Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage

Lenard I. Lesser, MD; Alex H. Krist, MD, MPH; Douglas B. Kamerow, MD, MPH; Andrew W. Bazemore, MD, MPH

Disclosures

Ann Fam Med. 2011;9(1):44-49. 

In This Article

Discussion

Our analysis shows that Medicare covered many USPSTF recommended preventive services. A substantial disconnect was evident, however, especially in 2 areas: coordination of care, and coverage of nonrecommended services.

Congress first tried to increase coverage of preventive coordination in 2005, when it authorized the WMV, or Initial Preventive Physical Examination, which is the first time Medicare could specifically pay clinicians to coordinate prevention. In 2008, Congress tried to fix one of the problems with the WMV—that seniors could get a WMV only during the first 6 months of enrolling—by expanding the window to 1 year.

Despite its intent, 3 realities undermined the WMV's contributions to optimal preventive care: (1) only 6% of persons get their WMV;[6] (2) all USPSTF-recommended services applicable to adults for the rest of their lives cannot reasonably be covered in a single visit at the age of 65 years;[17] and (3), to be effective, many preventive services require periodic repetition beyond a single visit. The reasons for the low uptake of the WMV are unclear, but possible reasons are logistical issues and patients not being aware of the benefit.[18]

Some might argue that some of the preventive services, such as blood pressure and obesity screening, can take place during regular visits. Current fee-for-service billing practices, however, allow a provider to bill only for problems, not prevention. As any primary care physician knows, these important prevention topics often get crowded out of a busy office visit focused on multiple medical problems. For example, blood pressure measurements are to be taken with the patient sitting on in a chair, with feet on floor, after 5 minutes of rest. The measurement is then is to be repeated, with an average calculated.[19] Implementing this type of screening takes considerable time and coordination.

Congress has yet again tried to fix the lack of coverage for preventive coordination with the Patient Protection and Affordability Act of 2010.[20] Starting in 2011, every Medicare beneficiary will be covered for annual wellness visits, removing the time window restriction of the WMV. The final requirements of the annual wellness visit were recently published and include several components that will likely improve the coverage of preventive coordination.[21]

Even if there is greater coverage of an annual wellness visit, prevention will not improve if seniors have a low uptake of the benefit, as shown with the WMV. The new wellness visit will fix the problem of the low uptake of the WMV only if most seniors were not getting a WMV because of it being restricted to the first year of being an enrollee. If the reasons for low uptake are logistical issues (ie physician documentation, patient awareness), then the yearly wellness visit may not fix this problem. Alternatively, incorporating preventive coordination into regular office visits may be best way to administer prevention. If so, then a fix that relies on a fee-for-service visit may not work. An alternative strategy, such as bundled or bonus payments (such as the Physician Quality Reporting Initiative),[22] may turn out to be more effective.

The other finding in our analysis was the discrepancy between covered and recommended preventive services. Instead of providing payment to clinicians for recommended preventive services, Medicare pays clinicians to provide 7 services that are not recommended, potentially increasing harm, as well as medical costs, to patients.[23] Patient harms are well documented and include anxiety from false-positive test results, unnecessary follow-up tests, and unnecessary complications from subsequent testing and treatments.[24] Costs include both the direct cost of the initial preventive service and the extensive downstream costs associated with nonbeneficial follow-up testing and treatments.

In 2008, Congress ceded authority to approve preventive services coverage to the DHHS, allowing Medicare to create preventive services coverage policies using the same processes they currently use to determine diagnostic testing and treatment coverage. The law did not allow Medicare coverage to drop previously authorized, but ineffective services, however.

Congress has again tried to fix this problem with the Health Care Reform Act of 2010.[20] The new law reinforces the ability of the secretary of the DHHS to add services to Medicare that were not given a D rating by the USPSTF. It also authorizes the secretary to remove preventive services not given an A, B, C, or I rating by the USPSTF. Although doing so could improve the agreement between USPSTF recommendations and Medicare reimbursement, it still remains to be seen how this law will be implemented. As shown previously, the secretary has had the ability to add new services since 2008, but has yet to do so.

Our study did not attempt to measure utilization rates of preventive services, and our findings do not imply that absence of Medicare payment prevents a service from being implemented or that payment for a nonindicated screening service implies support for providing the service. Even so, payment practices are well-established drivers of clinician behavior. Future research is required to better quantify the relationship between paying for prevention and utilization costs among Medicare beneficiaries.

Although the new health care reform law provides new initiatives to improve the delivery of preventive services, it is now up to Medicare to align itself with the USPSTF recommendations and usher in an era of improved quality of care through effective prevention. Congress should simultaneously increase support for research on the delivery and effectiveness of preventive services.

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