Medicare Preventive Services: Most Beneficiaries Receive Some but
Not All Recommended Services (21-SEP-04, GAO-04-1004T). 	 
                                                                 
Preventive care depends on identifying health risks and on taking
steps to control these risks. In contrast, Medicare, the federal 
health program insuring almost 35 million beneficiaries age 65 or
older, was established largely to help pay beneficiaries' health 
care costs when they became ill or injured. Congress has	 
broadened Medicare coverage over time to include specific	 
preventive services, such as flu shots and certain		 
cancer-screening tests, and the Medicare Prescription Drug,	 
Improvement, and Modernization Act of 2003 (MMA) added coverage  
for several preventive services, including a one-time preventive 
care examination for new enrollees, which will start in 2005.	 
GAO's work, done before MMA, included analyzing data from four	 
national health surveys to examine the extent to which Medicare  
beneficiaries received preventive services through physician	 
visits. GAO also interviewed officials from the Centers for	 
Medicare & Medicaid Services (CMS) and other experts and reviewed
the results of past demonstrations and studies to assess expected
benefits and limits of different delivery options for preventive 
care, including a one-time preventive care examination. 	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-1004T					        
    ACCNO:   A12670						        
  TITLE:     Medicare Preventive Services: Most Beneficiaries Receive 
Some but Not All Recommended Services				 
     DATE:   09/21/2004 
  SUBJECT:   Beneficiaries					 
	     Disease detection or diagnosis			 
	     Health care programs				 
	     Health hazards					 
	     Health insurance					 
	     Health statistics					 
	     Health surveys					 
	     Physicians 					 
	     Preventive health care services			 
	     Medicare program					 

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GAO-04-1004T

United States Government Accountability Office

GAO Testimony

Before the Subcommittee on Health, Committee on Energy and Commerce, House
of Representatives

For Release on Delivery

Expected at 2:00 p.m. EDT MEDICARE PREVENTIVE

Tuesday, Sept. 21, 2004

SERVICES

        Most Beneficiaries Receive Some but Not All Recommended Services

Statement of Janet Heinrich
Director, Health Care-Public Health Issues

GAO-04-1004T

Highlights of GAO-04-1004T, a testimony before the Subcommittee on Health,
Committee on Energy and Commerce, House of Representatives

Preventive care depends on identifying health risks and on taking steps to
control these risks. In contrast, Medicare, the federal health program
insuring almost 35 million beneficiaries age 65 or older, was established
largely to help pay beneficiaries' health care costs when they became ill
or injured. Congress has broadened Medicare coverage over time to include
specific preventive services, such as flu shots and certain
cancer-screening tests, and the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA) added coverage for several preventive
services, including a one-time preventive care examination for new
enrollees, which will start in 2005.

GAO's work, done before MMA, included analyzing data from four national
health surveys to examine the extent to which Medicare beneficiaries
received preventive services through physician visits. GAO also
interviewed officials from the Centers for Medicare & Medicaid Services
(CMS) and other experts and reviewed the results of past demonstrations
and studies to assess expected benefits and limits of different delivery
options for preventive care, including a onetime preventive care
examination.

www.gao.gov/cgi-bin/getrpt?GAO-04-1004T.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Janet Heinrich on
202-512-7119.

September 2004

MEDICARE PREVENTIVE CARE

Most Beneficiaries Receive Some but Not All Recommended Services

Most Medicare beneficiaries receive some but not all recommended
preventive services. Our analysis of year 2000 data shows that nearly 9 in
10 Medicare beneficiaries visited a physician at least once that year;
beneficiaries made, on average, six visits or more within the year. Still,
many did not receive recommended preventive services, such as flu or
pneumonia vaccinations. Moreover, many are apparently unaware that they
may have conditions, such as high cholesterol, that preventive services
are meant to detect. In one 1999-2000 nationally representative survey
where people were physically examined and asked a series of questions,
nearly one-third of people age 65 or older whom the survey found to have
high cholesterol measurements said they had not before been told by a
physician or other health professional that they had high cholesterol.
Projected nationally, this percentage translates into about 2.1 million
people who may have had high cholesterol without knowing it.

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

14.4

High blood pressure

High cholesterol

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.

A one-time preventive care examination may help orient new beneficiaries
to Medicare and provide further opportunity for beneficiaries to receive
some preventive services. Covering a one-time preventive care examination
does not ensure, however, that beneficiaries will receive the recommended
preventive services they need over the long term or consistently improve
health or lower costs. CMS is exploring an alternative that would provide
beneficiaries with systematic health risk assessments by means other than
visits to physicians. A key component of this early effort involves the
coupling of risk assessments with follow-up interventions, such as
referrals for follow-up care.

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today as you discuss seniors' health and the
preventive care benefits in the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA). Overall preventive care depends
heavily on identifying health risks associated with the onset or
progression of disease and on taking steps to reduce or mitigate these
risks. The Medicare program, in contrast, was established largely to help
pay beneficiaries' health care costs when they became ill or injured. Over
time, however, Congress has broadened Medicare coverage to include
specific preventive services, such as immunizations for influenza and
pneumonia and screening tests for certain cancers, that aim to keep an
illness or condition from developing or becoming more serious. Most
recently, in passing the MMA, Congress added coverage, to start in 2005,
for a onetime preventive care examination for new enrollees and for
selected other preventive services.1

As these new benefits are implemented under MMA, you have inquired about
lessons learned from previous research on delivery options for preventive
services. Since 2002, we have done a series of reports for Congress that
examines the delivery of preventive care services to Medicare
beneficiaries. My statement today summarizes some relevant findings from
our work done before MMA, specifically:

o  	the extent to which Medicare beneficiaries receive preventive services
through physician visits, and

o  	some of the expected benefits and limitations of delivering services
through a one-time preventive care examination, including discussion of
another delivery option being explored by the Centers for Medicare &
Medicaid Services (CMS).

My testimony today is based on reports and testimony we have issued since
2002.2 Our work for these products included a synthesis of

1Pub. L. No. 108-173, 117 Stat. 2066.

2See U.S. General Accounting Office, Medicare: Beneficiary Use of Clinical
Preventive Services, GAO-02-422 (Washington, D.C.: April 2002); Medicare:
Use of Preventive Services Is Growing but Varies Widely, GAO-02-777T
(Washington, D.C.: May 23, 2002); and Medicare: Most Beneficiaries Receive
Some but Not All Recommended Preventive Services, GAO-03-958 (Washington,
D.C.: September 2003).

information on preventive care received by people age 65 or older3 from
four nationally representative health surveys;4 a review of the results of
past related research demonstrations and congressionally mandated studies;
and interviews with Department of Health and Human Services (HHS) and CMS
officials and other experts. This work allows us to discuss the benefits
and limitations of the delivery of preventive services through a one-time
examination. This body of work was conducted from August 2001 through
August 2003 in accordance with generally accepted government auditing
standards. In July 2004, we updated information on recommended preventive
services and on the status of a CMS effort to explore another delivery
option.

In summary, although they typically visit a physician several times during
a year, most Medicare beneficiaries receive some but not all recommended
preventive services. Our analysis of year 2000 data shows that nearly 9 in
10 Medicare beneficiaries visited a physician at least once that year, and
beneficiaries made an average of six visits or more within the year.
Despite these opportunities, 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 or older. Moreover, many Medicare
beneficiaries are apparently unaware that they may have conditions that
preventive services are meant to detect. For example, in one 1999-2000
nationally representative survey during which people received physical
examinations, nearly one-third of people age 65 or older whom the survey

3We focused this work on the people covered by Medicare who are 65 or
older-about 86 percent of the entire Medicare population. Besides this age
group, Medicare also covered about 5.8 million disabled persons younger
than age 65, whom our work did not include. Throughout this testimony,
except where otherwise noted, we use the term "Medicare beneficiaries" to
refer only to those beneficiaries age 65 or older.

4The 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.

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 translates into 2.1
million people age 65 or older who may have had high cholesterol without
knowing it.

A one-time preventive care examination may provide an opportunity for
beneficiaries to receive some preventive services while orienting new
beneficiaries to Medicare. But covering an initial examination does not
ensure that beneficiaries receive the recommended preventive services they
need. The results of a CMS demonstration conducted in the late 1980s and
early 1990s indicated that offering Medicare beneficiaries packages of
broad-based preventive services slightly improved the use of some
services, such as immunizations and cancer screenings, but did not
consistently improve health or lower costs. CMS is exploring an
alternative for Medicare preventive care that, by means other than a
physician's examination, would provide systematic health risk assessments
to Medicare beneficiaries. A key component of this demonstration, which is
still in development, is to address concerns that to be effective, risk
assessments must be coupled with follow-up interventions, such as
referrals for follow-up care.

Background 	Preventive health care can extend lives and promote well-being
among our nation's seniors. Medicare now covers a number of preventive
services, including immunizations, such as hepatitis B and influenza, and
cancer screenings, such as Pap smears and colonoscopies. Not all
beneficiaries, however, avail themselves of covered preventive services.
Some beneficiaries may simply choose not to use these services, but others
may be unaware that the services are available or covered by Medicare.
Further, for some beneficiaries, certain services may not be warranted or
may be of limited value. Appropriate preventive care depends on an
individual's age and particular health risks, not simply on the results of
a standard battery of tests.

To evaluate preventive care for different age and risk groups, HHS in 1984
established the U.S. Preventive Services Task Force, a panel of
privatesector experts. The task force recommends certain screening,
immunization, and counseling services for people age 65 or older. Medicare
covers some, but not all, of these services (see table 1).

Table 1: Preventive Services Recommended by the U.S. Preventive Services
Task Force or Covered by Medicare as of August 2003

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

Service

                                  Immunization

          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       

Screening

     Cervical cancer: Pap smear    Recommends againstc 1990 Copayment with no 
                                                                  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 recommends 1998   No copayment or 
             blood testf                                           deductible 
     Colorectal cancer: flexible                       1998   Copayment after 
          sigmoidoscopy or         Strongly recommends            deductibleg 
            colonoscopyf                                    

Osteoporosis: bone mass measurement Recommends (women only) 1998 Copayment after
 deductible Prostate cancer: prostate-specific antigen Insufficient evidence to
    2000 Copayment after deductibled test and/or digital rectal examination
                            recommend for or against

            Glaucoma             Insufficient        2002     Copayment after 
                                  evidence to                      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                 
       prevention, dental                                           N/A
             health                                           
      Aspirin for primary                         Not covered                 
         prevention of        Strongly recommends                   N/A
     cardiovascular events                                    

Source: U.S. GAO-03-958 and U.S. Preventive Services Task Force, Guide to
Clinical Preventive Services, 2nd ed. (Washington, D.C.: 1996) and related
updates. According to a task force official, since our 2003 report was
issued, the task force has also recommended diabetes screening for people
age 65 or older at risk of this disease.

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 covered under Medicare as "preventive" services,
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 a 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 harm 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 provided
in an ambulatory surgical center.

Medicare's fee-for-service program5 does not cover regular periodic
examinations, where clinicians might assess an individual's health risk
and provide needed preventive services. Beneficiaries could and still can,
however, receive some of these services during office visits for other
health issues.

In late 2003, MMA added coverage under Medicare for a one-time "initial
preventive physician evaluation" if performed within 6 months after an
individual's enrollment under Part B of the program.6 Covered services
under the examination include measurement of height, weight, and blood
pressure; an electrocardiogram; and education, counseling, and referral
services for screenings and other preventive services covered by Medicare.
MMA also added coverage for various screening tests to identify

5"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. Our September
2003 report indicated that about 84 percent of Medicare enrollees were in
the fee-for-service program.

6The Medicare Program is divided into three parts. Part A provides
hospital insurance coverage, and Part B provides coverage for supplemental
medical insurance benefits, such as the preventive health care services
discussed above. Part C requires managed care plans participating in the
Medicare + Choice program to provide all the basic benefits covered under
Parts A and B.

Most Beneficiaries Receive Some but Not All Recommended Preventive
Services

cardiovascular disease (and related abnormalities) in "elevated risk"
beneficiaries and diabetes in "at risk" beneficiaries.7 The new coverage
applies to services provided on or after January 1, 2005.

Nationally representative survey data show that Medicare beneficiaries
visit physicians often and that most report receiving "routine checkups."
These data do not show, however, which specific services were delivered
during those "checkups." Despite the frequency of visits, many Medicare
beneficiaries do not receive the full range of recommended preventive
services. Data also show that many beneficiaries may not know about their
risk for health conditions that preventive care is meant to detect.

From 2000 survey data and U. S. Bureau of the Census estimates of people
age 65 or older, we estimated that beneficiaries visited a physician at
least six times that year, on average, mainly for illnesses or medical
conditions. Only about 1 in 10 visits occurred when beneficiaries were
well (see fig. 1).8

7The new preventive care services requirements appear at Pub. L. No.
108-27, S:S: 611-613, 117 Stat. 2303-2306 (adding sections 1861(s)(2)(W),
(X), and (Y) to SSA) (to be codified at 42 U.S.C. S:S: 1395x(s)(2)(W),
(X), and (Y).)

8Because Medicare's fee-for-service program covers 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 employerprovided
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.

Figure 1: Major Reasons for Physician Visits by Medicare Beneficiaries in
the Feefor-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 because of 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
flareups." We combined these results in this figure.

Even though the majority of visits to physicians were to treat illness or
health conditions, most Medicare beneficiaries reported receiving what
they considered to be "routine checkups." In CDC's 2000 Behavioral Risk
Factor Surveillance System Survey, for example, 93 percent of respondents
age 65 or older reported that they had received a "routine checkup" within
the previous 2 years.9 This survey did not, however, provide information
on which specific services were delivered during those checkups. Data from
another survey, enumerating services provided during office visits,
indicated that Medicare beneficiaries do receive some preventive services
during visits when they are ill or being treated for a health condition.

9In 2000, data from CMS's Medicare Current Beneficiary Survey also showed
that 88 percent of Medicare beneficiaries reported that they visited a
physician at least once that year.

Despite how often Medicare beneficiaries visit physicians, relatively few
beneficiaries receive the full range of recommended preventive services
covered by Medicare. As we reported in 2002, for example, although 91
percent of female Medicare beneficiaries in our analysis received at least
one preventive service, only 10 percent were screened for cervical,
breast, and colon cancer and were also immunized against influenza and
pneumonia.10 Our analysis of additional data for our 2003 report showed
that many Medicare beneficiaries still did not receive certain recommended
preventive services. The task force recommends, for example, that all
people age 65 or older receive an annual influenza vaccination and at
least one pneumonia vaccination. According to data from CMS's Medicare
Current Beneficiary Survey of 2000, however, about 30 percent of Medicare
beneficiaries did not receive an influenza vaccination, and 37 percent had
never had a pneumonia vaccination.

Many Medicare beneficiaries may not know that they are at risk for health
conditions that preventive care could detect-strong evidence that they may
not be receiving the full range of recommended preventive services.11 For
example, data from CDC's NHANES for 1999-2000 show that, of beneficiaries
participating in this nationally representative survey who, as part of the
survey, had a physical examination and were found to have elevated blood
pressure readings at that time, 32 percent reported that no physician or
other health professional had told them about the condition before. On the
basis of this survey, we estimate that, during the period when the survey
was conducted, 21 million Medicare beneficiaries may have been at risk for
high blood pressure, and an estimated 6.6 million of them may have been
unaware of this risk. Similarly, 32 percent of those found by the survey
to have a high cholesterol level reported that no one had told them that
they had high cholesterol. Projected nationally, this percentage
translates into 2.1 million Medicare beneficiaries who may have had high
cholesterol without knowing it (see fig. 2).

10In 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 or older who
have had adequate recent screenings with normal Pap smears and are not
otherwise at increased risk for cervical cancer."

11The source of data for this statement was CDC's NHANES of 1999-2000.
This survey oversampled; that is, it 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.

Figure 2: Estimated Number of Medicare Beneficiaries Age 65 or Older Who
Were Aware or 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.

A one-time initial preventive care examination covered by Medicare may
offer opportunity to deliver some preventive services but alone is not
enough to ensure better health among beneficiaries. Information from a CMS
demonstration and from other related studies shows that ensuring receipt
of follow-up care will be important to improving beneficiaries' health. A
proposed CMS demonstration, currently in design, will explore another
preventive care delivery option and examine the value of linking
beneficiaries to needed follow-up services.12

As proponents of a one-time "Welcome to Medicare" examination told us,
such an examination could be a means to better ensure that health care
providers have enough time to identify individual Medicare beneficiaries'
health risks and provide preventive services appropriate for their risks.
It could be used to orient new beneficiaries to Medicare and encourage
them to make informed choices about providers and plans. Nevertheless, a
one-

An Initial Examination May Improve Preventive Care, but Follow-up Is Also
Key

12We confirmed in July 2004 that this CMS demonstration was still in the
design phase.

time examination does not ensure delivery of the full range of preventive
services. Primary care physicians typically cannot provide services such
as mammography screenings for breast cancer or colonoscopies for colon
cancer, because these services usually require specialists.

It also is uncertain whether a one-time or periodic examination would be
an effective way to improve beneficiaries' health. For example, one
previous CMS initiative that included preventive health care visits ended
with mixed results. In the late 1980s and early 1990s, the agency
conducted a congressionally mandated demonstration to test varied health
promotion and disease prevention services, such as free preventive visits,
health risk assessment, and behavior counseling, to see if they would
increase use of preventive services, improve health, or lower health care
expenditures for Medicare beneficiaries.13 The agency's final report,
published in 1998, concluded that the demonstration services were
marginally effective in raising the use of some simple disease-prevention
measures, such as immunizations and cancer screenings, but did not
consistently improve beneficiary health or reduce the use of hospital or
skilled nursing services.14 The report tempered these results by pointing
out that the relatively brief period during which the services were
provided (roughly 2 years) and the limited number of follow-ups and
beneficiary contacts with providers (one to two) may have been inadequate
to achieve measurable outcomes.

Determining how to better ensure adequate follow-up once health risks are
identified is a concern that a new CMS project aims to evaluate. CMS is
exploring an alternative for Medicare preventive care that would provide
systematic health risk assessments to fee-for-service beneficiaries
through a means other than examination by a physician. In the late 1990s,
the agency commissioned the RAND Corporation to evaluate the potential
effectiveness of health risk assessment programs. Such programs collect
information from individuals; identify their risk factors; and refer the
individuals to at least one intervention to promote health, sustain
function,

13The Consolidated Omnibus Budget Reconciliation Act of 1985 directed CMS
(then known as the Health Care Financing Administration) to conduct a
4-year demonstration (see Pub.

L. No. 99-272, S: 9314, 100 Stat. 82, 194-196 (1986)), which was extended
for an additional year by the Omnibus Budget Reconciliation Act of 1990,
Pub. L. No. 101-508, S: 4164, 104 Stat. 1388, 1388-100.

14Donna E. Shalala, Medicare Prevention Demonstration: Final Report, RC
87-172 (Washington, D.C.: Department of Health and Human Services, 1998).

or prevent disease.15 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.16 In addition, the study stated that to be
effective, risk assessment questionnaires must be coupled with follow-up
interventions, such as referrals to appropriate services. The study
recommended that CMS conduct a demonstration to test costeffectiveness and
other aspects of the health risk assessment approach for Medicare
beneficiaries.

Following through on the study's findings, CMS has begun designing a
demonstration project focused on Medicare fee-for-service beneficiaries,
called the Medicare Senior Risk Reduction Program, to identify health
risks and follow up with preventive services provided by means other than
examinations by physicians. The program will use a beneficiary-focused
health risk assessment questionnaire to assess health risks, such as
lifestyle behaviors, and use of clinical preventive and screening
services. The program will test different approaches to administering
health risk assessments, creating feedback reports, and providing
follow-up services, such as referring beneficiaries to health-promoting
community services including physical activity and social support groups.
According to project researchers, the program will tailor preventive
interventions to individual risks; track patient risks and health over
time; and provide beneficiaries with self-management tools and
information, health behavior advice, and end-of-life counseling where
appropriate. The design phase had not been finalized as of last week and,
according to a CMS official, still required approval from HHS and the
Office of Management and Budget.17

15A 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.

16Southern 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.

17The demonstration's final cost was uncertain at the time our report was
completed in September 2003. CMS was spending approximately $1 million on
the developmental work.

Concluding Observations

Current data indicate that many opportunities exist for Medicare
beneficiaries to receive preventive care, but many beneficiaries
nonetheless fail to receive the full range of recommended services.
Although some beneficiaries may not choose to seek these services, others
may not be aware that these services are available and covered by
Medicare. Our work shows that more needs to be done to deliver preventive
services to those beneficiaries who need them, because many people may
have a health condition that preventive services can easily diagnose, and
yet they may not know that they have this condition.

A one-time preventive care examination will add a dedicated opportunity
for delivering preventive care and could help reduce the gap in the
preventive services that Medicare beneficiaries receive. At the same time,
it is not a panacea. Ensuring that beneficiaries receive needed services
and follow-up care is likely to remain a challenge.

Mr. Chairman, this concludes my prepared statement. I will be happy to
answer any questions that you or Members of this Committee may have.

Contact and For future contacts regarding this testimony, please call
Janet Heinrich at (202) 512-7119. Katherine Iritani, Matt Byer, Ellen W.
Chu, Lisa Lusk, andAcknowledgments Behn Miller Kelly also made key
contributions to this testimony.

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