, and use of preventive services. The Medicare Senior
Risk Reduction Program will test different approaches to administering
health risk assessments, creating feedback reports, and providing
follow-up services, such as referring beneficiaries to health-promoting
community services including physical activity and social support groups.
According to project researchers, the program will tailor preventive
interventions to individual risks; track patient risks and health over
time; and provide beneficiaries with self-management tools and
information, health behavior advice, and end-of-life counseling where
appropriate. The design phase is scheduled for completion in late 2003,
when CMS will decide whether to conduct a full demonstration.30 According
to CMS officials, the potential demonstration's final cost was uncertain
at the time our report was completed. CMS is spending approximately $1
million on the developmental work.

Unlike some health risk assessment programs, CMS's program will be limited
to questionnaires and follow-up contacts; it will not directly provide
clinical screening such as blood pressure or cholesterol measurements.
Instead, the program will concentrate on identifying, through information
provided by the beneficiary, any modifiable lifestyle

30 According to CMS, the demonstration would also require approval from
the Office of Management and Budget.

and behavioral risk factors and on referring beneficiaries to services for
reducing those risks. CMS officials and researchers did indicate, however,
that the program's risk assessment tools will collect information on
needed immunizations and cancer screenings and alert beneficiaries and
their physicians to any needed services.

    CMS Is Also Exploring Ways to Improve Care for Those with Identified Health
    Risks and Conditions

CMS has other initiatives under way that may help improve the delivery of
preventive services within the fee-for-service program. The first is the
Medicare Stop Smoking Program, a smoking cessation demonstration project
for fee-for-service beneficiaries. Recognizing that smoking is the single
most preventable cause of disease and death in the United States, posing a
significant health risk to the aged, CMS launched the demonstration to
identify the most effective service to help beneficiaries stop smoking.
The demonstration will evaluate the effectiveness of different smoking
cessation services. The four services being tested are: (1) reimbursement
for provider counseling, (2) reimbursement for provider counseling and for
smoking cessation drugs or nicotine replacement therapy, (3) access to a
telephone counseling quit-line plus reimbursement for nicotine replacement
therapy, and (4) provision of written information on smoking cessation.
Seven states are participating in the demonstration: Alabama, Florida,
Missouri, Ohio, Oklahoma, Nebraska, and Wyoming. The study will be
completed in 2004, with the results published in 2005. CMS has budgeted
approximately $14 million for this project.

CMS is also developing a physician group-practice demonstration that was
required by the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000.31 The aim of this demonstration is to provide
incentives for physicians to coordinate and manage the overall health care
needs of Medicare fee-for-service beneficiaries, especially those with
chronic health conditions. Under the 3-year demonstration, physician
groups will be paid on a fee-for-service basis and may, in some
circumstances, earn a bonus from savings achieved if the average Medicare
expenditure for beneficiaries in their group of patients is below an
established target.32 Up to six physician group practices will be selected

31 Pub. L. No. 106-554, app. F, S: 412, 114 Stat. 2763, 2763a-509.

32 Annual performance targets will be established for each participating
physician group, equal to the average Medicare expenditures of
beneficiaries assigned to that group during the base period and adjusted
for health status and expenditure growth.

to participate in the demonstration, which is expected to start during
2003. Under the mandate, the aggregate expenditures for this demonstration
must be budget neutral. Any bonus payments made to physician groups must
therefore be taken from savings produced by the participating
organizations.

Finally, a 4-year coordinated-care demonstration is currently under way at
16 sites. Authorized by the Balanced Budget Act of 1997, this
demonstration examines private-sector best practices for coordinating the
care of patients with complex chronic conditions.33 These conditions
include congestive heart failure, other heart and lung diseases, liver
diseases, diabetes, psychiatric disorders, Alzheimer's disease or other
dementia, and cancer. CMS is testing whether care coordination
programs-such as those that develop a plan of care after a complete
assessment of patient needs and offer patient education, health care
service arrangements, and coordination with providers-can, without
increasing program costs, improve the quality of care and reduce avoidable
hospital admissions among Medicare beneficiaries with chronic diseases.
The selected sites mix case management and disease management models in
their practices;34 operate in urban and rural settings around the country;
and include hospitals, retirement communities, and academic medical
centers. CMS is required to formally evaluate the projects every 2 years
after implementation and report to the Congress on its findings. HHS
officially announced the selected sites in January 2001, and as of May
2003, the 16 sites had enrolled approximately 10,000 Medicare
beneficiaries in the demonstration. CMS officials stated that the
demonstration could eventually enroll more than 36,000 beneficiaries,
although half of these will serve as a control group who will not receive
coordinated care. CMS officials told us that they expect this
demonstration to also be budget neutral. That is, they anticipate that
overall costs to Medicare for providing the services will be offset by
savings achieved from providing the care coordination services.

33 Pub. L. No. 105-33, S: 4016, 111 Stat. 343, 345.

34 Case management services would be provided to help manage general
health, and disease management services would be provided to help manage a
specific disease.

Concluding Observations

Agency Comments

Most Medicare beneficiaries receive some preventive services, but many do
not receive services that can help prevent and manage their health risks
and conditions early, before significant health problems occur. Services
recommended for all people in this age group are not delivered
consistently. Perhaps of most concern, nearly one-third of beneficiaries
who were screened and identified as having elevated blood pressure or high
cholesterol measures in a nationally representative survey had not
previously been told by their physicians or other health providers that
they had these conditions. Projected nationally, the survey results
translate into millions of people who could be unaware that they have a
health condition whose treatment could prevent or delay much more
significant health concerns.

The solutions to ensure that beneficiaries receive needed services are not
obvious. The experience of selected Medicare + Choice plans shows that no
single approach stands out. All plans we contacted had a means to identify
health risks, to provide feedback on risks to patients or their
physicians, and to follow up with interventions to reduce those risks. But
the follow-up programs, approaches, and priorities differed among the
plans we contacted, and few had evaluated their approaches in a manner
that would indicate whether these programs could, without significantly
increasing costs, improve health outcomes for Medicare beneficiaries.
Nevertheless, some current research shows promise for improving the
delivery of preventive services-particularly when there are follow-up
interventions, such as referrals to appropriate services.

We obtained comments on our draft from HHS as well as from the health
plans we contacted. HHS generally concurred with our findings and provided
examples of CMS's successes in promoting existing preventive services and
in identifying strategies that might be used in future health promotion
efforts. HHS also clarified the status of its program evaluating the use
of individual health risk assessments, which is in development, and
clarified its Medicare Stop Smoking Program, which will assess options for
a new benefit for smoking cessation but not necessarily lead to CMS
coverage for these benefits. HHS emphasized that only the Congress can
decide which preventive services or benefits Medicare covers. HHS also
updated its estimate of this program's budget. We incorporated these
clarifications in the draft.

HHS also commented that without sufficient evidence, the report links
beneficiaries' lack of knowledge that they may have certain conditions,
such as high blood pressure, with evidence that they are not receiving the

full range of preventive services. We did not intend to link these
statements, but we have independent evidence for each of them and have
added information to our summary of results to help clarify this evidence.
HHS's comments are reproduced in appendix IV.

HHS and the health plans 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 issue
date.
We are sending copies of this report to the Secretary of HHS, the
Administrator of CMS, the Director of CDC, and others who are interested.
We will make copies available to others on request. In addition, the
report
will be available at no charge on the GAO Web site at http://www.gao.gov.

If you or your staff have any questions, please contact me at (202)
512-7119
or Katherine Iritani, Assistant Director, at (206) 287-4820. Other
individuals
who made contributions to this report include Matthew Byer, Sophia Ku,
and Tina Schwien.

Sincerely yours,

Janet Heinrich
Director, Health Care-Public Health Issues

                       Appendix I: Scope and Methodology

Because no single source contained all the information we needed to assess
the extent to which Medicare beneficiaries receive preventive services
through existing physician visits, we used data from four national health
surveys: three conducted by the Centers for Disease Control and Prevention
(CDC) and one conducted by the Centers for Medicare & Medicaid Services
(CMS) (see table 2). For example, CMS's Medicare Current Beneficiary
Survey samples Medicare beneficiaries, asking them for detailed
information on their demographic characteristics, insurance coverage, and
health status but asking only a few questions about specific preventive
services received during physician visits. In contrast, CDC's National
Ambulatory Medical Care Survey samples physicians about office visits,
rather than the people who made those visits. The survey contains
information about reasons for office visits and about diagnostic and
preventive services provided during visits, but it cannot be used to
determine the extent to which Medicare beneficiaries received these
services.1

 Table 2: Four National Health Surveys with Preventive Services Data, 1999-2000

                    Survey Data year Sample size Description

Behavioral Risk Factor Surveillance System, CDC

2000 	Annual target of 189,450 adults

A state-based random telephone survey of U.S. adults covering a wide range
of behaviors affecting health. The largest continuing telephone survey in
the United States, it provides national as well as state-specific
estimates.

 National Ambulatory 2000 27,369 office visits, of A national sample survey of
                      visits to office-based physicians in

Medical Care Survey, CDC

which 7,381 were made by people age 65 and older the United States.
Detailed information about each visit, such as major reason for the visit
and diagnostic and preventive services ordered or provided, is collected
through a patient record form completed by the physicians' offices.
National Health and Nutrition Examination Survey, CDC

1999-2000 	9,965 people, of which 1,392 were age 65 and older

This survey gathers nationally representative data on the health and
nutrition of the U.S. population through direct physical examinations and
interviews.

      Medicare Current 2000 About 16,000 Medicare A continuous survey of a
  representative national sample of the Beneficiary Survey, CMS beneficiaries

Medicare population that collects detailed data on beneficiaries'
insurance coverage, health status and functioning, and health care use and
expenditures.

Source: CDC and CMS.

For our analyses of these surveys, we extracted data for people age 65 and
older to represent Medicare beneficiaries, because almost 95 percent of

1 The National Ambulatory Medical Care Survey is conducted by CDC's
National Center for Health Statistics. See the Web site
http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm for details on the
survey design.

Appendix I: Scope and Methodology

the population in this age group was enrolled in Medicare in 2000.2 Also,
because the National Ambulatory Medical Care Survey samples office visits
to physicians, not the people who made the visits, to estimate the average
number of physician visits made by Medicare beneficiaries, we first
estimated the number of visits made by patients age 65 and older using
this database, and then divided this number by the U.S. Bureau of the
Census estimates of the civilian noninstitutionalized population age 65
and older. To determine the major reasons for physician visits and the
specific types of preventive services provided to Medicare beneficiaries
in the fee-for-service program, we used visit data in this survey for
patients age 65 and older who did not belong to a health maintenance
organization and whose visits were not paid on a capitated basis.3 Tables
3 to 5 show the estimates and standard errors in data from the National
Ambulatory Medical Care Survey 2000 on major reasons for physician visits
and on the preventive diet counseling services provided during those
visits. We also tested at the 95 percent confidence level the statistical
significance of differences we observed between nonillness and other types
of visits in the proportion of visits where preventive screening tests
(e.g., cholesterol and blood tests) were provided.

Table 3: Estimated Proportion of Fee-for-Service Physician Visits Made by
People Age 65 and Older, by Major Reason for the Visits, 2000

                                             Estimated               Standard 
                                   Sample  number (in    Estimated   error of 
                      Major reason  size   thousands)  percentage  percentage 
                     Acute problem  1,155       32,843        25.8 
          Chronic problem, routine  2,081       53,701        42.2 
                  Chronic problem,                                 
                          flare-up     532      13,254        10.4 
              Pre- or postsurgery,                                 
                  injury follow-up     577      12,533         9.8 
                   Nonillness care     395      12,479         9.8 
                  Blank or unknown      84        2495         2.0 

Source: GAO analysis of the National Ambulatory Medical Care Survey, CDC.

2 According to data from CDC's Behavioral Risk Factor Surveillance System,
in 2000, almost 95 percent of adults age 65 and older reported having
Medicare coverage.

3 "Capitated" refers to a method of payment for health services in which
an individual or institutional provider is paid a fixed amount for each
person served, without regard to the actual number or nature of services
provided to each person in a set period of time.

Appendix I: Scope and Methodology

Table 4: Estimated Proportion of Fee-for-Service Physician Visits in Which
Diet Counseling Services Were Provided or Ordered, by Major Reason for the
Visits, 2000

                                         Estimated                   Standard 
                              Sample    number (in     Estimated     error of 
                Major reason     size   thousands) percentagea     percentage 
               Acute problem    1,155        4,138          12.6 
            Chronic problem,                                     
                     routine    2,081       11,785          22.0 
            Chronic problem,                                     
                    flare-up      532        1,673          12.6 
             Nonillness care      395        2,295          18.4 

Source: GAO analysis of the National Ambulatory Medical Care Survey, CDC.

aThe differences in rates of services provided among the different types
of visits were not statistically significant. According to CDC, diet
counseling services could be underreported because the survey captured
this information only if it was contained in the medical record. If the
physician provided counseling but did not write it in the chart,
counseling would not have been captured in the survey.

Table 5: Estimated Proportion of Fee-for-Service Physician Visits in Which
Blood Pressure Measurements Were Provided or Ordered, by Major Reason for
the Visits, 2000

                                             Estimated               Standard 
                                   Sample   number (in   Estimated   error of 
                      Major reason  size   thousands)  percentagea percentage 
                     Acute problem  1,155       18,491        56.3 
          Chronic problem, routine  2,081       31,706        59.0 
                  Chronic problem,                                 
                          flare-up   532         7,870        59.4 
                   Nonillness care   395         7,762        62.2 

Source: GAO analysis of the National Ambulatory Medical Care Survey, CDC.

aThe differences in rates of services provided among the different types
of visits were not statistically significant.

To estimate the proportion of Medicare beneficiaries who had health
conditions that they were not previously aware of-specifically, high blood
pressure or high cholesterol-we used data from both the interview and the
physical examination portions of CDC's National Health and Nutrition
Examination Survey (see app. III for methodology and results from this
analysis).

To describe the preventive care approaches of Medicare + Choice plans, we
consulted with national experts and officials from the American

Appendix I: Scope and Methodology

Association of Health Plans and chose five plans considered to have
innovative preventive care programs. Together, these five plans serve more
than 1.2 million Medicare beneficiaries in 15 states and the District of
Columbia (see table 6). We interviewed officials from each plan and
reviewed documents, including plan-provided studies or evaluations of
their preventive services programs. We reviewed the scope and methodology
of the studies done by some of the plans, but we did not independently
verify the accuracy of the data.

Table 6: Medicare + Choice Plans Included in GAO's Study

Beneficiaries Medicare + Choice plans Geographic areas served served

             AvMed Health Plans                               Florida  24,400 
          Highmark Blue Cross &                          Pennsylvania 
                    Blue Shield                                       182,000 
              Kaiser Permanente     California, Colorado, District of 
                                 Columbia, Georgia, Hawaii, Maryland, 
                                   Ohio, Oregon, Virginia, Washington 880,000 
            Oxford Health Plans     Connecticut, New Jersey, New York  72,000 

                   Group Health Cooperative Washington 59,300

Source: Plan officials and plan Web sites.

To examine the alternatives for identifying and reducing health risks and
CMS's efforts in exploring them, we reviewed available literature,
including results of past demonstrations and congressionally mandated
studies, and interviewed experts in the field, including those conducting
studies and developing position papers for the Partnership for Prevention,
a nonprofit organization funded by the Robert Wood Johnson Foundation. We
also interviewed Department of Health and Human Services and CMS officials
and reviewed documents on planned and present CMS demonstrations related
to preventive services.

Appendix II: Preventive Services Recommended by the U.S. Preventive Services
Task Force or Covered by Medicare

Year first covered by Task force recommendation Medicare as preventive
Medicare cost-sharing Service for age 65+ service requirementsa

Immunization Screening

        Pneumococcal          Recommends         1981            None         
         Hepatitis B       No recommendation     1984         Copayment after 
                                                                   deductible 
          Influenza           Recommends         1993            None         
Tetanus-diphtheria (Td)    Recommends     Not coveredb         N/A         
          boosters                                        
          Varicella           Recommends     Not coveredb         N/A         

      Cervical cancer: pap smear Recommends        1990     Copayment with no 
                     againstc                                     deductibled 
      Breast cancer: mammography Recommendse       1991     Copayment with no 
                                                                   deductible 
    Vaginal cancer: pelvic exam Not evaluated      1998     Copayment with no 
                                                                  deductibled 
     Colorectal cancer: fecal-occult Strongly      1998       No copayment or 
                    recommends                                     deductible 
                   blood testf                              
       Colorectal cancer: flexible Strongly        1998       Copayment after 
                    recommends                                    deductibleg 
          sigmoidoscopy or colonoscopy f                    
    Osteoporosis: bone mass Recommends (women      1998       Copayment after 
                      only)                                        deductible 
                   measurement                              
      Prostate cancer: prostate-Insufficient       2000      dCopayment after 
                   evidence to                                     deductible 
    specific antigen test and/or recommend for              
                    or against                              
            digital rectal examination                      
        Glaucoma Insufficient evidence to          2002       Copayment after 
                                                                   deductible 
                       recommend for or against             
           Vision impairment Recommends         Not covered        N/A        
          Hearing impairment Recommends         Not covered        N/A        
       Height, weight, and blood Recommends     Not covered        N/A        
                     pressure                               
Cholesterol measurement Strongly recommends  Not covered        N/A        
           Problem drinking Recommends          Not covered        N/A        
              Depression Recommends             Not covered        N/A        
                    Counseling                              
       Smoking cessation, injury Recommends     Not covered        N/A        
            prevention, dental health                       
     Aspirin for primary prevention Strongly    Not covered                   
                    recommends                                     N/A
             of cardiovascular events                       

Source: U.S. General Accounting Office, Medicare: Use of Preventive
Services Is Growing but Varies Widely, GAO-02-777T (Washington, D.C.:
April 12, 2002), and U.S. Preventive Services Task Force, Guide to
Clinical Preventive Services, 2nd ed. (Washington, D.C.: 1996) and related
updates.

Appendix II: Preventive Services Recommended by the U.S. Preventive
Services Task Force or Covered by Medicare

aApplicable Medicare cost-sharing requirements generally include a 20
percent copayment after a $100 per year deductible. Specifically, each
year, beneficiaries are responsible for 100 percent of the payment amount
until those payments equal a specified deductible amount, $100 in 2003.
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. 42 U.S.C. S: 1395(a)(1) (2000).

bAlthough the tetanus-diphtheria (Td) and varicella (chickenpox) booster
vaccinations are not now covered under Medicare as a "preventive" service,
these treatments might be covered under Medicare if necessary to a
beneficiary's medical treatment. Medicare provides coverage for medical
treatment and services that are "reasonable and necessary for the
diagnosis or treatment of an illness or injury," provided that the
services or products used are "safe and effective" and not merely
"experimental." 42 U.S.C. S: 1395(a)(1)(A) (2000).

cThe task force recommends against routinely screening women older than 65
for cervical cancer if they have had adequate recent screening with normal
Pap smears and are not otherwise at high risk for cervical cancer.

dThe costs of the laboratory test portion of these services are not
subject to copayment or deductible. The beneficiary is subject to a
deductible, copayment, or both for physician services only.

eThe task force recommends screening mammography, with or without a
clinical breast examination, every 1-2 years for women age 40 and older.

fData are insufficient to determine which strategy is best to balance
benefits against potential harms or cost-effectiveness. Barium enemas are
covered as an alternative if a physician determines that their screening
value is equal to or greater than sigmoidoscopy or colonoscopy.

gThe copayment has increased from 20 to 25 percent for services rendered
in an ambulatory surgical center.

Appendix III: National Health and Nutrition Examination Survey Methodology and
Results

Background 	Conducted by the Centers for Disease Control and Prevention's
(CDC) National Center for Health Statistics, the National Health and
Nutrition Examination Survey (NHANES) is a nationwide population-based
survey designed to estimate the health and nutrition of the
noninstitutionalized U.S. civilian population. Our analysis was based on
data gathered during NHANES 1999-2000, which represent the most recent
information available. This survey comprises two parts: an in-home
interview and a health examination. During the in-home interview,
participants are asked about their health status, disease history, and
diet; during the health examination, participants receive a number of
tests, including blood pressure readings and a blood test to determine
total serum cholesterol.1 Details of the survey design, questionnaires,
and examination components are available at
http://www.cdc.gov/nchs/nhanes.htm.

Scope, Methodology, 	For our analysis, we used the NHANES data described
in table 7 to determine if participants age 65 and older2 had high blood
pressure or high

and Results 	total serum cholesterol. We used the same criteria for these
conditions as CDC and the National Heart Blood and Lung Institute use to
estimate the conditions' prevalence.

Table 7: NHANES Data GAO Used to Determine if Participants Had Measures of
Specific Health Conditions

                          Health condition NHANES data

                                       a

High blood pressure Averageb systolic blood pressure >= 140 during NHANES
exam

or

Averageb diastolic blood pressure >= 90 during NHANES exam

or

Participant reported during NHANES interview that he or she took
hypertension medication

High total cholesterola Total cholesterol level >= 240 at NHANES
examination

Source: CDC criteria and GAO methodology.

aCDC's definitions of high blood pressure and high total cholesterol.

1 Which examinations and blood tests a participant had depended on that
participant's age and sex.

2 Of the 9,282 individuals participating in both the NHANES interview and
examination components, 1,196 were age 65 and older.

Appendix III: National Health and Nutrition Examination Survey Methodology
and Results

bParticipants' blood pressure was measured three or four times during the
1-day physical examination. For our analysis, we determined the average of
these blood pressure measurements and applied CDC's definition of high
blood pressure.

To determine whether the participants age 65 and older found by
examination to have elevated measures of these health conditions were
previously unaware of having them, we used patients' responses from the
NHANES interview. During the interview, participants were asked if they
had ever been told by a physician or health professional that they had
certain conditions, including high blood pressure and high cholesterol.

Tables 8 and 9 show the estimates and standard errors from 1999-2000
NHANES data for specific health conditions and level of awareness among
participants age 65 and older.

Table 8: People Age 65 and Older in the United States Found to Have
Measures of Specific Health Conditions, NHANES 1999-2000

                                          Estimated            
                             Sample   number in the Estimated  Standard error 
            Health condition   size U.S. population proportion  of proportion 
                  High blood    835      21,000,000      71.6%           2.07 
                    pressure                                   
                  High total    250                      25.6%           1.76 
                 cholesterol              7,100,000            

                        Source: GAO analysis of NHANES.

Table 9: People Age 65 and Older in the United States Found to Have
Measures of Specific Health Conditions and Who Reported They Had Not
Previously Been Told They Might Have the Condition, NHANES 1999-2000

                                              Estimated              Standard 
          Not previously told of Sample   number in the Estimated    error of 
            the health condition   size U.S. population proportion proportion 
             High blood pressure    254       6,600,000      31.6%       2.02 
                High total serum                                   
                     cholesterol     87       2,100,000      32.1%       4.65 

Source: GAO analysis of NHANES.

Estimated numbers, proportions, and standard errors were obtained using
SUDAAN, a computer program for analyzing data from complex sample surveys,
as suggested in the NHANES Analytic Guidelines.

Appendix IV: Comments from the Department of Health and Human Services

Appendix IV: Comments from the Department of Health and Human Services

Appendix IV: Comments from the Department of Health and Human Services

Appendix IV: Comments from the Department of Health and Human Services

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