January 18, 2011

Medicare Coverage for Preventive Services Needs to Be Reassessed, Researchers Say

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RESEARCH TRIANGLE PARK, N.C.—Medicare coverage of preventive services needs to be reassessed, according to a new study that looked at how well U.S. Preventive Services Task Force recommendations match up with Medicare reimbursement.

The study, published in the January/February issue of the Annals of Family Medicine, was conducted with researchers from the University of California, Los Angeles, Virginia Commonwealth University, RTI International and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

The researchers found that Medicare needs to better coordinate with USPSTF goals, with a focus on preventive screening exams and counseling, to prevent a glitch in service delivery.

The authors are also urging Congress to support research on how to deliver preventive care services, of which only 6 percent of Medicare recipients take advantage.

"By expanding coverage for the preventive health visit, the health care reform law provides avenues to align Medicare payments with the recommendations of the USPSTF, and for better coordination between screenings and clinical services," said Dr. Lenard Lesser, the study's lead author and a family physician and researcher with the Robert Wood Johnson Foundation Clinical Scholars at UCLA."For these reforms to be effective, however, Medicare beneficiaries must take advantage of the expanded coverage and get their annual check-ups."

The researchers looked at how well Medicare and the USPSTF guidelines matched up before health care reform. "A"-rated preventive services that take priority include screening for cervical and colon cancer, high blood pressure, cholesterol and tobacco use for men and women separately because of different risk factors. Services rated "B" include screenings for abdominal aortic aneurysm, alcohol use with counseling if needed, genetic risk for breast cancer, depression, diabetes, obesity and weight management counseling and osteoporosis as well as breast cancer screening and counseling for a healthy diet.

The researchers divided Medicare coverage for preventive screening into two categories—assessment and scheduling preventive screening tests and the actual test with counseling. They found the only service completely covered by Medicare was screening for abdominal aortic aneurysm.

The other 14 services were only partly covered in one of the categories—assessment and scheduling the test or the test itself with counseling.

The researchers also noted that Medicare reimbursed for 44 percent of services not recommended from the USPST, spiking costs for non-recommended screenings. Examples include heart screening exams in low-risk individuals, colon cancer screening over age 85 and cervical cancer screening for women who no longer need it.

The authors say that health care reform should mean better coverage for preventive medical services and suggest that Medicare has an important opportunity to coordinate with recommendations from the USPSTF to provide better quality of care to recipients. Otherwise, "practices will likely promote both inadequate and excessive delivery of preventive services."

Dr. Lesser's co-authors were Dr. Alex Krist of Virginia Commonwealth University, Dr. Douglas Kamerow of RTI International, and Dr. Andrew Bazemore of the Robert Graham Center.