oversight

Medicare: Most Beneficiaries Receive Some but Not All Recommended Preventive Services

Published by the Government Accountability Office on 2003-09-08.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 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 

                                               September 2003


                                               MEDICARE

                                               Most Beneficiaries Receive Some but Not
Highlights of GAO-03-958, a report to the      All Recommended Preventive Services
Chairman, Subcommittee on Oversight
and Investigations, Committee on Energy
and Commerce, House of Representatives




Medicare, the federal health                   Most Medicare beneficiaries receive some preventive services through their
program insuring almost 35 million             visits to physicians, but relatively few receive the full range of preventive
beneficiaries age 65 and older,                services available. Survey data showed, for example, that in 2000 about 30
covers certain preventive services,            percent of beneficiaries did not receive a flu shot, and 37 percent had never
such as flu shots and                          been vaccinated against pneumonia. Moreover, many Medicare beneficiaries
mammograms. Most beneficiaries
receive care through Medicare’s
                                               are apparently unaware that they may have conditions that preventive
fee-for-service program, under                 services are meant to detect. For example, in a 1999–2000 nationally
which they generally receive these             representative survey during which people received physical examinations,
services as part of visits to the              nearly one-third of those age 65 and older who were found to have high
doctor for specific illnesses or               cholesterol measurements said they had not previously been told by a
conditions. Other beneficiaries                physician or other health professional that they had high cholesterol.
receive services under Medicare’s              Projected nationally, this percentage could represent 2.1 million people.
managed care program, called                   Estimated Number of Medicare Beneficiaries Age 65 and Older Who Were Aware or Unaware
Medicare + Choice. GAO was asked               That They Might Have High Blood Pressure or High Cholesterol, 1999–2000
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                 Note: About one-third of Medicare beneficiaries examined and found to have high cholesterol or
surveys and reviewing five                     elevated blood pressure measurements were previously unaware that they might have the
                                               condition, representing millions nationwide.
Medicare + Choice plans
considered to have innovative                  No clear “best practice” approach to delivering preventive care stands out
approaches to delivering                       among the innovative Medicare + Choice plans GAO studied. All five plans
preventive services. GAO also                  identify health risks, provide feedback on risks to patients or their
interviewed Department of Health               physicians, and follow up to reduce those risks. But their follow-up
and Human Services (HHS) and                   programs, approaches, and priorities differ, and little is known about the
CMS officials and reviewed                     effectiveness of these efforts for the Medicare-age population.
documents on CMS demonstrations
related to preventive services.
                                               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-
www.gao.gov/cgi-bin/getrpt?GAO-03-958.         for-service program—could provide more opportunities, but at increased
To view the full report, including the scope   cost and without guarantee that preventive services would actually be
and methodology, click on the link above.      provided to Medicare beneficiaries.
For more information, contact Janet Heinrich
on 202-512-7250.
                                               HHS generally concurred with the findings of this report.
Contents 



Letter                                                                                        1
                 Results in Brief 
                                                           3
                 Background
                                                                  5
                 Most Beneficiaries Receive Some Preventive Services, but Not All 

                   That Are Recommended                                                       7
                 Medicare + Choice Plans Reviewed Assess Health Risks Using
                   Varying Approaches                                                       11
                 New Ways to Improve the Provision of Preventive Services within
                   Medicare’s Fee-for-Service Program Are Promising but Untested            17
                 Concluding Observations                                                    24
                 Agency Comments                                                            24

Appendix I       Scope and Methodology                                                      26



Appendix II 	    Preventive Services Recommended by the U.S.
                 Preventive Services Task Force or Covered
                 by Medicare                                                                30



Appendix III 	   National Health and Nutrition Examination Survey
                 Methodology and Results                                                    32



Appendix IV 	    Comments from the Department of Health and Human
                 Services                                         34



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




                 Page i                                 GAO-03-958 Medicare Preventive Services
          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        





          Page ii                                GAO-03-958 Medicare Preventive Services
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Page iii                                       GAO-03-958 Medicare Preventive Services
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).



                                   Page 1                                        GAO-03-958 Medicare Preventive Services
     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:

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




     Page 2                                           GAO-03-958 Medicare Preventive Services
                     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.


                     Most Medicare beneficiaries receive some but not all recommended
Results in Brief 	   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


                     Page 3                                  GAO-03-958 Medicare Preventive Services
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


Page 4                                  GAO-03-958 Medicare Preventive Services
             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
Background   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:




             Page 5                                  GAO-03-958 Medicare Preventive Services
•	  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).
• 	 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).
• 	 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.




     Page 6                                          GAO-03-958 Medicare Preventive Services
                              Medicare beneficiaries typically visit a physician several times during a
Most Beneficiaries            year and most receive some preventive services, but most do not receive
Receive Some                  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
Preventive Services,          estimate that beneficiaries visit a physician at least six times a year, on
but Not All That Are          average, mainly for illnesses or medical conditions.7 About 1 in 10 visits
                              occurred when beneficiaries were well, and most Medicare beneficiaries
Recommended                   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        In 2000, 88 percent of Medicare beneficiaries reported that they visited a
Visit Physicians Often, and   physician at least once that year.8 On the basis of data from CDC’s
Most Report Receiving         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
Routine Checkups              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.



                              Page 7                                          GAO-03-958 Medicare Preventive Services
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




             53%                                                Chronic problem
                                                                (Routine and flare-up)

                                             26%                Acute problem



                                             10%                Pre- and postsurgery
                                                                or injury follow-up

                                     10%                        Nonillness care

                                                                Unknown
                                  2%
         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.




Page 8                                                          GAO-03-958 Medicare Preventive Services
                            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        Despite how often Medicare beneficiaries visit physicians, many of them
Visits, Many Medicare       do not receive a full complement of recommended preventive services,
Beneficiaries Do Not        including some recommended by the U.S. Preventive Services Task Force
                            and currently covered by Medicare. As we reported earlier, use of specific
Receive the Full Range of   preventive services varies widely by service.11 Although each preventive
Recommended Preventive      service we reviewed was delivered to a majority of Medicare beneficiaries,
Services                    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.”




                            Page 9                                        GAO-03-958 Medicare Preventive Services
                            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   Many Medicare beneficiaries may not know that they are at risk for health
Unaware of Their Risk for   conditions that preventive care could detect—strong evidence that they
Health Conditions That      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
Preventive Care Is Meant    beneficiaries participating in this nationally representative survey who had
to Detect                   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.




                            Page 10                                          GAO-03-958 Medicare Preventive Services
                      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



                                                                                                     14.4
                       High blood pressure

                                                                           6.6




                                                                     5.0
                           High cholesterol
                                                          2.1

                                                0     2     4    6     8     10    12     14     16
                                                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
Medicare + Choice     for delivering preventive services, but several common themes emerge
Plans Reviewed        from their efforts. First, nearly all identify members’ health risks and
                      inform them or their providers about specific services that might be
Assess Health Risks   needed. For example, some plans mail questionnaires to members, seeking
Using Varying         information, such as when certain screening tests were last performed;
                      other plans review claims and prescription data to identify at-risk
Approaches            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.



                      Page 11                                                           GAO-03-958 Medicare Preventive Services
Plans Use a Combination      Although all the Medicare + Choice plans we reviewed use questionnaires
of Ways to Identify Health   to meet the requirement that they conduct health assessments for newly
Risks                        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. § 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.




                             Page 12                                        GAO-03-958 Medicare Preventive Services
                          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    After identifying the health risks of Medicare beneficiaries—whether new
Follow-up Means to        enrollees or existing members—plans we contacted reported that they
Reduce Identified Risks   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.




                          Page 13                                        GAO-03-958 Medicare Preventive Services
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



Page 14                                                  GAO-03-958 Medicare Preventive Services
                             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        Few of the health plans we contacted had specifically evaluated whether
Outcomes or Cost Savings     their approaches to risk identification and reduction lead either to
for Medicare Beneficiaries   improved health outcomes for Medicare beneficiaries or to cost savings
                             for the plan. From those plans that have such information, the available
Are Limited                  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.




                             Page 15                                GAO-03-958 Medicare Preventive Services
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.




Page 16                                         GAO-03-958 Medicare Preventive Services
                      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.


                      Several options have been suggested for improving the provision of
New Ways to Improve   preventive services within Medicare’s fee-for-service program. They
the Provision of      include adding a new benefit for a nonillness-related examination, either a
                      one-time “welcome-to-Medicare” examination for new beneficiaries or an
Preventive Services   examination available to all beneficiaries on a periodic basis. Although
within Medicare’s     covering a one-time or periodic nonillness examination could be easily
                      administered and could increase the receipt of some preventive services,
Fee-for-Service       doing so could also increase Medicare costs without necessarily ensuring
Program Are           that beneficiaries receive the full range of preventive services. CMS has
Promising but         tested similar options in the past and found that they produced mixed
                      results. It is now examining an alternative that would essentially create a
Untested              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.




                      Page 17                                         GAO-03-958 Medicare Preventive Services
                            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        A one-time “welcome-to-Medicare” examination for new beneficiaries has
Center on Adding a          been proposed as a means to better ensure that health care providers have
Preventive Examination to   enough time to identify individual Medicare beneficiaries’ health risks and
                            provide preventive services appropriate for their risks.23 Proponents assert
the Medicare Fee-for-       that a one-time benefit could combine a health evaluation with screenings
Service Program             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.




                            Page 18                                      GAO-03-958 Medicare Preventive Services
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).




Page 19                                          GAO-03-958 Medicare Preventive Services
                            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         CMS is exploring one alternative for Medicare preventive care that would
Alternative for Assessing   provide systematic health risk assessments to fee-for-service beneficiaries
Health Risks and            through a means other than physician visits. In the late 1990s, the agency
                            commissioned the RAND Corporation to evaluate the potential
Delivering Preventive       effectiveness of health risk assessment programs. Similar to the
Services                    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, § 9314, 100 Stat. 82, 194 (1986), and extended
                            for 1 year by the Omnibus Budget Reconciliation Act of 1990, Pub. L. No. 101-508, § 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.



                            Page 20                                           GAO-03-958 Medicare Preventive Services
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.




Page 21                                       GAO-03-958 Medicare Preventive Services
                           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      CMS has other initiatives under way that may help improve the delivery of
Ways to Improve Care for   preventive services within the fee-for-service program. The first is the
Those with Identified      Medicare Stop Smoking Program, a smoking cessation demonstration
                           project for fee-for-service beneficiaries. Recognizing that smoking is the
Health Risks and           single most preventable cause of disease and death in the United States,
Conditions                 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, § 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.




                           Page 22                                              GAO-03-958 Medicare Preventive Services
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, § 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.




Page 23                                                GAO-03-958 Medicare Preventive Services
                  Most Medicare beneficiaries receive some preventive services, but many
Concluding        do not receive services that can help prevent and manage their health risks
Observations      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
Agency Comments   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


                  Page 24                                 GAO-03-958 Medicare Preventive Services
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 





Page 25                                   GAO-03-958 Medicare Preventive Services
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   2000 	        Annual target of 189,450   A state-based random telephone survey of U.S. adults
Surveillance System, CDC               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,                   which 7,381 were made      the United States. Detailed information about each visit, such
CDC                                    by people age 65 and       as major reason for the visit and diagnostic and preventive
                                       older                      services ordered or provided, is collected through a patient
                                                                  record form completed by the physicians’ offices.
National Health and       1999–2000 	 9,965 people, of which      This survey gathers nationally representative data on the
Nutrition Examination                 1,392 were age 65 and       health and nutrition of the U.S. population through direct
Survey, CDC                           older                       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.




                                        Page 26                                         GAO-03-958 Medicare Preventive Services
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           1.7
    Chronic problem, routine                   2,081                    53,701           42.2           1.7
    Chronic problem,
    flare-up                                     532                    13,254           10.4           0.8
    Pre- or postsurgery,
    injury follow-up                             577                    12,533            9.8           1.1
    Nonillness care                              395                    12,479            9.8           1.1
    Blank or unknown                               84                       2495          2.0           0.4
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.




Page 27                                                            GAO-03-958 Medicare Preventive Services
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           3.0
    Chronic problem,
    routine                                   2,081                     11,785             22.0           3.0
    Chronic problem,
    flare-up                                     532                        1,673          12.6           2.5
    Nonillness care                              395                        2,295          18.4           3.6
Source: GAO analysis of the National Ambulatory Medical Care Survey, CDC.
a
 The 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
                                                                                              a
    Major reason                              size               thousands)         percentage    percentage
    Acute problem                             1,155                     18,491             56.3           3.2
    Chronic problem, routine                  2,081                     31,706             59.0           2.9
    Chronic problem,
    flare-up                                     532                        7,870          59.4           4.8
    Nonillness care                              395                        7,762          62.2           4.8
Source: GAO analysis of the National Ambulatory Medical Care Survey, CDC.
a
 The 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



Page 28                                                            GAO-03-958 Medicare Preventive Services
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
 Group Health Cooperative                    Washington                                        59,300
 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
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.




Page 29                                                       GAO-03-958 Medicare 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
                                                                                                                                                           a
 Service                                        for age 65+                                    service                                         requirements
 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
                                                                    e
 Breast cancer: mammography                     Recommends                                     1991                                            Copayment with no deductible
                                                                                                                                                                                           d
 Vaginal cancer: pelvic exam                    Not evaluated                                  1998                                            Copayment with no deductible
 Colorectal cancer: fecal-occult                Strongly recommends                            1998                                            No copayment or deductible
 blood testf
 Colorectal cancer: flexible   Strongly recommends                                             1998                                            Copayment after deductibleg
                             f
 sigmoidoscopy or colonoscopy

 Osteoporosis: bone mass                        Recommends (women only)                        1998                                            Copayment after deductible
 measurement
                                                                                                                                                                                       d
 Prostate cancer: prostate-                     Insufficient evidence to                       2000                                            Copayment after 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 recommends                            Not covered                                     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.




                                                                 Page 30                                                              GAO-03-958 Medicare Preventive Services
Appendix II: Preventive Services
Recommended by the U.S. Preventive Services
Task Force or Covered by Medicare




a
 Applicable 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. § 1395(a)(1) (2000).
b
 Although 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. § 1395(a)(1)(A) (2000).
c
 The 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.
d
The 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.
e
 The task force recommends screening mammography, with or without a clinical breast examination,
every 1–2 years for women age 40 and older.
f
 Data 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.
g
 The copayment has increased from 20 to 25 percent for services rendered in an ambulatory surgical
center.




Page 31                                                GAO-03-958 Medicare Preventive Services
Appendix III: National Health and Nutrition
Examination Survey Methodology and
Results
                        Conducted by the Centers for Disease Control and Prevention’s (CDC)
Background 	            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.


                        For our analysis, we used the NHANES data described in table 7 to
Scope, Methodology, 	   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
                            High blood pressure     a
                                                           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.
                        a
                        CDC’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.




                        Page 32                                                 GAO-03-958 Medicare Preventive Services
                 Appendix III: National Health
                 and Nutrition Examination
                 Survey Methodology and
                 Results




b
Participants’ 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 pressure              835             21,000,000         71.6%              2.07
    High total cholesterol           250              7,100,000         25.6%              1.76
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.




Page 33                                                GAO-03-958 Medicare Preventive Services
Appendix IV: Comments from the
Department of Health and Human Services




         Page 34            GAO-03-958 Medicare Preventive Services
          Appendix IV: Comments from the Department
          of Health and Human Services




Page 35                                               GAO-03-958 Medicare Preventive Services
          Appendix IV: Comments from the Department
          of Health and Human Services




Page 36                                               GAO-03-958 Medicare Preventive Services
                     Appendix IV: Comments from the Department
                     of Health and Human Services




(290204)
           Page 37                                               GAO-03-958 Medicare Preventive Services
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