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Assessing America's Health Risks: How Well Are Medicare's Clinical Preventive Benefits Serving America's Seniors? How Will the Next Generation of Preventive Medical Treatments be Incorporated and Promoted in the Health Care System?"
Subcommittee on Oversight and Investigations
Mr. Tom Grissom
Chairman Greenwood, Congressman
Deutsch, distinguished Subcommittee members, thank you for inviting me to
discuss Medicare coverage of preventive services. Preventive care services can
extend lives and promote wellness among America's seniors.
The President, the Secretary, and CMS strongly support preventive health
care services for Medicare beneficiaries, and the Administration has proposed
several initiatives related to prevention that I will discuss in greater detail
later in my testimony. First, I
would like to discuss the nature of preventive health care benefits in the
Medicare program and what benefits are currently covered under Medicare. BACKGROUNDWhen Medicare was established in 1965, the program covered only those health care services necessary for the diagnosis or treatment of illness or injury, as limited by the Medicare statute and reflecting the health care system at that time. Consequently, Medicare, as a general rule, did not cover routine screening or other purely preventive benefits. However, Congress recently has expanded the program to come closer to modeling the preventive care concepts in private health care programs and has added a number of preventive and screening benefits to the program. Both the Balanced Budget Act of 1997 (BBA) and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) significantly added to, or expanded, the preventive benefits covered by Medicare. These benefits include:
The BBA and BIPA also required
CMS to conduct analyses of Medicare preventive benefits. Under the BBA, we worked in conjunction with the Institute of
Medicine and the U.S. Preventive Services Task Force to conduct a study of
short- and long-term costs and benefits of expanding or modifying preventive or
other services covered by Medicare. This
analysis was completed in December 1999. Similarly, we are currently working with the National Academy
of Sciences in conjunction with the U.S. Preventive Services Task Force to
conduct, as required under BIPA, a study on the addition of coverage of routine
thyroid screening using a thyroid stimulating hormone test as a preventive
benefit. In addition to the prevention
benefits added to the program since 1997, Medicare has begun to offer additional
preventive health care services through the Medicare+Choice program.
Unlike the Medicare fee-for-service program whose benefits are tied to
statute, the private companies that provide Medicare+Choice have the flexibility
to cover additional services, such as immunizations, exercise programs, cancer
screening, and health education, that are not covered under the traditional
Medicare benefits package. For
example, one Medicare+Choice plan in California has a successful outreach program to
increase influenza vaccination rates among their elderly and chronically ill
beneficiaries to reduce mortality and morbidity among these at-risk populations.
And a Boston Medicare+Choice plan has a comprehensive disease management
program for its enrollees with diabetes. The
result has been significant increases in the share of enrollees who receive
preventive treatments like annual retinal eye exams and kidney tests, and better
blood sugar control and cholesterol levels, all of which prevent the
life-threatening complications of diabetes.
The Administration is
committed to providing greater availability of innovative preventive benefits by
making private plan options more widely available to beneficiaries.
This is key to improving beneficiary access to preventive benefits and to
strengthening the overall Medicare program. In addition, Medicare+Choice
programs typically provide some form of disease management or care coordination
program, a service not covered in traditional Medicare. Several studies have
suggested that case management and disease management programs can improve
medical treatment plans, reduce avoidable hospital admissions, and promote other
desirable outcomes. Coordination of
care has the potential to improve the health status and quality of life for
beneficiaries with chronic illnesses. We
believe disease management has potential for preventing the worsening of chronic
health conditions, and we are currently undertaking a series of disease
management demonstration projects to explore a variety of ways to improve
beneficiary care in the traditional Medicare plan. THE ADMINISTRATION'S COMMITMENT TO
PREVENTIVE CARE Obviously, Medicare's
coverage of preventive benefits has come a long way since the statute was
written in the 1960s when the positive impact of preventive services was not
fully understood. However,
Medicare's coverage of preventive services can be improved. Under current law, Congress must enact legislation
authorizing Medicare to cover specific preventive benefits. This approach can lead to fragmentation, and may not be
consistent with a comprehensive, evidence-based approach to health promotion.
The President recognizes the need to improve and strengthen the Medicare
program by moving its benefits package from a reactive, acute care model to one
that comprehensively and systematically emphasizes health promotion and disease
prevention. As part of his
principles for strengthening Medicare, the President has proposed to give
seniors better coverage of preventive treatments by making existing preventive
benefits cost-free for seniors. Secretary Thompson has
reinforced the Administration's commitment to disease prevention by promoting
healthy behavior as a priority for his Department, and even discussing in recent
weeks his personal efforts to adopt a healthier lifestyle. To this end, HHS supports a number of programs to promote
better health for all Americans, including:
HEALTH PROMOTION ACTIVITIES
Secretary Thompson, Administrator Scully, and I support the President's commitment to expand beneficiary access to preventive health services, and we are working on ways to improve health quality for America's most vulnerable citizens. As you may know, simply offering coverage for preventive health care services is not always enough to guarantee that Medicare beneficiaries take advantage of the benefits. That is why we strive to use efficient and cost effective approaches by partnering with other agencies and organizations, utilizing Medicare contractors to educate people with Medicare about covered preventive services and encouraging beneficiaries to use these services. To this end, we include health promotion information as a part of many education campaigns that address different aspects of the Medicare program or Medicare+Choice options. We have established partnerships with other HHS agencies, such as the Centers for Disease Control and Prevention (CDC) and the NIH's National Cancer Institute (NCI) to carry out health promotion initiatives, distribute outreach kits, and produce multi-media, multi-year campaigns involving numerous partners at the local and national level. In addition, we integrate communications about preventive services with other Medicare educational initiatives, such as:
In
addition, we emphasize the importance of prevention in education campaigns on
the radio and through television public service announcements, print materials
and media kits, websites, and articles in journals and newsletters. Through these campaigns, we are targeting high-risk
populations and health care practitioners whom we know have a tremendous
influence in encouraging healthy behavior. We are actively working to find out how best to increase use of preventive services needed by the Medicare population. We are studying a variety of successful interventions to test their effectiveness in the elderly population. In addition, we are working closely at the state level with our Quality Improvement Organizations (QIOs, formerly Peer Review Organizations) to monitor and to improve usage and quality of care for Medicare beneficiaries. We have set a goal for the QIOs of improving the utilization of flu and pneumonia vaccinations and breast cancer screening. To this end, the QIOs are actively reaching out to Medicare beneficiaries to increase the use of these three preventive services. They are also targeting racial and ethnic groups that have low rates of use. We are currently evaluating the success of these QIO efforts, and expect results later this year. Through our work with the QIOs and through other research, we know that compelling evidence exists that race and ethnicity correlate with health disparities. We are exploring a demonstration project to identify and test cost-effective models of intervention that have a high probability of positively impacting one or more health outcomes; including health status, functional status, quality of life, health-related behavior, consumer satisfaction, health care costs, and appropriate utilization of covered services. We have contracted with Brandeis University to report on interventions that could be used among the targeted ethnic and racial minority populations. At the conclusion of the demonstrations, we will deliver a report to Congress on the cost-effectiveness of the projects, as well as the quality of preventive services provided and beneficiary satisfaction. CMS'
INNOVATIONS IN PREVENTIVE CARE SERVICES A growing body of
literature indicates that chronic disease and functional disability can be
measurably reduced or postponed through lifestyle changes, and that healthy
behaviors are particularly beneficial for the elderly.
We have addressed some of the clinical preventive services that
contribute to a healthy aging experience, and are just beginning to explore how
to address behavioral risk factors, which account for 70 percent of the physical
decline that occurs with aging, with the remaining 30 percent due to genetic
factors. To this end, we developed
the Healthy Aging Project in collaboration with the Agency for Healthcare
Research and Quality, the Centers for Disease Control and Prevention, the
Administration on Aging, and the National Institutes of Health.
The Healthy Aging Project aims to identify, test, and disseminate
evidence-based approaches to promote health and prevent functional decline in
older adults. We contracted with RAND
to produce several reports synthesizing the evidence on how to improve the
delivery of Medicare clinical preventive and screening benefits and exploring
how behavioral risk factor reduction interventions might be implemented in
Medicare. We have been using these
reports to guide demonstration projects testing ways to improve Medicare
beneficiaries' health - and have already identified ways to change our
policies for the better. The first
report, Interventions That Increase the
Utilization of Medicare-funded Preventive Services for Persons Aged 65 and Older,
states that organizational changes are effective in improving the delivery of
preventive services. As a result of
this research and a 14-state pilot conducted in collaboration with CDC, we are
making regulatory changes. These
changes will promote vaccinations, and encourage the use of standing orders for
flu and pneumococcal vaccinations in all health care settings.
Standing orders permit appropriate non-physician staff to offer these
services. In addition to the regulatory
changes for standing orders that have come out of the Healthy Aging Project, we
are using the research gleaned from this project to explore methods to encourage
behavioral changes in the Medicare population, which could form the basis for
the "next generation" of Medicare benefits. Additionally, we, along with our partners at NIH and AHRQ, have developed a demonstration to test the most effective strategies for achieving smoking cessation in Medicare beneficiaries. The demonstration will compare the impact of offering three different approaches to smoking cessation on quit rates. We expect to start recruiting smokers to participate in the demonstration this fall. The study will be completed in 2004. We also are developing
a potential project that would examine the use of health risk appraisal programs
with targeted follow-up interventions. We
have reviewed evidence related to health risk appraisal programs and their
effectiveness in achieving positive behavior change, particularly in the areas
of diet and physical activity. There
is evidence that these programs improve physical activity levels and reduce
blood pressure. We are in the process of developing a test of how health risk
appraisal programs could improve Medicare beneficiaries' health.
We look forward to working with Congress as we continue to develop
groundbreaking ways to integrate preventive health care services into the
Medicare program. CONCLUSION
Empirical evidence shows that preventive health care services are vital for improving the quality and duration of life. Just last month, Secretary Thompson, speaking at the National Press Club, emphasized his philosophy, "a little prevention won't kill you," and noted that even modest behavioral changes and increased attention to health can prevent or control myriad diseases and chronic conditions. We here at CMS, along with the Secretary and the President recognize the benefits that preventive health services provide. We are working to improve access to these services and to develop innovative ways to offer prevention-related health services to the Medicare population. In closing, I would like to thank Congressman Greenwood for his interest in preventive health care and the Committee for inviting me to testify today. We look forward to Congress' continued interest and support for this vital issue. I am happy to answer any questions.
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