This is the accessible text file for GAO report number GAO-02-422 
entitled 'Medicare: Beneficiary Use of Clinical Preventive Services' 
which was released on April 12, 2002. 

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United States General Accounting Office: 
GAO: 

Report to the Chairman, Subcommittee on Oversight and Investigations, 
Committee on Energy and Commerce, House of Representatives: 

April 2002: 

Medicare: 

Beneficiary Use of Clinical Preventive Services: 	
		
GAO-02-422: 

Contents: 

Letter: 

Results in Brief: 

Background: 

Use of Preventive Services Is Growing but Varies Widely: 

Efforts Under Way to Increase Use of Some Preventive Services: 

Agency Comments and Our Evaluation: 

Appendix I: Comments from the Centers for Medicare and Medicaid 
Services: 

Appendix II: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Preventive Services Covered by the Medicare Program as of 
January 2002: 

Table 2: Percentage of Medicare Beneficiaries Age 65 and Older Using 
Preventive Services in 1995, 1997, and 1999: 

Table 3: Variation in State Usage Rates for Preventive Services by
Medicare Beneficiaries 65 and Older, 1999: 

Table 4: Percentages of Medicare Beneficiaries 65 and Older Using
Preventive Services by Income and Education, 1999: 

Abbreviations: 

BRFSS: Behavior Risk Factor Surveillance Survey: 

CDC: Centers for Disease Control and Prevention: 

CMS: Centers for Medicare and Medicaid Services: 

NCI: National Cancer Institute: 

PRO: Peer Review Organization: 

[End of section] 

United States General Accounting Office: 
Washington, DC 20548: 

April 12, 2002: 

The Honorable Jim Greenwood: 
Chairman: 
Subcommittee on Oversight and Investigations: 
Committee on Energy and Commerce: 
House of Representatives: 

Dear Mr. Chairman: 

Preventive health care services can extend lives and promote well-
being among our nation's seniors. For example, immunizations against 
the flu can prevent thousands of hospitalizations and deaths each year 
among those age 65 and older. Screening for some types of cancer may 
extend and improve the quality of life through early detection and 
treatment. Such preventive services are a growing part of Medicare, 
the federal government's health insurance program for some 34 million 
Americans age 65 and older, as well as 6 million younger disabled 
persons. Medicare, administered by the Centers for Medicare and 
Medicaid Services (CMS), now covers 10 preventive services-3 types of 
immunizations and 7 types of screening.[Footnote 1] 

Although Medicare provides coverage for these preventive services, 
some beneficiaries do not receive them. These beneficiaries may, for 
example, face barriers in obtaining the services or simply choose not 
to use them. To help ensure that preventive services are being 
delivered to those beneficiaries who need them, CMS sponsors efforts-—
called "interventions"-—aimed at increasing preventive service usage 
rates. 

You asked us to examine two questions regarding preventive services 
for older Americans: 

* To what extent are Medicare beneficiaries using covered preventive 
services? 

* What action has CMS taken to increase use of preventive services 
among the Medicare population? 

To answer these questions, we estimated Medicare beneficiaries' use of 
services from a nationwide, state-based survey conducted by the 
Centers for Disease Control and Prevention (CDC).[Footnote 2] We 
obtained information about effective techniques to increase use of 
preventive services from published reports and discussions with 
program officials at the federal and state levels[Footnote 3] who are 
responsible for implementing projects intended to increase the use of 
preventive services. For both questions, we conducted interviews with 
officials from the Department of Health and Human Services, CDC, the 
National Institutes of Health, CMS, and the Agency for Health Care 
Research and Quality. We also spoke with representatives from the 
Partnership for Prevention, a nonprofit association involved in the 
research and promotion of preventive services. We conducted our work 
from August through February 2002 in accordance with generally 
accepted government auditing standards. 

While the use of preventive services offered under Medicare has 
increased over time, use of these services varies widely by service 
and state. It also varies by ethnic group, income, and education. From 
1995 through 1999, the proportion of all Medicare beneficiaries 
immunized against flu and pneumonia, as well as the proportion of 
women who received screens for cervical and breast cancer, increased 
steadily. Nevertheless, in 1999, usage rates varied considerably among 
individual services. For example, the 75 percent usage rate for breast 
cancer screening was considerably higher than the 55 percent rate for 
pneumonia immunizations. However, even for widely used preventive 
services such as breast cancer screening, state-by-state usage rates 
ranged from 66 to 86 percent. Among ethnic groups, differences were 
greatest for immunizations. About 70 percent of whites reported 
receiving flu shots within the past year compared to 49 percent of 
African Americans. The disparities between income and educational 
groups were greatest for cancer screening. While most Medicare 
beneficiaries received at least one covered preventive service, a much 
smaller number received additional preventive services covered under 
Medicare. For example, 1999 data showed that while 91 percent of 
female Medicare beneficiaries received at least one preventive 
service, only 10 percent of these beneficiaries were screened for 
cervical, breast, and colon cancer, as well as immunized against flu 
and pneumonia. 

CMS pays for interventions aimed at increasing the use of three 
services—breast cancer screening and immunizations against flu and 
pneumonia—in each state. CMS also pays for interventions that focus on 
increasing use of services by ethnic groups and income groups with low 
usage rates. The majority of techniques being used in these 
interventions, such as developing reminder systems medical offices can 
use to alert providers and patients when breast cancer screenings are 
needed, have been found effective in the past. CMS is evaluating what 
the current efforts are accomplishing and expects the results later in 
2002. 

In commenting on a draft of this report, CMS stated that the report 
did not consider many of CMS's publication and education campaigns 
that were either completed or underway to increase use of Medicare 
covered preventive services. We chose to focus mainly on those types 
of interventions that studies showed to be the most effective in 
ensuring that patients obtain services. 

Background: 

When the Medicare program was established in 1965, it only covered 
health care services for the diagnosis or treatment of illness or 
injury. Preventive services did not fall into either of these 
categories and, consequently, were not covered. Since 1980, the 
Congress has amended Medicare law several times to add coverage for 
certain preventive services for different age and risk groups within 
the Medicare population. (See table 1.) For most of these services, 
Medicare requires some degree of cost-sharing by beneficiaries, 
although most beneficiaries have additional insurance, which may cover 
most, if not all, of these cost-sharing requirements.[Footnote 4] Some 
services, such as pneumonia and flu shots and the fecal-occult blood 
test for colorectal cancer, have no cost-sharing requirements. 

Table 1: Preventive Services Covered by the Medicare Program as of 
January 2002: 

Service: Immunizations: Pneumococcal; 
Year first covered: 1981; 
Groups covered: All beneficiaries; 
Frequency of service: As needed (probably once per lifetime); 
Cost-sharing service requirements[A]: None. 

Service: Immunizations: Hepatitis B; 
Year first covered: 1984; 
Groups covered: Beneficiaries at intermediate or high risk of 
contracting hepatitis B; 
Frequency of service: As needed (probably once per lifetime); 
Cost-sharing service requirements[A]: Copayment after deductible. 

Service: Immunizations: Influenza; 
Year first covered: 1993; 
Groups covered: All beneficiaries; 
Frequency of service: Every year; 
Cost-sharing service requirements[A]: None. 

Service: Screening services: Cervical cancer—pap smear; 
Year first covered: 1990; 
Groups covered: All female beneficiaries; 
Frequency of service: Every 2 years; 
Cost-sharing service requirements[A]: Copayment with no deductible[B]. 

Service: Screening services: Breast cancer—mammography; 
Year first covered: 1991; 
Groups covered: Female beneficiaries 35 to 39; 
Frequency of service: One baseline mammogram for this period; 
Cost-sharing service requirements[A]: Copayment with no deductible. 

Service: Screening services: Breast cancer—mammography; 
Year first covered: 1991; 
Groups covered: Female beneficiaries 40 and older; 
Frequency of service: Every year; 
Cost-sharing service requirements[A]: Copayment with no deductible. 

Service: Screening services: Vaginal cancer—pelvic exam; 
Year first covered: 1998; 
Groups covered: All female beneficiaries; 
Frequency of service: Every 2 years[C]; 
Cost-sharing service requirements[A]: Copayment with no deductible[B]. 

Service: Screening services: Colorectal cancer—fecal-occult blood test; 
Year first covered: 1998; 
Groups covered: Beneficiaries 50 and older; 
Frequency of service: Every year; 
Cost-sharing service requirements[A]: No copayment or deductible. 

Service: Screening services: Colorectal cancer—sigmoidoscopy[D]; 
Year first covered: 1998; 
Groups covered: Beneficiaries 50 and older; 
Frequency of service: Every 4 years; 
Cost-sharing service requirements[A]: Copayment after deductible[E]. 

Service: Screening services: Colorectal cancer—colonoscopy[D]; 
Year first covered: 1998; 
Groups covered: All beneficiaries; 
Frequency of service: Every 10 years[F]; 
Cost-sharing service requirements[A]: Copayment after deductible. 

Service: Screening services: Osteoporosis—bone mass measurement; 
Year first covered: 1998; 
Groups covered: Estrogen-deficient female beneficiaries at clinical 
risk for osteoporosis as well as other qualified individuals[G]; 
Frequency of service: Every 2 years[H]; 
Cost-sharing service requirements[A]: Copayment after deductible. 

Service: Screening services: Prostate cancer—prostate-specific antigen 
test and/or digital rectal examination; 
Year first covered: 2000; 
Groups covered: Men 50 and older; 
Frequency of service: Every year; 
Cost-sharing service requirements[A]: Copayment after deductible. 

Service: Screening services: Glaucoma; 
Year first covered: 2002; 
Groups covered: Beneficiaries medically determined to be at high risk 
for glaucoma; 
Frequency of service: Every year; 
Cost-sharing service requirements[A]: Copayment after deductible. 

[A] Applicable Medicare cost-sharing requirements generally include a 
20 percent copayment after a $100 per year deductible. Each year, 
beneficiaries are responsible for 100 percent of the payment amount 
until those payments equal a specified deductible amount, $100 in 
2002. Thereafter, beneficiaries are responsible for a copayment that 
is usually 20 percent of the Medicare approved amount. For certain 
tests, the copayment may be higher. See 42 U.S.C. § 1395(a)(1). 

[B] The costs of the laboratory test portion of these services are not 
subject to copayment or deductible. The beneficiary is subject to a 
deductible and/or copayment for physician services only. 

[C] The exam is covered once every 12 months if the beneficiary has 
had an abnormality within the prior 3 years or is otherwise determined 
to be a high-risk candidate for cervical cancer. 

[D] The doctor can decide to use a barium enema instead of a 
sigmoidoscopy or colonoscopy for beneficiaries 50 and older. The 
frequency of service is the same as the sigmoidoscopy or colonoscopy 
it substitutes for. 

[E] The copayment is increased from 20 to 25 percent for services 
rendered in an ambulatory surgical center. 

[F] Beneficiaries medically determined to be at high risk may receive 
a colonoscopy every 2 years. 

[G] The statute defines "other qualified individuals" as 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). 

[H] CMS permits coverage of a bone mass measurement at any time—sooner 
than 2 years—if the service is medically necessary. See 42 CFR § 
410.31(c). 

[End of table] 

Many other preventive services exist besides those specifically 
covered as preventive services under Medicare, such as blood pressure 
screening and cholesterol screening. Although Medicare does not 
explicitly provide coverage for these other services, Medicare 
beneficiaries may receive some of them during office visits for other 
medical problems. Data from surveys of Medicare beneficiaries indicate 
that the receipt of such services is common.[Footnote 5] For example, 
in 1999, nearly 98 percent of seniors reported that they had had their 
blood pressure checked within the last 2 years, and more than 88 
percent of seniors reported having their cholesterol checked within 
the prior 5 years. At least a portion of these services were likely 
ordered by physicians in order to diagnose the causes of medical 
problems, and were paid for by Medicare as such. 

To identify how best to increase use of preventive services needed by 
the Medicare population, CMS sponsors reviews of studies that examine 
various kinds of interventions that have been used in the past for 
populations age 65 and older. CMS also takes action to implement 
interventions in each state through its Peer Review Organization (PRO) 
program.[Footnote 6] Under this program, CMS contracts with 37 
organizations responsible for each state, U.S. territory, and the 
District of Columbia. The PRO program, which is designed to monitor 
and improve quality of care for Medicare beneficiaries, currently 
includes the goal of increasing the use of flu and pneumonia 
immunizations, as well as breast cancer screening, in each state. 
These organizations collaborate with hospitals and health care 
professionals, suggesting systemic changes to improve how preventive 
services are provided. CMS also conducts a variety of health promotion 
activities to educate beneficiaries about the benefits of preventive 
services and to encourage their use. These include the publication of 
brochures on certain covered services and media campaigns. 

Use of Preventive Services Is Growing but Varies Widely: 

Use of preventive services offered under Medicare has increased over 
time. Some services are used more extensively than others, and use of 
individual services varies by state and, to a lesser extent, by 
demographic characteristics such as ethnicity, income, and education. 
Although opportunities remain to increase the use of preventive 
services within Medicare, there are limits to the extent some 
beneficiaries would be expected to use certain services. 

The Use of Individual Preventive Services Has Increased over Time but 
a Minority Receive Multiple Services: 

Information on usage for 4 of the 10 preventive services covered under 
Medicare is available in the data we used[Footnote 7]-—immunizations 
against pneumonia and flu and screening for cervical and breast 
cancer.[Footnote 8] This information shows that beneficiaries age 65 
and older are increasing their use of all 4 services. (See table 2.) 
For example, 68 percent of beneficiaries received flu shots in 1999, 
compared with 60 percent in 1995. 

Table 2: Percentage of Medicare Beneficiaries Age 65 and Older Using 
Preventive Services in 1995, 1997, and 1999: 

Service and frequency: Immunizations: Pneumococcal—ever; 
Year first covered under Medicare: 1981; 
National usage rate, 1995[A]: 38%; 
National usage rate, 1997: 46%; 
National usage rate, 1999: 55%. 

Service and frequency: Immunizations: Influenza—within previous year; 
Year first covered under Medicare: 1993; 
National usage rate, 1995[A]: 60%; 
National usage rate, 1997: 66%; 
National usage rate, 1999: 68%. 

Service and frequency: Screening services: Cervical cancer—pap smear 
within previous 3 years; 
Year first covered under Medicare: 1990; 
National usage rate, 1995[A]: 70%; 
National usage rate, 1997: 71%; 
National usage rate, 1999: 72%. 

Service and frequency: Screening services: Breast cancer—mammogram 
within previous 2 years; 
Year first covered under Medicare: 1991; 
National usage rate, 1995[A]: 66%; 
National usage rate, 1997: 72%; 
National usage rate, 1999: 75%. 

[A] For 1995 only, values obtained from CDC's BRFSS web site data. 
These 1995 data includes Puerto Rico, and may include some survey 
respondents not enrolled in Medicare. 

Source: CDC's BRFSS for 50 states and the District of Columbia. 

[End of table] 

In 1999, although each preventive service was used by the majority of 
Medicare beneficiaries, fewer receive multiple preventive services. 
For example, 1999 data show that while 91 percent of female Medicare 
beneficiaries received at least 1 preventive service, only 10 percent 
of these beneficiaries were screened for cervical,[Footnote 9] breast, 
and colon cancer,[Footnote 10] as well as immunized against flu and 
pneumonia. These data also show that 44 percent of male beneficiaries 
were immunized against both flu and pneumonia. When colorectal 
screening is included in this set of services, the proportion of men 
who had received all 3 services falls to less than 27 percent. 

Use of Services Varies by State and Other Demographic Characteristics: 

While national rates provide an overall picture of current use, they 
mask substantial differences in how seniors living in different states 
use some services. For example, the national breast cancer screening 
rate for Medicare beneficiaries was 75 percent in 1999, but rates for 
individual states ranged from a low of 66 percent to a high of 86 
percent. In table 3, we show the range over which state estimates of 
preventive service usage rates vary from lowest to highest for 
selected states.[Footnote 11] 

Table 3: Variation in State Usage Rates for Preventive Services by 
Medicare Beneficiaries 65 and Older, 1999: 
	
Preventive service[A]: Immunizations: Pneumococcal—ever; 
National usage rate percentage[B]: 55%; 
Usage rate range among states percentage: 51 to 62%; 
Number of states included in range[C]: 24. 

Preventive service[A]: Immunizations: Influenza—within previous year; 
National usage rate percentage[B]: 68%; 
Usage rate range among states percentage: 63 to 77%; 
Number of states included in range[C]: 30. 

Preventive service[A]: Screening services: Breast cancer—mammogram
within previous 2 years; 
National usage rate percentage[B]: 75%; 
Usage rate range among states percentage: 66 to 86%; 
Number of states included in range[C]: 21. 

Preventive service[A]: Screening services: Colorectal cancer—fecal-
occult blood test in past year; 
National usage rate percentage[B]: 25%; 
Usage rate range among states percentage: 14 to 37%; 
Number of states included in range[C]: 34. 

Preventive service[A]: Screening services: Colorectal cancer—colonoscopy
or sigmoidoscopy within previous 5 years; 
National usage rate percentage[B]: 40%; 
Usage rate range among states percentage: 27 to 46%; 
Number of states included in range[C]: 24. 

[A] Data were unavailable for Medicare population use of hepatitis B 
immunization and screening services for osteoporosis. 

[B] National usage rate includes all states and the District of 
Columbia. 

[C] This includes the number of states whose 95 percent confidence 
intervals for the respective preventive services were narrower than 10 
percentage points. State specific data were not included for cervical 
cancer screening because none met this level of precision. 

Source: CDC's BRFSS for 50 states and the District of Columbia. 

[End of table] 

While usage rates for each service varied from state to state, the 
services with the highest rates in each state were generally the same. 
For example, in most states, screening rates for breast and cervical 
cancer were higher than rates for colorectal screens.
Usage rates for Medicare beneficiaries also varied based on ethnicity, 
and on socioeconomic status, as defined by income and education. By 
ethnicity, the biggest differences occurred in use of immunization 
services. For example, 1999 data show that about 57 percent of whites 
and 54 percent of "other"[Footnote 12] ethnic groups were immunized 
against pneumonia, compared to about 37 percent of African Americans 
and Hispanics. Similarly, about 70 percent of whites and "other" 
ethnic groups received flu shots during the year compared to 49 
percent of African Americans. The only other statistically significant 
difference between ethnic groups was for the fecal-occult blood test 
for colon cancer, for which 26 percent of whites received screenings 
within the past year compared to 16 percent of Hispanics and "other" 
ethnic groups.[Footnote 13] For income and education, in general, as 
income and education rose, the rates at which individuals used 
preventive services also increased. (See table 4.) 

Table 4: Percentages of Medicare Beneficiaries 65 and Older Using 
Preventive Services by Income and Education, 1999: 
			
Screening service[A]: Immunizations: Pneumococcal-ever; 
Income: Less than $25,000: 53.7%; 
Income: $25,000	and over: 57.5%; 
Education: Less than high school: 47.9%; 
Education: High school and some college: 56.4%; 
Education: College graduate and postgraduate: 60.1%. 

Screening service[A]: Immunizations: Influenza-within previous year; 
Income: Less than $25,000: 65.2%; 
Income: $25,000	and over: 71.0%; 
Education: Less than high school: 61.7%; 
Education: High school and some college: 68.6%; 
Education: College graduate and postgraduate: 72.6%. 

Screening service[A]: Preventive services: Cervical cancer-pap smear 
within previous 3 years; 
Income: Less than $25,000: 66.1%; 
Income: $25,000	and over: 81.5%; 
Education: Less than high school: 62.0%; 
Education: High school and some college: 74.8[B]%; 
Education: College graduate and postgraduate: 78.6[B]%. 

Screening service[A]: Preventive services: Breast cancer-mammogram 
within previous 2 years; 
Income: Less than $25,000: 69.7%; 
Income: $25,000	and over: 84.2%; 
Education: Less than high school: 65.3%; 
Education: High school and some college: 76.9%; 
Education: College graduate and postgraduate: 84.0%. 

Screening service[A]: Preventive services: Colorectal cancer-fecal-
occult blood test in previous year; 
Income: Less than $25,000: 21.3%; 
Income: $25,000	and over: 28.1%; 
Education: Less than high school: 19.7%; 
Education: High school and some college: 25.3%; 
Education: College graduate and postgraduate: 29.7%. 

Screening service[A]: Preventive services: Colorectal cancer-
colonoscopy or sigmoidoscopy within previous 5 years; 
Income: Less than $25,000: 36.8%; 
Income: $25,000	and over: 46.1%; 
Education: Less than high school: 33.3%; 
Education: High school and some college: 40.2%; 
Education: College graduate and postgraduate: 48.3%. 

[A] Data were unavailable for Medicare population utilization of 
Hepatitis B immunization and screening services for osteoporosis. 

[B] All differences between income and education groups are 
statistically significant except for cervical cancer screening 
services for high school graduates and above. 

Source: CDC's BRFSS for 50 states and the District of Columbia. 

[End of table] 

Opportunities and Limitations Exist to Increase the Use of Preventive 
Services: 

Various studies have identified a variety of factors affecting 
beneficiary decisions to seek preventive care, including low patient 
awareness of the benefits of the services as well as the need for 
service. Some factors, such as those involving patient awareness of 
the benefits, may represent opportunities to increase the use of 
preventive services. For example, see the following. 

* In a 1997 report, the Agency for Healthcare Research and Quality 
found that, although patients may be unaware of the risks or symptoms 
of colorectal cancer, they are more likely to participate in screening 
once they understand the nature and risks of the disease. 

* Data from CMS's 1999 Medicare Current Beneficiary Survey show that, 
while about one-fourth of beneficiaries who did not receive flu shots 
were unaware of the benefits of obtaining this immunization, about 
half of the people who were not immunized avoided getting the shot for 
reasons such as concerns about side effects and whether doing so would 
effectively prevent illness. 

On the other hand, usage rates alone may not provide a clear picture 
of success, and may mask inherent limitations to increasing usage 
rates. For example, survey data show that 44 percent of women age 65 
and over have had hysterectomies[Footnote 14]-—an operation that 
usually includes removing the cervix. For these women, researchers 
state that cervical cancer screening may not be necessary unless they 
have a prior history of cervical cancer.[Footnote 15] Also, according 
to officials in charge of research on preventive services at the 
National Institutes of Health, it is reasonable for beneficiaries, 
their families, or their providers to decide to forgo services because 
of the limited benefits they would offer patients with terminal 
illnesses or of advanced age. These officials explained that research 
has shown, for example, that the benefits of cancer screening 
services, such as for prostate, breast, and colon cancer, can take 10 
years or more to materialize, a time frame that could exceed the life 
expectancy of as much as half of the Medicare population.[Footnote 16] 

CMS officials also pointed out that the controversy over the 
effectiveness of some services, such as mammography and prostate 
cancer screening, may add to the difficulty in further improving 
screening rates for these services. The benefit of mammography has 
recently been challenged by two Danish researchers and an independent 
group of experts on the National Cancer Institute's (NCI) advisory 
panel citing serious flaws in 6 of the 8 clinical trials that showed 
benefits. However, subsequent to the Danish report and the NCI panel's 
statement, both the NCI and the U.S. Preventive Services Task Force 
[Footnote 17] reiterated their recommendation for regular mammography 
screening. While acknowledging the methodological limitations in these 
trials, the U.S. Preventive Services Task Force concluded that the 
flaws in these studies were unlikely to negate the reasonable, 
consistent, and significant mortality reductions observed in these 
trials. Routine screening for prostate cancer is also a matter of 
controversy. For example, the American Cancer Society and the American 
Urological Association support routine prostate cancer screening, 
while the U.S. Preventive Services Task Force and others[Footnote 18] 
state that there is insufficient evidence to support it. 

Efforts Under Way to Increase Use of Some Preventive Services: 

CMS has studied various types of interventions to increase the use of 
preventive services among seniors. These studies show that many types 
of interventions can potentially be effective, but also that 
interventions must be tailored to the circumstances of specific 
situations. CMS is funding efforts in every state to implement 
interventions for three preventive services that Medicare covers. CMS 
also has efforts under way aimed at increasing the use of preventive 
services among minority and low-income seniors. 

Studies Identify Effective Methods to Increase Use of Services: 

CMS has sponsored reviews of studies looking at the effectiveness of 
interventions to increase use of preventive services among people age 
65 and older. One of these reviews evaluated the effectiveness of 
interventions targeting people over age 65 for five services covered by 
Medicare—immunizations for flu and pneumonia and screenings for 
breast, cervical, and colon cancer.[Footnote 19] The report evaluated 
218 separate studies on interventions designed to increase use of 
preventive services. The studies were performed in both academic and 
nonacademic settings in various geographic areas, and in a mixture of 
reimbursement systems. Most of the interventions studied that involved 
pneumococcal and influenza immunizations were targeted toward persons 
over 65 years of age, while cancer screening interventions were 
targeted at adults, but not necessarily those 65 years of age. 

This evaluation concluded that no specific intervention was 
consistently most effective for all services and settings, and that 
success depended on how closely the intervention addressed the unique 
circumstances in each state and for different populations within each 
state, while also taking into account the cost and difficulty of 
implementation. Obstacles to improved screening rates can differ 
across states thus requiring different approaches. For example, 
officials responsible for improving the use of preventive services in 
Idaho and Washington explained that while a significant barrier in 
Idaho was beneficiary access to Medicare providers, this was not a 
barrier in Washington. The CMS evaluation also showed that using 
multiple interventions generally provided greater success than using a 
single approach. 

The types of interventions evaluated in the CMS-sponsored review 
[Footnote 20] included a variety of efforts targeting health delivery 
systems, providers, and patients. The key conclusion the report drew 
from the literature was that organizational and system change, such as 
the use of standing orders[Footnote 21] and the use of financial 
incentives, were the most consistent at producing the largest increase 
in the use of preventive services. These and other interventions found 
to be effective follow. 

* System Change. These interventions change the way a health system 
operates so that patients are more likely to receive services. For 
example, medical or administrative staff may be given responsibility 
to ensure that patients receive services, or standing orders may be 
implemented in nursing homes to allow nonphysician personnel to 
administer immunizations without a physician's order. 

* Incentives. These interventions include gifts or vouchers to 
patients for free services. Medicare allows this type of approach only 
in limited circumstances.[Footnote 22] 

* Reminders. These interventions include computer-generated or other 
approaches by which medical offices (1) reminded physicians to provide 
the preventive service as part of services performed during a medical 
visit or (2) generated notices to patients that it was time to make an 
appointment for the service. Studies show that reminders to either 
patients or physicians can effectively improve rates for cancer 
screening. However, a computerized provider reminder is consistently 
more cost effective than notifying the patient directly when a 
computerized information system is already available in a physician's 
medical office. Patient reminders that are personalized or signed by 
the patient's physician are more effective than generic reminders. 

* Education. These interventions include pamphlets, classes, or public 
events providing information for physicians or beneficiaries on 
coverage, benefits, and time frames for services. The study found that 
while the effect of patient education is significant, it is 
consistently less effective than system change, incentives, or 
reminders. 

CMS Is Sponsoring Interventions to Increase Use of Three Services: 

CMS is implementing interventions in all states through its PRO 
program. Under this program, CMS contracts with 37 PROs, each 
responsible for monitoring and improving the quality of care for 
Medicare beneficiaries in one or more states, in U.S. territories, or 
in the District of Columbia. These efforts are currently aimed at 
three preventive services offered under Medicare—immunizations against 
flu and pneumonia and screening for breast cancer. CMS chose these 
topics based on their public health importance and other factors. CMS 
also contracts with select PROs to provide support and assistance to 
all PROs for each area of focus. For example, CMS has contracted with 
two of the existing PROs, one for flu and pneumonia immunizations and 
one for breast cancer screening, to provide support and share 
information among the PROs regarding their efforts to improve usage 
rates for these services. Our discussions with the officials from 
these two PROs indicate that, for immunizations, most PROs are 
focusing on ways to better educate patients and providers on the 
importance of getting flu and pneumonia shots. For breast cancer 
screening, efforts are focusing on developing integrated reminder 
systems, such as chart stickers or computer-based alerts that 
physicians' offices can use to contact patients on a timely basis. 

Officials for the two PROs providing support indicated that most PROs 
were implementing multiple interventions. For example, in a newsletter 
intended to help PROs share information, officials at one PRO reported 
that they have developed concurrent breast cancer screening 
interventions for their state, which are targeted at physicians and 
their staffs, nurses, and beneficiaries. Officials for this PRO report 
the following. 

* For physicians and their staffs, they (1) host seminars to teach 
them about reminder and billing systems, (2) provide toolkits that 
include reminder systems, checklists, and other materials, and (3) 
conduct on-site consultations to encourage providers to implement 
system changes. 

* For nurses, they are conducting a campaign intended to increase 
awareness and encourage nurses and student nurses to identify female 
friends and family members who are overdue for mammograms. The 
campaign includes information packets, a newsletter, and information 
booths at nursing organization meetings. 

* For beneficiaries, the PRO publishes a periodic newsletter on the 
subject of preventive medicine. This newsletter includes articles on 
the importance of mammography for early detection of breast cancer. 

CMS has taken steps to evaluate the success of PRO efforts. CMS 
officials explained that the contracts with the PRO organizations are 
"performance based" and provide financial incentives as a reward for 
superior outcomes. The contracts include a methodology in which the 
performance of the PRO for each state, U.S. territory, and the 
District of Columbia is scored based on 22 indicators, including flu 
and pneumonia vaccination rates and mammography rates. The performance 
of the PRO in each state will then be ranked against all other states 
in order to identify the higher and lower performing PROs. CMS intends 
to automatically renew the contracts with the top 75 percent of the 
PROs for the next contract cycle, which begins in 2002. The PRO 
contracts also contain financial performance incentives allowing each 
PRO to receive up to an additional 2 percent payment based on the 
positive outcomes of their interventions. CMS officials expect 
information on the results by the summer of 2002. Consequently, we 
have not assessed the outcome of PRO efforts or CMS's methodology for 
measuring PRO performance. 

While the current efforts include 3 of the 10 preventive services 
covered by Medicare, CMS is also developing indicators and performance 
measures necessary for interventions to increase use of screening 
services for osteoporosis and colorectal and prostate cancer. CMS 
officials stated that such interventions would be implemented in 
future contracts with PROs. CMS is not currently developing indicators 
for the remaining preventive services covered by Medicare—hepatitis B 
immunizations or screenings for glaucoma and vaginal cancer. 

CMS Is Also Sponsoring Interventions to Increase Use of Services among 
Minorities and Low-Income Seniors: 

CMS is also sponsoring PRO interventions and projects in each state to 
increase use of preventive services by minorities and low-income 
Medicare beneficiaries. CMS-funded research on successful 
interventions for the general Medicare population 65 and older 
concluded that evidence was insufficient to determine how best to 
increase use of services by minorities and low-income seniors across 
various geographic settings. Differences in how populations use 
preventive services are sometimes found even when the populations have 
similar geographic settings or delivery systems. For example, a study 
showed that although use of flu shots among white and African American 
seniors is higher under managed care than fee-for-service, the 
significant disparities in levels of use between these ethnic groups 
persist in both these environments.[Footnote 23] 

To begin addressing these information gaps, CMS requires that each PRO 
conduct a project focusing on one of several specified Medicare 
populations. This population can be low-income seniors enrolled in 
both Medicare and Medicaid or one of several minority groups: American 
Indians, Alaska Natives, Asian Americans and Pacific Islanders, 
African Americans, or Hispanics. For the population chosen, the PRO is 
to target interventions for one service. The projects in most states 
are focusing on increasing breast cancer screening or flu and 
pneumonia immunization among African American or low-income seniors. 
PROs are required to identify the barriers that exist for the selected 
population and service, and to implement interventions specifically 
designed to address these barriers for patients and providers. A 
summary of PRO efforts to increase services for minorities and low-
income seniors is expected to be published sometime after the spring 
of 2002. 

Other studies or projects under way by CMS also aim to identify 
barriers and increase use of services by certain Medicare populations. 
For example, the Congress directed CMS to conduct a demonstration 
project to, among other things, develop and evaluate methods to 
eliminate disparities in cancer prevention screening measures. 
[Footnote 24] The law specifies a total of nine demonstration projects 
to include two state-level demonstrations for each of four minority 
groups (American Indians, including Alaska Natives, Eskimos, and 
Aleuts; Asian Americans and Pacific Islanders; African Americans; and 
Hispanics) and one project in the Pacific Islands. In addition, one of 
the projects must have a rural focus and one must have an urban focus 
for each group. CMS expects to produce a report by December 2002, 
after the project's first phase is completed, identifying best 
practices and models to be tested in demonstration projects. The 
second phase, which is to start around December 2002, is to test these 
models by implementing them in actual demonstration projects intended 
to determine which methods are most effective in reducing the 
incidence of cancer and improving minority health by overcoming 
barriers to the use of preventive services in the target populations. 
A report evaluating the cost effectiveness of the demonstration 
projects, the quality of preventive services provided, and beneficiary 
and health care provider satisfaction is due to the Congress in 2004. 

Agency Comments and Our Evaluation: 

We obtained comments on our draft report from CMS. CMS commented that 
the draft report focused on the activities of its PROs and did not 
consider all of CMS's health promotion activities. CMS provided 
details on its publication and educational campaigns to inform 
Medicare beneficiaries about preventive service benefits and to 
encourage their use. CMS's comments are reproduced in appendix I. 

We acknowledge that our report does not describe all of CMS's health 
promotion/education activities underway that relate to increasing the 
use of preventive services among the Medicare population. While 
beneficiary education activities are worthwhile, CMS studies have 
shown that other interventions, such as those that are directed at 
changing the way a health delivery system operates so that patients 
are more likely to receive services, are more effective. Because PROs 
and CMS demonstration projects are accountable for facilitating the 
implementation of these types of interventions, we focused our efforts 
in describing these activities and the status of their evaluations. We 
have revised the report to make it clear that PRO activities are in 
addition to other CMS beneficiary education efforts. 

CMS also provided technical comments that we considered and 
incorporated where appropriate. 

As arranged with your office, unless you release its contents earlier, 
we plan no further distribution of this report until 30 days after its 
issuance date. At that time we will send copies of this report to the 
secretary of health and human services, the administrator of the 
Centers for Medicare and Medicaid Services, the director of the 
Centers for Disease Control and Prevention, and others who are 
interested. We will also make copies available to others on request. 

If you or your staff have any questions, please contact me at (202) 
512-7119, or Frank Pasquier at (206) 2874861. Other major contributors 
are included in appendix II. 

Sincerely yours, 

Signed by: 

Janet Heinrich: 
Director, Health Care—Public Health Issues: 

[End of section] 

Appendix I: Comments from the Centers for Medicare and Medicaid 
Services: 

Department Of Health & Human Services: 
Centers for Medicare & Medicaid Service: 
Administrator: 
Washington, DC 20201: 

Date: March 29, 2002: 

To: Janet Heinrich: 
Director: 
Health Care—Public Health Issues: 

From: [Signed by} Thomas A. Scully: 
Administrator: 

Subjects: General Accounting Office (GAO) Draft Report, Medicare 
Beneficiary Use of Clinical Preventive Services: Utilization Under 
Medicare (GAO-02-422): 

Thank you for sending the above-referenced report for comments. We 
appreciate GAO's examination of the utilization of preventive services 
under the Medicare program. 

At the Centers for Medicare & Medicaid Services (CMS), 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. We include health 
promotion information as a part of other education campaigns that 
address different aspects of the Medicare program or Medicare+Choice 
options. We also incorporate health promotion messages with 
information that is communicated to beneficiaries on an everyday basis 
(e.g., services such as the 1-800-MEDICARE help-line, Medicare.gov., 
Medicare summary notices, and the Medicare & You handbook). 

It is in this context that we are commenting on the draft report. We 
note at the outset that the draft focuses only on activities conducted 
by Quality Improvement Organizations (formerly referred to as Peer 
Review Organizations or PROs) and does not consider other CMS efforts 
to increase the use of Medicare-covered preventive services. We 
suggest that GAO expand the report to cover many significant CMS 
activities that have not been addressed. 

The following list of activities highlights some of the measures CMS 
has undertaken in the areas of health promotion, quality measurement, 
and health assessment activities: 

Health Promotion Activities: 

Our goal is to inform Medicare beneficiaries about the preventive 
service benefits and to encourage their use, and we educate 
beneficiaries in a variety of ways: 

The CMS has established partnerships with other Department of Health 
and Human Services' agencies such as the Centers for Disease Control 
and Prevention (CDC) and the National Cancer Institute (NCI) to carry 
out health promotion initiatives ranging from a limited distribution 
of outreach kits to full-blown national 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. For instance: 

* The Medicare & You handbook includes information on preventive 
services, and CMS publishes and distributes a brochure entitled, 
Medicare Preventive Services. To Help Keep You Healthy. Medicare and 
You is distributed to all beneficiary households. 

* Medicare carriers and intermediaries include messages on preventive 
services when sending out Medicare Summary Notices (MSNs) during 
certain months of the year to correspond with health themes (e.g., 
March is Colorectal Cancer Awareness Month). They also discuss these 
services and give out materials when giving talks on other Medicare 
issues, and include articles on preventive services in their 
newsletters and on their Websites. 

* The CMS regional offices disseminate information on preventive 
services during other information campaigns (e.g., during Regional 
Education About Choices in Health (REACH) campaigns). 

* The 1-800-MEDICARE help line and Medicare.gov Internet site include 
information on preventive services that corresponds with particular 
calendar health themes. 

We use opportunities such as these whenever possible to promote the 
use of preventive services covered by Medicare. 

Our educational campaigns vary in their level of intensity and 
duration and use of resources, depending on factors such as 
opportunities to partner with other agencies, priorities established 
for Medicare contractors, available funding, and agreement within the 
medical community on appropriate screening practices. Campaigns may 
utilize radio and television public service announcements, Video News 
Release (VNRs), print materials and media kits, Websites, and articles 
in journals, newsletters, and other means. In addition, the campaigns 
target high-risk populations, which are generally minorities. They 
also target health care practitioners since they are some of the 
greatest influences on patient behavior. 

The CMS has entered into numerous Intra-Agency agreements to carry out 
health promotion campaigns and other initiatives. The following 
activities are being carried out to educate Medicare beneficiaries 
about covered preventive services: 

Covered Service: Bone Mass Measurement: 

Mission: 

Raise awareness concerning the disease, osteoporosis and the available 
interventions, including Bone Mass Density (BMD) testing, as well as 
Medicare coverage of BMD tests. 

Background: 

Focus testing of Medicare beneficiaries indicates a need to raise 
public awareness about the disease and pertinent tests. In an effort 
to raise public awareness, we conducted formative research to 
determine Medicare beneficiaries' and providers' attitudes about the 
disease, as well as their knowledge of the disease and bone density 
tests. The CMS partners with CDC and the Agency for HealthCare 
Research and Quality (AHRQ) with whom CMS has an intra-agency 
agreement. 

We have provided coverage and payment information on BMD tests in the 
publications, Medicare Preventive Services and Medicare and You 
handbook. 

Covered Services: Diabetes Self-Management Benefits/Medical Nutrition 
Therapy: 

National Campaign (The Power to Control Diabetes): 

Mission: 

Help older adults understand the importance of routine self-monitoring 
of blood sugar levels to delay or prevent the complications of 
diabetes. Increase awareness of older adults about comprehensive 
diabetes care and Medicare benefits. 

Background: 

The CMS has partnered with the National Diabetes Education Program 
(NDEP) since 1998. We chose to partner with this organization because 
NDEP is jointly sponsored by the National Institute of Diabetes and 
Digestive and Kidney Diseases and the Centers for Disease Control and 
Prevention. The goal of the NDEP is to reduce the morbidity and 
mortality associated with diabetes and its complications. 

The beneficiary education campaign in 2001 encouraged beneficiaries to 
control their blood sugar and publicized the expanded Medicare benefit 
for blood sugar management. Over 3.2 million people were reached via 
print media and 2.2. million people via television campaigns. We will 
distribute The Power to Control Diabetes health care practitioner kits 
in spring 2002. 

In order to strengthen grassroots efforts to increase awareness of 
older adults about comprehensive diabetes care and Medicare benefits, 
we plan to build a dissemination network of community-based 
organizations, community service organizations, ethnic minority 
organizations, and other NDEP partners. We also will establish a 
synchronized approach to increase awareness of older adults by 
educating NDEP work groups and partners that target their outreach 
efforts to audiences such as health care providers, African Americans, 
Native Americans, Asian-Americans, Alaskan and Pacific Islanders, 
Hispanics, business and labor organizations, interfaith communities, 
and others. 

The new campaign message will be: "Be Smart About Your Heart: Know the 
ABC's of Diabetes--Al C, Blood Pressure and Cholesterol." The campaign 
target audience will be caregivers, health care providers, community 
organizations, adults age 65 and older who have diabetes, and family 
members of adults age 65 and older who have diabetes. The campaign 
message will be "Comprehensive care of diabetes is essential, and 
Medicare helps individuals ages 65 and older to manage their illness 
through comprehensive self-management and nutritional benefits that 
can help them stay healthier and be more independent." 

An upcoming campaign in conjunction with the National Institutes of 
Health (NIB) National Eye Institute will promote the new Medicare 
benefit for glaucoma detection. The benefit provides coverage for an 
annual dilated eye examination for Medicare beneficiaries at high risk 
for glaucoma (including those with diabetes). See below for more 
details. 

Covered Service: Glaucoma Screening: 

Mission: 

To promote the new Medicare benefit for glaucoma detection. Prevent 
vision loss from glaucoma through early detection and treatment. 
Empower older adults to take charge of their visual health. 

Background: 
We have formed a partnership with NIH's National Eye Institute to 
promote the new Medicare benefit for glaucoma detection, which was 
effective January 1, 2002. 

Activities include a media campaign (January-February 2002), 
development of a community outreach kit including materials and 
strategies for local promotion, and a kit for health care 
professionals. A press release was issued on January 14, 2002, 
announcing that Medicare now covers glaucoma detection eye 
examinations. The target audience includes eligible Medicare 
beneficiaries who are defined as people with diabetes, people at high 
risk for developing the disease, and African-Americans over age 50. 
The secondary audience will be aging networks, primary care physicians 
and other health care providers. 

Covered Service: Colorectal Cancer Screening: 

National Colorectal Cancer (CRC) Action Campaign (Screen for Life): 

Mission: 

Increase utilization of the Medicare benefit. 

Background: 

After enactment of the Balanced Budget Act of 1997, CMS began working 
in partnership with the CDC to develop the Screen for Life (SFL) 
campaign, which began in March 1999. The NCI has provided technical 
support to the campaign. The SFL campaign--a multiyear, multimedia, 
national CRC education campaign--informs men and women age 50 and 
older (the age at greatest risk of developing CRC) about the 
importance of regular CRC screening tests. The campaign's 
communication objectives are to: inform the public about the benefits 
of CRC screening; motivate the target audience to talk with their 
health care providers to establish a CRC screening program, and 
promote Medicare's CRC screening benefits. 

Materials continue to be developed and distributed each year. Press 
releases and new materials are issued during March, National CRC 
Awareness Month. Materials target people aged 50 and older and people 
with Medicare. Many of the materials target African-Americans. 
Examples of materials include: four versions of a Medicare oriented 
"Good News" poster targeting African-American, Caucasian, Hispanic, 
and Asian-American populations; brochures (English and Spanish); print 
slicks; fact sheets; and articles. 

The CRC information and materials are widely distributed via the 
following channels: annual press releases and media kits; VNRs; 
televised public service announcements (PSAs); Internet articles; 
messages on beneficiary MSNs; the 1-800 MEDICARE help line; 
Medicare.gov; distribution of materials at meetings, health fairs, and 
presentations; newsletters; slicks in magazines; and radio play. The 
following organizations participate in distributing materials: 
Medicare contractors (carriers, intermediaries, Quality Improvement 
Organizations); State Health Departments; partners participating in 
the National CRC Awareness Month campaign; and CMS Central Office and 
Regional Office staff. 

Covered Service: Flu and Pneumonia Vaccinations: 

National Flu/Pneumonia Campaign (Get the Flu Shot Not the Flu): 

Mission: 

Increase the utilization of Medicare's influenza and pneumococcal 
vaccination benefits. 

Background: 

As discussed in the GAO report, CMS's 53 Quality Improvement 
Organizations are contractually obligated to address increasing flu 
and pneumococcal vaccinations as one of their six clinical priority 
areas and are actively involved in the campaign. 

During the past year, we worked with providers to realize their 
significant roles in motivating patients to get vaccinated, and to 
discuss and promote influenza and pneumococcal vaccinations with their 
patients. We encouraged physicians and their office personnel to 
promote influenza and pneumococcal vaccinations by hanging posters on 
their office or clinic walls to function as reminders for both 
providers and their patients, and by using wall charts to track 
immunizations. These activities will continue. 

Postcards were produced with the key message to "Get the Flu Shot, Not 
the Flu." Messages were included on MSNs and Explanation of Medicare 
Benefits (EOMBs), advising beneficiaries that shots given in January 
were just as effective as those given during October. In addition, we 
added a message in the yearly provider enrollment package, encouraging 
providers to vaccinate their high-risk patients before mass 
vaccinations. We also prepared an article in the CMS Health Watch. 

Covered Service: Mammograms: 

National Mammography Campaign (Not Just Once, But For a Lifetime): 

Mission: 

Increase utilization of the Medicare benefit of annual screening 
mammograms. 

Background: 

This national campaign which spreads the word about the importance of 
regularly-scheduled screening mammograms for early detection of breast 
cancer. The campaign also works to increase beneficiaries' and 
providers' awareness of the annual screening mammography benefit. As 
discussed in GAO's report, we also work with CMS's 53 Quality 
Improvement Organizations (QIOs) to increase screening mammograms, as 
breast cancer is one of the QIOs' six clinical priority areas. 

Covered Service: Pap Tests/Pelvic Exams: 

Pap Tests/Cervical Cancer Awareness (A Healthy Habit for Life): 

Mission: 

Raise awareness of women with Medicare about Medicare's preventive 
screening Pap test benefit as an effective means to screen for 
cervical cancer and to remind health care providers that Pap tests may 
be appropriate for their older patients. 

Background: 

Via an interagency agreement, we partner with the National Cancer 
Institute (NCI) to educate Medicare-aged women and their health care 
practitioners about the continued benefit of Pap tests and the 
Medicare benefit. We are working to correct myths about cervical 
cancer that serve as barriers to providers recommending Pap tests and 
Medicare-aged women getting them. 

To coincide with Cervical Health Month, information has been placed on 
our provider Websites along with statistics about the impact of 
cervical cancer across age/race/ethnic groups. In addition, messages 
about cervical health have been printed on Medicare Summary Notices 
and Explanations of Medicare Benefits sent to beneficiaries. Also, 
information was included on Medicare.gov and cms.gov, and articles 
were placed in newsletters. 

As specified in the intra-agency agreement with NCI, we developed and 
printed a brochure entitled "Pap Tests for Older Women: A Healthy 
Habit for Life." We also developed and distributed a provider kit that 
includes screening recommendations, a Pap test tear off-sheet with 
cervical health information for a general population, and screening
recommendations for health care providers that discuss ethnic/racial 
disparities. The CMS and NCI's contractor have conducted surveys to 
learn the extent to which the materials were used and to garner 
information about preferred distribution channels. The contractor will 
provide CMS and NCI with a report of findings and recommendations for 
future development and distribution of materials. 

Covered Service: Prostate Cancer Screening: 

Mission: 

Raise awareness about the coverage of Prostate Cancer Screening. 

Background: 

In an effort to develop appropriate messages targeted at this group of 
Medicare beneficiaries, we entered into an intra-agency agreement with 
AHRQ to obtain appropriate promotional and awareness messages, based 
on its evidence report and the U.S. Preventive Services Task Force 
recommendations. 

The CDC is developing various materials to address prostate cancer 
concerns and to raise awareness about screening. These materials will 
be distributed nationally and will be tailored for the Medicare 
beneficiary. 

[End of section] 

Appendix II: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Frank Pasquier (206) 287-4861: 

Acknowledgments: 

Other major contributors to this report include Lacinda Ayers, Matthew
Byer, Jennifer Cohen, Jennifer Major, Behn Miller, and Stan Stenersen. 

[End of section] 

Footnotes: 

[1] A recent bill proposes adding visual acuity, hearing impairment, 
cholesterol, and hypertension screenings as well as expanding the 
eligibility of individuals for bone density screenings. See H.R. 2058, 
107th Cong. § 203 (2001). 

[2]The Behavioral Risk Factor Surveillance System (BRFSS), the survey 
we used, is an ongoing, state-based, random-digit-dialed telephone 
survey of U.S. civilian, noninstitutionalized adults 18 years or 
older. We used data from 1995, 1997, and 1999. Data from this survey 
are self-reported. 

[3] These included peer review organizations (PROs) under CMS contract 
to improve quality of Medicare services. We talked to the two lead 
PROs responsible for supporting PRO efforts to increase flu and 
pneumococcal immunizations and breast cancer screening services, as 
well as to the PRO leading efforts to reduce disparities in the use of 
preventive services among disadvantaged populations. We also talked to 
three PROs responsible for increasing use of services in states with 
the lowest, median, and highest utilization rates. These six PROs were 
geographically dispersed across the nation. 

[4] U.S. General Accounting Office, Medigap Insurance: Plans Are 
Widely Available but Have Limited Benefits and May Have High Costs, 
[hyperlink, http://www.gao.gov/products/GAO-01-941] (Washington, D.C.: 
July 31, 2001). 

[5] Survey data are from the CDC's BRFSS 1999. 

[6] During the course of our review CMS began referring to these 
entities as Quality Improvement Organizations. CMS officials told us 
that CMS plans to formalize the name change in a future Federal 
Register notice. 

[7] The data were from the CDC's BRFSS for 50 states and the District 
of Columbia. BRFSS does not contain data for colorectal cancer 
screening for 1995 and 1997. 

[8] Although Medicare has covered immunizations for hepatitis B since 
1984, usage data are not available. 

[9] We excluded women who reported having had hysterectomies before 
calculating the usage rate for the cervical cancer screen. 

[10] Sigmoidoscopy or colonoscopy in past 5 years or fecal-occult 
blood test in past year. 

[11] We excluded states whose 95 percent confidence intervals for that 
service were wider than 10 percentage points. 

[12] "Other" ethnic groups include survey respondents who reported an 
ethnicity other than African American, Hispanic, or white. 

[13] There was no statistically significant difference between the 
rate at which the ethnic groups used cervical and breast cancer 
screening or the sigmoidoscopy/colonoscopy colorectal cancer 
screenings. Likewise, there was no statistically significant 
difference between the rates that African Americans and Hispanics were 
immunized against pneumonia or that whites and "other" ethnic groups 
were immunized for either pneumonia or the flu. 

[14] Data are from the CDC's BRFSS, 2000. 

[15] CDC researchers report that among the general population, over 80 
percent of hysterectomies are performed for noncancerous conditions 
such as fibroids and endometriosis. 

[16] One half of the Medicare population is age 75 and older, and in 
1997, the life expectancy for 75 year olds was about 86.2 years. 

[17] The U.S. Preventive Services Task Force is a committee of medical 
experts convened by the Department of Health and Human Services to 
evaluate evidence and make recommendations for clinical preventive 
services such as mammography and prostate cancer screening. 

[18] These organizations include the American College of Physicians, 
the National Cancer Institute, and the American College of Preventive 
Medicine. 

[19] Health Care Financing Administration, Evidence Report and 
Evidence-Based Recommendations: Interventions that Increase the 
Utilization of Medicare-Funded Preventive Services for Persons Age 65 
and Older, Publication No. HCFA-02151 (Prepared by Southern California 
Evidence-based Practice Center/RAND, 1999). 

[20] Health Care Financing Administration, Evidence Report and 
Evidence-Based Recommendations: Interventions that Increase the 
Utilization of Medicare-Funded Preventive Services for Persons Age 65 
and Older. 

[21] CMS is conducting a standing orders pilot through its PRO program 
in nine states (using five additional states as control states) to 
test organizational and system change in nursing homes. 

[22] Under certain circumstances, Medicare providers may offer 
incentives for preventive services. Specifically, under regulations 
which became effective April 26, 2000, providers may forgo some 
compensation by waiving coinsurance and deductible payments for 
medical services, including Medicare preventive services. In addition, 
other types of incentives—such as free transportation or gift 
certificates—are also allowed so long as the incentive is not 
disproportionately large in relationship to the value of the 
preventive service. Under no circumstances may cash or instruments 
convertible to cash be used. See 42 CFR § 1003.101. 

[23] E.C. Schneider, MD, MSc, et al, "Racial Disparity in Influenza 
Vaccination: Does Managed Care Narrow the Gap Between African 
Americans and Whites?" JAMA, Volume 286, Number 12, (September 26, 
2001). 

[24] See the Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act of 2000, Public Law 106-554, Appendix F, § 122, 114 
Stat. 2763, 2763A-476 classified to 42 U.S.C. § 1395b-1 nt. 

[End of section] 

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