Medicare:

Most Beneficiaries Receive Some but Not All Recommended Preventive Services

GAO-03-958: Published: Sep 8, 2003. Publicly Released: Oct 8, 2003.

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Medicare, the federal health program insuring almost 35 million beneficiaries age 65 and older, covers certain preventive services, such as flu shots and mammograms. Most beneficiaries receive care through Medicare's fee-for-service program, under which they generally receive these services as part of visits to the doctor for specific illnesses or conditions. Other beneficiaries receive services under Medicare's managed care program, called Medicare + Choice. GAO was asked to determine (1) the extent to which beneficiaries received recommended preventive services through existing visits, (2) whether approaches used by Medicare + Choice plans provide insight for improving delivery of preventive care services for fee-for-service beneficiaries, and (3) what the Centers for Medicare & Medicaid Services (CMS) is doing to explore suggested options for delivering preventive care to fee-for-service beneficiaries. GAO's work included analyzing data from four national health surveys and reviewing five Medicare + Choice plans considered to have innovative approaches to delivering preventive services. GAO also interviewed Department of Health and Human Services (HHS) and CMS officials and reviewed documents on CMS demonstrations related to preventive services.

Most Medicare beneficiaries receive some preventive services through their visits to physicians, but relatively few receive the full range of preventive services available. Survey data showed, for example, that in 2000 about 30 percent of beneficiaries did not receive a flu shot, and 37 percent had never been vaccinated against pneumonia. Moreover, many Medicare beneficiaries are apparently unaware that they may have conditions that preventive services are meant to detect. For example, in a 1999-2000 nationally representative survey during which people received physical examinations, nearly one-third of those age 65 and older who were found to have high cholesterol measurements said they had not previously been told by a physician or other health professional that they had high cholesterol. Projected nationally, this percentage could represent 2.1 million people. No clear "best practice" approach to delivering preventive care stands out among the innovative Medicare + Choice plans GAO studied. All five plans identify health risks, provide feedback on risks to patients or their physicians, and follow up to reduce those risks. But their follow-up programs, approaches, and priorities differ, and little is known about the effectiveness of these efforts for the Medicare-age population. CMS has begun the development work to design a project evaluating the use of individual assessments of health risks, followed by counseling and other services, as a way to improve preventive care delivery. Another suggested approach--adding a routine physical examination benefit to Medicare's fee-for-service program--could provide more opportunities, but at increased cost and without guarantee that preventive services would actually be provided to Medicare beneficiaries.

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