oversight

Medicare: Use of Preventive Services Could Be Better Aligned with Clinical Recommendations

Published by the Government Accountability Office on 2012-01-18.

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

               United States Government Accountability Office

GAO            Report to Congressional Requesters




January 2012
               MEDICARE

               Use of Preventive
               Services Could Be
               Better Aligned with
               Clinical
               Recommendations




GAO-12-81
                                              January 2012

                                              MEDICARE
                                              Use of Preventive Services Could Be Better Aligned
                                              with Clinical Recommendations
Highlights of GAO-12-81, a report to
congressional requesters




Why GAO Did This Study                        What GAO Found
Preventive care services have the             Use of some preventive services—cardiovascular disease screening and cervical
potential to improve health outcomes          cancer screening—by FFS beneficiaries generally aligned with clinical
and lower health care expenditures.           recommendations, but use of other cancer screenings for certain age groups,
This report examines (1) whether              osteoporosis screening, and immunizations did not. In particular, among women
preventive service use by Medicare            aged 65 to 74, for whom breast cancer screening is recommended biannually by
fee-for-service (FFS) beneficiaries           the Task Force, only two out of three received a mammogram in 2008 or 2009.
aligns with recommendations from the          Among beneficiaries aged 65 to 75, about one out of four received any of the
U.S. Preventive Services Task Force           Task Force recommended regimens for colorectal cancer screening from 2005
and the Advisory Committee on
                                              through 2009. Among men aged 75 or older, about two out of five received a
Immunization Practices (ACIP), (2) use
                                              Prostate-Specific Antigen test for prostate cancer—a test that required no cost
of the Welcome to Medicare (WTM)
exam and its association with use of
                                              sharing—from 2006 through 2009 even though the Task Force recommended
preventive services, (3) preventive           against this service for that age group. Use of osteoporosis screening—for which
service use in Medicare Advantage             Medicare coverage is limited—and influenza and pneumococcal immunizations
(MA) relative to FFS, and (4) service         was generally lower than recommended by the Task Force or ACIP. The
use among MA health maintenance               Department of Health and Human Services has the authority to modify coverage
organizations (HMO) and efforts by            of Medicare preventive services—such as osteoporosis screening—consistent
high-performing HMOs to encourage             with Task Force recommendations.
preventive care. To do this, GAO
                                              Fewer than 7 percent of FFS beneficiaries who became eligible for the WTM
selected eight preventive services that
                                              exam in 2008 received it. For FFS beneficiaries who became eligible in 2006 and
had Task Force or ACIP guidelines for
the general Medicare population. GAO          received the exam, use rates for all of the selected preventive services GAO
analyzed the most recently available          reviewed were higher than for beneficiaries who did not have the exam.
data from Medicare claims, a                  Specifically, use of selected preventive services from 2006 through 2009 was
beneficiary survey, and MA plan               greater by about 3 to 20 percentage points for women and about 4 to
ratings. GAO also interviewed                 17 percentage points for men.
representatives of selected HMOs.             Compared to beneficiaries in FFS, those in MA HMOs reported greater use of
What GAO Recommends                           immunizations and cholesterol tests but not cancer screenings, holding
                                              demographic and geographic factors constant. There was no discernable
Congress should consider requiring            difference in use rates between FFS beneficiaries and those in MA non-HMO
beneficiaries to share the cost of a          plans. Overall, Medicare beneficiaries who did not receive certain preventive
service if the Task Force recommends          services commonly reported that they had limited information on prevention; had
against use of that particular service        concerns about discomfort, side effects, or efficacy; or their doctor did not
for those beneficiaries. The                  recommend the services.
Administrator of CMS should provide
coverage for Task Force                       HMO performance data from the Centers for Medicare & Medicaid Services’
recommended services, as she                  (CMS) Medicare Health Plan Compare ratings show that use varied substantially
determines is appropriate considering         for the preventive services we examined. Representatives from higher-
cost-effectiveness and other criteria.        performing HMOs reported using tools such as clinical guidelines, performance
CMS agreed that preventive service            monitoring and feedback, and financial incentives to encourage physicians to
use could be improved, but stated that        provide preventive services. HMO representatives also said they developed
GAO likely undercounted use of some           newsletters, phone messages, and websites to highlight the availability of
preventive services. The agency also          preventive services and enhanced benefits to encourage enrollees’ use of
pointed out that it has recently added        preventive care.
coverage for several new preventive
services.
View GAO-12-81. For more information,
contact James C. Cosgrove at (202) 512-7114
or cosgrovej@gao.gov.

                                                                                     United States Government Accountability Office
Contents


Letter                                                                                      1
               Background                                                                   6
               FFS Use of Tests for Cardiovascular Disease and Cervical Cancer
                 Generally Aligned with Recommendations, but Use of Other
                 Preventive Services Did Not                                              12
               Few FFS Beneficiaries Had a Welcome to Medicare Exam; Its Use
                 Was Associated with Greater Utilization of Preventive Services           25
               Beneficiaries in MA HMOs Reported Higher Use of Immunizations
                 and Cholesterol Tests than Those in FFS                                  29
               Preventive Care Use Varied Widely among MA HMOs; Higher-
                 Performing HMOs Provided Information and Offered Incentives
                 to Promote Preventive Care                                               31
               Conclusions                                                                39
               Matter for Congressional Consideration                                     39
               Recommendation for Executive Action                                        40
               Agency and Industry Comments and Our Evaluation                            40

Appendix I     Scope and Methodology                                                      43



Appendix II    Medicare Part B Coverage and Cost Sharing for Preventive
               Services as of September 2011                                              50



Appendix III   Tables with Full Analysis of Preventive Service Use in Medicare
               FFS                                                                        53



Appendix IV    Use of the Welcome to Medicare Exam by Medicare FFS
               Beneficiaries Who Reached Age 65 in 2008                                   63



Appendix V     Comments from the Department of Health and Human Services                  64



Appendix VI    GAO Contact and Staff Acknowledgments                                      67




               Page i                                   GAO-12-81 Medicare Preventive Services
Tables
         Table 1: Medicare Part B Coverage and Cost Sharing for Selected
                  Preventive Services, 2009                                           7
         Table 2: Use of Cholesterol Tests by Male Medicare FFS
                  Beneficiaries during the 5-year Period 2005 through 2009          13
         Table 3: Use of Screening Pap Tests by Female Medicare FFS
                  Beneficiaries during the 3-year Period 2007 through 2009          14
         Table 4: Use of the Influenza Vaccination by Medicare FFS
                  Beneficiaries for the July 2008 through June 2009 Flu
                  Season                                                            15
         Table 5: Use of the Pneumococcal Vaccination during the 5-year
                  Period 2005 through 2009 by Medicare FFS Beneficiaries
                  Aged 65 as of January 1, 2005                                     16
         Table 6: Use of Bone Mass Measurements by Female Medicare FFS
                  Beneficiaries during the 5-year Period 2005 through 2009          18
         Table 7: Use of Mammography by Female Medicare FFS
                  Beneficiary Age during the 2-year Period 2008 through
                  2009                                                              20
         Table 8: Use of Colorectal Cancer Screening and Diagnostic
                  Services by Medicare FFS Beneficiaries Aged 65 to 75,
                  2005 through 2009                                                 21
         Table 9: Use of Colorectal Cancer Screening Services by Medicare
                  FFS Beneficiaries Aged 76 or Older, 2005 through 2009             22
         Table 10: Use of PSA Tests by Male Medicare FFS Beneficiaries
                  during the 4-year Period 2006 through 2009                        23
         Table 11: Use of Selected Preventive Service among Urban and
                  Rural Medicare FFS Beneficiaries                                  24
         Table 12: Use of Selected Preventive Service among Medicare FFS
                  Beneficiaries Who Live in a HPSA and Those Who Do Not             25
         Table 13: 2006 through 2009 Use of Selected Preventive Services by
                  Female Medicare FFS Beneficiaries Who Became Eligible
                  for a Welcome to Medicare (WTM) Exam in 2006                      27
         Table 14: 2006 through 2009 Use of Selected Preventive Services by
                  Male Medicare FFS Beneficiaries Who Became Eligible for
                  a Welcome to Medicare (WTM) Exam in 2006                          28
         Table 15: Common Reasons Medicare Beneficiaries Reported for
                  Not Using Certain Preventive Services, 2009                       31
         Table 16: Use of Cholesterol Tests by Male Medicare FFS
                  Beneficiaries during the 5-year Period 2005 through 2009          53
         Table 17: Use of Screening Pap Tests by Female Medicare FFS
                  Beneficiaries during the 3-year Period 2007 through 2009          54



         Page ii                                  GAO-12-81 Medicare Preventive Services
          Table 18: Use of Influenza Vaccination by Medicare FFS
                  Beneficiaries for the July 2008 through June 2009 Flu
                  Season                                                             55
          Table 19: Use of the Pneumococcal Vaccination during the 5-year
                  Period 2005 through 2009 by Medicare FFS Beneficiaries
                  Aged 65 as of January 1, 2005                                      56
          Table 20: Use of Bone Mass Measurements by Female Medicare
                  FFS Beneficiaries during the 5-year Period 2005 through
                  2009                                                               57
          Table 21: Use of Screening and Diagnostic Mammography by
                  Female Medicare FFS Beneficiaries Aged 65 to 74 during
                  the 2-year Period 2008 through 2009                                58
          Table 22: Use of Screening Mammography by Female Medicare
                  FFS Beneficiaries Aged 75 or Older during the 2-year
                  Period 2008 through 2009                                           59
          Table 23: Use of Colorectal Cancer Screening and Diagnostic
                  Services by Medicare FFS Beneficiaries Aged 65 to 75,
                  2005 through 2009                                                  60
          Table 24: Use of Colorectal Cancer Screening Services by Medicare
                  FFS Beneficiaries Aged 76 or Older, 2005 through 2009              61
          Table 25: Use of PSA Tests by Male Medicare FFS Beneficiaries
                  during the 4-year Period 2006 through 2009                         62


Figures
          Figure 1: Distribution of HMOs by Service and 2011 Medicare
                   Compare Star Rating                                               33
          Figure 2: Distribution of HMO Beneficiaries by Service and 2011
                   Medicare Compare Star Rating                                      34




          Page iii                                 GAO-12-81 Medicare Preventive Services
Abbreviations
AAA               Abdominal Aortic Aneurysm
ACIP              Advisory Committee on Immunization Practices
AHIP              America’s Health Insurance Plans
AHRQ              Agency for Healthcare Research and Quality
AWV               Annual Wellness Visit
CAHPS             Consumer Assessment of Healthcare Providers and
                    Systems
CDC               Centers for Disease Control and Prevention
CMS               Centers for Medicare & Medicaid Services
EKG               electrocardiogram
ESRD              end-stage renal disease
FFS               fee-for-service
HCPCS             Healthcare Common Procedure Coding System
HEDIS             Healthcare Effectiveness Data and Information Set
HHS               Department of Health and Human Services
HIV               human immunodeficiency virus
HMO               health maintenance organization
HPSA              Health Professional Shortage Area
HRSA              Health Resources and Services Administration
ICD               International Classification of Diseases
IPPE              Initial Preventive Physical Examination
MA                Medicare Advantage
MCBS              Medicare Current Beneficiary Survey
MIPPA             Medicare Improvements for Patients and Providers Act of
                    2008
NCQA              National Committee on Quality Assurance
PFFS              Private Fee-for-Service
PPACA             Patient Protection and Affordable Care Act
PPO               Preferred Provider Organization
PSA               Prostate-Specific Antigen
Task Force        U.S. Preventive Services Task Force
VIS               Vaccine Information Statement
WTM exam          Welcome to Medicare exam


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Page iv                                            GAO-12-81 Medicare Preventive Services
United States Government Accountability Office
Washington, DC 20548




                                   January 18, 2012

                                   The Honorable Max Baucus
                                   Chairman
                                   Committee on Finance
                                   United States Senate

                                   The Honorable Tom Harkin
                                   Chairman
                                   Committee on Health, Education, Labor and Pensions
                                   United States Senate

                                   The Honorable Sheldon Whitehouse
                                   Untied States Senate

                                   Over the past several years, preventive health care services have
                                   received increased attention for their potential to improve health
                                   outcomes and lower health care expenditures. Researchers have found
                                   that certain preventive services are effective in early diagnosis or reduced
                                   prevalence of diseases that contribute to the growth in Medicare
                                   spending. As of the end of 2011, Medicare covered 30 preventive
                                   services, including 3 types of immunizations, various screenings for a
                                   number of diseases, and several other types of preventive services under
                                   Part B. 1 To encourage beneficiary use, the Patient Protection and
                                   Affordable Care Act (PPACA) removed beneficiary cost-sharing
                                   requirements for many Medicare-covered preventive services. 2
                                   Additionally, PPACA created an annual wellness visit benefit—which
                                   allows Medicare beneficiaries a yearly examination without cost sharing—
                                   in part to improve the identification of needed preventive services. Prior to
                                   this new benefit, the only coverage for a physical was the Welcome to
                                   Medicare exam, a one-time benefit for new beneficiaries.



                                   1
                                    Medicare Part B covers physician, outpatient hospital, home health care, and certain
                                   other services.
                                   2
                                     Cost sharing can include coinsurance—a percentage of the cost—or a copayment—a
                                   fixed amount toward the cost. Although PPACA eliminated the deductible and coinsurance
                                   for certain preventive services, beneficiaries may still be required to pay coinsurance for
                                   the office visit during which the service takes place. Pub. L. No. 111-148, § 4103-04,
                                   10406, 124 Stat. 119, 553, 975 (2010).




                                   Page 1                                             GAO-12-81 Medicare Preventive Services
These changes are important for the vast majority of the roughly
36 million beneficiaries covered by fee-for-service (FFS) or “traditional”
Medicare, and the nearly 12 million beneficiaries enrolled in Medicare
Advantage (MA) plans as of 2010. 3, 4 Because MA organizations—which
typically offer plans with a number of different benefit packages—bear a
certain amount of financial risk and are assessed for quality, they may
have an incentive to encourage preventive care use to better control
expenditures and improve performance. 5 Given their organizational
characteristics, health maintenance organizations (HMO) in particular
may be able to employ strategies with both providers and beneficiaries to
promote greater use of preventive services than is feasible in Medicare
FFS.

Despite Medicare’s expanded coverage and the removal of financial
barriers for certain preventive services, research suggests that use of
some preventive services may not be optimal. Some researchers have
raised concerns that the use of some preventives services is low—overall
or for particular patient populations. 6 Other researchers have noted the
overuse and misuse of certain preventive services. 7 To enhance
appropriate provision of preventive services by primary care clinicians
and health systems, the Department of Health and Human Services’


3
 MA organizations, which sponsor MA plans, are private health insurers that contract with
the Centers for Medicare & Medicaid Services (CMS) to provide health care to Medicare
beneficiaries. MA organizations must provide all Medicare-covered services (except
hospice care) and may sponsor multiple plans with different benefits, cost-sharing
requirements, and premiums.
4
 Some FFS beneficiaries may be insulated from the reduction in cost sharing if they have
supplemental insurance coverage, which pays expenses not covered by Medicare.
5
 A study of MA benefits found that most plans covered certain preventive services with no
cost sharing. In 2009, the share of MA beneficiaries enrolled in plans that did not require
cost sharing for eight preventive services ranged from 84 and 100 percent, depending on
the service. See M. Gold and M.C. Hudson, Medicare Advantage Benefit Design: What
Does It Provide, What Doesn’t It Provide, and Should Standards Apply? (prepared by
Mathematica Policy Research, Inc. for AARP Public Policy Institute, March 2009).
6
 M.V. Maciosek et al., “Priorities Among Effective Clinical Preventive Services,” American
Journal of Preventive Medicine, 31, no. 1 (2006): 52-61.
7
 D. Steinwachs et al., “National Institutes of Health State-of-the-Science Conference
Statement: Enhancing Use and Quality of Colorectal Cancer Screening,” Annals of
Internal Medicine, vol. 152, no. 10 (2010):663-667. C. Sima et al., “Cancer Screening
Among Patients With Advanced Cancer,” Journal of the American Medical Association,
vol. 304, no. 14 (2010): 1584-1591.




Page 2                                             GAO-12-81 Medicare Preventive Services
(HHS) Agency for Healthcare Research and Quality (AHRQ) provides the
U.S. Preventive Services Task Force—a group composed of
independent, private-sector experts in prevention and evidence-based
medicine—with research support. The Task Force reviews evidence from
randomized control trials and other studies documenting the effectiveness
of clinical preventive services. It then issues recommendations for
providers and may include guidance on the sex and age groups most
likely to benefit from the service, as well as the interval of the service. The
Task Force does not make recommendations with regard to vaccines;
rather, it defers to the Centers for Disease Control and Prevention’s
(CDC) Advisory Committee on Immunization Practices (ACIP). 8 The
Centers for Medicare & Medicaid Services (CMS)—the agency within
HHS that administers the Medicare program—relies on recommendations
by the Task Force when considering coverage of a new preventive
service. However, research has shown that Medicare coverage does not
always correspond with the specifications of Task Force
recommendations. 9

You asked us about a range of issues concerning use of preventive
services, particularly in the Medicare program. This report examines
(1) the extent to which use of preventive services by FFS beneficiaries
aligns with Task Force or ACIP recommendations, (2) the extent to which
FFS beneficiaries use the Welcome to Medicare exam and whether use
of that service is associated with higher use of preventive care services,
(3) how preventive service use in MA compares to use in FFS, and (4) the
extent to which use varies among MA HMOs and which practices the
better performing HMOs find effective in promoting use of preventive
services.

To determine the extent to which preventive service use by FFS
beneficiaries aligns with guidelines, we selected eight Medicare-covered
preventive services that had related Task Force or ACIP usage
recommendations for the general Medicare population. In making our
selection, we excluded certain services for which the recommendations


8
 ACIP is a committee of 15 experts selected by the Secretary of HHS that provides
recommendations for vaccination administration, including a schedule of recommended
vaccines for adults and children.
9
 L.I. Lesser et al., “Comparison Between US Preventive Services Task Force
Recommendations and Medicare Coverage,” Annals of Family Medicine, 9, no. 1 (2011):
44-49.




Page 3                                          GAO-12-81 Medicare Preventive Services
were primarily aimed at high-risk populations or populations with specific
diagnoses. We analyzed a 5 percent sample of FFS claims from 2005
through 2009 to determine use rates based on service-specific age
groups and intervals outlined in Task Force or ACIP recommendations. 10
We excluded claims for beneficiaries who were under the age of 65 or
were not continuously enrolled in Medicare Part B. We also excluded
beneficiaries who resided in institutions, were qualified for Medicare due
to end-stage renal disease (ESRD), and were enrolled at any time in MA
during the period of study. We recognize that guidelines may not apply to
all beneficiaries due to individual circumstances, and that 100 percent use
of recommended services is unrealistic. We considered Medicare FFS
use to be in alignment with the Task Force and ACIP if at least three in
four beneficiaries overall received a recommended service. We also
considered use to be in alignment if no more than one in four
beneficiaries overall received a service that the Task Force
recommended against having.

To assess the use of the Welcome to Medicare exam, we analyzed a
5 percent sample of 2008 and 2009 FFS claims for this service by eligible
beneficiaries. To examine the association, if any, between the Welcome
to Medicare exam and use of preventive services, we compared
100 percent of claims for a selection of recommended preventive services
from 2006 through 2009 for beneficiaries who became eligible for a
Welcome to Medicare exam in 2006 and received it with those for
beneficiaries who did not have that exam.

To compare preventive service use in MA to use in FFS Medicare, we
analyzed beneficiary survey results because claims data for services
provided to MA beneficiaries are not available from CMS. Using 2008 and
2009 Medicare Current Beneficiary Survey (MCBS) data and plan
enrollment data supplied by CMS, we examined the effect enrollment in
MA HMO and MA non-HMO organizations had on reported use compared
with FFS beneficiaries’ reported use. We analyzed these data using a
logistic regression model that included the effects of contract type, age,
dual-eligibility, education, race, income, marital status, health status, and




10
  The Medicare 5 percent files contain claims and demographic information for 5 percent
of the Medicare FFS population. Files are constructed such that results from this analysis
are generalizable to the entire FFS Medicare population.




Page 4                                             GAO-12-81 Medicare Preventive Services
geographic location. 11 This analysis allowed us to isolate the effect of
beneficiaries’ enrollment choice, holding other beneficiary characteristics
constant.

To examine differences in utilization of preventive services across HMOs,
we reviewed information on relative utilization for five services posted on
CMS’s Medicare Health Plan Compare website for 2011. 12 To learn about
approaches for improving delivery of preventive services, we interviewed
officials from six HMOs that ranked among the top performing for
provision of selected preventive services and had enrollment of 37,000 or
greater in January 2011.

We ensured the reliability of the Medicare claims data, MCBS data, and
Plan Compare data used in this report by performing appropriate
electronic data checks and by interviewing agency officials who were
knowledgeable about the data. Analyzing claims data on preventive
service use risks undercounting because some preventive services are
available outside of Medicare (such as at community events), and would
not be reflected in the claims data. Analyzing survey or self-reported data
on preventive service use risks overcounting due to reasons such as
interviewee recollection errors or inclination to give a socially desirable
response. However, we found the data were sufficiently reliable for the
purpose of our analyses. Appendix I contains a more complete
description of our methodology.

We conducted this performance audit from September 2010 through
January 2012, in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the
audit to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives. We




11
  The MCBS is a survey of a nationally representative sample of the Medicare population,
including both aged and disabled beneficiaries. The survey data are released annually
and the results are contained in two data files, Access to Care and Cost and Use. The
Access to Care file contained responses related to preventive care.
12
  We analyzed Plan Compare data on colorectal cancer screening, influenza vaccination,
mammography, osteoporosis screening, and pneumococcal vaccination. The Plan
Compare database contained use rate information for cholesterol testing but it was based
on a subset of beneficiaries with certain diseases. The database did not include
information on cervical cancer screening or PSA tests.




Page 5                                           GAO-12-81 Medicare Preventive Services
                       believe that the evidence obtained provides a reasonable basis for our
                       findings and conclusions based on our audit objectives.



Background
Medicare Coverage of   When the Medicare program was established in 1965, it covered health
Preventive Services    care services for the diagnosis or treatment of illness or injury, but did not
                       cover preventive services. Since 1980, Congress has expanded coverage
                       of preventive services for the Medicare population several times. For
                       instance, the Balanced Budget Act of 1997 added coverage of prostate
                       and colorectal cancer screening, among other things. Later, the Medicare
                       Prescription Drug, Improvement, and Modernization Act of 2003
                       mandated coverage of a one-time Initial Preventive Physical Examination
                       (IPPE)—also known as the Welcome to Medicare (WTM) exam—for new
                       Part B enrollees. The WTM exam includes a review of medical history,
                       blood pressure, vision, height, as well as weight, and planning for
                       patients’ preventive service needs. The WTM exam was initially available
                       to beneficiaries within the first 6 months of enrollment beginning in 2005,
                       but the Medicare Improvements for Patients and Providers Act of 2008
                       (MIPPA) extended the period of eligibility to within the first 12 months of
                       enrollment beginning in 2009. MIPPA also gave HHS authority to add
                       coverage of new preventive services through its National Coverage
                       Determination process when HHS determines services are reasonable
                       and necessary for the prevention or early detection of an illness,
                       recommended by the Task Force, and appropriate for beneficiaries.
                       Medicare coverage and cost sharing for selected preventive services in
                       2009—the year relevant to several of the findings in this report—is shown
                       in table 1.




                       Page 6                                     GAO-12-81 Medicare Preventive Services
Table 1: Medicare Part B Coverage and Cost Sharing for Selected Preventive Services, 2009
                                                                                                                                  a
Selected preventive service            Medicare coverage                                            Beneficiary cost sharing
Vaccinations
                                                                                                          b
Influenza vaccination                  Covered once every influenza season in the fall or None
                                       winter, for all beneficiaries
                                                                                                          b
Pneumococcal vaccination               Covered as needed, likely once in a lifetime for all None
                                       beneficiaries
Screening services
                                                                                             c
Breast cancer—mammography              Covered annually for beneficiaries 40 or older               20 percent of approved amount
Cardiovascular disease—                Covered every 5 years for all beneficiaries                  None for the lab work, but may have required
cholesterol test                                                                                    20 percent of the approved amount for the
                                                                                                    physician office visit
Cervical cancer—pap test               Covered biannually for all female beneficiaries,             None for the lab work, but 20 percent of the
                                       annually for female beneficiaries at high risk               approved amount for the administration
Colorectal cancer—colonoscopy,         Fecal occult blood test and flexible sigmoidoscopy           20 percent of the approved amount for
fecal occult blood test, or flexible   covered for beneficiaries aged 50 or older, and              colonoscopy and flexible sigmoidoscopy;
                d
sigmoidoscopy                          colonoscopy covered without minimum age;                     none for the fecal occult blood test lab work,
                                       colonoscopy covered every 10 years or 4 years                but 20 percent of the approved amount for an
                                       after a previous flexible sigmoidoscopy; fecal               office visit associated with it
                                       occult blood test covered annually; flexible
                                       sigmoidoscopy covered every 4 years, or
                                                                               e
                                       10 years after a previous colonoscopy
Osteoporosis—bone mass                 Covered biannually, or more often if medically               20 percent of the approved amount for the
measurement                            necessary, for people with certain medical                   test, and the deductible applied to this service
                                       conditions or that meet certain criteria
Prostate cancer—Prostate-              PSA test covered annually for men 50 or older                None for the lab work, but 20 percent of the
                           f
Specific Antigen (PSA) test                                                                         approved amount for the physician office visit;
                                                                                                    the deductible applied for the physician office
                                                                                                    visit
Other
Initial Preventive Physical            Beginning in 2009, Medicare covered a WTM          20 percent of the approved amount for the
Examination (IPPE) or Welcome          exam for all new beneficiaries within 12 months of service
to Medicare (WTM) exam                 enrollment
                                               Source: GAO analysis of CMS information.
                                               a
                                                Cost sharing may have been different for several components of a preventive service, such as the
                                               administration of the service, any lab testing that may be involved with the service, and the physician
                                               office visit associated with the service. In addition, some services when provided in a hospital setting
                                               may have required cost sharing of a different amount.
                                               b
                                                If the provider did not accept assignment for providing the vaccination, the beneficiary may have had
                                               to pay for 100 percent of the vaccination up front and submit a claim to Medicare for reimbursement,
                                               and the provider may have charged more than the Medicare-approved payment.
                                               c
                                                   Medicare also covered one baseline mammogram for women 35-39.
                                               d
                                                Medicare also covered a barium enema as a form of colorectal cancer screening, but because the
                                               Task Force does not recommend it, it was not included in our analysis.
                                               e
                                                   Screening intervals for some of these tests were shortened for beneficiaries at high risk.
                                               f
                                               Medicare also covered an annual digital rectal exam as a form of prostate cancer screening, but
                                               because the Task Force does not endorse it, it was not included in our analysis.




                                               Page 7                                                         GAO-12-81 Medicare Preventive Services
PPACA created further incentives for Medicare beneficiaries to obtain
preventive care. In addition to covering wellness visits annually, beginning
January 1, 2011, PPACA eliminated cost sharing for the WTM exam and
for covered preventive services that are appropriate for a beneficiary and
recommended by the Task Force for any indication or population. Prior to
the implementation of PPACA, influenza and pneumococcal
immunizations and clinical lab testing for preventive services were
available with no cost sharing, but many other preventive services had
some cost-sharing requirements. Further, PPACA gave HHS the authority
to modify or eliminate coverage of certain preventive services. 13 (For
specifics on Medicare preventive services coverage and cost sharing for
2011, see app II.)

In developing regulations implementing these provisions, CMS
acknowledged that although the Task Force may find a service to
produce net benefits for only certain patients, the services would be
available to all beneficiaries without cost sharing. 14 In instances where the
Task Force recommends against the use of a service by a certain
population, CMS expects providers to limit delivery to those beneficiaries
for whom it is clinically appropriate on a case-by-case basis. CMS also
noted that if, at a later date, concern is raised about the appropriateness
of a service for a specific population, it may use its authority to adjust
Medicare coverage for that service.

In addition, PPACA required HHS to implement a national public-private
partnership for prevention and health promotion outreach and education.
In June 2011, CMS announced the “Share the News. Share the Health.”
campaign to educate Medicare providers, beneficiaries, and caregivers
about new and expanded prevention-related benefits. The goal of the
campaign is to encourage use of those preventive services that are now
available to beneficiaries without cost sharing.




13
  HHS can (1) modify the coverage of most of the preventive services enumerated in the
statutory provision on the WTM exam to the extent that the modification is consistent with
Task Force recommendations, (2) modify which services are included in the WTM exam,
and (3) eliminate payment for those services that the Task Force determines have no net
benefit or that the harms outweigh the benefits. § 4105, 124 Stat. at 558 (adding
42 U.S.C. § 1395m(n)).
14
 Medicare Program; Payment Policies Under the Physician Fee Schedule and Other
Revisions to Part B for CY 2011. 75 Fed. Reg. 73,170, 73,415 (Nov. 29, 2010).




Page 8                                             GAO-12-81 Medicare Preventive Services
Public Reporting on the      As of July 2011, roughly one in four Medicare beneficiaries were enrolled
Use of Preventive Services   in approximately 3,700 MA plans sponsored by 667 parent MA
in MA                        organizations. Nearly two-thirds of MA enrollees were covered by HMOs.
                             HMOs tend to limit utilization outside the organization’s network of
                             providers to a greater degree than other MA organization types. They are
                             also more likely to coordinate care across providers and provider types.
                             Other MA organization types, such as Preferred Provider Organizations
                             or Private Fee-for-Service organizations, are more similar to Medicare
                             FFS in that enrollees face fewer limitations on their choice of providers.

                             Each year CMS posts information on its website about MA organizations’
                             performance in delivering preventive services and other performance
                             measures. 15 The information is available in CMS’ Medicare Health Plan
                             Compare database, which compiles information comparing MA
                             organizations’ performance from survey and administrative data. CMS
                             assigns ratings—ranging from one to five stars—for each measure, which
                             are based on an MA organization’s performance compared to other
                             organizations. 16 The star ratings are designed to indicate meaningful
                             differences between MA organizations and thus the cut points vary by
                             service. For example, a mammography use rate of below 59 percent
                             would yield one star, while a use rate of 82 percent or above would yield
                             five stars. Conversely, for colorectal cancer screening, one star plans had
                             use rates of less than 36 percent while five star plans had use rates equal
                             to or above 70 percent. Better-scoring MA organizations may attract new
                             enrollees and, beginning in 2012, may qualify for Medicare bonus
                             payments.




                             15
                               Some measures, such as breast cancer screening, are based on data for broad
                             populations that may be limited only by age range or sex. Other measures, such as
                             cholesterol screening for patients with diabetes, are based on groups of individuals who
                             have displayed some risk of illness.
                             16
                               Plan Compare data are compiled at the organization level and thus the star ratings are
                             the same across each organization’s plans. Not all organizations in the database have
                             information for every measure; some organizations are not required to report data for
                             certain measures, others may be too new or too small, or there may not be enough data to
                             calculate the measure.




                             Page 9                                            GAO-12-81 Medicare Preventive Services
Development of Task   When developing its recommendations for specific preventive services,
Force and ACIP        the Task Force takes into account the medical evidence on benefits
Recommendations       across a broad population; that is, whether the benefits across a broad
                      population outweigh the harms. A commonly cited potential benefit is
                      preventing the development of a condition through early diagnosis. For
                      example, medication therapy as a result of cholesterol testing to detect
                      lipid disorders may substantially decrease the incidence of coronary heart
                      disease. Likewise, treatment as a result of the early detection of cancer
                      may increase one’s odds of survival from cancer. The Task Force also
                      takes into consideration any potential harms related to specific preventive
                      services. These include pain or complications associated with the
                      screening procedures themselves or with the procedures used as a
                      follow-up to screening. For example, risks associated with colonoscopies
                      include perforations and other complications that can arise from the
                      invasive procedure. Similarly, treatment of conditions identified through
                      screening can cause harms that may be viewed as worse than the
                      underlying condition.

                      The Task Force reviews clinical research and issues a recommendation
                      statement and evidence report giving each service a grade, as follows:

                      •    An “A” grade means that the Task Force recommends the service
                           because there is high certainty that the net benefit is substantial.

                      •    A “B” grade means that the Task Force recommends the service
                           because there is high certainty that the net benefit is moderate or
                           there is moderate certainty that the net benefit is moderate to
                           substantial.

                      •    A “C” grade means that the Task Force recommends against routinely
                           providing the service because, although there may be considerations
                           that support providing the service in an individual patient, there is at
                           least moderate certainty that the net benefit is small. 17




                      17
                        Prior to May 2007, a “C” grade meant that the Task Force made no recommendation for
                      or against the provision of the service because it found at least fair evidence that the
                      service could improve health outcomes but concluded that the balance of benefits and
                      harms was too close to justify a general recommendation.




                      Page 10                                          GAO-12-81 Medicare Preventive Services
•   A “D” grade means that the Task Force recommends against the
    service because there is moderate or high certainty that the service
    has no net benefit or that the harms outweigh the benefits.

•   An “I Statement” means that the Task Force concludes that the
    current evidence is insufficient to assess the balance of benefits and
    harms of the service.

AHRQ officials have noted that the Task Force’s recommendations are
designed as guidance for clinicians, not coverage policies for health
insurers. They maintain that patients should have access to preventive
services and that decisions to obtain a particular service should rest with
patients, based on their values and preferences. For example, although
colorectal cancer screening for people age 86 or older in the general
population received a D grade, the service may be appropriate for certain
older beneficiaries given their health status. At the same time, AHRQ
officials noted that the Task Force position on “D” rated services is that
physicians should discourage most patients from obtaining such services.

Similarly, ACIP takes into account benefits and risks of vaccines in
developing its recommendations, and CDC publishes information on the
benefits and risks of vaccines through its Vaccine Information Statements
(VIS). ACIP experts review clinical research to obtain information related
to disease morbidity and mortality, safety, efficacy, effectiveness, and
cost-effectiveness of specific vaccines. Potential benefits may be short-
term protection from the disease, in the case of the influenza vaccine, or
long term, in the case of the pneumococcal vaccine, as well as preventing
the spread of infection. The VISs for influenza and pneumococcal
immunizations generally report minimal risks with these vaccines.




Page 11                                   GAO-12-81 Medicare Preventive Services
                                While FFS beneficiaries’ use of cardiovascular and cervical cancer tests
FFS Use of Tests for            generally aligned with clinical recommendations, use of immunizations
Cardiovascular                  and osteoporosis screenings was low compared to recommendations,
                                and tests for breast, colorectal, and prostate cancer were generally not
Disease and Cervical            aligned with recommendations for certain age groups. Alignment with
Cancer Generally                recommendations was generally lower for beneficiaries living in rural and
Aligned with                    provider shortage areas.

Recommendations,
but Use of Other
Preventive Services
Did Not
Use of Cardiovascular and
Cervical Cancer Tests
Generally Aligned with
Recommendations
Cholesterol testing to detect   We found that more than four out of five male FFS beneficiaries received
lipid disorders                 a cholesterol test in the 5-year period 2005 through 2009, indicating that
                                utilization generally aligned with Task Force recommendations. Because
                                lipid disorders are a risk factor for cardiovascular disease and other heart-
                                related conditions, the Task Force strongly recommends cholesterol
                                screening (grade A) for men aged 35 or older to detect lipid disorders. 18, 19
                                Although the Task Force states that the optimal screening interval is
                                uncertain, it notes that a reasonable interval for cholesterol screening to
                                detect a lipid disorder would be once every 5 years. Cholesterol testing
                                may also be conducted for the purpose of monitoring cholesterol after a
                                diagnosis of abnormal levels, and thus may be done more frequently than
                                for screening to identify cardiovascular disease risk. From 2005 through
                                2009, approximately 84 percent of male beneficiaries aged 65 or older



                                18
                                  Among available lipid screening tools, the Task Force endorses total cholesterol and
                                high density lipoprotein-cholesterol testing samples as the preferred tests.
                                19
                                  In 2008, the Task Force updated its recommendation statement to strongly recommend
                                screening women aged 45 or older for lipid disorders only if they are at increased risk for
                                heart disease. Because claims data are not sufficiently detailed to ascertain which female
                                beneficiaries were at increased risk, we could not reliably analyze use of cholesterol
                                screening in high-risk women.




                                Page 12                                            GAO-12-81 Medicare Preventive Services
                                 received at least one cholesterol test, with the majority receiving two or
                                 more such tests. 20 Overall use of cholesterol testing was somewhat lower
                                 for male beneficiaries 85 or older, but remained relatively high. (See
                                 table 2.)

                                 Table 2: Use of Cholesterol Tests by Male Medicare FFS Beneficiaries during the
                                 5-year Period 2005 through 2009

                                     Numbers in percent
                                                             a
                                     Male beneficiaries                     No services     One service         Two or more services
                                     All                                             16.2             8.3                             75.5
                                     65 to 74                                        16.4             7.9                             75.8
                                     75 to 84                                        15.2             8.6                             76.2
                                     85 or older                                     21.7           12.3                              66.0
                                 Source: GAO analysis of CMS Medicare claims data.

                                 Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
                                 age 65, (2) beneficiaries who were not continuously enrolled in Medicare Parts A and B during the
                                 period of study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries
                                 who were enrolled at any time in Medicare Advantage during the period of study.
                                 a
                                 Denotes the beneficiary’s age as of January 1, 2005.


Pap testing to detect cervical   In general, female FFS beneficiaries’ use of cervical cytology, or Pap
cancer                           tests, was relatively low, which generally aligns with Task Force
                                 recommendations. For women 65 or older, the Task Force recommended
                                 against routine screening (grade D) if they have had a recent normal Pap
                                 test and are not otherwise at high risk for cervical cancer. 21, 22 After
                                 reviewing evidence, the Task Force concluded that screening women
                                 older than 65 is associated with an increased risk for potential harm,
                                 including false-positive results and invasive procedures. However, for
                                 women under age 65 who have been sexually active and have a cervix,
                                 the Task Force strongly recommended the use of Pap tests to detect



                                 20
                                   It was beyond of the scope of this report to determine the reason for which the
                                 cholesterol testing was administered. Additionally, claims data may undercount the actual
                                 use of cholesterol testing, as some beneficiaries may receive cholesterol testing outside of
                                 FFS Medicare, such as at a health fair.
                                 21
                                   The Task Force also recommends against screening with Pap test in women who have
                                 had a total hysterectomy for benign disease.
                                 22
                                   Prior to May 2007, a D grade indicated that the Task Force recommended against
                                 routinely providing the service to asymptomatic patients.




                                 Page 13                                                     GAO-12-81 Medicare Preventive Services
cervical cancer, and stated that annual screening achieves outcomes no
better than screening every 3 years. 23, 24

Although claims data do not identify women who are at high risk for
cervical cancer, use appears to align with recommendations.
Approximately 23 percent of female beneficiaries aged 65 or older
received a screening Pap test from 2007 through 2009. Use was lower for
older beneficiaries; approximately 17 percent of women 75 to 84 and
6 percent of women 85 or older received one or more Pap tests. (See
table 3.)

Table 3: Use of Screening Pap Tests by Female Medicare FFS Beneficiaries during
the 3-year Period 2007 through 2009

    Numbers in percent
                                a
    Female beneficiaries                    No services    One service         Two or more services
    All                                             77.0            17.8                               5.2
    65 to 74                                        69.1            23.7                               7.3
    75 to 84                                        83.1            13.4                               3.5
    85 or older                                     93.9              5.1                              1.0
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
age 65, (2) beneficiaries who were not continuously enrolled in Medicare Parts A and B during the
period of study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries
who were enrolled at any time in Medicare Advantage during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2007.




23
  Because beneficiaries may have continued receiving Pap tests at the interval
recommended for younger women, we used a 3-year period to assess use in the
Medicare population.
24
  In October 2011, the Task Force submitted a draft update to its 2003 recommendation,
proposing to issue an ‘A’ grade for Pap smear every 3 years in women ages 21 to 65, and
proposing to issue a “D” grade for Pap smear in women younger than age 21. The draft
recommendation still issues a “D” grade for Pap smear in women older than age 65 who
have had adequate prior screening and are not otherwise at high risk for cervical cancer.




Page 14                                                     GAO-12-81 Medicare Preventive Services
Use of Immunizations and
Osteoporosis Screenings
Was Lower than
Recommended
Vaccination to prevent     Medicare claims data indicated that use of the influenza vaccination was
influenza virus            low relative to the ACIP recommendation that it be received every year.
                           Despite the absence of cost sharing, only about half of all beneficiaries 65
                           or older had a Medicare claim for the influenza vaccination during the
                           2008-09 influenza season. 25 A higher proportion of women than men had
                           a claim for the influenza vaccine, and older beneficiaries were more likely
                           to have such claims than younger beneficiaries. (See table 4.)

                           Table 4: Use of the Influenza Vaccination by Medicare FFS Beneficiaries for the July
                           2008 through June 2009 Flu Season

                               Numbers in percent
                                               a                                                                                    b
                               Beneficiaries                                   No vaccinations        One or more vaccinations
                               All                                                        50.9                                  49.1
                               Female                                                     49.2                                  50.9
                               Male                                                       53.4                                  46.6
                               65 to 74                                                   55.7                                  44.3
                               75 to 84                                                   45.8                                  54.2
                               85 or older                                                45.3                                  54.7
                           Source: GAO analysis of CMS Medicare claims data.

                           Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
                           age 65, (2) beneficiaries who were not continuously enrolled in Medicare Parts A and B during the
                           period of study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries
                           who were enrolled at any time in Medicare Advantage during the period of study.
                           a
                           Denotes the beneficiary’s age as of July 1, 2008.
                           b
                            Less than one half of 1 percent received two or more influenza vaccinations for the July 2008
                           through June 2009 flu season.


                           Medicare claims data, however, may undercount the actual use of the
                           influenza vaccine because some beneficiaries receive this service from
                           nontraditional sources of care, such as a workplace or health fair. Survey
                           data—which can capture use of clinical services outside of Medicare—
                           suggest that a substantially higher proportion of beneficiaries received


                           25
                             Some beneficiaries, such as those who are very ill, may not be appropriate candidates
                           for the influenza vaccination.




                           Page 15                                                          GAO-12-81 Medicare Preventive Services
                         influenza vaccinations. In a 2009 CDC survey, more than 31 percent of
                         older adults reported they had not received an influenza vaccination in the
                         past year. 26

Vaccination to prevent   Although ACIP recommends that beneficiaries 65 or older receive the
pneumonia                pneumococcal vaccination, few newly enrolled FFS beneficiaries received
                         one within 5 years of Medicare enrollment even though it was available
                         without cost sharing. 27, 28 During the 5 years from 2005 through 2009,
                         about 27 percent of beneficiaries aged 65 as of January 1, 2005, received
                         a pneumococcal vaccination. Use did not vary substantially between
                         women and men. (See table 5.)

                         Table 5: Use of the Pneumococcal Vaccination during the 5-year Period 2005
                         through 2009 by Medicare FFS Beneficiaries Aged 65 as of January 1, 2005

                             Numbers in percent
                                                                                                                                a
                             Beneficiaries                                   No vaccination        One or more vaccinations
                             All                                                       72.7                                 27.3
                             Female                                                    71.7                                 28.4
                             Male                                                      73.9                                 26.1
                         Source: GAO analysis of CMS Medicare claims data.

                         Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries who
                         were not continuously enrolled in Medicare Parts A and B during the period of study, (2) beneficiaries
                         residing in institutions, (3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in
                         Medicare Advantage during the period of study.
                         a
                          Less than 2 percent of beneficiaries aged 65 at the beginning of the 5-year period 2005 through
                         2009 received two or more pneumococcal vaccinations.




                         26
                          Centers for Disease Control and Prevention, Administration on Aging, Agency for
                         Healthcare Research and Quality, and Centers for Medicare & Medicaid Services,
                         Enhancing Use of Clinical Preventive Services Among Older Adults (Washington, D.C.:
                         AARP), 2011.
                         27
                           We analyzed use of the pneumococcal vaccination for beneficiaries who were aged 65
                         as of January 1, 2005, to determine whether they received it between 2005 and 2009—a
                         period generally covering their first 5 years of enrollment in Medicare FFS.
                         28
                           Pneumococcal vaccination is recommended for all adults aged 65 or older who were
                         vaccinated over 5 years prior and were less than 65 years of age at the time of the prior
                         vaccination. Pneumococcal vaccination is also recommended for adults aged 65 or older
                         who lack documentation of vaccination.




                         Page 16                                                         GAO-12-81 Medicare Preventive Services
                           Similar to measurement issues regarding influenza vaccination and
                           cholesterol testing, these claims data may undercount the actual use of
                           the pneumococcal vaccine because beneficiaries may receive this service
                           from sources outside of Medicare. According to the 2009 CDC survey,
                           more than 33 percent of older adults reported never having received a
                           pneumococcal vaccination. 29

Bone mass measurement to   Relative to Task Force recommendations, female FFS beneficiaries’ use
detect osteoporosis        of bone mass measurement was low. The Task Force recommends that
                           women aged 65 or older be screened for osteoporosis with a bone mass
                           measurement (grade B). Regarding the appropriate screening interval,
                           the Task Force suggests that a minimum of 2 years between screenings
                           may be necessary to discern notable differences in bone density, but that
                           longer intervals may be necessary to improve the prediction of fracture
                           risk. From 2005 through 2009, approximately 53 percent of female
                           beneficiaries who were aged 65 or older at the beginning of 2005
                           received at least one bone mass measurement screening. Older
                           beneficiaries had lower use of this service; about 50 percent of
                           beneficiaries aged 75 to 84 received at least one bone mass
                           measurement, and about 30 percent of beneficiaries aged 85 or older
                           received a bone mass measurement. (See table 6.)




                           29
                            Centers for Disease Control and Prevention, Administration on Aging, Agency for
                           Healthcare Research and Quality, and Centers for Medicare & Medicaid Services,
                           Enhancing Use of Clinical Preventive Services Among Older Adults. (Washington, D.C.:
                           AARP), 2011.




                           Page 17                                         GAO-12-81 Medicare Preventive Services
Table 6: Use of Bone Mass Measurements by Female Medicare FFS Beneficiaries
during the 5-year Period 2005 through 2009

    Numbers in percent
                                a
    Female beneficiaries                    No services    One service        Two or more services
    All                                             47.4           29.3                             23.3
    65 to 74                                        42.2           31.2                             26.6
    75 to 84                                        50.3           28.5                             21.2
    85 or older                                     70.5           19.7                               9.8
Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously
enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions,
(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage
during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2005.


One factor that may have contributed to the relatively low use of bone
mass measurement is that Medicare coverage is limited. Although the
Task Force recommends the screening for all female beneficiaries aged
65 or older, Medicare covers this service only for people who have certain
medical conditions or meet certain criteria. 30 To the degree that coverage
for preventive care is a significant determinant of service use, not having
coverage could explain why some beneficiaries have not received the
service. In 2010, PPACA gave HHS the authority to modify coverage of
Medicare preventive services—including bone mass measurement—
when the change is consistent with Task Force recommendations.




30
  Beneficiaries need to meet one of the following criteria to be eligible for bone mass
measurement coverage: be estrogen deficient and at clinical risk for osteoporosis; have
vertebral abnormalities; be receiving glucocorticoid therapy for more than 3 months; have
primary hyperparathyroidism; or be in the process of monitoring to assess response to
FDA-approved osteoporosis drug therapy.




Page 18                                                     GAO-12-81 Medicare Preventive Services
Use of Breast, Colorectal,
and Prostate Cancer Tests
Generally Did Not Align
with Recommendations for
Certain Age Groups
Screening mammography to     Use of mammography is low relative to recommendations for younger
detect breast cancer         Medicare FFS beneficiaries, indicating that use generally does not align
                             with recommendations for that age group. The Task Force recommends
                             that women aged 50 to 74 receive a screening mammogram every
                             2 years (grade B). Because some high-risk women may receive a
                             diagnostic mammogram in lieu of a screening mammogram, we included
                             both types of claims in our analysis for younger beneficiaries. 31 We found
                             that, among women aged 65 to 74, roughly two out of three beneficiaries
                             received either a screening or diagnostic mammogram in 2008 or 2009. 32

                             For women 75 or older, the Task Force reported that evidence is
                             insufficient to assess the additional benefits and harms of screening
                             mammography (with a grade of I). About 41 percent of women in that age
                             group received at least one screening mammogram in 2008 or 2009, and
                             22 percent of women 85 or older received at least one screening
                             mammogram. (See table 7.)




                             31
                               Diagnostic mammograms are administered when evidence already exists that a
                             beneficiary may have or be at risk to develop breast cancer—that is, when a beneficiary is
                             symptomatic. However, some asymptomatic, high-risk women may be given a diagnostic
                             mammogram instead of a screening mammogram.
                             32
                               We included screening and diagnostic mammograms in the analysis for the younger
                             population because diagnostic mammograms are sometimes given for the purpose of
                             screening in high-risk women, and because beneficiaries who received diagnostic testing
                             would not necessarily be expected to receive additional screening.




                             Page 19                                           GAO-12-81 Medicare Preventive Services
                               Table 7: Use of Mammography by Female Medicare FFS Beneficiary Age during the
                               2-year Period 2008 through 2009

                                   Numbers in percent
                                                                                                                       One or more
                                                               a
                                   Female beneficiaries             Type of mammogram            No mammogram         mammograms
                                   65 to 74                        Screening or diagnostic                    35.5                 64.5
                                   75 or older                                 Screening only                 59.5                 40.5
                                       75 to 84                                Screening only                 52.9                 47.1
                                       85 or older                             Screening only                 77.9                 22.1
                               Source: GAO analysis of CMS Medicare claims data.

                               Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously
                               enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions,
                               (4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage
                               during the period of study.
                               a
                               Denotes the beneficiary’s age as of January 1, 2008.


Testing to detect colorectal   We found that use of colorectal cancer testing regimens was low relative
cancer                         to the recommendations for younger FFS beneficiaries. For beneficiaries
                               aged 50 to 75, the Task Force recommends using one of three different
                               regimens to screen for colorectal cancer (grade A): fecal occult blood
                               testing once per year, a sigmoidoscopy every 5 years along with fecal
                               occult blood testing every 3 years, or a colonoscopy every 10 years. 33 For
                               beneficiaries aged 65 to 75, we computed use rates using codes for
                               screening and diagnostic services because it is likely that at least some
                               services claimed as diagnostic were for screening purposes. 34
                               Beneficiaries who satisfied one of the colorectal cancer screening
                               regimens from 2005 through 2009 were deemed to have met the
                               recommendation, and those who satisfied none of the regimens were
                               considered to not have met the recommendation. 35 From 2005 through


                               33
                                 Screening colonoscopies and sigmoidoscopies are examples of multiple types of
                               colorectal cancer testing. Diagnostic colonoscopies and sigmoidoscopies are administered
                               when symptomatic evidence already exists that a beneficiary may have colorectal cancer
                               or had it in the past.
                               34
                                 Also, because beneficiaries who received diagnostic testing would not necessarily be
                               expected to receive additional screening, we included both screening and diagnostic
                               services for the recommended population of beneficiaries aged 65 to 75.
                               35
                                 Screening colonoscopy is recommended every 10 years. We reviewed data for 2005
                               through 2009, which allowed us to maintain a robust sample. Not including colonoscopy
                               services from 2000 through 2004 may have resulted in undercounting the share of
                               beneficiaries who met the recommended regimens.




                               Page 20                                                          GAO-12-81 Medicare Preventive Services
2009, about one quarter of Medicare FFS beneficiaries aged 65 to 75
followed any of the recommended regimens. (See table 8.)

Table 8: Use of Colorectal Cancer Screening and Diagnostic Services by Medicare
FFS Beneficiaries Aged 65 to 75, 2005 through 2009

    Numbers in percent
                    a
    Beneficiaries                               Followed a regimen        Did not follow a regimen
    All aged 65 to 75                                         25.5                                  74.5
    Female                                                    27.0                                  73.0
    Male                                                      23.5                                  76.5
Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously
enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions,
(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage
during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2005.


Among older Medicare FFS beneficiaries, use of colorectal cancer testing
regimens generally aligned with recommendations. The Task Force
recommends against routine screening in adults aged 76 to 85 (grade C),
and recommends against any screening for adults aged 86 or older
(grade D). 36 Using only claims for services coded as screenings, we
found that about 6 percent of beneficiaries aged 76 to 85 received a
colorectal cancer screening regimen. Among beneficiaries aged 86 or
older,
2 percent met any of the regimens. Because routine screening of older
beneficiaries is discouraged by the Task Force, these low rates indicate
general alignment with recommended use. (See table 9.)




36
  According to AHRQ officials, the Task Force believes there are circumstances where
individuals may benefit from a “D” grade service, but “D” services are not recommended
for the general population.




Page 21                                                      GAO-12-81 Medicare Preventive Services
                                   Table 9: Use of Colorectal Cancer Screening Services by Medicare FFS
                                   Beneficiaries Aged 76 or Older, 2005 through 2009

                                       Numbers in percent
                                                       a
                                       Beneficiaries                                   Followed a regimen      Did not follow a regimen
                                       Female                                                         5.4                              94.6
                                       Male                                                           6.4                              93.6
                                       76 to 85                                                       6.3                              93.7
                                       86 or older                                                    2.0                              98.0
                                   Source: GAO analysis of CMS Medicare claims data.

                                   Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously
                                   enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions,
                                   (4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage
                                   during the period of study.
                                   a
                                   Denotes the beneficiary’s age as of January 1, 2005.


Prostate-Specific Antigen          We found that rates of PSA screening differed substantially from the Task
(PSA) testing to detect prostate   Force recommendation for older FFS beneficiaries. In 2008, the Task
cancer                             Force recommended against screening for prostate cancer (grade D) for
                                   men aged 75 or older. 37 The Task Force noted that treatment for prostate
                                   cancer as a result of screening can cause moderate to substantial harms,
                                   and some men who are treated would not have developed symptoms
                                   related to the cancer during their lifetime. Among beneficiaries aged 75 or
                                   older, more than 40 percent received a PSA test, with 35 percent of those
                                   at least 85 years old having the screening at least once. Approximately
                                   one in five beneficiaries aged 75 or older received two or more PSA tests
                                   in our 4-year study period. By statute, beneficiaries were not required to
                                   share the cost of the PSA test. 38

                                   For men younger than 75, the Task Force reported that current evidence
                                   was insufficient to assess the balance of benefits and harms of PSA
                                   testing for prostate cancer (with a grade of I). It further stated that PSA
                                   screening as infrequently as once every 4 years could yield as much
                                   benefit as annual screening. Among male beneficiaries aged 65 to 74,
                                   about half received at least one PSA test in our 4-year study period. (See
                                   table 10.)



                                   37
                                     In October 2011, the Task Force submitted a draft update to its 2008 recommendation,
                                   proposing to issue a “D” grade for PSA testing in men of all ages.
                                   38
                                        Beneficiaries may have been required to pay coinsurance for the physician visit.




                                   Page 22                                                         GAO-12-81 Medicare Preventive Services
                             Table 10: Use of PSA Tests by Male Medicare FFS Beneficiaries during the 4-year
                             Period 2006 through 2009

                                 Numbers in percent
                                                         a
                                 Male beneficiaries                     No services     One service         Two or more services
                                 All                                             50.9           23.6                              25.6
                                 65 to 74                                        48.0           23.5                              28.5
                                 75 or older                                     55.3           23.8                              20.9
                                       75 to 84                                  53.7           24.1                              22.1
                                       85 or older                               65.0           21.5                              13.6
                             Source: GAO analysis of CMS Medicare claims data.

                             Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
                             age 65, (2) beneficiaries who were not continuously enrolled in Medicare Parts A and B during the
                             period of study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries
                             who were enrolled at any time in Medicare Advantage during the period of study.
                             a
                             Denotes the beneficiary’s age as of January 1, 2006.


                             For more detail on Medicare beneficiaries’ use of the eight selected
                             preventive services, see appendix III.


Lack of Alignment with       For all of the recommended preventive services in our study where use
Recommendations Was          did not align with recommendations, FFS beneficiaries living in rural areas
Particularly Evident for     or areas with provider shortages had consistently lower use rates than
                             their counterparts in urban areas. Rural beneficiaries had slightly lower
Beneficiaries Who Live in    use rates than urban beneficiaries, ranging from about 1 percentage point
Rural or Provider Shortage   lower for use of colorectal cancer screening to about 6 percentage points
Areas                        lower for bone mass measurement. (See table 11.)




                             Page 23                                                     GAO-12-81 Medicare Preventive Services
Table 11: Use of Selected Preventive Service among Urban and Rural Medicare FFS
Beneficiaries

    Numbers in percent
                                                                                           Percentage
                                                                                                  point
                                                                  Urban         Rural       difference
    Use of influenza vaccination during 2008 to 2009
    flu season                                                       50.2        45.6                -4.6
    Use of pneumococcal vaccination within first 5 years
                                   a
    of enrollment beginning in 2005                                  28.4        24.2                -4.2
    Use of bone mass measurement by women, 2005
    through 2009                                                     54.0        47.7                -6.3
    Up-to-date colorectal cancer screening by
                                             b
    beneficiaries 65 to 75, 2005 through 2009                        25.7        24.8                -0.9
    Use of mammography by women 65-74 from 2008
                c
    through 2009                                                     65.3        62.0                -3.3
Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously
enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions,
(4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage
during the period of study.
a
    These data include only beneficiaries who were aged 65 as of January 1, 2005.
b
    Denotes the beneficiary’s age as of January 1, 2005.
c
Denotes the beneficiary’s age as of January 1, 2008.


Similarly, FFS beneficiaries living in Health Professional Shortage Areas
(HPSA) had lower use rates than beneficiaries who did not live in
HPSAs. 39 For example, influenza immunization rates were about
11 percentage points lower for HPSA beneficiaries than for non-HPSA
beneficiaries, and bone mass measurement use rates for women living in
a HPSA were about 8 percentage points lower than their counterparts.
(See table 12.)




39
  HPSAs are urban/rural areas, population groups, or medical facilities that have a
shortage of primary medical care, dental, or mental health providers. CMS makes bonus
payments to physicians who provide medical care in geographic areas designated as
Primary Care HPSAs. Approximately 66 million Americans live in a Primary Care HPSA.




Page 24                                                    GAO-12-81 Medicare Preventive Services
                         Table 12: Use of Selected Preventive Service among Medicare FFS Beneficiaries
                         Who Live in a HPSA and Those Who Do Not

                             Numbers in percent
                                                                                                                    Percentage
                                                                                        Not                                point
                                                                                      HPSA             HPSA          difference
                             Use of influenza vaccination during 2008
                             to 2009 flu season                                         49.9             39.4               -10.5
                             Use of pneumococcal vaccination within first
                                                                    a
                             5 years of enrollment beginning in 2005                    27.8             22.5                 -5.3
                             Use of bone mass measurement by women,
                             2005 through 2009                                          53.2             44.8                 -8.4
                             Up-to-date colorectal cancer screening by
                                                                      b
                             beneficiaries 65 to 75, 2005 through 2009                  25.7             23.3                 -2.4
                             Use of mammography by women 65 to 74,
                                              c
                             2008 through 2009                                          65.0             58.4                 -6.6
                         Source: GAO analysis of CMS Medicare claims data.

                         Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously
                         enrolled in Medicare Parts A and B during the period of study, (3) beneficiaries residing in institutions,
                         (4) ESRD beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage
                         during the period of study.
                         a
                             These data include only beneficiaries who were aged 65 as of January 1, 2005.
                         b
                             Denotes the beneficiary’s age as of January 1, 2005.
                         c
                         Denotes the beneficiary’s age as of January 1, 2008.




                         A small number of FFS beneficiaries received a Welcome to Medicare
Few FFS                  (WTM) exam. Among beneficiaries who became eligible for the WTM in
Beneficiaries Had a      2006 and subsequently received it, use of preventive services was higher.
Welcome to Medicare
Exam; Its Use Was
Associated with
Greater Utilization of
Preventive Services




                         Page 25                                                    GAO-12-81 Medicare Preventive Services
Less than 7 Percent of FFS   Very few FFS beneficiaries who reached age 65 during 2008, and were
Beneficiaries Had the        thus eligible for a WTM exam sometime in 2008 or 2009, received a WTM
Welcome to Medicare          exam in either year. 40 Overall, 6.6 percent of beneficiaries received the
                             WTM exam after becoming eligible for it in 2008. Specifically,
Exam
                             •    about the same proportion of women and men had a WTM exam,

                             •    urban beneficiaries had similar use rates as rural beneficiaries, and

                             •    a somewhat smaller share of beneficiaries who lived in a HPSA used
                                  the exam (4.2 percent) compared to beneficiaries who did not live in a
                                  HPSA (6.8 percent).

                             For more detail on Medicare beneficiaries’ use of the WTM exam, see
                             appendix IV.


Among FFS Beneficiaries      Use of selected preventive services was higher for FFS beneficiaries who
Who Received the             had a WTM exam after becoming eligible for it in 2006 compared to those
Welcome to Medicare          who did not receive the exam. 41
Exam, Use of Preventive
                             Female beneficiaries who received the WTM exam had higher Medicare
Services Was Higher          use rates than female beneficiaries who did not receive the exam for each
                             of five services we reviewed. For example, use of bone mass
                             measurement over the period 2006 through 2009 was about 20
                             percentage points higher for female beneficiaries who received the WTM
                             exam than for those who did not receive the WTM exam. 42 Similarly, the
                             rate at which female beneficiaries had at least three influenza
                             vaccinations over the period was about 15 percentage points higher



                             40
                               In 2008, beneficiaries were eligible for a WTM exam for up to 6 months after enrollment,
                             and beginning January 1, 2009, new beneficiaries became eligible for a WTM exam within
                             12 months of enrollment.
                             41
                               It is possible that users of the WTM exam were generally more inclined to be users of
                             other preventive services as well. Determining the cause of the higher use of preventive
                             services was beyond the scope of our objective.
                             42
                               In this analysis, we examined a cohort of beneficiaries who turned 65 in 2006—1 year
                             after the WTM benefit became available—and was thus eligible for a WTM exam
                             sometime in 2006 or 2007. We then examined preventive service use from 2006 through
                             2009 in beneficiaries who received the WTM exam compared with beneficiaries who did
                             not receive the WTM exam.




                             Page 26                                           GAO-12-81 Medicare Preventive Services
among those who received the WTM exam compared to those who did
not receive the exam. 43 (See table 13.)

Table 13: 2006 through 2009 Use of Selected Preventive Services by Female
Medicare FFS Beneficiaries Who Became Eligible for a Welcome to Medicare (WTM)
Exam in 2006

Numbers in percent
                                                         Female          Female
                                                    beneficiaries  beneficiaries
                                                      who had a who did not have Percentage point
                                                      WTM exam     a WTM exam          difference
                               a
Influenza vaccinations                                     47.4               32.3                     15.1
Pneumococcal vaccination                                   17.3               14.6                      2.7
Colorectal cancer screening                                44.7               34.3                     10.4
Bone mass measurement                                      65.3               45.1                     20.2
Mammogram                                                  38.3               30.4                      7.9
Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries residing in institutions,
(3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in Medicare Advantage
during the period of study.
a
 Influenza vaccinations are recommended annually. Because beneficiaries reached age 65 at some
point during 2006, and thus may have been in Medicare for less than 4 years, this rate reflects
beneficiaries who had claims for three or more influenza vaccinations.


Similarly, male beneficiaries who received the WTM exam had higher
Medicare use rates of vaccinations and selected screenings than male
beneficiaries who did not receive the exam. For example, the rate at
which male beneficiaries had at least three influenza vaccinations was
about 17 percentage points higher among those who received the WTM
exam compared with those who did not receive the exam. Male
beneficiaries who received the WTM exam had a colorectal cancer
screening rate about 13 percentage points higher than male beneficiaries
who did not receive the exam. (See table 14.)




43
  Because influenza vaccination is recommended annually, one would expect a
beneficiary that was new to Medicare sometime in 2006 to have received at least three
influenza vaccinations from 2006 through 2009.




Page 27                                                     GAO-12-81 Medicare Preventive Services
Table 14: 2006 through 2009 Use of Selected Preventive Services by Male Medicare
FFS Beneficiaries Who Became Eligible for a Welcome to Medicare (WTM) Exam in
2006

    Numbers in percent
                                                     Male           Male
                                             beneficiaries beneficiaries                 Percentage
                                                who had who did not have                        point
                                             a WTM exam    a WTM exam                     difference
                               a
    Influenza vaccinations                             42.0                   25.2               16.8
    Pneumococcal vaccination                           16.7                   12.3                 4.4
    Colorectal cancer screening                        40.7                   27.5               13.2
    Cardiovascular disease screening                   86.7                   74.4               12.3
Source: GAO analysis of CMS Medicare data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries residing in institutions,
(3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in Medicare Advantage
during the period of study.
a
 Influenza vaccinations are recommended annually. Because beneficiaries reached age 65 at some
point during 2006, and thus may have been in Medicare for less than 4 years, this rate reflects
beneficiaries who had claims for three or more influenza vaccinations.




Page 28                                                  GAO-12-81 Medicare Preventive Services
                         Relative to beneficiaries in FFS, those enrolled in HMOs—the most
Beneficiaries in MA      popular type of MA plan—reported higher use rates for some preventive
HMOs Reported            services. 44 Specifically, survey data indicate that beneficiaries enrolled in
Higher Use of            MA HMOs in 2009 had slightly greater use of immunizations and
                         cholesterol tests compared to beneficiaries in FFS, holding constant
Immunizations and        demographic and geographic factors. 45 For HMO beneficiaries, 46
Cholesterol Tests than   •    reported use of cholesterol screening in the preceding 12 months was
Those in FFS                  3.6 percentage points higher,

                         •    reported use of the influenza vaccine during the most recent flu
                              season was 4.0 percentage points higher, and

                         •    reported use of the pneumococcal vaccination at least once in the
                              beneficiary’s lifetime was 3.0 percentage points higher.



                         However, the data did not indicate a difference between reported use of
                         various cancer screening tests. 47 For breast, cervical, colorectal, and
                         prostate cancer screenings, we did not find a statistically significant
                         difference in reported utilization between MA HMO and FFS beneficiaries,
                         when holding other factors constant. This was equally true among
                         younger beneficiaries and older beneficiaries for breast, colorectal, and




                         44
                           This is consistent with previous research on preventive service use in Medicare
                         managed care. A study of survey data for 2001 found that, holding other factors constant,
                         beneficiaries in Medicare+Choice—now known as MA—plans were slightly more likely to
                         be high users of certain preventive services relative to those in Medicare FFS. See
                         Ozminkowski et al., “Predictors of Preventive Service Use Among Medicare Beneficiaries,”
                         Health Care Financing RevIew, Spring 2006, Volume 27, Number 3: 5-23.
                         45
                           To account for other factors that may influence preventive service use, we used logistic
                         regression to hold constant the impact of beneficiaries’ age, sex, dual-eligibility status,
                         education level, marital status, income, race, Hispanic heritage, health status, and
                         residence by state and metropolitan area.
                         46
                           For enrollment status, we were able to classify 96 percent of survey respondents as
                         enrolled in Medicare FFS, an MA HMO, or another type of MA organization (such as
                         preferred provider organizations or private FFS organizations).
                         47
                           The MCBS varies some questions from year to year. Although not asked in 2009, our
                         analysis of the responses regarding osteoporosis tests in 2008 showed no statistically
                         significant difference in reported use rates by type of enrollment.




                         Page 29                                            GAO-12-81 Medicare Preventive Services
prostate cancer screenings—services that have different Task Force
recommendations for the different age groups. 48

We were not able to discern a distinction in use rates between enrollees
in FFS and enrollees in other types of MA organizations. Holding other
factors constant, there was no statistically significant difference in
reported use rates by FFS and MA non-HMO enrollees for any of the
services we examined. This result may stem from the fact that non-HMO
plans are structurally more similar to FFS than HMOs.

When asked why they did not have a particular preventive service,
beneficiaries commonly indicated that they had limited information on
prevention and relied on providers to initiate preventive care, regardless
of whether the beneficiaries were enrolled in FFS, MA HMOs, or MA non-
HMO organizations. Among the more common reasons beneficiaries
gave for not having a preventive service were that they did not know it
was needed; they had concerns about discomfort, side effects, or
efficacy; or their provider did not recommend it to them. Table 15 shows
the proportion of beneficiaries, regardless of their enrollment choice, who
cited these reasons for not having one of three services where the use
rates in our analysis of Medicare claims were generally lower than
desired based on clinical guidelines—influenza vaccination,
pneumococcal vaccination, and mammography for younger beneficiaries.
For example, about half of beneficiaries who reported never having
received a pneumococcal vaccination said that they did not know it was
needed, and more than half of beneficiaries who reported not receiving an
influenza vaccination in the previous winter said they were concerned
about discomfort, side effects, or efficacy. Furthermore, a substantial
share of surveyed beneficiaries for whom certain preventive services are
recommended indicated that they were unaware that those services were
Medicare-covered benefits. 49




48
  For breast and prostate cancer screening, younger respondents were ages 65 to 74 and
older respondents were age 75 and older. For colorectal cancer screening, the age groups
were 65 to 75 and 76 and older, respectively.
49
  For instance, among beneficiaries age 65 to 75, about one in four reported that they did
not know or thought Medicare did not cover colorectal cancer screening.




Page 30                                            GAO-12-81 Medicare Preventive Services
                        Table 15: Common Reasons Medicare Beneficiaries Reported for Not Using Certain
                        Preventive Services, 2009

                            Numbers in percent
                                                                    Reason reported for not having service
                                                                                 Concerned about
                                                             Did not know it      discomfort, side         Doctor did not
                                                                           a                       b                    c
                                                               was needed      effects, or efficacy        recommend it
                            Pneumococcal vaccination
                            ever                                       50.2                      20.9                      21.2
                            Influenza vaccination in
                            the previous winter                        16.3                      51.9                       9.7
                            Mammogram in the
                            previous year (women 65
                            to 74 years old)                           20.5                      14.1                      10.1
                        Source: GAO analysis of MCBS data.

                        Note: Survey respondents may have given multiple answers.
                        a
                         Data include responses for “wasn’t needed,” “didn’t know it was needed,” “no need,” or “nothing
                        wrong.”
                        b
                         Data include responses for “don’t like (shots/needles, mammograms);” “could have side effects;”
                        “don’t think it prevents (flu, pneumonia, cancer);” or “could cause (flu, pneumonia, cancer).”
                        c
                         Data include responses for “doctor did not recommend,” or “doctor recommended against getting
                        shot/allergic to shot/medical reasons.”




                        Among MA HMOs, use of preventive services varied widely and tended to
Preventive Care Use     be higher among HMOs with greater enrollment. Higher-performing
Varied Widely among     HMOs told us they generally share guidelines, monitor work performance,
                        and offer financial incentives to encourage the provision of preventive
MA HMOs; Higher-        care by providers. These HMOs also reported using outreach and benefit
Performing HMOs         incentives to encourage enrollees to obtain preventive care services.
Provided Information
and Offered
Incentives to Promote
Preventive Care




                        Page 31                                                 GAO-12-81 Medicare Preventive Services
Preventive Service Use   MA HMO performance data from CMS’s Medicare Health Plan Compare
Ranged Widely among      database show that use—based on star ratings—varied substantially for
HMOs and Was Higher in   the five preventive services we examined: colorectal cancer screening,
                         the influenza vaccine, mammography, osteoporosis testing, and the
HMOs with Greater        pneumococcal vaccine. 50 In developing the star ratings for each service,
Enrollment               CMS selected cut points from data on reported utilization rates. 51 The cut
                         points produced a range in the average use rates for each star category.
                         For each of the five preventive services, the difference in average use
                         rates between one-star and five-star MA HMOs was 30 percentage points
                         or more in 2009. For example, the average mammography use rate for
                         HMOs with five stars was 86 percent, while the average mammography
                         use rate for HMOs with one star was 53 percent.

                         Although the average number of stars assigned to MA HMOs was similar
                         across the selected services—ranging from a low of 2.7 for
                         mammography to a high of 3.1 for colorectal cancer and osteoporosis
                         testing—the distribution of HMO star ratings varied significantly by
                         service. Notably,

                         •    For colorectal cancer screening, 34 percent of HMOs received either
                              one or two stars while 41 percent of HMOs had four or five stars.

                         •    For the influenza vaccinations, the same proportion of HMOs—
                              20 percent—garnered one star as they did five stars.

                         •    For mammography, nearly half of the HMOs had fewer than three
                              stars and 10 percent achieved five stars.

                         •    For pneumococcal vaccinations, HMOs were more evenly distributed,
                              with roughly 20 percent of HMOs in each of the five star categories.
                              (See fig 1.)



                         50
                           Using enrollment data from January 2010, we were able to match 353 HMOs in the Plan
                         Compare database with just under 7 million MA beneficiaries. Roughly one quarter of the
                         HMOs did not have star ratings for at least one of the five preventive services we
                         examined because they were too new, too small, unable to report, or not required to report
                         data. However, those that did not have star ratings accounted for less than 2 percent of
                         enrollees for any of the five services.
                         51
                           The use rates for colorectal cancer screening and mammography were based on
                         administrative data while the use rates for osteoporosis testing and the vaccines were
                         based on survey data.




                         Page 32                                           GAO-12-81 Medicare Preventive Services
Figure 1: Distribution of HMOs by Service and 2011 Medicare Compare Star Rating




Note: Although MA organizations may sponsor a number of different plan benefit packages, star data
are aggregated across plans to the organization level. Data are derived from a combination of
administrative sources for 2009 and surveys for 2009 and 2010.


We also found that, for the preventive services we examined, larger
HMOs generally had higher star ratings than smaller HMOs. When
weighted by enrollment, the average HMO star rating ranged from 3.3 to
3.9 across our study services. For colorectal cancer screening and
pneumococcal vaccination, more than 6 in 10 HMO beneficiaries were
enrolled in organizations with four- or five-star ratings. Roughly half of
HMO beneficiaries were enrolled in organizations that had the top two
ratings for mammography and osteoporosis screening. For influenza
vaccinations, almost 4 in 10 HMO beneficiaries were enrolled in an




Page 33                                                GAO-12-81 Medicare Preventive Services
organization with four or five stars and more than a third were enrolled in
organizations with three stars. (See fig 2.)

Figure 2: Distribution of HMO Beneficiaries by Service and 2011 Medicare Compare
Star Rating




Note: Percentages may not add to 100 due to rounding. Although MA organizations may sponsor a
number of different plan benefit packages, star data are aggregated across plans to the organization
level. Data are derived from a combination of administrative sources for 2009 and surveys for 2009
and 2010. Organization ratings were weighted by January 2010 enrollment data from CMS.


A number of possible reasons could explain why HMOs with higher
enrollment tend to have higher star ratings. A Medicare Payment Advisory
Commission analysis of some of the measures used to determine star




Page 34                                                 GAO-12-81 Medicare Preventive Services
                           ratings found that older, more established HMOs had higher use rates—
                           which increase the chance of a higher star rating for the organization—
                           than newer HMOs. 52 These organizations may benefit from a more
                           extensive infrastructure and a more loyal enrollee base that may allow
                           them to increase total enrollment over time. Also, CMS has been
                           publishing plan ratings since 2006, and the ratings themselves may have
                           helped drive beneficiary migration to better-rated organizations.


Higher-Performing HMOs     Representatives from higher-performing MA HMOs said they employed a
Disseminated Guidelines,   number of tools at the organization level—such as clinical guidelines,
Monitored Performance,     performance monitoring and feedback, and financial incentives—to
                           encourage physicians to provide preventive services.
and Offered Financial
Incentives to Encourage    To develop guidelines about preventive service use for their physicians,
Physicians’ Provision of   representatives from the HMOs said they relied on Task Force
Preventive Services        recommendations and, in some cases, recommendations of other entities
                           as well. Some HMOs considered the Task Force recommendations a key
                           source of information, while others said they also consulted a range of
                           other sources, such as the American Cancer Society and specialty
                           societies. Two HMOs told us they collaborated with other guideline
                           sponsors in the states where they operate to develop sets of common
                           clinical guidelines.

                           While recognizing the important role of clinical recommendations, HMOs
                           used public reporting of performance data to set targets for high rates of
                           preventive service use. They specifically cited the National Committee on
                           Quality Assurance’s (NCQA) Healthcare Effectiveness Data and
                           Information Set (HEDIS) 53 measures and CMS’s Medicare Health Plan
                           Compare measures. For example, HMOs used data on preventive service
                           use specified in HEDIS—which includes use rates for services such as
                           influenza immunization, breast cancer screening, and colorectal cancer
                           screening—to establish utilization goals. Several HMOs said they set their


                           52
                            Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment
                           Policy (Washington, D.C.: March 2011).
                           53
                             HEDIS consists of 75 measures that include preventive services and contains data from
                           Medicare Advantage plans collected on behalf of CMS. Not all HEDIS measures align with
                           Task Force recommendations; for example, HEDIS measures mammography use by
                           women through age 69 while the Task Force recommends mammography for women up
                           to age 75.




                           Page 35                                         GAO-12-81 Medicare Preventive Services
annual utilization targets to the 90th percentile of the use rates reported in
the NCQA Quality Compass—an online database that features up to
3 years of performance data from HEDIS and the Consumer Assessment
of Healthcare Providers and Systems (CAHPS). 54 They explained that
public reporting in Plan Compare is a way to compare their performance
to the performance of their competitors and will be increasingly important
in the future when Medicare bonus payments will be based on these
data. 55

Monitoring providers’ provision of care and giving feedback were
important motivators to increase utilization. HMOs routinely monitor
physicians’ delivery of preventive services by conducting retrospective
reviews. 56 Typically, they collect and evaluate data on use rates monthly
or quarterly to determine whether individual practitioners are meeting
performance targets or if additional efforts are needed. For example, one
organization said it maintained an electronic registry of patient screenings
and tests that was updated monthly; another reported it was about to
implement a system that would compute utilization for the previous
12 months on a quarterly basis. Several HMOs based their monitoring at
the individual physician level, while one focused on physician group
practices. The HMOs we contacted also commonly used provider
feedback to encourage the provision of preventive services. The
representatives stated that provider feedback was a significant motivator
of physician behavior, particularly when their performance was compared
to others in the network. Several HMOs stated that they either sent out
reports on utilization to providers or made them available to providers




54
  CAHPS is an annual CMS patient satisfaction survey of Medicare beneficiaries.
55
  PPACA, as amended by the Health Care and Education Reconciliation Act of 2010,
stipulated that organizations with a cumulative average of four stars out of a possible five
would be eligible for bonus payments. However, in November 2010, CMS announced it
would test an alternative approach that would provide bonuses to organizations with three
stars or higher.
56
  Although representatives of some HMOs reported that they monitored preventive
service use to identify potential overuse of services, in general, HMO representatives did
not indicate that curbing inappropriate use of preventive services through referrals or prior
approval was a high priority.




Page 36                                             GAO-12-81 Medicare Preventive Services
                           who wanted to see them. Representatives of one HMO said they followed
                           up their reports by meeting with individual physicians. 57

                           Representatives of some of the HMOs also reported using clinical
                           reminders to support the delivery of preventive services. By integrating
                           clinical reminders into their electronic medical records, the HMOs could
                           prompt physicians at the point of service. Other HMOs said they notified
                           physicians about needed screenings and vaccines for their patients.
                           However, representatives of some HMOs commented that they
                           discontinued this practice because it appeared to be ineffective.

                           Another key strategy employed by HMOs is to reward the delivery of
                           preventive services through provider financial incentives. Most of the
                           organizations used some form of performance-based compensation that
                           included using preventive service measures. The staff of one of the six
                           HMOs said future contracts will associate bonuses with HEDIS-based
                           goals. Providers will be rewarded with incentive payments, but the
                           amounts that will be paid were described as “small.”


HMOs Used Outreach and     A representative of one MA HMO said emphasis on enrollees is more
Benefit Incentives to      effective than emphasis on providers as it becomes a teachable moment
Encourage Enrollees’ Use   for the enrollees. Ultimately, beneficiary action is an essential component
                           of preventive care delivery, and several HMOs suggested that some
of Preventive Care         beneficiaries are resistant to receiving preventive care. Representatives
                           of one HMO noted that certain beneficiaries are skeptical of preventive
                           services, such as vaccines, which can make delivery of preventive care
                           difficult. This HMO suggested certain beneficiaries who are very ill may
                           not benefit from all types of preventive care given their underlying medical
                           condition. HMO representatives gave us examples of enrollee populations
                           that have anxiety or ambivalence about preventive care.

                           Representatives of the HMOs described various initiatives directed at
                           enrollees. Most commonly, they distributed enrollee education materials
                           that outline preventive service recommendations. They developed



                           57
                             CMS is implementing a physician feedback reporting program. CMS plans to use
                           information from the feedback program to adjust payments to physicians starting in 2015.
                           See GAO, Medicare Physician Feedback Program: CMS Faces Challenges with
                           Methodology and Distribution of Physician Reports, GAO-11-720 (Washington, D.C.:
                           Aug. 12, 2011).




                           Page 37                                           GAO-12-81 Medicare Preventive Services
newsletters, phone messages, and websites to highlight the availability of
preventive services. They also conducted health fairs and used their
disease and care management programs to attempt to improve
immunization and screening rates.

Several HMOs employed software programs that identified gaps in care
to identify the enrollees who need specific preventive services. For
example, one HMO reported that when an enrollee contacts its staff, the
HMO’s data system provides the staff member with information
concerning the enrollee’s preventive care status. Also, regardless of
whether enrollees initiate contact, this HMO’s staff contact enrollees to
alert them about the need for a preventive service. Several HMOs’ efforts
also targeted specific populations. For example, some HMOs conducted
outreach among high-risk enrollees to raise awareness and encourage
screening and vaccinations.

The HMOs also offered incentives to enrollees directed at increasing the
number that get vaccinations or screenings each year. To reduce
financial barriers, some HMOs did not impose cost-sharing requirements
for certain preventive services, such as screenings for cervical or
colorectal cancer, even before PPACA required elimination of cost
sharing for these services in FFS. In addition, all of the HMOs we
interviewed had broader coverage of preventive services, such as
covering an annual physical exam, before Medicare FFS implemented
such coverage. One HMO reported that it also covered vaccinations by
non-network providers to increase enrollees’ access and that this action
had boosted utilization rates. Another HMO offered enrollees incentives,
such as tote bags, when they visit a provider to obtain a mammogram.

These higher-performing HMOs also noted that their organizational
structure contributed to their ability to encourage preventive care. One
HMO said its new enrollees may have had long-standing relationships
with network providers because they used these providers as members of
the organization’s commercial HMO before they became eligible for
Medicare. Additionally, unlike FFS Medicare, there is a primary care focus
in HMOs. As an example of a benefit of that focus, one HMO
representative said primary care providers have a more holistic view of a
patient’s health status. Furthermore, HMOs suggested that if Medicare
FFS could employ care coordination—a process in which an individual or
group helps to arrange a patient’s primary and specialty health care
services—it may be able to utilize measures HMOs now use to promote
preventive care use.



Page 38                                  GAO-12-81 Medicare Preventive Services
                Adherence to Task Force and ACIP recommendations is uneven among
Conclusions     Medicare FFS beneficiaries, with use of a number of services falling short
                or exceeding age-specific clinical recommendations. Likewise, MA HMO
                performance data revealed wide variation in service use across
                organizations. This information indicates the considerable challenge in
                achieving closer alignment of patterns of use with evidence-based
                recommendations for preventive care. Even when beneficiaries were not
                required to share the cost of a service—as with immunizations—many
                were not receiving the recommended preventive services. Therefore,
                efforts may be needed that go beyond eliminating out-of-pocket costs for
                a core set of preventive services, as PPACA has done.

                Use of preventive services could be improved to better align with Task
                Force and ACIP recommendations by providing more information to both
                beneficiaries and providers. For some services, beneficiaries may not be
                aware of the preventive services that they need or their physicians may
                not have discussed certain preventive services, resulting in lower than
                recommended use. For other services, use rates were substantial even
                though the Task Force recommended against their provision for certain
                subpopulations. Beneficiaries and providers may not be aware that some
                preventive services are recommended for specific age groups and not
                recommended for others.

                Furthermore, better alignment of preventive service use with Task Force
                and ACIP recommendations is unlikely without appropriate Medicare
                coverage. Low use of some recommended services which have a
                recommendation grade of “A” or “B”—such as bone mass measurement
                for osteoporosis screening—may result, in part, from limitations on which
                beneficiaries are covered or how frequently the service is covered.
                Conversely, the absence of cost sharing for services with a
                recommendation grade of “D”—such as the PSA test—may send an
                inappropriate signal to Medicare beneficiaries. Thus, Medicare coverage
                and cost-sharing policies do not always encourage the use of high-valued
                preventive services—those recommended by the Task Force—and
                discourage use of low-value services—those for which clinical evidence
                suggests that the risks generally outweigh the benefits.


                To further align Medicare beneficiary use of preventive services with Task
Matter for      Force recommendations, Congress should consider requiring
Congressional   beneficiaries who receive services with a grade of “D” to share the cost,
                notwithstanding that cost sharing may not be required for other
Consideration   beneficiaries receiving the same services.


                Page 39                                  GAO-12-81 Medicare Preventive Services
                      The Administrator of CMS should take steps to better align Medicare
Recommendation for    beneficiary use of preventive services with Task Force recommendations,
Executive Action      including providing coverage of services with an “A” or “B” grade for the
                      recommended population and at the recommended frequency, as she
                      determines is appropriate considering cost-effectiveness and other
                      criteria.


                      We received written comments on a draft of this report from HHS and oral
Agency and Industry   comments on a portion of the draft from representatives of America’s
Comments and Our      Health Insurance Plans (AHIP). 58 HHS’s general comments are included
Evaluation            as appendix V. The agency also provided technical comments, which we
                      incorporated as appropriate.

                      HHS agreed that there is room for improvement in preventive service use
                      by Medicare beneficiaries, but noted that FFS preventive service use
                      rates are likely higher than we reported due to inherent difficulties in
                      relying on claims data and the time frame of the analysis. Specifically, the
                      agency stated that our claims-based analysis of vaccinations likely
                      underestimated actual 2009 use rates because not all vaccine providers
                      bill Medicare directly; it cited higher 2009 use rates derived from
                      telephone survey responses. In the report, we acknowledge that FFS
                      claims may not account for all utilization if beneficiaries obtain services
                      from sources that do not bill Medicare. We further report that CDC survey
                      data showed higher use rates for both influenza and pneumococcal
                      vaccinations. At the same time, we note that self-reported data collected
                      by surveys may overcount use of preventive services for various reasons.

                      In addition, HHS commented that our use rates for colorectal cancer
                      screening would have been more accurate if we had examined a 10-year
                      period—the recommended time frame for a screening colonoscopy for
                      those not at high risk; again, it cited higher use rates for a related
                      colorectal cancer screening measure derived from survey data. For two of
                      the three recommended regimens for detecting colorectal cancer, our
                      review of 5 years of Medicare claims data corresponds to the
                      recommended frequencies—fecal occult blood testing every year or a
                      sigmoidoscopy every 5 years along with fecal occult blood testing every



                      58
                        AHIP is a national trade association representing health insurance companies, including
                      those participating in the Medicare Advantage program.




                      Page 40                                           GAO-12-81 Medicare Preventive Services
3 years. For the third regimen—a colonoscopy every 10 years—we note
in the report that our decision to use a 5-year time frame for this service
may have resulted in an undercount of the share of beneficiaries who met
the recommendation. Because our methodology required continuous
enrollment in Medicare FFS during the period of examination, we chose
the shorter time frame in order to obtain a robust sample of beneficiaries,
as well as to allow for the inclusion of younger beneficiaries in our
analysis.

HHS also commented that, because the report examined service use as
of 2009, it does not capture the influence of PPACA changes to
beneficiary cost sharing, which it expects will increase use of certain
preventive services over time. When we began our review, Medicare
claims for 2009 were the most current data available. We describe the
January 2011 changes in beneficiary cost sharing in the report, but
measuring their effect on utilization—which may not be evident for some
time—was not possible. Nevertheless, our analysis demonstrates that for
certain services—such as immunizations—the absence of cost sharing
has not been sufficient to align FFS beneficiary use with Task Force
recommendations.

In response to our recommendation, HHS pointed out that it has recently
used its authority to expand Part B benefits to cover several new
preventive services. This additional coverage, however, does not address
the misalignment that remains between Medicare coverage for certain
services and the corresponding Task Force recommendations. As we
noted in the report, for example, bone mass measurement for
osteoporosis screening has a recommendation grade of “B” from the Task
Force for all women over the age of 65. Yet, Medicare coverage for this
service is limited to those who meet specific clinical criteria. As a result,
not all women over the age of 65 are eligible for this benefit. We have
altered the language of our recommendation to clarify that, in addition to
covering new services recommended by the Task Force, CMS should
ensure that all beneficiaries for whom a current recommendation applies
have coverage for that service at the recommended frequency, as
appropriate.

In their oral comments, AHIP representatives said the report
demonstrated that, through the use of innovative tools such as
performance feedback and incentives, MA plans are leaders in promoting
greater use of preventive services. They also noted that, as it is currently
structured, Medicare FFS cannot apply the kinds of management tools
used by HMOs.


Page 41                                    GAO-12-81 Medicare Preventive Services
As we agreed with your offices, unless you publicly announce the
contents of this report earlier, we plan no further distribution of it until
30 days from its date. We are sending copies of this report to the
Secretary of Health and Human Services. The report will also be available
at no charge on our website at http://www.gao.gov.

If you or your staffs have any questions about this report, please contact
me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made major contributions to
this report are listed in appendix VI.




James C. Cosgrove
Director, Health Care




Page 42                                   GAO-12-81 Medicare Preventive Services
Appendix I: Scope and Methodology
                            Appendix I: Scope and Methodology




                            This appendix describes our methodology for addressing the four
                            objectives: (1) the extent to which use of preventive services by fee-for-
                            service (FFS) beneficiaries aligns with U.S. Preventive Services Task
                            Force or the Advisory Council on Immunization Practices (ACIP)
                            recommendations, (2) the extent to which FFS beneficiaries use the
                            Welcome to Medicare (WTM) exam and whether use of that service is
                            associated with higher use of preventive care services, (3) how
                            preventive service use in Medicare Advantage (MA) compares to use in
                            FFS, and (4) the extent to which use varies among MA health
                            maintenance organizations (HMO) and which practices the better
                            performing HMOs find effective in promoting use of preventive services.
                            To address the objectives, we analyzed the most recently available data
                            from Medicare claims, a beneficiary survey, and MA plan ratings. The
                            appendix also describes our efforts to ensure the reliability of the data.


Preventive Service Use      To determine the extent to which preventive service use aligns with
Alignment with Task Force   guidelines, we selected certain Medicare-covered preventive services that
Recommendations             had related Task Force or ACIP guidelines for the general Medicare
                            population. We identified all Medicare-covered preventive services, but
                            included only those that had an “A,” “B,” “C,” or “D” grade from the Task
                            Force or an ACIP recommendation for some groups of beneficiaries. 1 We
                            excluded preventive services for which the recommendations were
                            primarily aimed at high-risk populations and populations with specific
                            diagnoses because identifying the appropriate target population cannot
                            be done reliably. Finally, we excluded preventive services that are only
                            recommended by providers through the use of the WTM exam or billed
                            through the WTM exam. We recognize that guidelines may not apply to
                            all beneficiaries due to individual circumstances, and that 100 percent use
                            of recommended services is unrealistic. We considered Medicare FFS
                            use to be in alignment with the Task Force and ACIP if at least three in
                            four beneficiaries overall received a recommended service. We also
                            considered use to be in alignment if no more than one in four
                            beneficiaries overall received a service that the Task Force
                            recommended against having.




                            1
                             In some instances, services we reviewed had a grade of “I” for certain age groups, but all
                            selected services at least had one “A,” “B,” “C,” or “D” grade recommendation.




                            Page 43                                            GAO-12-81 Medicare Preventive Services
Appendix I: Scope and Methodology




To determine FFS beneficiaries’ use rates for the selected preventive
services, we analyzed claims data from 2005 through 2009 from a
5 percent sample of beneficiaries. Measurement intervals varied by
service based on service-specific age and frequency parameters outlined
in Task Force or ACIP guidelines. CMS provided a list of relevant
Healthcare Common Procedure Coding System (HCPCS) codes and
International Classification of Diseases (ICD) diagnosis and procedure
codes for the services for which claims could be submitted. Using claims
from Physician, Inpatient, Outpatient, and Skilled Nursing Facility
5 Percent Standard Analytic Files and enrollment data from CMS’s
Denominator file for the same 5 percent sample, we created an estimate
of the use rates of the selected preventive services for service-specific
time frames, based on Task Force and ACIP recommendations.

•   Influenza Vaccine: Because it is recommended once a year, we
    examined claims from the 2008 to 2009 flu season.

•   Pneumococcal Vaccine: Because it is recommended once for those
    65 or older, we examined beneficiaries who were 65 years old as of
    January 1, 2005, and examined claims from 2005 through 2009.

•   Mammography: Because it is recommended once every 2 years, we
    examined claims in 2008 and 2009.

    •     Mammography is recommended for women 50 through 74. To
          account for all potential screenings, we included both screening
          and diagnostic HCPCS codes when analyzing use rates for
          women 65 through 74. When analyzing use for women aged 75 or
          older, we only included screening codes.

•   Cervical Cancer Screening: Because the recommended interval was
    every 3 years, we examined claims from 2007 through 2009.

•   Cholesterol Screening: Because the Task Force suggests that a
    reasonable interval may be every 5 years, we examined claims from
    2005 to 2009. Because it is recommended for all men aged 35 or
    older (but only high-risk women), we only examined claims for male
    beneficiaries.

•   Colorectal Cancer Screening: Because the Task Force recommends
    most services annually or every 5 years, we examined colorectal
    cancer screening claims from 2005 through 2009.



Page 44                                   GAO-12-81 Medicare Preventive Services
Appendix I: Scope and Methodology




    •     Colorectal cancer screening is recommended for beneficiaries
          aged 50 through 75. To account for all potential screenings, we
          included both screening and diagnostic HCPCS codes when
          analyzing use rates for beneficiaries 65 through 75. When
          analyzing use for beneficiaries aged 76 or older, we only included
          screening codes.

•   Osteoporosis Screening: Because the Task Force notes that a
    screening interval of a minimum of 2 years may be necessary to
    discern notable differences in bone density, but that longer intervals
    may also be necessary, we calculated bone mass measurement
    claims from 2005 through 2009.

•   Prostate Cancer Screening: For men younger than 75, the Task Force
    concluded that evidence was insufficient to assess the balance of
    benefits and harms of PSA testing. Because it found that PSA
    screening as infrequently as once every 4 years could yield as much
    benefit as annual screening, we measured use of the PSA test over a
    4-year period 2006 through 2009.

The Medicare 5 percent files contain claims and demographic information
for 5 percent of the Medicare FFS population. Files are constructed such
that results from this analysis are generalizable to the entire FFS
Medicare population.

We excluded the following beneficiaries from the denominator:
beneficiaries under the age of 65, beneficiaries with MA enrollment,
beneficiaries who had End Stage Renal Disease (ESRD), beneficiaries
who were institutionalized, and beneficiaries who were only partially
enrolled in Medicare part A or B during the interval of study. To analyze
urban/rural beneficiary status, we used the CMS Core Based Statistical
Area state and county code crosswalk to match with the state and county
code information in the Denominator file. To analyze Health Professional
Shortage Area (HPSA) beneficiary status, we used the Health Resources
and Services Administration (HRSA) Primary Care HPSA zip code
crosswalk to match with the zip code information in the Denominator file.
We determined that the urban/rural status of beneficiaries in the 5 percent
denominator file is proportionate to the 100 percent denominator file, and
thus geographic weights were not necessary for our analysis.




Page 45                                     GAO-12-81 Medicare Preventive Services
                         Appendix I: Scope and Methodology




Welcome to Medicare      To assess FFS beneficiaries’ use of the Welcome to Medicare exam, we
Exam Use                 analyzed a 5 percent sample of 2008 and 2009 claims for eligible
                         beneficiaries—that is, beneficiaries who became eligible for the Welcome
                         to Medicare exam sometime in 2008. We excluded the following
                         beneficiaries from the denominator: beneficiaries with MA enrollment,
                         beneficiaries who had ESRD, beneficiaries who were institutionalized,
                         and beneficiaries who were not simultaneously enrolled in both Medicare
                         part A and B for at least 6 months in 2009.

                         To determine the association, if any, between the Welcome to Medicare
                         exam and use of preventive services, we compared claims for a selection
                         of recommended preventive services from 2006 through 2009 for
                         beneficiaries who became eligible for a Welcome to Medicare exam in
                         2006 and received it with those for beneficiaries who did not have that
                         exam. We constructed a data set that consisted of 100 percent of the
                         beneficiaries who reached age 65 in 2006. We also excluded the
                         following beneficiaries from the data set: beneficiaries with MA
                         enrollment, beneficiaries who had ESRD, beneficiaries who were
                         institutionalized, and beneficiaries who were only partially enrolled in
                         Medicare part A or B anytime from 2007 through 2009. Looking
                         separately at female and male beneficiaries, we counted claims for
                         recommended preventive services between 2006 and 2009 using CMS-
                         provided HCPCS and ICD codes from 100 percent of the Medicare
                         claims. For female beneficiaries, we calculated the rate of having
                         received at least three influenza vaccines, at least one pneumococcal
                         vaccination, one bone mass measurement, one colorectal cancer
                         screening, and one mammography. For male beneficiaries we calculated
                         the rate of having received at least three influenza vaccines, at least one
                         pneumococcal vaccination, one colorectal cancer screening, and one
                         cholesterol test. For mammography and colorectal cancer screenings, we
                         included both diagnostic and screening codes.


Medicare Advantage and   To compare preventive service use in MA to use in FFS, we analyzed
Fee-for-Service Use      beneficiary survey results, as claims data for services provided to MA
                         beneficiaries are not available from CMS. Using 2009 Medicare Current
                         Beneficiary Survey (MCBS) data and plan enrollment data supplied by
                         CMS, we examined the effect that enrollment in MA HMO plans and non-




                         Page 46                                   GAO-12-81 Medicare Preventive Services
Appendix I: Scope and Methodology




HMO plans had on use compared with FFS. 2 The MCBS interview data
contained responses from a sample of 14,695 MA and FFS beneficiaries
as well as weights that can be used for making estimates for the
population enrolled in Medicare during the year.

The 2009 MCBS contained survey questions for seven of our selected
preventive services: cholesterol testing, mammography, pap testing, PSA
testing, colorectal cancer testing, influenza vaccination, and
pneumococcal vaccination. We constructed a measure for colorectal
cancer screening using several survey variables. The survey question for
pneumococcal vaccination asked if the respondents had ever had the
service while the questions for the other services either asked about the
most recent year—the question for influenza vaccination asked about the
recent flu season—or asked about certain time intervals that allowed us
to group answers in a way to measure utilization within the last year. The
2008 MCBS contained a question on osteoporosis testing and we
conducted the same analysis using the survey and enrollment data from
2008.

Our analysis accounted for the effects of contract type, age, dual-
eligibility, education, sex, race, Hispanic heritage, income, marital status,
health status, and geographic location. We omitted beneficiaries in
institutional settings or those under 65 as well as those who did not give a
response on any of the included questions on beneficiary characteristics.
These filters yielded a dataset of 11,216 respondents representing
34 million beneficiaries.

Although the MCBS contained an array of useful variables on beneficiary
characteristics, the variable for MA enrollment was not particularly useful
for our purposes as 95 to 96 percent of MA enrollees were classified as
“risk HMO enrollees” for every month in 2009 while data from monthly
CMS enrollment data showed a much different distribution. For example,
the CMS enrollment file for February 2009 showed that 63 percent of MA
enrollees were enrolled in HMO plans, 22 percent were enrolled in Private
Fee-for-Service (PFFS) plans and another 12 percent were enrolled in
Preferred Provider Organization (PPO) plans, with the remainder


2
 The MCBS is a survey of a nationally representative sample of the Medicare population,
including both aged and disabled beneficiaries. The survey data are released annually
and the results are contained in two data files, Access to Care and Cost and Use. The
Access to Care file contained responses related to preventive care.




Page 47                                          GAO-12-81 Medicare Preventive Services
                             Appendix I: Scope and Methodology




                             scattered among some other plan categories. At our request, CMS
                             supplied us with a crosswalk that allowed us to map respondents to MA
                             organization contract number. As each organization contract number had
                             a unique plan type, we were able to associate each contract number with
                             its plan type using mapping available in CMS MA enrollment data. Based
                             on this mapping, the resulting distribution approximated the CMS-
                             reported distribution of enrollees by plan type. Of this group, we were able
                             to assign all but 4 percent of enrollees to one of three enrollment
                             categories—FFS, MA HMO, and MA non-HMO (both PFFS and PPO
                             enrollees). Beneficiaries were assigned to a category if they were enrolled
                             no more than 1 month in a different plan type. Those who were enrolled
                             at least 2 months in multiple categories were not assigned.

                             We used logistic regression to estimate the marginal effect of
                             beneficiaries’ enrollment choice on the use of a selected preventive
                             service, holding other beneficiary characteristics constant. We reported
                             the differences if the results were statistically significant at the 95 percent
                             confidence level.

                             To determine reasons beneficiaries report for not receiving preventive
                             services, we examined MCBS follow-up questions for respondents who
                             indicated they had not received a particular preventive service. For
                             example, a respondent may indicate they did not know the test was
                             needed or their doctor did not recommend it. We compared the
                             distribution of reasons given by nonrecipients of those services by
                             question and by enrollment category.


Comparison of MA HMO         Because our analysis of MCBS data indicated that only MA HMOs
Use of Preventive Services   displayed a statistically significant difference in use rates from FFS, we
                             limited our examination of any differences in utilization of preventive
                             services to MA HMOs. Using information on star ratings for 2011 posted
                             on CMS’s Medicare Health Plan Compare website, we examined ratings
                             for five of the eight selected preventive services: Colorectal cancer
                             screening, influenza vaccination, mammography, osteoporosis testing,
                             and pneumococcal vaccination. 3 The ratings are based on relative use
                             rates across plans and, although they are displayed by plan, they are


                             3
                              The Plan Compare database contained use rate information for cholesterol testing but it
                             was based on a subset of beneficiaries with certain diseases. The database did not
                             include information on cervical cancer screening or PSA tests.




                             Page 48                                           GAO-12-81 Medicare Preventive Services
                             Appendix I: Scope and Methodology




                             actually determined at the contract organization level. In order to analyze
                             the distribution of HMO beneficiaries as well as the distribution of HMO
                             organizations, we associated each organization with enrollment data from
                             January 2010 because it represented a midpoint in the range of dates of
                             the source data. 4 We identified HMO organizations using the plan type
                             variable in the enrollment file. Of the 575 MA organizations in the 2011
                             Plan Compare, 353 were HMOs with enrollment in January 2010. Of the
                             353, between 262 and 288 had star rankings for the selected services,
                             the remainder were either not required to report data, were too new or too
                             small, or had insufficient data to calculate a particular measure.


Practices Considered         To learn about approaches for improving delivery of preventive services,
Effective by MA              we interviewed officials from six HMOs that ranked among the top
Organizations                performing for provision of selected preventive services and had
                             enrollment of 37,000 or greater in January 2011. The HMOs we selected
                             had five stars on four of our selected services and at least four stars on
                             the remaining service.


Data Reliability and Audit   We ensured the reliability of the Medicare claims data, MCBS data, and
Standards                    Plan Compare data used in this report by performing appropriate
                             electronic data checks and by interviewing agency officials who were
                             knowledgeable about the data. We found the data were sufficiently
                             reliable for the purpose of our analyses.

                             We conducted this performance audit from September 2010 through
                             January 2012 in accordance with generally accepted government auditing
                             standards. Those standards require that we plan and perform the audit to
                             obtain sufficient, appropriate evidence to provide a reasonable basis for
                             our findings and conclusions based on our audit objectives. We believe
                             that the evidence obtained provides a reasonable basis for our findings
                             and conclusions based on our audit objectives.




                             4
                              The star ratings are based on use rates from administrative data from 2009 and survey
                             data from 2009 and 2010.




                             Page 49                                          GAO-12-81 Medicare Preventive Services
Appendix II: Medicare Part B Coverage and
                                           Appendix II: Medicare Part B Coverage and
                                           Cost Sharing for Preventive Services as of
                                           September 2011


Cost Sharing for Preventive Services as of
September 2011

                              Year first                                                                            Beneficiary cost
                                                                                                                           a
Service                        covered     Groups covered                           Frequency of service            sharing
Vaccinations
                                                                                                                         b
Pneumococcal vaccination          1981     All beneficiaries                        As needed                       None
                                                                                    (likely once per lifetime)
                                                                                                                         b
Hepatitis B vaccination           1984     Beneficiaries at intermediate or     Scheduled dosages are               None
                                           high risk of contracting hepatitis B required
                                                                                                                         b
Influenza vaccination             1993     All beneficiaries                        Once every flu season           None
Screening services
                                                                                                    c                    b
Cervical cancer—pap test          1990     All female beneficiaries                 Every 2 years                   None
                                                                                d                                        b
Breast cancer—                    1991     Female beneficiaries 40 or older         Every year                      None
mammography
                                                                                                    c                    b
Vaginal cancer—pelvic             1998     All female beneficiaries                 Every 2 years                   None
exam
Colorectal cancer—fecal           1998     Beneficiaries 50 or older                Every year                      None for screening;
occult blood test                                                                                                   generally 20 percent of
                                                                                                                    approved amount for visit
                                                                                                    e
Colorectal cancer—barium          1998     Beneficiaries 50 or older when           Every 4 years                   20 percent of approved
enema                                      used instead of a flexible                                               amount
                                           sigmoidoscopy or colonoscopy
                                                                                                                         b
Colorectal cancer—flexible        1998     Beneficiaries 50 or older                Every 4 years or                None
sigmoidoscopy                                                                       10 years after a
                                                                                                 e
                                                                                    colonoscopy
                                                                                                                         b
Colorectal cancer—                1998     All beneficiaries                        Every 10 years or               None
colonoscopy                                                                         4 years after a flexible
                                                                                                    e
                                                                                    sigmoidoscopy
                                                                                                    g                    b
Osteoporosis—bone mass            1998     Estrogen-deficient female                Every 2 years                   None
measurement                                beneficiaries at clinical risk for
                                           osteoporosis as well as other
                                                                 f
                                           qualified individuals
Prostate cancer—Prostate-         2000     Male beneficiaries 50 or older           Every year                      20 percent of approved
Specific Antigen test                                                                                               amount for visit and
                                                                                                                    deductible for visit may
                                                                                                                         h
                                                                                                                    apply
Prostate cancer—digital           2000     Male beneficiaries 50 or older           Every year                      20 percent of approved
rectal examination                                                                                                  amount and deductible
                                                                                                                                     h
                                                                                                                    applies for visit
Glaucoma                          2002     Beneficiaries determined to be at        Every year                      20 percent of approved
                                                                 i
                                           high risk for glaucoma                                                   amount after annual
                                                                                                                              h
                                                                                                                    deductible
Cardiovascular disease—           2004     For beneficiaries whose physician One-time                               20 percent of approved
screening electrocardiogram                ordered as part of a Welcome to                                          amount after annual
                                                                                                                              h
(EKG)                                      Medicare exam                                                            deductible




                                           Page 50                                                      GAO-12-81 Medicare Preventive Services
                                           Appendix II: Medicare Part B Coverage and
                                           Cost Sharing for Preventive Services as of
                                           September 2011




                              Year first                                                                            Beneficiary cost
                                                                                                                           a
Service                        covered     Groups covered                          Frequency of service             sharing
Diabetes                          2005     Beneficiaries with risk factors         Up to twice a year               None for screening;
                                           such as hypertension, history of                                         generally 20 percent of
                                           dyslipidemia, obesity, a history of                                      approved amount for visit
                                           high blood sugar
Cardiovascular disease—           2005     Beneficiaries with no signs or          Every 5 years                    None for screening;
cholesterol test                           symptoms of cardiovascular                                               generally 20 percent of
                                           disease                                                                  approved amount for visit
                                                                                                                          b
Abdominal Aortic Aneurysm         2007     Beneficiaries medically                 One-time                         None
(AAA)—ultrasound                           determined to be at risk for AAA
                                           and given a referral during the
                                           Welcome to Medicare exam
Human immunodeficiency            2009     All beneficiaries who ask for the       Every year for                   None for screening;
virus (HIV)                                test, pregnant women, and               beneficiaries at increased       generally 20 percent of
                                           beneficiaries at increased risk for     risk, or up to three times       approved amount for visit
                                           infection                               per pregnancy
Other
Diabetes outpatient self-         1998     Diabetic beneficiaries with written Up to 10 hours of training           20 percent of approved
management training                        order from provider                 first year, up to 2 hours            amount after annual
                                                                                                                              h
                                                                               follow-up training                   deductible
                                                                               subsequent years
                                                                                                                          b
Medical nutrition therapy         2002     Beneficiaries with diabetes,            Up to 3 hours of training        None
                                           kidney disease, or who have             first year, 2 hours training
                                           had a kidney transplant within          subsequent years
                                           the past 3 years, and that are
                                           referred by a physician
                                                                                                                          b
Initial Preventive Physical       2005     All beneficiaries within 1 year         One-time                         None
Examination (IPPE) or                      of enrollment
Welcome to Medicare
(WTM) exam
Smoking and tobacco use           2005     All beneficiaries who use tobacco Up to eight visits every               None for beneficiaries
cessation                                                                    year                                   who have not been
                                                                                                                    diagnosed with related
                                                                                                                            j
                                                                                                                    illness
                                                                                                                          b
Annual Wellness Visit             2011     All beneficiaries enrolled in Part B Every year                          None
(AWV)                                      for at least 1 year who have not
                                           had an IPPE or AWV within the
                                           past year
                                           Sources: CMS, GAO.

                                           Note: In October 2011, CMS announced new coverage of alcohol misuse counseling and depression
                                           screening; CMS also announced in November 2011 new coverage of screening for Sexually
                                           Transmitted Infections, high-intensity behavioral counseling to prevent Sexually Transmitted
                                           Infections, and intensive behavioral therapy to reduce the risk of cardiovascular disease as well as
                                           obesity.
                                           a
                                            Cost sharing may be different for several components of a preventive service, such as the
                                           administration of the service, any lab testing that may be involved with the service, and the physician
                                           office visit associated with the service. Some services when provided in a hospital setting may require
                                           a separate copayment for the hospital visit.




                                           Page 51                                                  GAO-12-81 Medicare Preventive Services
Appendix II: Medicare Part B Coverage and
Cost Sharing for Preventive Services as of
September 2011




b
 If the provider does not accept assignment for providing the service, the beneficiary may have to pay
for 100 percent of the service up front and submit a claim to Medicare for reimbursement, and the
provider may charge more than the Medicare-approved payment.
c
 Medicare covers annual pap and pelvic exams for women who are at high risk for cervical or vaginal
cancers and for women who are of childbearing age who have had an abnormal Pap test result within
the past 3 years.
d
    Medicare also covers one baseline mammogram for women 35-39.
e
    Medicare-covered screening intervals for these tests are shortened for beneficiaries at high risk.
f
The statute defines “qualified individuals” to include also those who have vertebral abnormalities or
primary hyperparathyroidism, or who are receiving long-term glucocorticoid steroid or osteoporosis
drug therapy. See 42 U.S.C. § 1395x(rr)(2).
g
 CMS permits coverage of a bone mass measurement more frequently if the service is medically
necessary. 42 C.F.R. § 410.31(c) .
h
 Each year, beneficiaries are responsible for 100 percent of the payment amount until those
payments equal a specified deductible amount, $162 in 2011.
i
High-risk populations include those with diabetes, a family history of glaucoma, African Americans
aged 50 or older, and Hispanics aged 65 or older. 42 C.F.R. § 410.23(a)(2).
j
Beneficiaries who have been diagnosed with an illness caused or complicated by tobacco use must
still pay 20 percent of the approved amount after the annual deductible.




Page 52                                                      GAO-12-81 Medicare Preventive Services
Appendix III: Tables with Full Analysis of
               Appendix III: Tables with Full Analysis of
               Preventive Service Use in Medicare FFS



Preventive Service Use in Medicare FFS

               This appendix provides complete details of our analyses of the following
               Medicare preventive services: cholesterol tests, pap tests, influenza
               vaccinations, pneumococcal vaccinations, bone mass measurements,
               mammograms, colorectal cancer screenings, and PSA tests.

               Table 16: Use of Cholesterol Tests by Male Medicare FFS Beneficiaries during the 5-
               year Period 2005 through 2009

                   Numbers in percent
                                           a,b
                   Male beneficiaries                      No services    One service        Two or more services
                   All                                             16.2             8.3                            75.5
                   65 to 74                                        16.4             7.9                            75.8
                   75 to 84                                        15.2             8.6                            76.2
                   85 or older                                     21.7           12.3                             66.0
                   Not dual                                        16.0             8.2                            75.9
                   Dual                                            19.9           10.0                             70.1
                   White                                           15.6             8.2                            76.3
                   Black                                           24.3             9.8                            65.9
                   Hispanic                                        22.7           10.2                             67.2
                   Asian                                           12.7             7.6                            79.7
                   Other/Unknown                                   23.7             8.1                            68.2
                   Urban                                           15.1             7.8                            77.1
                   Rural                                           19.6             9.9                            70.5
                   South                                           15.7             8.0                            76.3
                   West                                            19.0             9.2                            71.8
                   Midwest                                         16.7             9.2                            74.1
                   Northeast                                       13.9             6.8                            79.3
                   Other/Unknown                                   18.9             7.2                            73.9
                   Not HPSA                                        15.8             8.2                            76.0
                   HPSA                                            21.2             9.8                            69.0
               Source: GAO analysis of CMS Medicare claims data.

               Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
               age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of
               study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were
               enrolled at any time in Medicare Advantage during the period of study.
               a
               Denotes the beneficiary’s age as of January 1, 2005.
               b
                Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
               an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




               Page 53                                                     GAO-12-81 Medicare Preventive Services
Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 17: Use of Screening Pap Tests by Female Medicare FFS Beneficiaries during
the 3-year Period 2007 through 2009

    Numbers in percent
                                a,b
    Female beneficiaries                      No services   One service       Two or more services
    All                                              77.0           17.8                              5.2
    65 to 74                                         69.1           23.7                              7.3
    75 to 84                                         83.1           13.4                              3.5
    85 or older                                      93.9             5.1                             1.0
    Not dual                                         75.7           18.7                              5.6
    Dual                                             86.3           11.5                              2.1
    White                                            76.3           18.3                              5.4
    Black                                            81.6           14.7                              3.7
    Hispanic                                         86.2           11.7                              2.1
    Asian                                            84.7           12.8                              2.6
    Other/Unknown                                    81.1           15.4                              3.6
    Urban                                            76.5           18.0                              5.4
    Rural                                            78.7           17.1                              4.3
    South                                            75.6           18.9                              5.5
    West                                             79.8           16.2                              4.1
    Midwest                                          78.6           16.9                              4.5
    Northeast                                        75.4           18.3                              6.3
    Other/Unknown                                    89.7             9.2                             1.1
    Not HPSA                                         76.8           18.0                              5.3
    HPSA                                             80.1           16.0                              3.9
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of
study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were
enrolled at any time in Medicare Advantage during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2007.
b
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




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Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 18: Use of Influenza Vaccination by Medicare FFS Beneficiaries for the July
2008 through June 2009 Flu Season

    Numbers in percent
                    a,b
    Beneficiaries              No vaccinations             One vaccination Two or more vaccinations
    All                                             50.9              48.8                            0.3
    Female                                          49.2              50.6                            0.3
    Male                                            53.4              46.4                            0.2
    65 to 74                                        55.7              44.1                            0.2
    75 to 84                                        45.8              53.9                            0.3
    85 or older                                     45.3              54.4                            0.3
    Not dual                                        49.4              50.3                            0.3
    Dual                                            63.2              36.5                            0.3
    White                                           48.9              50.9                            0.3
    Black                                           70.2              29.6                            0.1
    Hispanic                                        73.1              26.7                            0.2
    Asian                                           52.4              47.2                            0.4
    Other/Unknown                                   59.1              40.6                            0.3
    Urban                                           49.8              49.9                            0.3
    Rural                                           54.4              45.4                            0.2
    South                                           51.5              48.3                            0.3
    West                                            55.2              44.6                            0.2
    Midwest                                         48.0              51.7                            0.3
    Northeast                                       48.9              50.7                            0.4
    Other/Unknown                                   93.1               6.9                            0.0
    Not HPSA                                        50.1              49.6                            0.3
    HPSA                                            60.6              39.2                            0.2
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of
study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were
enrolled at any time in Medicare Advantage during the period of study.
a
Denotes the beneficiary’s age as of July 1, 2008.
b
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




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Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 19: Use of the Pneumococcal Vaccination during the 5-year Period 2005
through 2009 by Medicare FFS Beneficiaries Aged 65 as of January 1, 2005

    Numbers in percent
                    a
    Beneficiaries                No vaccinations One vaccination Two or more vaccinations
    All                                             72.7          25.8                                1.5
    Female                                          71.7          26.9                                1.5
    Male                                            73.9          24.5                                1.6
    Not dual                                        72.1          26.5                                1.5
    Dual                                            78.4          19.8                                1.8
    White                                           71.6          26.8                                1.6
    Black                                           82.4          16.5                                1.1
    Hispanic                                        84.7          13.9                                1.3
    Asian                                           75.7          22.8                                1.6
    Other/Unknown                                   76.3          22.7                                1.1
    Urban                                           71.6          26.7                                1.7
    Rural                                           75.8          23.1                                1.1
    South                                           73.2          25.2                                1.6
    West                                            74.4          24.3                                1.3
    Midwest                                         71.2          27.2                                1.6
    Northeast                                       71.4          27.1                                1.6
    Other/Unknown                                   97.1           2.9                                0.0
    Not HPSA                                        72.2          26.2                                1.6
    HPSA                                            77.6          21.2                                1.3
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries who
were not continuously enrolled in Parts A and B during the period of study, (2) beneficiaries residing
in institutions, (3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in
Medicare Advantage during the period of study.
a
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




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Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 20: Use of Bone Mass Measurements by Female Medicare FFS Beneficiaries
during the 5-year Period 2005 through 2009

    Numbers in percent
                                a,b
    Female beneficiaries                      No services   One service       Two or more services
    All                                              47.4           29.3                            23.3
    65 to 74                                         42.2           31.2                            26.6
    75 to 84                                         50.3           28.5                            21.2
    85 or older                                      70.5           19.7                              9.8
    Not dual                                         45.7           29.8                            24.6
    Dual                                             59.8           25.8                            14.4
    White                                            46.0           29.8                            24.2
    Black                                            62.7           24.5                            12.8
    Hispanic                                         54.5           27.6                            18.0
    Asian                                            50.7           27.9                            21.5
    Other/Unknown                                    53.3           26.2                            20.5
    Urban                                            46.0           29.5                            24.5
    Rural                                            52.3           28.6                            19.2
    South                                            45.8           29.6                            24.6
    West                                             47.2           29.3                            23.5
    Midwest                                          49.9           29.6                            20.5
    Northeast                                        47.8           28.1                            24.0
    Other/Unknown                                    45.3           30.2                            24.6
    Not HPSA                                         46.8           29.5                            23.7
    HPSA                                             55.2           27.1                            17.8
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of
study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were
enrolled at any time in Medicare Advantage during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2005.
b
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




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Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 21: Use of Screening and Diagnostic Mammography by Female Medicare FFS
Beneficiaries Aged 65 to 74 during the 2-year Period 2008 through 2009

    Numbers in percent
                                a,b
    Female beneficiaries                            No mammogram       One or more mammograms
    All aged 65 to 74                                        35.5                                   64.5
    Not dual                                                 33.2                                   66.8
    Dual                                                     51.3                                   48.7
    White                                                    34.3                                   65.8
    Black                                                    40.9                                   59.1
    Hispanic                                                 51.6                                   48.4
    Asian                                                    51.7                                   48.3
    Other/Unknown                                            45.6                                   54.4
    Urban                                                    34.7                                   65.3
    Rural                                                    38.0                                   62.0
    South                                                    35.8                                   64.3
    West                                                     37.8                                   62.2
    Midwest                                                  34.7                                   65.3
    Northeast                                                33.7                                   66.3
    Other/Unknown                                            44.5                                   55.5
    Not HPSA                                                 35.0                                   65.0
    HPSA                                                     41.6                                   58.4
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of
study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were
enrolled at any time in Medicare Advantage during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2008.
b
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




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Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 22: Use of Screening Mammography by Female Medicare FFS Beneficiaries
Aged 75 or Older during the 2-year Period 2008 through 2009

    Numbers in percent
                                a,b
    Female beneficiaries                            No mammogram       One or more mammograms
    All aged 75 or older                                     59.5                                   40.5
    75 to 84                                                 52.9                                   47.1
    85 or older                                              77.9                                   22.1
    Not dual                                                 57.3                                   42.7
    Dual                                                     73.8                                   26.2
    White                                                    58.4                                   41.6
    Black                                                    64.7                                   35.4
    Hispanic                                                 71.5                                   28.5
    Asian                                                    74.3                                   25.7
    Other/Unknown                                            68.6                                   31.4
    Urban                                                    59.2                                   40.8
    Rural                                                    60.4                                   39.6
    South                                                    59.1                                   40.9
    West                                                     60.0                                   40.0
    Midwest                                                  58.6                                   41.4
    Northeast                                                60.3                                   39.7
    Other/Unknown                                            88.2                                   11.8
    Not HPSA                                                 59.1                                   40.9
    HPSA                                                     64.2                                   35.8
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of
study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were
enrolled at any time in Medicare Advantage during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2008.
b
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




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Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 23: Use of Colorectal Cancer Screening and Diagnostic Services by Medicare
FFS Beneficiaries Aged 65 to 75, 2005 through 2009

    Numbers in percent
                    a,b
    Beneficiaries                                   Followed a regimen     Did not follow a regimen
    All beneficiaries 65 to 75                                    25.5                              74.5
    Female                                                        27.0                              73.0
    Male                                                          23.5                              76.5
    Not dual                                                      26.1                              73.9
    Dual                                                          19.8                              80.2
    White                                                         25.8                              74.2
    Black                                                         24.8                              75.2
    Hispanic                                                      19.2                              80.8
    Asian                                                         19.3                              80.7
    Other/Unknown                                                 21.8                              78.2
    Urban                                                         25.7                              74.3
    Rural                                                         24.8                              75.2
    South                                                         26.1                              73.9
    West                                                          23.2                              76.8
    Midwest                                                       25.3                              74.7
    Northeast                                                     26.6                              73.4
    Other/Unknown                                                 24.3                              75.7
    Not HPSA                                                      25.7                              74.3
    HPSA                                                          23.3                              76.7
Source: GAO analysis of CMS Medicare claims data.

Note: These data exclude (1) beneficiaries under age 65, (2) beneficiaries who were not continuously
enrolled in Parts A and B during the period of study, (3) beneficiaries residing in institutions, (4) ESRD
beneficiaries, and (5) beneficiaries who were enrolled at any time in Medicare Advantage during the
period of study.
a
Denotes the beneficiary’s age as of January 1, 2005.
b
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




Page 60                                                        GAO-12-81 Medicare Preventive Services
Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 24: Use of Colorectal Cancer Screening Services by Medicare FFS
Beneficiaries Aged 76 or Older, 2005 through 2009

    Numbers in percent
                    a,b
    Beneficiaries                                   Followed a regimen     Did not follow a regimen
    All beneficiaries 76 or older                                  5.8                              94.3
    Female                                                         5.4                              94.6
    Male                                                           6.4                              93.6
    76 to 85                                                       6.3                              93.7
    86 or older                                                    2.0                              98.0
    Not dual                                                       6.0                              94.0
    Dual                                                           3.6                              96.4
    White                                                          5.9                              94.1
    Black                                                          5.3                              94.7
    Hispanic                                                       3.5                              96.5
    Asian                                                          4.3                              95.7
    Other/Unknown                                                  3.9                              96.1
    Urban                                                          5.7                              94.3
    Rural                                                          5.8                              94.2
    South                                                          5.8                              94.2
    West                                                           5.4                              94.6
    Midwest                                                        6.6                              93.4
    Northeast                                                      4.9                              95.1
    Other/Unknown                                                  0.6                              99.4
    Not HPSA                                                       5.8                              94.2
    HPSA                                                           5.3                              94.7
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of
study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were
enrolled at any time in Medicare Advantage during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2005.
b
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




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Appendix III: Tables with Full Analysis of
Preventive Service Use in Medicare FFS




Table 25: Use of PSA Tests by Male Medicare FFS Beneficiaries during the 4-year
Period 2006 through 2009

    Numbers in percent
                            a,b
    Male beneficiaries                      No services    One service        Two or more services
    All                                             50.9           23.6                             25.6
    65 to 74                                        48.0           23.5                             28.5
    75 or older                                     55.3           23.8                             20.9
          75 to 84                                  53.7           24.1                             22.1
          85 or older                               65.0           21.5                             13.6
    Not dual                                        50.1           23.6                             26.3
    Dual                                            60.6           23.1                             16.3
    White                                           49.5           23.9                             26.6
    Black                                           59.9           21.7                             18.5
    Hispanic                                        67.4           21.2                             11.4
    Asian                                           67.1           19.9                             13.0
    Other/Unknown                                   64.1           19.2                             16.7
    Urban                                           52.5           23.3                             24.3
    Rural                                           46.0           24.5                             29.4
    South                                           48.0           24.0                             28.0
    West                                            60.5           22.3                             17.2
    Midwest                                         44.1           24.8                             31.1
    Northeast                                       56.1           22.7                             21.3
    Other/Unknown                                   92.3             5.7                              2.1
    Not HPSA                                        51.1           23.6                             25.4
    HPSA                                            48.6           23.9                             27.5
Source: GAO analysis of CMS Medicare claims data.

Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries under
age 65, (2) beneficiaries who were not continuously enrolled in Parts A and B during the period of
study, (3) beneficiaries residing in institutions, (4) ESRD beneficiaries, and (5) beneficiaries who were
enrolled at any time in Medicare Advantage during the period of study.
a
Denotes the beneficiary’s age as of January 1, 2006.
b
 Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




Page 62                                                     GAO-12-81 Medicare Preventive Services
Appendix IV: Use of the Welcome to
              Appendix IV: Use of the Welcome to Medicare
              Exam by Medicare FFS Beneficiaries Who
              Reached Age 65 in 2008


Medicare Exam by Medicare FFS
Beneficiaries Who Reached Age 65 in 2008

                  Numbers in percent
                                  a
                  Beneficiaries                            Received WTM exam          Did not receive WTM exam
                  All                                                      6.6                                    93.4
                  Female                                                   7.0                                    93.0
                  Male                                                     6.1                                    93.9
                  Not dual                                                 7.3                                    92.7
                  Dual                                                     1.1                                    99.0
                  White                                                    7.3                                    92.7
                  Black                                                    1.7                                    98.3
                  Hispanic                                                 0.7                                    99.3
                  Asian                                                    3.4                                    96.6
                  Other/Unknown                                            3.7                                    96.3
                  Urban                                                    6.7                                    93.3
                  Rural                                                    6.3                                    93.7
                  South                                                    6.1                                    93.9
                  West                                                     6.4                                    93.6
                  Midwest                                                  8.0                                    92.0
                  Northeast                                                6.4                                    93.7
                  Other/Unknown                                            0.0                                   100.0
                  Not HPSA                                                 6.8                                    93.2
                  HPSA                                                     4.2                                    95.8
              Source: GAO analysis of CMS Medicare claims data.

              Note: Percentages may not add to 100 due to rounding. These data exclude (1) beneficiaries who
              were not continuously enrolled in Parts A and B during 2008 and half of 2009, (2) beneficiaries
              residing in institutions, (3) ESRD beneficiaries, and (4) beneficiaries who were enrolled at any time in
              Medicare Advantage during 2008.
              a
               Enrollment data have limitations in accurately identifying beneficiary race and ethnicity, resulting in
              an underreporting of Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives.




              Page 63                                                    GAO-12-81 Medicare Preventive Services
Appendix V: Comments from the Department
             Appendix V: Comments from the Department
             of Health and Human Services



of Health and Human Services




             Page 64                                    GAO-12-81 Medicare Preventive Services
Appendix V: Comments from the Department
of Health and Human Services




Page 65                                    GAO-12-81 Medicare Preventive Services
Appendix V: Comments from the Department
of Health and Human Services




Page 66                                    GAO-12-81 Medicare Preventive Services
Appendix VI: GAO Contact and Staff
                  Appendix VI: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  James C. Cosgrove, (202) 512-7114 or cosgrovej@gao.gov
GAO Contact
                  In addition to the contact named above, individuals making key
Acknowledgments   contributions to this report include Rosamond Katz, Assistant Director;
                  Todd D. Anderson; and Kate Nast. Zhi Boon and Elizabeth T. Morrison
                  also provided valuable assistance.




(290889)
                  Page 67                                  GAO-12-81 Medicare Preventive Services
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