Medicare: Few Beneficiaries Use Colorectal Cancer Screening and
Diagnostic Services (Testimony, 03/06/2000, GAO/T-HEHS-00-68).

Pursuant to a congressional request, GAO discussed Medicare
beneficiaries' use of screening and diagnostic services to prevent
colorectal cancer, focusing on: (1) the extent to which Medicare
beneficiaries (both aged and disabled) are using colorectal cancer
screening and diagnostic services; and (2) efforts to address barriers
identified as limiting use.

GAO noted that: (1) the use of colorectal cancer screening and
diagnostic services by Medicare beneficiaries is very low relative to
recommended use rates and has remained almost unchanged over the past 5
years; (2) although guidelines recommend annual fecal occult blood
testing for all people aged 50 and older, only 9 percent of
fee-for-service beneficiaries received that test each year; (3) use
rates for flexible sigmoidoscopy are significantly lower and have also
remained constant at about 2 percent of beneficiaries; (4) women's use
of some colorectal cancer screening and diagnostic services was slightly
higher than men's, and white beneficiaries received the services at
somewhat higher rates than African Americans, Asians, and Hispanics; (5)
although use data are not available for Medicare beneficiaries in health
maintenance organizations, research suggests that enrollees in managed
care plans are at least as likely to have colorectal cancer screening as
those in fee-for-service Medicare; (6) various factors contribute to the
low use of screening and diagnostic services, some of which are
beginning to be addressed by public health agencies and private
organizations; and (7) key among these is poor patient awareness of
recommendations and coverage for screening, physician reluctance to
perform the procedures because of the time and complexity involved, and
lack of monitoring systems to encourage greater use.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-00-68
     TITLE:  Medicare: Few Beneficiaries Use Colorectal Cancer
	     Screening and Diagnostic Services
      DATE:  03/06/2000
   SUBJECT:  Health care programs
	     Health insurance
	     Health resources utilization
	     Health maintenance organizations
	     Cancer
	     Health care services
	     Cancer research
	     Health surveys
	     Elderly persons
IDENTIFIER:  Medicare Choice Program
	     Medicare Program
	     NCQA Health Plan Employer Data and Information Set

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   * For Release on Delivery
     Expected at 1:00 p.m.

Monday, Mar. 6, 2000

GAO/T-HEHS-00-68

MEDICARE

Few Beneficiaries Use Colorectal Cancer Screening and Diagnostic Services

        Statement of William J. Scanlon, Director

Health Financing and Public Health Issues

Health and Human Services Division

Testimony

Before the Special Committee on Aging,

U.S. Senate

United States General Accounting Office

GAO

Medicare: Few Beneficiaries Use Colorectal Cancer Screening and Diagnostic
Services

Mr. Chairman and Members of the Committee:

We are pleased to be here today to discuss the use of Medicare-covered
screening and diagnostic services to prevent colorectal cancer and minimize
its effect on beneficiaries' health status through early detection and
treatment. Colorectal cancer is the second leading cause of cancer death in
the United States. Currently, only about a third of all colorectal cancers
are diagnosed at an early stage. Widespread screening aims to detect the
disease early, and in many cases, the detection and removal of precancerous
growths may actually prevent colorectal cancer. The Balanced Budget Act of
1997 expanded Medicare coverage to include colorectal cancer screening
services. The Congress' decision to include colorectal cancer screening as a
Medicare benefit reflected an awareness that early screening and detection
are important to maintaining beneficiaries' health.

At your request, we examined the extent to which this new preventive health
service has been used since its addition to the Medicare benefit package.
Accordingly, my remarks will focus on (1) the extent to which Medicare
beneficiaries (both aged and disabled) are using colorectal cancer screening
and diagnostic services and (2) efforts to address barriers identified as
limiting use. To do this analysis, we determined patient use rates from
Medicare claims data from 1995 through June 1999. We could not measure use
rates for screening services alone because of coding and other technical
issues. In addition, we reviewed recent literature and obtained information
from medical specialty organizations, patient advocacy groups, agencies in
the Department of Health and Human Services (HHS), and several health
maintenance organizations (HMO) with Medicare contracts.

In brief, we found that the use of colorectal cancer screening and
diagnostic services by Medicare beneficiaries is very low relative to
recommended use rates and has remained almost unchanged over the past 5
years. Although guidelines recommend annual fecal occult blood testing for
all people aged 50 and older, only 9 percent of fee-for-service
beneficiaries received that test each year. Use rates for flexible
sigmoidoscopy are significantly lower and have also remained constant at
about 2 percent of beneficiaries. Women's use of some colorectal cancer
screening and diagnostic services was slightly higher than men's, and white
beneficiaries received the services at somewhat higher rates than African
Americans, Asians, and Hispanics. Although use data are not available for
Medicare beneficiaries in HMOs, research suggests that enrollees in managed
care plans are at least as likely to have colorectal cancer screening as
those in fee-for-service Medicare. Various factors contribute to the low use
of screening and diagnostic services, some of which are beginning to be
addressed by public health agencies and private organizations. Key among
these is poor patient awareness of recommendations and coverage for
screening, physician reluctance to perform the procedures because of the
time and complexity involved, and lack of monitoring systems to encourage
greater use.

Background

Research shows that the number of people developing and dying of colorectal
cancer could be reduced through screening (identifying people with
precursors to or early signs of the disease) and surveillance (monitoring
people with previously diagnosed colorectal disease). Studies have shown
that in the majority of colorectal cancers, noncancerous polyps grow slowly
for 10 years or longer in the colon in a benign state before becoming
cancerous. Identification and removal of the polyps during that time can
prevent colorectal cancer from developing. In 1997, a consortium led by the
American Gastroenterological Association produced clinical practice
guidelines to address uncertainty about the choice and frequency of
screening tests for different groups of patients. For people at average risk
of developing colorectal cancer, the practice guidelines recommend that
people aged 50 and older have a fecal occult blood test annually, a flexible
sigmoidoscopy every 5 years, an optional double-contrast barium enema every
5 to10 years, and a colonoscopy every 10 years. For groups at high risk,
experts recommend more frequent screening through colonoscopy.

The Medicare benefit for colorectal cancer screening addresses several of
the clinical practice recommendations. Before January 1, 1998, Medicare
covered the fecal occult blood test, sigmoidoscopy, colonoscopy, and barium
enema only for diagnosis and treatment, such as for evaluating a specific
complaint or monitoring an existing medical condition. The Balanced Budget
Act of 1997 extended coverage of these services for screening purposes, with
no coinsurance and deductible for the fecal occult blood test. For all other
tests, the cost sharing is the same as for treatment services, which is
payment of 20 percent of the Medicare approved amount after the yearly
deductible. For people at average risk for colorectal cancer (those with no
predisposing factors), Medicare now pays for a screening fecal occult blood
test every year and a screening sigmoidoscopy every 4 years for
beneficiaries aged 50 and older. In addition, for individuals at high risk,
Medicare covers a screening colonoscopy every 2 years. For both risk groups,
a double-contrast barium enema may be substituted at the same frequency as
the sigmoidoscopy or the colonoscopy, if the physician believes that it is
appropriate.

Few Beneficiaries Have Colorectal Cancer Screening or Use Diagnostic
Services

Overall use of colorectal cancer screening and diagnostic services among
Medicare beneficiaries is generally low. Despite the issuance of the
clinical practice guidelines in 1997 and the expanded Medicare benefit that
became effective in 1998, use has not changed significantly since 1995. Use
rates for these services varied slightly among demographic groups and across
states. Studies show that the use of colorectal cancer screening services in
managed care health plans is the same as or higher than in fee-for-service
arrangements.

Overall Use of Colorectal Cancer Screening and Diagnostic Services Remains
Low

Among the colorectal cancer screening and diagnostic services, the most
common and least invasive is the fecal occult blood test. In 1999, the use
rate for this service was 9.1 percent of beneficiaries, well below the
recommended rate of once a year. In the same year, the use rate for flexible
sigmoidoscopy, which is covered every 4 years, was 1.9 percent, while 3.8
percent of beneficiaries received a colonoscopy. Figure 1 shows use rates
for these services over the past 5 years.

Source: GAO analysis of Health Care Financing Administration claims data.

Similar data are not available on the use of colorectal cancer services by
enrollees in the Medicare managed care program, called Medicare+Choice,
because the Health Care Financing Administration (HCFA) does not require
Medicare+Choice plans to report patient-specific data. However, evidence
suggests that colorectal cancer screening rates among Medicare HMO
beneficiaries may be similar to or higher than use rates among
fee-for-service beneficiaries. In a recent synthesis of studies on the use
of preventive care, researchers found that enrollees in managed care plans
were at least as likely as those in other plans to obtain colorectal cancer
screening services. One-third of comparisons of colorectal cancer screening
use found that managed care enrollees were more likely to use the services
and two-thirds of comparisons found no difference in use between enrollees
in managed care plans and nonmanaged care plans. Enrollees in group and
staff model HMOs-which accounted for 4.4 percent of Medicare beneficiaries
in 1998-were significantly more likely than those in fee-for-service
Medicare or other types of HMOs to obtain preventive services in general.

The Use of Screening and Diagnostic Services Varied Slightly Among
Demographic Groups and States

   * Women had higher use rates in 1999 for fecal occult blood test (about
     10 percent, compared with 8 percent for men) and similar rates for
     flexible sigmoidoscopy and colonoscopy.
   * Beneficiaries aged 70 to 79 were most likely to use screening and
     diagnostic services, but their use rates were only about 13 percent
     higher than for those aged 65 to 69 or 80 to 84.
   * White beneficiaries received the screening and diagnostic services at
     consistently higher rates (about 15 percent in 1999) than Asians (about
     13 percent), African Americans (approximately 9 percent), or Hispanics
     (approximately 8 percent).
   * In general, a higher percentage of beneficiaries in Massachusetts and
     Rhode Island (18 to 20 percent) received screening and diagnostic
     services consistently over the 5-year period than beneficiaries in
     other states. (See figure 2 for more information about use rates across
     states.)

Source: GAO Analysis of Health Care Financing Administration claims data.

Efforts To Overcome Barriers To Colorectal Cancer Screening

Patient Barriers

Although information for patients is essential, it may not be enough. In
1998, the Centers for Disease Control and Prevention (CDC), in partnership
with HCFA, conducted 14 focus groups with adults aged 50 and older to
examine the factors that inhibit appropriate use of colorectal cancer
screening. Consistent with AHRQ's 1997 study, CDC found that the
participants were not aware that colorectal cancer is the third most
prevalent cancer, nor were they aware of the benefits of screening and early
detection. However, the focus groups also revealed that older adults,
particularly those older than 65, are unwilling to discuss issues of
colorectal cancer screening, even with their physicians. Representatives of
several physician and patient groups echoed these results, telling us that
many people find colorectal cancer screening tests inconvenient or
embarrassing or that they may be concerned about potential discomfort during
the screening.

Because Medicare now covers colorectal cancer screening services, HCFA is
taking steps to promote beneficiary awareness of the new benefit, as are
other agencies within HHS. For example,

   * HCFA's Medicare and You handbook, which was mailed last year to all
     beneficiaries, describes the colorectal cancer screening benefit along
     with other covered preventive services. In addition, HCFA has
     distributed pamphlets regarding colorectal cancer screening to
     beneficiary groups, posters for senior citizen centers, and television
     and radio public service announcements, some of which target women and
     African Americans.
   * Along with the American Cancer Society, CDC has established the
     National Colorectal Cancer Roundtable to bring together state health
     departments, professional medical societies, and other public and
     private organizations to promote colorectal cancer screening among
     medical providers and the public. The roundtable seeks to determine
     clinical and consumer barriers to screening, assess current public
     awareness of and interest in screening, and develop and disseminate
     promotional messages.
   * In collaboration with HCFA and the National Cancer Institute (NCI), CDC
     has launched a public awareness campaign, "Screen for Life," to promote
     colorectal cancer screening that includes public service announcements
     and brochures in both English and Spanish, press kits, and a Web site
     on colorectal cancer (www.cdc.gov/cancer/screenforlife). CDC has also
     supported studies regarding participation in screening.

In addition, some health plans that participate in Medicare+Choice have set
up programs to encourage the appropriate use of screening services. While
these activities do not represent those of the managed care industry
overall, they illustrate a variety of approaches to improving patients' use
of colorectal cancer screening tools. For example:

   * Kaiser Permanente in Northern California has screened more than 300,000
     members older than 50 with sigmoidoscopy and has reported a one-third
     reduction in advanced colorectal cancer cases among the targeted
     population.
   * Group Health Cooperative in Puget Sound has used mailings to members to
     provide information about the importance of regular screening and to
     improve familiarity with the screening procedures.
   * Aetna U.S. Healthcare mails a fecal occult blood test kit to members
     aged 50 and older, along with instructions for completing the test, and
     educational materials about colorectal cancer. The plan's Prudential
     Center for Health Care Research is conducting a study to determine the
     rate of colorectal cancer screening among plan members older than 50,
     assess barriers to screening, and improve screening rates.

Physician Barriers

Physicians practices, too, can affect rates of colorectal cancer screening.
In a 1999 report, CDC stated that physicians may lack skills (such as
training in prevention) or time to counsel patients, or they may be
unfamiliar with updated colorectal cancer screening guidelines (which now
have broad-based support). A study of primary care physicians in a large
health care system found that half of those trained in flexible
sigmoidoscopy chose not to perform this procedure. The reasons most often
given were the time required for the procedure, the availability of
adequately trained staff, and the availability of flexible sigmoidoscopy
services from other clinicians. One study has also attributed the reluctance
of primary care physicians to provide this screening to their impression
that reimbursement rates are inadequate to cover their costs.

Federal agencies, physicians' groups, and others have special programs to
address the lack of widespread physician use of these services. For example,

   * To obtain nationally representative data on barriers to colorectal
     cancer screening and early intervention, NCI is supporting a survey of
     primary and specialty care physicians and health plan medical directors
     that will assess physicians' knowledge, attitudes, and practice
     patterns.
   * Both the American Association of Family Physicians (AAFP) and the
     American College of Physicians have guidelines for their members. In
     addition, AAFP distributed information to its members about the new
     Medicare coverage for these services and the importance of screening
     patients.
   * A program developed by a large academic medical center in Louisiana has
     an arrangement with local primary care physicians that allows patients
     to be referred to the clinic one morning every week, without
     appointments, for screening flexible sigmoidoscopies.

Health System Barriers

Unlike other preventive care services, such as cholesterol screening, breast
cancer screening, and cervical cancer screening, colorectal cancer screening
is not a component of the Health Plan Employer Data and Information Set
(HEDIS), a standardized, voluntary HMO performance reporting system
developed by the National Committee on Quality Assurance (NCQA). NCQA plays
an influential role in prevention by including HEDIS reporting in its
accreditation standards. That is, plans seeking accreditation encourage
their network physicians to improve the delivery and reporting of measured
services. AHRQ, with support from CDC, is working with NCQA and researchers
at RAND and the Harvard University School of Public Health to develop
measures of colorectal cancer screening that could possibly be included in
HEDIS. Developing effective measures to determine whether enrollees are
screened appropriately is more challenging because only one of the screening
services is recommended annually.

Concluding Observations

GAO Contact and Acknowledgments

For future contacts regarding this testimony, please call Jan Heinrich,
Associate Director, Health Financing and Public Health at (202) 512-7250.
Other individuals who made key contributions include Jenny Grover, Rosamond
Katz, and Debbie Spielberg.

Appendix

Medicare Beneficiaries' Use Rates for Colorectal Cancer Screening and
Diagnostic Services, 1995-99

The table shows demographic and geographic differences in use rates. The
rates represent the percentage of Medicare beneficiaries having a fecal
occult blood test, flexible sigmoidoscopy, colonoscopy, or barium enema. The
rates include use of these services for screening, diagnostic, and, in the
case of colonoscopy, treatment purposes.
                   1995       1996        1997       1998        1999
 Total             13.6%      13.2%       12.6%      13.1%       14.1%
 Gender
 Male              12.8       12.4        11.9       12.1        13.2
 Female            14.2       13.8        13.2       13.8        14.8
 Race
 White             14.2       13.8        13.3       13.9        14.9
 Black             9.0        8.9         8.5        8.4         9.1
 Asian             11.8       11.2        8.9        11.2        12.6
 Hispanic          8.0        8.2         5.9        7.7         8.1
 Other and
 unknown           10.5       10.5        11.9       9.0         10.6
 Age
 Younger than
 65                4.6        4.6         4.5        4.5         4.9
 65-69             15.0       14.6        13.7       14.7        15.6
 70-74             16.6       16.2        15.6       16.3        17.6
 75-79             16.8       16.4        15.7       16.4        17.9
 80-84             15.2       14.8        14.4       14.8        15.9
 85 and older      10.9       10.5        10.3       10.0        11.0
 State
 Alabama           15.1       15.1        9.5        10.5        12.4
 Alaska            11.1       10.9        8.3        9.9         10.7
 Arizona           14.8       11.6        11.4       12.8        14.6
 Arkansas          13.3       11.7        9.6        11.1        11.4
 California        15.5       15.6        15.4       13.2        14.9
 Colorado          6.3        5.9         5.9        9.9         9.6
 Connecticut       9.8        9.2         8.7        12.9        15.3
 Delaware          15.5       15.5        15.0       15.0        17.1
 District of
 Columbia          16.5       16.0        14.6       13.1        13.8
 Florida           15.6       15.6        15.2       16.9        18.6
 Georgia           13.6       11.4        10.7       12.1        13.5
 Hawaii            15.6       12.9        13.8       16.7        20.3
 Idaho             7.4        7.4         7.0        10.2        9.8
 Illinois          12.4       12.3        12.0       11.5        11.8
 Indiana           6.8        6.5         6.2        10.0        10.5
 Iowa              15.5       11.0        7.7        12.1        12.3
 Kansas            13.1       9.4         10.7       11.9        12.9
 Kentucky          12.1       11.6        11.8       12.5        13.5
 Louisiana         7.3        6.7         7.1        8.2         8.8
 Maine             17.8       16.9        15.7       16.5        16.9
 Maryland          18.2       17.2        17.2       17.0        19.5
 Massachusetts     19.4       19.9        19.1       18.3        19.9
 Michigan          16.2       16.2        16.3       15.8        15.6
 Minnesota         10.6       12.0        12.7       13.7        14.9
 Mississippi       10.9       11.1        10.5       10.9        11.9
 Missouri          11.4       10.2        10.6       11.9        12.5
 Montana           7.8        7.7         7.5        9.1         10.9
 Nebraska          10.6       7.0         8.2        9.6         10.7
 Nevada            9.7        7.5         8.2        9.0         10.4
 New Hampshire     16.6       16.8        15.7       16.9        16.6
 New Jersey        15.8       16.0        15.5       14.9        16.1
 New Mexico        8.3        8.5         9.1        10.1        8.2
 New York          17.2       17.4        15.2       14.4        15.7
 North
 Carolina          13.6       12.9        12.8       12.7        14.2
 North Dakota      12.3       8.4         8.0        12.4        11.9
 Ohio              14.4       13.5        13.1       12.1        11.4
 Oklahoma          10.3       10.6        10.9       12.1        11.9
 Oregon            11.8       13.6        11.8       12.0        14.5
 Pennsylvania      14.4       14.1        13.7       14.0        15.5
 Rhode Island      18.1       19.1        20.2       17.5        17.8
 South
 Carolina          16.2       16.7        15.6       15.4        14.5
 South Dakota      12.8       7.1         7.2        10.7        12.8
 Tennessee         12.4       12.4        11.8       10.2        10.9
 Texas             13.1       13.2        13.1       13.0        14.1
 Utah              7.3        6.8         6.6        8.1         10.2
 Vermont           17.8       17.0        16.0       16.4        15.6
 Virginia          9.7        10.4        10.5       12.8        14.9
 Washington        10.5       10.9        11.0       13.5        15.0
 West Virginia     11.3       11.2        10.4       10.2        10.4
 Wisconsin         7.6        7.7         7.5        11.8        12.9
 Wyoming           10.6       8.1         6.7        9.6         10.0

Note: Rates for 1999 are estimated from claims paid January through June
1999.

Source: GAO analysis of Health Care Financing Administration claims data.

(201026)

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