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entitled 'Medicare: Most Beneficiaries Receive Some but Not All 
Recommended Preventive Services' which was released on October 08, 
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Report to the Chairman, Subcommittee on Oversight and Investigations, 
Committee on Energy and Commerce, House of Representatives:

United States General Accounting Office:

GAO:

September 2003:

MEDICARE:

Most Beneficiaries Receive Some but Not All Recommended Preventive 
Services:

Medicare:

GAO-03-958:

GAO Highlights:

Highlights of GAO-03-958, a report to the Chairman, Subcommittee on 
Oversight and Investigations, Committee on Energy and Commerce, House 
of Representatives

Why GAO Did This Study:

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.

What GAO Found:

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. 

HHS generally concurred with the findings of this report.


www.gao.gov/cgi-bin/getrpt?GAO-03-958.

To view the full report, including the scope and methodology, click on 
the link above. For more information, contact Janet Heinrich on 
202-512-7250.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

Most Beneficiaries Receive Some Preventive Services, but Not All That 
Are Recommended:

Medicare + Choice Plans Reviewed Assess Health Risks Using Varying 
Approaches:

New Ways to Improve the Provision of Preventive Services within 
Medicare's Fee-for-Service Program Are Promising but Untested:

Concluding Observations:

Agency Comments:

Appendix I: Scope and Methodology:

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

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

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

Tables:

Table 1. Feedback Processes Described by Medicare + Choice Plans:

Table 2: Four National Health Surveys with Preventive Services Data, 
1999-2000:

Table 3: Estimated Proportion of Fee-for-Service Physician Visits Made 
by People Age 65 and Older, by Major Reason for the Visits, 2000:

Table 4: Estimated Proportion of Fee-for-Service Physician Visits in 
Which Diet Counseling Services Were Provided or Ordered, by Major 
Reason for the Visits, 2000:

Table 5: Estimated Proportion of Fee-for-Service Physician Visits in 
Which Blood Pressure Measurements Were Provided or Ordered, by Major 
Reason for the Visits, 2000:

Table 6: Medicare + Choice Plans Included in GAO's Study:

Table 7: NHANES Data GAO Used to Determine if Participants Had Measures 
of Specific Health Conditions:

Table 8: People Age 65 and Older in the United States Found to Have 
Measures of Specific Health Conditions, NHANES 1999-2000:

Table 9: People Age 65 and Older in the United States Found to Have 
Measures of Specific Health Conditions and Who Reported They Had Not 
Previously Been Told They Might Have the Condition, NHANES 1999-2000:

Figures:

Figure 1: Major Reasons for Physician Visits by Medicare Beneficiaries 
in the Fee-for-Service Program, 2000:

Figure 2: Estimated Number of Medicare Beneficiaries Age 65 and Older 
Who Were Aware and Unaware That They Might Have High Blood Pressure or 
High Cholesterol, 1999-2000:

Abbreviations:

AMA: American Medical Association:

ACE Inhibitor: Angiotensin-converting enzyme inhibitor:

BRFSS: Behavior Risk Factor Surveillance Survey:

CDC: Centers for Disease Control and Prevention:

CMS: Centers for Medicare & Medicaid Services:

HHS: Department of Health and Human Services:

NHANES: National Health and Nutrition Examination Survey:

Td: Tetanus-diphtheria:

United States General Accounting Office:

Washington, DC 20548:

September 8, 2003:

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

Dear Mr. Chairman:

Medicare, the federal government's health insurance program that covers 
almost 35 million people age 65 and older, was created largely to help 
pay beneficiaries' health care costs once they become ill or 
injured.[Footnote 1] For the most part, the federal government pays 
physicians and other health care providers to treat Medicare 
beneficiaries for illnesses and health conditions. In addition, the 
Congress has broadened Medicare coverage to include specific preventive 
services, aimed at either (1) keeping an illness or condition from 
developing or (2) keeping it from becoming more serious through early 
detection and subsequent management. Immunization against influenza (a 
"flu shot") is an example of the first type of preventive service; a 
mammogram to detect breast cancer is an example of the second. Overall 
preventive care depends heavily on identifying health risks associated 
with the onset or progression of disease and taking steps to reduce or 
mitigate these risks.

We previously reported to you that Medicare beneficiaries' use of 
covered preventive services has increased over time but varies widely 
from service to service.[Footnote 2] In response, you asked us to 
follow up on several issues. One issue is the success of providing 
preventive services through a Medicare service delivery system based 
primarily on treating existing illnesses and health conditions. Under 
Medicare's fee-for-service program, which enrolls about 84 percent of 
Medicare beneficiaries, no specific provision exists for a routine 
annual physical or checkup that could be a vehicle for delivering 
preventive services.[Footnote 3] Unless beneficiaries in the fee-for-
service program have supplemental insurance that covers such a checkup, 
they may have to depend on receiving preventive services during their 
visits for specific illnesses or conditions, or during other visits for 
those specific preventive services that Medicare does cover. A second 
issue is what can be learned about the effectiveness of preventive 
service approaches put in place by plans that contract with Medicare to 
offer health care on a managed care basis.[Footnote 4] These plans, 
which enroll about 14 percent of all Medicare beneficiaries under an 
option known as Medicare + Choice, generally offer a benefit for 
periodic checkups.[Footnote 5] Some of these Medicare + Choice plans 
are regarded as particularly innovative in assessing risk, providing 
screening services, and conducting prevention programs. This report 
addresses the following questions:

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

* What approaches for preventive care have been taken by selected 
Medicare + Choice plans, and what is known about their effectiveness 
for the Medicare beneficiaries they serve?

* What delivery options for identifying and reducing health risks have 
been suggested for Medicare fee-for-service beneficiaries, and are any 
of these options being explored by the Centers for Medicare & Medicaid 
Services (CMS), the agency administering the program?

Because no single source contained all the information we needed to 
assess the extent to which Medicare beneficiaries receive preventive 
services through existing physician visits, we analyzed data from four 
nationally representative health surveys. The Centers for Disease 
Control and Prevention's (CDC) Behavioral Risk Factor Surveillance 
System asks a range of health questions over the telephone, including 
if respondents received a "routine checkup" within the past year. CMS's 
Medicare Current Beneficiary Survey collects self-reported data, 
including whether respondents have received influenza or pneumonia 
immunizations. CDC's National Health and Nutrition Examination Survey 
(NHANES) collects data on health conditions by means of both 
comprehensive health examinations and interviews, where patients self-
report information, including whether a physician or other health 
professional has ever told them that they have a given health 
condition. Unlike the other surveys, which take a sample of the 
population, CDC's National Ambulatory Medical Care Survey samples 
physician practices, collecting detailed information about office 
visits, including the major reason for the visit and which preventive 
services were ordered or provided. In addition, this survey captured 
information that allowed us to assess whether visits by Medicare 
beneficiaries were on a fee-for-service basis. Unless otherwise noted, 
however, the data we report generally included beneficiaries from both 
systems.

To describe the approaches of selected Medicare + Choice plans in 
delivering preventive services, we assessed literature and interviewed 
national experts to identify plans that were considered innovative in 
preventive care. We then obtained information from five such plans: 
AvMed Health Plans, Group Health Cooperative, Highmark Blue Cross and 
Blue Shield, Kaiser Permanente, and Oxford Health Plans. Collectively, 
an estimated 1.2 million Medicare beneficiaries in 15 states plus the 
District of Columbia receive their health care under these plans. To 
determine suggested options for identifying and reducing health risks 
and what CMS is doing to assess them, we reviewed the results of past 
related research demonstrations and congressionally mandated studies 
and interviewed Department of Health and Human Services (HHS) and CMS 
officials and other experts. (App. I further describes our scope and 
methodology.) We conducted our work from October 2002 through August 
2003 in accordance with generally accepted government auditing 
standards.

Results in Brief:

Most Medicare beneficiaries receive some but not all recommended 
preventive services, although they typically visit a physician several 
times during a year. Our analysis of year 2000 data shows that nearly 9 
in 10 Medicare beneficiaries visited a physician at least once that 
year, with a beneficiary making an average of six visits or more within 
the year. Preventive services are delivered during all types of visits-
-whether for illnesses, health conditions, or nonillness care. 
Regardless of the reason for a visit, however, many beneficiaries did 
not receive recommended preventive services. In 2000, for example, 
about 30 percent of Medicare beneficiaries did not receive an influenza 
vaccination and 37 percent had never had a pneumonia vaccination, as 
recommended under current guidelines for people age 65 and older. 
Moreover, many Medicare beneficiaries may have conditions of potential 
concern that they are unaware of. For example, among the Medicare 
beneficiaries who participated in a nationally representative survey 
and were found through physical examinations to have high cholesterol, 
about one-third said they had not previously been told by a physician 
or other health professional that they might have this condition. 
Projected nationally, this percentage translates into about 2.1 million 
people age 65 and older.

Although they differ from one another in approach and emphasis, the 
preventive care approaches of the Medicare + Choice plans we reviewed 
share common elements. In particular, their approaches screen enrollees 
to identify health risks and then provide a number of follow-up 
activities designed to reduce those risks. The plans generally use 
combinations of methods to ascertain needed preventive services, 
including periodic preventive visits, health risk questionnaires, and 
periodic assessments of medical claims and pharmacy data. All plans 
also have follow-up strategies to help beneficiaries obtain needed 
preventive services, although their strategies and priorities vary. 
Follow-up interventions include counseling programs to encourage 
behavioral change, cancer screening for early detection of disease, and 
programs to coordinate and manage chronic conditions such as diabetes 
and cardiovascular disease. Although some plans furnished us with data 
suggesting that their approaches hold promise, few had conducted a 
systematic evaluation of whether the approaches improved health 
outcomes or lowered health care costs. Those studies that do show a 
relationship between greater use of preventive services and improved 
health outcomes or cost savings are limited in terms of how their 
findings might be generalized to Medicare beneficiaries.

Several options have been suggested for improving the provision of 
preventive services under Medicare's fee-for-service program, each with 
its own advantages and disadvantages. Two options center on adding a 
new benefit for a nonillness-related examination, specifically either 
(1) a one-time "welcome-to-Medicare" examination for new beneficiaries 
or (2) a periodic examination benefit for all beneficiaries. Coverage 
of a one-time or periodic wellness examination could be easily 
administered, and the examination could provide an opportunity for 
beneficiaries to receive some preventive services. Adding such a 
benefit, however, could increase Medicare costs and still not guarantee 
that beneficiaries receive the preventive services they need. The 
results of a past CMS demonstration indicate that offering Medicare 
beneficiaries packages of broad-based preventive services has not 
consistently improved health or lowered hospital and other costs. As a 
result, CMS has recently considered an alternative option that would 
essentially create a different structure using nonphysician providers 
to assess health risks and ensure the delivery of preventive services 
within the fee-for-service program. The agency has started the 
development work to design a project to examine whether assessments of 
individual health risks, combined with continued counseling and follow-
up services provided by nonphysicians, will improve delivery of 
preventive services and beneficiary health. CMS also has under way 
several other demonstration projects related to preventive care in the 
fee-for-service program, such as a smoking cessation program tailored 
to Medicare beneficiaries. Results from these demonstration efforts are 
not expected for several years.

HHS reviewed a draft of this report and generally concurred with the 
findings.

Background:

Many of the health conditions that people age 65 and older experience 
are preventable and linked to specific health risks. Some health risks 
are difficult to change, and some, such as a hereditary predisposition 
for a given disease, cannot be changed. For these, preventive services 
such as cancer screens can help identify disease in its early stages so 
that people can be referred to other services that can help manage or 
treat the disease. Other health risks, such as complications from 
influenza, can be successfully reduced by targeted preventive services. 
For example, studies show that immunizations against influenza can 
prevent thousands of hospitalizations and deaths each year among those 
age 65 and older. Health risks such as high blood pressure and high 
cholesterol are also considered health conditions because, if left 
alone, they can develop into potentially more significant conditions, 
such as cardiovascular disease, or lead to stroke.

The term preventive care covers a wide spectrum of actions aimed at 
reducing risks for deteriorating health and improving the detection and 
management of disease. Generally, preventive care is intended for three 
purposes:

* To prevent a health condition from occurring at all. Vaccinations and 
physical activity to reduce the risk of heart disease, for example, 
qualify as this first type of preventive care (termed primary 
prevention).

* To prevent or slow a condition's progression to more significant 
health conditions by detecting a disease in its early stages. 
Mammograms to detect breast cancer and other screens to detect disease 
early are examples of this second type of preventive care (termed 
secondary prevention).

* To prevent or slow a condition's progression to more significant 
health conditions by minimizing the consequences of a disease. Care 
coordination and self-management of an existing disease, such as 
diabetes or asthma, are examples of this third type of preventive care 
(termed tertiary prevention).

Many people associate the idea of preventive care with annual physical 
examinations, or "routine checkups," by a family doctor, a practice 
first proposed by the American Medical Association (AMA) in the early 
twentieth century. In the early 1980s, however, the AMA determined that 
appropriate preventive care depends on an individual's age and 
particular health risks, not simply on the results of a standard 
battery of tests.[Footnote 6] To evaluate preventive care for different 
age and risk groups, HHS in 1984 established a panel of experts called 
the U.S. Preventive Services Task Force. At present, the task force 
recommends certain screening, immunization, and counseling services for 
people age 65 and older (see app. II).

Medicare covers some, but not all, of the task force-recommended 
preventive services (see comparison in app. II). Medicare's fee-for-
service program--which comprises approximately 84 percent of Medicare 
beneficiaries--does not cover periodic checkups, where clinicians might 
assess an individual's health risk and provide needed preventive 
services. These Medicare beneficiaries may, however, receive some of 
these services during office visits for other health problems. Under 
Medicare + Choice, which covers about 14 percent of Medicare 
beneficiaries, a benefit for periodic checkups generally does exist.

Most Beneficiaries Receive Some Preventive Services, but Not All That 
Are Recommended:

Medicare beneficiaries typically visit a physician several times during 
a year and most receive some preventive services, but most do not 
receive the full range of recommended services. Based on 2000 survey 
data and U.S. Bureau of the Census estimates of people age 65 and 
older, we estimate that beneficiaries visit a physician at least six 
times a year, on average, mainly for illnesses or medical 
conditions.[Footnote 7] About 1 in 10 visits occurred when 
beneficiaries were well, and most Medicare beneficiaries reported 
having what they considered to be a "routine checkup" in the previous 
year. The purposes of these routine checkups and the specific services 
that are delivered during these visits, however, remain unknown. Many 
Medicare beneficiaries did not receive recommended preventive services, 
such as influenza and pneumonia immunizations. Moreover, another 
national survey indicated that a substantial share of Medicare 
beneficiaries who were at risk for a condition that preventive services 
are meant to identify said that they had not been told by a health 
professional that they might have that condition.

Medicare Beneficiaries Visit Physicians Often, and Most Report 
Receiving Routine Checkups:

In 2000, 88 percent of Medicare beneficiaries reported that they 
visited a physician at least once that year.[Footnote 8] On the basis 
of data from CDC's National Ambulatory Medical Care Survey, we estimate 
that, on average, beneficiaries visit physicians at least six times a 
year.[Footnote 9] Almost 9 in 10 visits made by beneficiaries in the 
fee-for-service program were to treat illnesses or health conditions: 
more than half the visits targeted preexisting (chronic) problems, more 
than one-fourth targeted illnesses of sudden or recent onset (acute), 
and about 10 percent of visits took place pre-or postsurgery or to 
follow up after injuries. Only about 10 percent of visits dealt with 
nonillness care when the patient was considered healthy (see fig. 
1).[Footnote 10]

Figure 1: Major Reasons for Physician Visits by Medicare Beneficiaries 
in the Fee-for-Service Program, 2000:

[See PDF for image]

Note: Numbers do not add to 100 percent due to rounding. The survey 
defined an "acute problem" as a condition or illness of sudden or 
recent onset, a "chronic problem" as a preexisting long-term or 
recurring condition or illness, and "nonillness care" as a general 
health maintenance examination or routine periodic examination of a 
presumably healthy person. For chronic problems, the survey reported 
results separately for "routine chronic problems" and for "chronic 
problem flare-ups." We combined these results in this figure. The 
separate results are found in app. I.

[End of figure]

Even though the majority of visits to physicians are for treating 
illness or health conditions, most Medicare beneficiaries reported 
receiving routine checkups. In CDC's 2000 Behavioral Risk Factor 
Surveillance System Survey, for example, 93 percent of respondents age 
65 and older reported that they had received a "routine checkup" within 
the previous 2 years. This survey did not, however, provide information 
on which specific services were delivered during those checkups. 
Indeed, as the following section shows, few beneficiaries receive all 
recommended services, although they receive some preventive services 
during visits when they are healthy as well as during visits to treat 
illnesses or health conditions.

Despite Frequency of Visits, Many Medicare Beneficiaries Do Not Receive 
the Full Range of Recommended Preventive Services:

Despite how often Medicare beneficiaries visit physicians, many of them 
do not receive a full complement of recommended preventive services, 
including some recommended by the U.S. Preventive Services Task Force 
and currently covered by Medicare. As we reported earlier, use of 
specific preventive services varies widely by service.[Footnote 11] 
Although each preventive service we reviewed was delivered to a 
majority of Medicare beneficiaries, relatively few beneficiaries 
received the full range of preventive services. For example, 91 percent 
of female Medicare beneficiaries received at least one preventive 
service, but only 10 percent were screened for cervical, breast, and 
colon cancer and also immunized against influenza and 
pneumonia.[Footnote 12] Our analysis of additional data since our 
previous report shows that many Medicare beneficiaries still do not 
receive certain recommended preventive services. The task force 
recommends, for example, that all people age 65 and older receive an 
annual influenza vaccination and at least one pneumonia vaccination. In 
CMS's Medicare Current Beneficiary Survey of 2000, however, about 30 
percent of Medicare beneficiaries did not receive an influenza 
vaccination, and 37 percent had never had a pneumonia vaccination.

Survey data showing the services provided during office visits indicate 
that Medicare beneficiaries do receive some preventive services during 
visits when they are ill or being treated for a health condition, and 
services are delivered at comparable rates during all types of visits, 
whether for nonillness care or for treating acute or chronic 
conditions. Beneficiaries in the fee-for-service program receive 
preventive services, such as cholesterol and blood tests, during visits 
when they are healthy and during visits to treat acute or chronic 
health conditions. Some tests are typically provided or ordered 
slightly more often during visits for nonillness care. In 2000, for 
example, blood tests for anemia[Footnote 13] were provided in about 16 
percent of visits for nonillness care, compared with 7 percent of 
visits for chronic problems and 5 percent of visits for acute 
conditions. Other preventive services were provided at similar rates 
during the different types of visits. For example, we estimate that 
blood pressure measurement, a clinical screen for conditions such as 
hypertension, was done during 56 to 62 percent of visits, depending on 
the type of visit. Diet counseling services were provided during 13 to 
20 percent of visits, depending on the type of visit.[Footnote 14]

Many Beneficiaries May Be Unaware of Their Risk for Health Conditions 
That Preventive Care Is Meant to Detect:

Many Medicare beneficiaries may not know that they are at risk for 
health conditions that preventive care could detect--strong evidence 
that they may not be receiving the full range of recommended preventive 
services.[Footnote 15] For example, data from CDC's NHANES for 1999-
2000 show that, of beneficiaries participating in this nationally 
representative survey who had a physical examination and were found to 
have elevated blood pressure readings at the time of the examination, 
32 percent reported that no physician or other health professional had 
ever told them about the condition. On the basis of this survey, we 
estimate that, during the period when the survey was conducted, 21 
million Medicare beneficiaries may have been at risk for high blood 
pressure, and an estimated 6.6 million of them may have been unaware of 
this risk. Similarly, 32 percent of those found in the 1999-2000 survey 
to have a high cholesterol level reported that no one had told them 
that they had high cholesterol. Projected nationally, this percentage 
translates into 2.1 million Medicare beneficiaries (see fig. 2).

Figure 2: Estimated Number of Medicare Beneficiaries Age 65 and Older 
Who Were Aware and Unaware That They Might Have High Blood Pressure or 
High Cholesterol, 1999-2000:

[See PDF for image]

Note: CDC's NHANES measured blood pressure three or four times during 
its 1-day physical examination. For our analysis, we calculated the 
average of the blood pressure measurements and applied CDC's definition 
of high blood pressure: that is, a patient's having an average systolic 
blood pressure equal to or greater than 140, or an average diastolic 
blood pressure equal to or greater than 90, or a patient who reported 
taking hypertension medication. CDC defined high cholesterol as a total 
cholesterol level equal to or greater than 240.

[End of figure]

Medicare + Choice Plans Reviewed Assess Health Risks Using Varying 
Approaches:

The Medicare + Choice plans we reviewed vary in their specific 
strategies for delivering preventive services, but several common 
themes emerge from their efforts. First, nearly all identify members' 
health risks and inform them or their providers about specific services 
that might be needed. For example, some plans mail questionnaires to 
members, seeking information, such as when certain screening tests were 
last performed; other plans review claims and prescription data to 
identify at-risk members who might need a screening test or other 
preventive service. Second, all plans have follow-up strategies to help 
beneficiaries obtain needed preventive services, although their 
strategies and priorities vary. Third, while limited data provided by 
some plans suggest promising results, most plans have not evaluated the 
degree to which their strategies improve health outcomes or affect 
health care costs for Medicare beneficiaries.

Plans Use a Combination of Ways to Identify Health Risks:

Although all the Medicare + Choice plans we reviewed use questionnaires 
to meet the requirement that they conduct health assessments for newly 
enrolled Medicare beneficiaries,[Footnote 16] they use a combination of 
approaches to identify health risks. The particular risks that plans 
seek to identify vary from plan to plan. Risks include those associated 
with depression or lack of physical activity; risks from not obtaining 
recommended immunizations or screenings, such as mammography; and more 
general risk of short-term hospitalization or illness.[Footnote 17] For 
example, Group Health Cooperative, Highmark Blue Cross and Blue Shield, 
and Kaiser Permanente use questionnaire information to calculate a risk 
score meant to represent each enrollee's probability of using health 
services heavily in the future. From its questionnaire, Kaiser 
Permanente also calculates the probability of 3-year survival for 
enrollees who have an existing advanced illness, as well as the 
probability that they will become dependent on others for daily care or 
need nursing home services during the next year (a condition Kaiser 
Permanente officials refer to as frailty). Oxford Health Plan, on the 
other hand, analyzes questionnaire data to assign enrollees a risk 
classification of high, moderate, or low and assigns patients to health 
management teams or programs appropriate for each risk level.

For existing members, plans use slightly different approaches to 
identify health risks, including information from claims and pharmacy 
data, annual risk assessment questionnaires, physician visits, and 
computer systems (called registries) that indicate when patients 
require specific preventive services. The specific approaches vary from 
plan to plan. For instance, Group Health Cooperative officials reported 
that they review the health risks, such as the immunization status, of 
their existing members through health maintenance visits, which they 
encourage Medicare beneficiaries to have every 2 years. During this 
visit, the provider reviews responses to a completed questionnaire that 
each patient is asked to bring to the visit and updates computer 
registry data, compiled from previous risk assessment questionnaires 
and physician visits. AvMed conducts a health risk assessment for each 
of its Medicare members and also uses claims and pharmacy data to 
identify members with specific diseases, so as to target preventive 
services. For example, using pharmacy and claims data to identify 
people with diabetes, AvMed invites these members to a health fair 
featuring services to prevent further progression of the disease. 
Paying a single copayment to attend the health fair, members can 
receive a number of services, such as a blood draw for laboratory work 
and vision and glaucoma screening.

Finally, some plans report that they have increased the use of specific 
preventive services through their participation in CMS-required 
national performance improvement projects.[Footnote 18] For example, 
Highmark reported that in 2002 the plan used medical claims data to 
identify female Medicare beneficiaries who had not received a mammogram 
within the past 2 years and notified the beneficiaries and their 
physicians. As a result, the officials reported that 60 percent of 
contacted beneficiaries went on to receive mammograms.

Plans Use a Variety of Follow-up Means to Reduce Identified Risks:

After identifying the health risks of Medicare beneficiaries--whether 
new enrollees or existing members--plans we contacted reported that 
they also make efforts to follow up on that information by providing 
feedback to enrollees about risks and referring them to specific, risk-
related preventive services. For example, all plans have approaches to 
prevent disease progression for individuals identified as having 
chronic health conditions. The plans sometimes differ in their types of 
follow-up and in their emphasis on different types of preventive 
services. Some plans we reviewed, for example, stress primary 
prevention activities, such as exercise programs for all members, to a 
greater degree than others.

To provide feedback, many plans contact members directly through 
letters or phone calls, encourage contact with primary care physicians, 
or combine written or oral feedback with follow-up physician 
examinations (see table 1).

Table 1: Feedback Processes Described by Medicare + Choice Plans:

Health plan: Group Health Cooperative; Feedback process: Using data 
available on computer registry, health professionals can review 
specific health risks with members. Health professionals also monitor 
the computer registry to track services members use.

Health plan: Kaiser Permanente; Feedback process: For new enrollees, 
physicians review a summary report and provide feedback during an 
initial office visit. In San Diego, existing members who visit health 
assessment centers receive a letter, based on a completed questionnaire 
and tests estimating "health age," that discusses ways of decreasing 
specific health risks, and they receive a second visit for a complete 
exam.

Health plan: Oxford Health Plans; Feedback process: Various departments 
receive health risk reports based on risk assessment questionnaires. 
Reports for high-risk members go to teams of registered nurses, who 
contact the members and their primary care physicians to coordinate 
care.

Health plan: Highmark Blue Cross and Blue Shield; Feedback process: 
Plan sends results of health risk assessment to physicians to 
facilitate discussion with patients. Members with risks related to 
smoking, heart disease, or osteoporosis receive letters. New members 
identified as at risk for being frail are referred to case managers, 
and members identified with chronic disease are referred to a condition 
management program for targeted interventions.

Health plan: AvMed Health Plans; Feedback process: Physicians receive 
health risk information from risk assessment questionnaires and 
pharmacy and claims data. Members identified as having specific risks 
are contacted directly by the plan if health promotion or disease 
management programs are available for them.

Source: Plan officials and plan documents.

[End of table]

In addition to educating members about their health risks, some plans 
also link members to specific preventive services to reduce or mitigate 
these risks. For example, plans may send targeted health promotion 
materials; offer 24-hour telephone access to a nurse to discuss health 
concerns; or offer access to fitness programs, nutrition courses, 
immunizations, exams, and disease management or care coordination 
programs. These care coordination programs resolve health care issues 
through various means, such as in-depth telephone evaluations, 
communication with primary care physicians, in-home visits, or 
connections with community resources like Meals on Wheels.

To refer Medicare members to preventive services, one plan we contacted 
emphasized directing them to primary prevention services, such as 
physical activity programs, while another plan emphasized connecting 
members to tertiary prevention services, such as disease management 
programs. For example, identifying physical activity and social 
isolation as two important predictors of overall health outcomes for 
seniors, Group Health Cooperative refers Medicare members to physical 
activity benefits and other primary prevention services. In contrast, 
acknowledging that most individuals age 65 or older have more than one 
chronic health condition, AvMed focuses more on identifying members 
with existing conditions and referring them to preventive services that 
can mitigate the condition. AvMed has created eight disease management 
programs covering conditions such as congestive heart failure, asthma, 
and diabetes. The goal is to provide members having these conditions 
with a series of condition-specific care interventions. For example, 
interventions for AvMed enrollees in the congestive heart failure 
program include prescribing specific drugs (such as ACE[Footnote 19] 
inhibitors, diuretics, and beta-blockers), providing self-directed 
care plans, and monitoring weight.

Some plans described how they track the success of their efforts to 
provide people with specific preventive care interventions. Highmark, 
for example, offers financial incentives to physicians who follow 
specific clinical guidelines for a given condition. The plan also gives 
physicians quarterly report cards, generated by a computer registry, 
that indicate whether their patients have received all the care 
recommended by the management programs in which the patients are 
enrolled. AvMed, on the other hand, tracks the number of members 
identified as eligible for specific disease management programs, 
whether the program was offered to all eligible members, and the number 
who enrolled. AvMed also reported setting, monitoring, and reporting on 
performance goals for the percentage of members receiving specific care 
interventions. For example, for enrollees in the congestive heart 
failure management program, AvMed tracks the percentage receiving an 
ACE inhibitor drug.

Assessments of Health Outcomes or Cost Savings for Medicare 
Beneficiaries Are Limited:

Few of the health plans we contacted had specifically evaluated whether 
their approaches to risk identification and reduction lead either to 
improved health outcomes for Medicare beneficiaries or to cost savings 
for the plan. From those plans that have such information, the 
available data suggest that offering disease management programs to 
people who have existing health conditions may hold promise, but most 
plans lacked evidence from controlled studies of a specific benefit to 
their Medicare members.

AvMed and Oxford are among the plans that have evaluated whether their 
approach improves health outcomes and saves money. For example, AvMed 
plan officials observed that, in all AvMed plans, including its 
Medicare + Choice plan, AvMed members with existing chronic conditions 
spent fewer days in the hospital during the same period when more of 
their members with existing conditions were enrolled in disease 
management programs. According to AvMed officials, between 2001 and 
2002, shorter hospital stays of Medicare congestive heart failure 
patients led to total savings of $1 million, and shorter hospital stays 
of asthma patients from all plans (not limited to Medicare 
beneficiaries) led to savings of $400,000. Similarly, Oxford has 
estimated savings attributed to various interventions, such as a mean 
savings of $219 per member per month from Medicare beneficiaries who 
voluntarily participated in a self-management workshop for diabetes, as 
compared with a random group of diabetic members who did not attend the 
workshop. Although these findings show potential to improve health and 
decrease costs, it is unclear from this information whether the 
decreased length of hospitalization and cost savings resulted from 
disease management or from other factors. It is also not clear what the 
long-term effects may be on Medicare beneficiaries and whether these 
observations would also apply to beneficiaries in a fee-for-service 
environment.

Some plans are evaluating specific aspects of their approaches as a 
first step in determining which approaches are effective. For example, 
Kaiser Permanente officials provided data demonstrating their ability 
to identify a certain type of health risk among Medicare beneficiaries, 
but they did not provide data demonstrating that their overall 
approaches to risk identification or risk reduction resulted in 
improved health outcomes or cost savings.[Footnote 20] Specifically, 
they found that three questions on the risk assessment questionnaire, 
along with the patient's age, predicted with a high degree of accuracy 
whether a person would need daily assistance from another person during 
the following year. Kaiser identified these people as at risk for 
frailty and through additional study found that, over the next decade, 
frail people spent more days in nursing homes than individuals who were 
not frail.[Footnote 21] Kaiser Permanente officials told us that they 
have not identified interventions that decrease or prevent frailty from 
developing but were instead focusing on identifying interventions to 
improve outcomes for those people once they were identified as 
frail.[Footnote 22]

In addition to reviewing the efforts of contacted Medicare + Choice 
plans, we reviewed several studies that evaluated the effectiveness of 
employer-sponsored approaches to providing preventive services, such as 
health risk assessment and feedback, to both employees and retirees. 
Although these studies conclude that employer-sponsored approaches hold 
promise in terms of increasing preventive services, improving health 
outcomes, and lowering cost, we found the results limited in how they 
might be generalized to all Medicare beneficiaries. For example, 
General Motors evaluated its companywide prevention program, which 
offered health risk assessments, individualized health profiles, a 
quarterly newsletter, a self-care book, and a toll-free health 
information line. The company reported that providing risk assessment 
and feedback helped participants lower their health risk status and 
that nearly half of this benefit was realized within the first of 5 
years. Although General Motors provides a similar risk appraisal 
program to retirees, this study did not include them, so the study's 
finding cannot be generalized to the Medicare population.

New Ways to Improve the Provision of Preventive Services within 
Medicare's Fee-for-Service Program Are Promising but Untested:

Several options have been suggested for improving the provision of 
preventive services within Medicare's fee-for-service program. They 
include adding a new benefit for a nonillness-related examination, 
either a one-time "welcome-to-Medicare" examination for new 
beneficiaries or an examination available to all beneficiaries on a 
periodic basis. Although covering a one-time or periodic nonillness 
examination could be easily administered and could increase the receipt 
of some preventive services, doing so could also increase Medicare 
costs without necessarily ensuring that beneficiaries receive the full 
range of preventive services. CMS has tested similar options in the 
past and found that they produced mixed results. It is now examining an 
alternative that would essentially create a different structure using 
nonphysician providers to assess health risks and connect individuals 
with preventive services. The design work will be completed at the end 
of 2003, and if the decision is made to conduct a demonstration, 
results would not be available for several years after that. Additional 
demonstrations also under way--such as one exploring effective smoking 
cessation approaches and one giving physicians incentives to coordinate 
and manage the overall health care needs of beneficiaries--may provide 
additional insights into coordinating and delivering appropriate 
preventive services within the Medicare fee-for-service program.

Two Proposed Options Center on Adding a Preventive Examination to the 
Medicare Fee-for-Service Program:

A one-time "welcome-to-Medicare" examination for new beneficiaries has 
been proposed as a means to better ensure that health care providers 
have enough time to identify individual Medicare beneficiaries' health 
risks and provide preventive services appropriate for their 
risks.[Footnote 23] Proponents assert that a one-time benefit could 
combine a health evaluation with screenings and immunizations, along 
with counseling about health promotion and disease prevention. It could 
also orient new beneficiaries to Medicare and encourage them to make 
informed choices about providers and plans. Health risk assessment and 
behavior counseling could be provided by a range of nonphysician 
professionals, including nurses, counselors, and dietitians.

A similar option would have Medicare cover an annual or periodic 
preventive visit available to all fee-for-service beneficiaries. In 
theory, many of the advantages of a one-time preventive visit would 
also apply to periodic examinations. For instance, dedicated preventive 
visits might provide greater opportunities for health care providers to 
assess and address health risks. Some evidence also suggests that a 
periodic health examination may increase use of preventive cancer 
screening and counseling services. For example, a National Cancer 
Institute-supported study surveyed general internists and family 
physician practices and their patients in 1992 and found that patients 
who had received a periodic health examination within the previous year 
were substantially more likely to have received appropriate cancer 
screening and counseling.[Footnote 24]

While these options have benefits, they also have potential drawbacks. 
Adding a benefit for a one-time or periodic examination to the Medicare 
fee-for-service package could increase the program's costs without 
necessarily ensuring that beneficiaries receive the full range of 
preventive services. The Congressional Budget Office in June 2002 
estimated that a one-time physical examination benefit for new 
enrollees could cost as much as $1.6 billion over the 2003-2012 
period.[Footnote 25] According to a Congressional Budget Office 
official, the agency has not recently estimated the potential costs of 
a Medicare benefit for examinations provided on a periodic basis. This 
cost, however, would likely be substantially higher than that of a one-
time visit for new beneficiaries. At the same time, establishing such a 
benefit would not necessarily ensure delivery of the full range of 
preventive services. In addition, primary care physicians typically 
cannot provide services such as mammography screenings for breast 
cancer and colonoscopies for colon cancer, because these services 
usually require specialists.

It also remains uncertain whether covering a one-time or periodic 
examination would be an effective means of improving beneficiary health 
outcomes. A previous CMS initiative that included preventive health 
care visits ended with mixed results. In the late 1980s and early 
1990s, the agency conducted a congressionally mandated demonstration to 
test varied health promotion and disease prevention services, such as 
free preventive visits, health risk assessment, and behavior 
counseling, to see if they would increase use of preventive services, 
improve health outcomes, and lower health care expenditures for 
Medicare beneficiaries.[Footnote 26] The agency's final report, 
published in 1998, concluded that the demonstration services were 
marginally effective in raising the use of some simple disease 
prevention measures, such as immunizations and cancer screenings, but 
did not consistently improve beneficiary health outcomes or reduce the 
use of hospital and skilled nursing services.[Footnote 27]

CMS Is Exploring an Alternative for Assessing Health Risks and 
Delivering Preventive Services:

CMS is exploring one alternative for Medicare preventive care that 
would provide systematic health risk assessments to fee-for-service 
beneficiaries through a means other than physician visits. In the late 
1990s, the agency commissioned the RAND Corporation to evaluate the 
potential effectiveness of health risk assessment programs. Similar to 
the approaches taken by the Medicare + Choice plans we reviewed, such 
programs collect information from individuals; identify their risk 
factors; and refer the individuals to at least one intervention to 
promote health, sustain function, or prevent disease.[Footnote 28] The 
study concluded that health risk assessment programs have increased 
beneficial behavior (particularly exercise) and improved physiological 
variables (particularly diastolic blood pressure and weight) and 
general health status. It also concluded that more research would help 
clarify the programs' effects on preventive services such as clinical 
screening.[Footnote 29] In addition, the study stated that to be 
effective, risk assessment questionnaires must be coupled with follow-
up interventions such as referrals to appropriate services. The study 
found limited but encouraging evidence on the effectiveness of health 
risk assessment programs but concluded that the evidence was 
insufficient to accurately estimate the programs' cost-effectiveness. 
The study recommended that CMS conduct a demonstration to test cost-
effectiveness and other aspects of the health risk assessment approach 
for Medicare beneficiaries.

Following up on the study's findings, CMS has begun designing a fee-
for-service-focused demonstration project, called the Medicare Senior 
Risk Reduction Program, to identify health risks and follow up with 
preventive services provided by means other than physician visits. The 
program will use a beneficiary-focused health risk assessment 
questionnaire to assess health risks, such as lifestyle behaviors, and 
use of clinical preventive and screening services. Because the 
demonstration is still in its design phase, the particular set of risk 
factors to be included is not yet final. Risk factors that might be 
addressed include preventable accidents such as falls, lack of 
exercise, high blood pressure, obesity, and use of preventive services. 
The Medicare Senior Risk Reduction Program will test different 
approaches to administering health risk assessments, creating feedback 
reports, and providing follow-up services, such as referring 
beneficiaries to health-promoting community services including 
physical activity and social support groups. According to project 
researchers, the program will tailor preventive interventions to 
individual risks; track patient risks and health over time; and provide 
beneficiaries with self-management tools and information, health 
behavior advice, and end-of-life counseling where appropriate. The 
design phase is scheduled for completion in late 2003, when CMS will 
decide whether to conduct a full demonstration.[Footnote 30] According 
to CMS officials, the potential demonstration's final cost was 
uncertain at the time our report was completed. CMS is spending 
approximately $1 million on the developmental work.

Unlike some health risk assessment programs, CMS's program will be 
limited to questionnaires and follow-up contacts; it will not directly 
provide clinical screening such as blood pressure or cholesterol 
measurements. Instead, the program will concentrate on identifying, 
through information provided by the beneficiary, any modifiable 
lifestyle and behavioral risk factors and on referring beneficiaries to 
services for reducing those risks. CMS officials and researchers did 
indicate, however, that the program's risk assessment tools will 
collect information on needed immunizations and cancer screenings and 
alert beneficiaries and their physicians to any needed services.

CMS Is Also Exploring Ways to Improve Care for Those with Identified 
Health Risks and Conditions:

CMS has other initiatives under way that may help improve the delivery 
of preventive services within the fee-for-service program. The first is 
the Medicare Stop Smoking Program, a smoking cessation demonstration 
project for fee-for-service beneficiaries. Recognizing that smoking is 
the single most preventable cause of disease and death in the United 
States, posing a significant health risk to the aged, CMS launched the 
demonstration to identify the most effective service to help 
beneficiaries stop smoking. The demonstration will evaluate the 
effectiveness of different smoking cessation services. The four 
services being tested are: (1) reimbursement for provider counseling, 
(2) reimbursement for provider counseling and for smoking cessation 
drugs or nicotine replacement therapy, (3) access to a telephone 
counseling quit-line plus reimbursement for nicotine replacement 
therapy, and (4) provision of written information on smoking cessation. 
Seven states are participating in the demonstration: Alabama, Florida, 
Missouri, Ohio, Oklahoma, Nebraska, and Wyoming. The study will be 
completed in 2004, with the results published in 2005. CMS has budgeted 
approximately $14 million for this project.

CMS is also developing a physician group-practice demonstration that 
was required by the Medicare, Medicaid, and SCHIP Benefits Improvement 
and Protection Act of 2000.[Footnote 31] The aim of this demonstration 
is to provide incentives for physicians to coordinate and manage the 
overall health care needs of Medicare fee-for-service beneficiaries, 
especially those with chronic health conditions. Under the 3-year 
demonstration, physician groups will be paid on a fee-for-service basis 
and may, in some circumstances, earn a bonus from savings achieved if 
the average Medicare expenditure for beneficiaries in their group of 
patients is below an established target.[Footnote 32] Up to six 
physician group practices will be selected to participate in the 
demonstration, which is expected to start during 2003. Under the 
mandate, the aggregate expenditures for this demonstration must be 
budget neutral. Any bonus payments made to physician groups must 
therefore be taken from savings produced by the participating 
organizations.

Finally, a 4-year coordinated-care demonstration is currently under way 
at 16 sites. Authorized by the Balanced Budget Act of 1997, this 
demonstration examines private-sector best practices for coordinating 
the care of patients with complex chronic conditions.[Footnote 33] 
These conditions include congestive heart failure, other heart and lung 
diseases, liver diseases, diabetes, psychiatric disorders, Alzheimer's 
disease or other dementia, and cancer. CMS is testing whether care 
coordination programs--such as those that develop a plan of care after 
a complete assessment of patient needs and offer patient education, 
health care service arrangements, and coordination with providers--can, 
without increasing program costs, improve the quality of care and 
reduce avoidable hospital admissions among Medicare beneficiaries with 
chronic diseases. The selected sites mix case management and disease 
management models in their practices;[Footnote 34] operate in urban and 
rural settings around the country; and include hospitals, retirement 
communities, and academic medical centers. CMS is required to formally 
evaluate the projects every 2 years after implementation and report to 
the Congress on its findings. HHS officially announced the selected 
sites in January 2001, and as of May 2003, the 16 sites had enrolled 
approximately 10,000 Medicare beneficiaries in the demonstration. CMS 
officials stated that the demonstration could eventually enroll more 
than 36,000 beneficiaries, although half of these will serve as a 
control group who will not receive coordinated care. CMS officials told 
us that they expect this demonstration to also be budget neutral. That 
is, they anticipate that overall costs to Medicare for providing the 
services will be offset by savings achieved from providing the care 
coordination services.

Concluding Observations:

Most Medicare beneficiaries receive some preventive services, but many 
do not receive services that can help prevent and manage their health 
risks and conditions early, before significant health problems occur. 
Services recommended for all people in this age group are not delivered 
consistently. Perhaps of most concern, nearly one-third of 
beneficiaries who were screened and identified as having elevated blood 
pressure or high cholesterol measures in a nationally representative 
survey had not previously been told by their physicians or other health 
providers that they had these conditions. Projected nationally, the 
survey results translate into millions of people who could be unaware 
that they have a health condition whose treatment could prevent or 
delay much more significant health concerns.

The solutions to ensure that beneficiaries receive needed services are 
not obvious. The experience of selected Medicare + Choice plans shows 
that no single approach stands out. All plans we contacted had a means 
to identify health risks, to provide feedback on risks to patients or 
their physicians, and to follow up with interventions to reduce those 
risks. But the follow-up programs, approaches, and priorities differed 
among the plans we contacted, and few had evaluated their approaches in 
a manner that would indicate whether these programs could, without 
significantly increasing costs, improve health outcomes for Medicare 
beneficiaries. Nevertheless, some current research shows promise for 
improving the delivery of preventive services--particularly when there 
are follow-up interventions, such as referrals to appropriate services.

Agency Comments:

We obtained comments on our draft from HHS as well as from the health 
plans we contacted. HHS generally concurred with our findings and 
provided examples of CMS's successes in promoting existing preventive 
services and in identifying strategies that might be used in future 
health promotion efforts. HHS also clarified the status of its program 
evaluating the use of individual health risk assessments, which is in 
development, and clarified its Medicare Stop Smoking Program, which 
will assess options for a new benefit for smoking cessation but not 
necessarily lead to CMS coverage for these benefits. HHS emphasized 
that only the Congress can decide which preventive services or benefits 
Medicare covers. HHS also updated its estimate of this program's 
budget. We incorporated these clarifications in the draft.

HHS also commented that without sufficient evidence, the report links 
beneficiaries' lack of knowledge that they may have certain conditions, 
such as high blood pressure, with evidence that they are not receiving 
the full range of preventive services. We did not intend to link these 
statements, but we have independent evidence for each of them and have 
added information to our summary of results to help clarify this 
evidence. HHS's comments are reproduced in appendix IV.

HHS and the health plans also provided technical comments that we 
considered and incorporated where appropriate.

As arranged with your office, unless you release its contents earlier, 
we plan no further distribution of this report until 30 days after its 
issue date. We are sending copies of this report to the Secretary of 
HHS, the Administrator of CMS, the Director of CDC, and others who are 
interested. We will make copies available to others on request. In 
addition, the report will be available at no charge on the GAO Web site 
at http://www.gao.gov.

If you or your staff have any questions, please contact me at (202) 
512-7119 or Katherine Iritani, Assistant Director, at (206) 287-4820. 
Other individuals who made contributions to this report include Matthew 
Byer, Sophia Ku, and Tina Schwien.

Sincerely yours,

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

[End of section]

Appendix I: Scope and Methodology:

Because no single source contained all the information we needed to 
assess the extent to which Medicare beneficiaries receive preventive 
services through existing physician visits, we used data from four 
national health surveys: three conducted by the Centers for Disease 
Control and Prevention (CDC) and one conducted by the Centers for 
Medicare & Medicaid Services (CMS) (see table 2). For example, CMS's 
Medicare Current Beneficiary Survey samples Medicare beneficiaries, 
asking them for detailed information on their demographic 
characteristics, insurance coverage, and health status but asking only 
a few questions about specific preventive services received during 
physician visits. In contrast, CDC's National Ambulatory Medical Care 
Survey samples physicians about office visits, rather than the people 
who made those visits. The survey contains information about reasons 
for office visits and about diagnostic and preventive services provided 
during visits, but it cannot be used to determine the extent to which 
Medicare beneficiaries received these services.[Footnote 35]

Table 2: Four National Health Surveys with Preventive Services Data, 
1999-2000:

Survey: Behavioral Risk Factor Surveillance System, CDC; Data year: 
2000; Sample size: Annual target of 189,450 adults; Description: A 
state-based random telephone survey of U.S. adults covering a wide 
range of behaviors affecting health. The largest continuing telephone 
survey in the United States, it provides national as well as state-
specific estimates.

Survey: National Ambulatory Medical Care Survey, CDC; Data year: 2000; 
Sample size: 27,369 office visits, of which 7,381 were made by people 
age 65 and older; Description: A national sample survey of visits to 
office-based physicians in the United States. Detailed information 
about each visit, such as major reason for the visit and diagnostic and 
preventive services ordered or provided, is collected through a patient 
record form completed by the physicians' offices.

Survey: National Health and Nutrition Examination Survey, CDC; Data 
year: 1999-2000; Sample size: 9,965 people, of which 1,392 were age 65 
and older; Description: This survey gathers nationally representative 
data on the health and nutrition of the U.S. population through direct 
physical examinations and interviews.

Survey: Medicare Current Beneficiary Survey, CMS; Data year: 2000; 
Sample size: About 16,000 Medicare beneficiaries; Description: A 
continuous survey of a representative national sample of the Medicare 
population that collects detailed data on beneficiaries' insurance 
coverage, health status and functioning, and health care use and 
expenditures.

Source: CDC and CMS.

[End of table]

For our analyses of these surveys, we extracted data for people age 65 
and older to represent Medicare beneficiaries, because almost 95 
percent of the population in this age group was enrolled in Medicare in 
2000.[Footnote 36] Also, because the National Ambulatory Medical Care 
Survey samples office visits to physicians, not the people who made the 
visits, to estimate the average number of physician visits made by 
Medicare beneficiaries, we first estimated the number of visits made by 
patients age 65 and older using this database, and then divided this 
number by the U.S. Bureau of the Census estimates of the civilian 
noninstitutionalized population age 65 and older. To determine the 
major reasons for physician visits and the specific types of preventive 
services provided to Medicare beneficiaries in the fee-for-service 
program, we used visit data in this survey for patients age 65 and 
older who did not belong to a health maintenance organization and whose 
visits were not paid on a capitated basis.[Footnote 37] Tables 3 to 5 
show the estimates and standard errors in data from the National 
Ambulatory Medical Care Survey 2000 on major reasons for physician 
visits and on the preventive diet counseling services provided during 
those visits. We also tested at the 95 percent confidence level the 
statistical significance of differences we observed between nonillness 
and other types of visits in the proportion of visits where preventive 
screening tests (e.g., cholesterol and blood tests) were provided.

Table 3: Estimated Proportion of Fee-for-Service Physician Visits Made 
by People Age 65 and Older, by Major Reason for the Visits, 2000:

Major reason: Acute problem; Sample size: 1,155; Estimated number (in 
thousands): 32,843; Estimated percentage: 25.8; Standard error of 
percentage: 1.7.

Major reason: Chronic problem, routine; Sample size: 2,081; Estimated 
number (in thousands): 53,701; Estimated percentage: 42.2; Standard 
error of percentage: 1.7.

Major reason: Chronic problem, flare-up; Sample size: 532; Estimated 
number (in thousands): 13,254; Estimated percentage: 10.4; Standard 
error of percentage: 0.8.

Major reason: Pre-or postsurgery, injury follow-up; Sample size: 577; 
Estimated number (in thousands): 12,533; Estimated percentage: 9.8; 
Standard error of percentage: 1.1.

Major reason: Nonillness care; Sample size: 395; Estimated number (in 
thousands): 12,479; Estimated percentage: 9.8; Standard error of 
percentage: 1.1.

Major reason: Blank or unknown; Sample size: 84; Estimated number (in 
thousands): 2495; Estimated percentage: 2.0; Standard error of 
percentage: 0.4.

Source: GAO analysis of the National Ambulatory Medical Care Survey, 
CDC.

[End of table]

Table 4: Estimated Proportion of Fee-for-Service Physician Visits in 
Which Diet Counseling Services Were Provided or Ordered, by Major 
Reason for the Visits, 2000:

Major reason: Acute problem; Sample size: 1,155; Estimated number (in 
thousands): 4,138; Estimated percentage[A]: 12.6; Standard error of 
percentage: 3.0.

Major reason: Chronic problem, routine; Sample size: 2,081; Estimated 
number (in thousands): 11,785; Estimated percentage[A]: 22.0; Standard 
error of percentage: 3.0.

Major reason: Chronic problem, flare-up; Sample size: 532; Estimated 
number (in thousands): 1,673; Estimated percentage[A]: 12.6; Standard 
error of percentage: 2.5.

Major reason: Nonillness care; Sample size: 395; Estimated number (in 
thousands): 2,295; Estimated percentage[A]: 18.4; Standard error of 
percentage: 3.6.

Source: GAO analysis of the National Ambulatory Medical Care Survey, 
CDC.

[A] The differences in rates of services provided among the different 
types of visits were not statistically significant. According to CDC, 
diet counseling services could be underreported because the survey 
captured this information only if it was contained in the medical 
record. If the physician provided counseling but did not write it in 
the chart, counseling would not have been captured in the survey.

[End of table]

Table 5: Estimated Proportion of Fee-for-Service Physician Visits in 
Which Blood Pressure Measurements Were Provided or Ordered, by Major 
Reason for the Visits, 2000:

Major reason: Acute problem; Sample size: 1,155; Estimated number (in 
thousands): 18,491; Estimated percentage[A]: 56.3; Standard error of 
percentage: 3.2.

Major reason: Chronic problem, routine; Sample size: 2,081; Estimated 
number (in thousands): 31,706; Estimated percentage[A]: 59.0; Standard 
error of percentage: 2.9.

Major reason: Chronic problem, flare-up; Sample size: 532; Estimated 
number (in thousands): 7,870; Estimated percentage[A]: 59.4; Standard 
error of percentage: 4.8.

Major reason: Nonillness care; Sample size: 395; Estimated number (in 
thousands): 7,762; Estimated percentage[A]: 62.2; Standard error of 
percentage: 4.8.

Source: GAO analysis of the National Ambulatory Medical Care Survey, 
CDC.

[A] The differences in rates of services provided among the different 
types of visits were not statistically significant.

[End of table]

To estimate the proportion of Medicare beneficiaries who had health 
conditions that they were not previously aware of--specifically, high 
blood pressure or high cholesterol--we used data from both the 
interview and the physical examination portions of CDC's National 
Health and Nutrition Examination Survey (see app. III for methodology 
and results from this analysis).

To describe the preventive care approaches of Medicare + Choice plans, 
we consulted with national experts and officials from the American 
Association of Health Plans and chose five plans considered to have 
innovative preventive care programs. Together, these five plans serve 
more than 1.2 million Medicare beneficiaries in 15 states and the 
District of Columbia (see table 6). We interviewed officials from each 
plan and reviewed documents, including plan-provided studies or 
evaluations of their preventive services programs. We reviewed the 
scope and methodology of the studies done by some of the plans, but we 
did not independently verify the accuracy of the data.

Table 6: Medicare + Choice Plans Included in GAO's Study:

Medicare + Choice plans: AvMed Health Plans; Geographic areas served: 
Florida; Beneficiaries served: 24,400.

Medicare + Choice plans: Group Health Cooperative; Geographic areas 
served: Washington; Beneficiaries served: 59,300.

Medicare + Choice plans: Highmark Blue Cross & Blue Shield; Geographic 
areas served: Pennsylvania; Beneficiaries served: 182,000.

Medicare + Choice plans: Kaiser Permanente; Geographic areas served: 
California, Colorado, District of Columbia, Georgia, Hawaii, Maryland, 
Ohio, Oregon, Virginia, Washington; Beneficiaries served: 880,000.

Medicare + Choice plans: Oxford Health Plans; Geographic areas served: 
Connecticut, New Jersey, New York; Beneficiaries served: 72,000.

Source: Plan officials and plan Web sites.

[End of table]

To examine the alternatives for identifying and reducing health risks 
and CMS's efforts in exploring them, we reviewed available literature, 
including results of past demonstrations and congressionally mandated 
studies, and interviewed experts in the field, including those 
conducting studies and developing position papers for the Partnership 
for Prevention, a nonprofit organization funded by the Robert Wood 
Johnson Foundation. We also interviewed Department of Health and Human 
Services and CMS officials and reviewed documents on planned and 
present CMS demonstrations related to preventive services.

[End of section]

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

Service: Immunization:  

Service: Pneumococcal; Task force recommendation for age 65+: 
Recommends; Year first covered by Medicare as preventive service: 1981; 
Medicare cost-sharing requirements[A]: None.

Service: Hepatitis B; Task force recommendation for age 65+: No 
recommendation; Year first covered by Medicare as preventive service: 
1984; Medicare cost-sharing requirements[A]: Copayment after 
deductible.

Service: Influenza; Task force recommendation for age 65+: Recommends; 
Year first covered by Medicare as preventive service: 1993; Medicare 
cost-sharing requirements[A]: None.

Service: Tetanus-diphtheria (Td) boosters; Task force recommendation 
for age 65+: Recommends; Year first covered by Medicare as preventive 
service: Not covered[B]; Medicare cost-sharing requirements[A]: N/A.

Service: Varicella; Task force recommendation for age 65+: Recommends; 
Year first covered by Medicare as preventive service: Not covered[B]; 
Medicare cost-sharing requirements[A]: N/A.

Service: Screening: 

Service: Cervical cancer: pap smear; Task force recommendation for age 
65+: Recommends against[C]; Year first covered by Medicare as 
preventive service: 1990; Medicare cost-sharing requirements[A]: 
Copayment with no deductible[D].

Service: Breast cancer: mammography; Task force recommendation for age 
65+: Recommends[E]; Year first covered by Medicare as preventive 
service: 1991; Medicare cost-sharing requirements[A]: Copayment with no 
deductible.

Service: Vaginal cancer: pelvic exam; Task force recommendation for age 
65+: Not evaluated; Year first covered by Medicare as preventive 
service: 1998; Medicare cost-sharing requirements[A]: Copayment with no 
deductible[D].

Service: Colorectal cancer: fecal-occult blood test[F]; Task force 
recommendation for age 65+: Strongly recommends; Year first covered by 
Medicare as preventive service: 1998; Medicare cost-sharing 
requirements[A]: No copayment or deductible.

Service: Colorectal cancer: flexible sigmoidoscopy or colonoscopy[F]; 
Task force recommendation for age 65+: Strongly recommends; Year first 
covered by Medicare as preventive service: 1998; Medicare cost-sharing 
requirements[A]: Copayment after deductible[G].

Service: Osteoporosis: bone mass measurement; Task force recommendation 
for age 65+: Recommends (women only); Year first covered by Medicare as 
preventive service: 1998; Medicare cost-sharing requirements[A]: 
Copayment after deductible.

Service: Prostate cancer: prostate-specific antigen test and/or digital 
rectal examination; Task force recommendation for age 65+: Insufficient 
evidence to recommend for or against; Year first covered by Medicare as 
preventive service: 2000; Medicare cost-sharing requirements[A]: 
Copayment after deductible[D].

Service: Glaucoma; Task force recommendation for age 65+: Insufficient 
evidence to recommend for or against; Year first covered by Medicare as 
preventive service: 2002; Medicare cost-sharing requirements[A]: 
Copayment after deductible.

Service: Vision impairment; Task force recommendation for age 65+: 
Recommends; Year first covered by Medicare as preventive service: Not 
covered; Medicare cost-sharing requirements[A]: N/A.

Service: Hearing impairment; Task force recommendation for age 65+: 
Recommends; Year first covered by Medicare as preventive service: Not 
covered; Medicare cost-sharing requirements[A]: N/A.

Service: Height, weight, and blood pressure; Task force recommendation 
for age 65+: Recommends; Year first covered by Medicare as preventive 
service: Not covered; Medicare cost-sharing requirements[A]: N/A.

Service: Cholesterol measurement; Task force recommendation for age 
65+: Strongly recommends; Year first covered by Medicare as preventive 
service: Not covered; Medicare cost-sharing requirements[A]: N/A.

Service: Problem drinking; Task force recommendation for age 65+: 
Recommends; Year first covered by Medicare as preventive service: Not 
covered; Medicare cost-sharing requirements[A]: N/A.

Service: Depression; Task force recommendation for age 65+: Recommends; 
Year first covered by Medicare as preventive service: Not covered; 
Medicare cost-sharing requirements[A]: N/A.

Service: Counseling: 

Service: Smoking cessation, injury prevention, dental health; Task 
force recommendation for age 65+: Recommends; Year first covered by 
Medicare as preventive service: Not covered; Medicare cost-sharing 
requirements[A]: N/A.

Service: Aspirin for primary prevention of cardiovascular events; Task 
force recommendation for age 65+: Strongly recommends; Year first 
covered by Medicare as preventive service: Not covered; Medicare cost-
sharing requirements[A]: N/A.

Source: U.S. General Accounting Office, Medicare: Use of Preventive 
Services Is Growing but Varies Widely, GAO-02-777T (Washington, D.C.: 
April 12, 2002), and U.S. Preventive Services Task Force, Guide to 
Clinical Preventive Services, 2nd ed. (Washington, D.C.: 1996) and 
related updates.

[A] Applicable Medicare cost-sharing requirements generally include a 
20 percent copayment after a $100 per year deductible. Specifically, 
each year, beneficiaries are responsible for 100 percent of the payment 
amount until those payments equal a specified deductible amount, $100 
in 2003. Thereafter, beneficiaries are responsible for a copayment that 
is usually 20 percent of the Medicare-approved amount. For certain 
tests, the copayment may be higher. 42 U.S.C. § 1395(a)(1) (2000).

[B] Although the tetanus-diphtheria (Td) and varicella (chickenpox) 
booster vaccinations are not now covered under Medicare as a 
"preventive" service, these treatments might be covered under Medicare 
if necessary to a beneficiary's medical treatment. Medicare provides 
coverage for medical treatment and services that are "reasonable and 
necessary for the diagnosis or treatment of an illness or injury," 
provided that the services or products used are "safe and effective" 
and not merely "experimental." 42 U.S.C. § 1395(a)(1)(A) (2000).

[C] The task force recommends against routinely screening women older 
than 65 for cervical cancer if they have had adequate recent screening 
with normal Pap smears and are not otherwise at high risk for cervical 
cancer.

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

[E] The task force recommends screening mammography, with or without a 
clinical breast examination, every 1-2 years for women age 40 and 
older.

[F] Data are insufficient to determine which strategy is best to 
balance benefits against potential harms or cost-effectiveness. Barium 
enemas are covered as an alternative if a physician determines that 
their screening value is equal to or greater than sigmoidoscopy or 
colonoscopy.

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

[End of table]

[End of section]

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

Background:

Conducted by the Centers for Disease Control and Prevention's (CDC) 
National Center for Health Statistics, the National Health and 
Nutrition Examination Survey (NHANES) is a nationwide population-based 
survey designed to estimate the health and nutrition of the 
noninstitutionalized U.S. civilian population. Our analysis was based 
on data gathered during NHANES 1999-2000, which represent the most 
recent information available. This survey comprises two parts: an in-
home interview and a health examination. During the in-home interview, 
participants are asked about their health status, disease history, and 
diet; during the health examination, participants receive a number of 
tests, including blood pressure readings and a blood test to determine 
total serum cholesterol.[Footnote 38] Details of the survey design, 
questionnaires, and examination components are available at http://
www.cdc.gov/nchs/nhanes.htm.

Scope, Methodology, and Results:

For our analysis, we used the NHANES data described in table 7 to 
determine if participants age 65 and older[Footnote 39] had high blood 
pressure or high total serum cholesterol. We used the same criteria for 
these conditions as CDC and the National Heart Blood and Lung Institute 
use to estimate the conditions' prevalence.

Table 7: NHANES Data GAO Used to Determine if Participants Had Measures 
of Specific Health Conditions:

Health condition: High blood pressure[A]; NHANES data: Average[B] 
systolic blood pressure Š 140 during NHANES exam; or; Average[B] 
diastolic blood pressure Š 90 during NHANES exam; or; Participant 
reported during NHANES interview that he or she took hypertension 
medication.

Health condition: High total cholesterol[A]; NHANES data: Total 
cholesterol level Š 240 at NHANES examination.

Source: CDC criteria and GAO methodology.

[A] CDC's definitions of high blood pressure and high total 
cholesterol.

[B] Participants' blood pressure was measured three or four times 
during the 1-day physical examination. For our analysis, we determined 
the average of these blood pressure measurements and applied CDC's 
definition of high blood pressure.

[End of table]

To determine whether the participants age 65 and older found by 
examination to have elevated measures of these health conditions were 
previously unaware of having them, we used patients' responses from the 
NHANES interview. During the interview, participants were asked if they 
had ever been told by a physician or health professional that they had 
certain conditions, including high blood pressure and high cholesterol.

Tables 8 and 9 show the estimates and standard errors from 1999-2000 
NHANES data for specific health conditions and level of awareness among 
participants age 65 and older.

Table 8: People Age 65 and Older in the United States Found to Have 
Measures of Specific Health Conditions, NHANES 1999-2000:

Health condition: High blood pressure; Sample size: 835; Estimated 
number in the U.S. population: 21,000,000; Estimated proportion: 71.6%; 
Standard error of proportion: 2.07.

Health condition: High total cholesterol; Sample size: 250; Estimated 
number in the U.S. population: 7,100,000; Estimated proportion: 25.6%; 
Standard error of proportion: 1.76.

Source: GAO analysis of NHANES.

[End of table]

Table 9: People Age 65 and Older in the United States Found to Have 
Measures of Specific Health Conditions and Who Reported They Had Not 
Previously Been Told They Might Have the Condition, NHANES 1999-2000:

Not previously told of the health condition: High blood pressure; 
Sample size: 254; Estimated number in the U.S. population: 6,600,000; 
Estimated proportion: 31.6%; Standard error of proportion: 2.02.

Not previously told of the health condition: High total serum 
cholesterol; Sample size: 87; Estimated number in the U.S. population: 
2,100,000; Estimated proportion: 32.1%; Standard error of proportion: 
4.65.

Source: GAO analysis of NHANES.

[End of table]

Estimated numbers, proportions, and standard errors were obtained using 
SUDAAN, a computer program for analyzing data from complex sample 
surveys, as suggested in the NHANES Analytic Guidelines.

[End of section]

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Office of Inspector General:

AUG 20 2003:

Ms. Janet Heinrich:

Director, Health Care - Public Health Issues United States General 
Accounting Office Washington, D.C. 20548:

Dear Ms. Heinrich:

Enclosed are the Department's comments on your draft report entitled, 
"Medicare: Most Beneficiaries Receive Some But Not All Recommended 
Preventive Services." The comments represent the tentative position of 
the Department and are subject to reevaluation when the final version 
of this report is received.

The Department also provided several technical comments directly to 
your staff.

The Department appreciates the opportunity to comment on this draft 
report before its publication.

Sincerely,

Dara Corrigan 
Acting Principal Deputy Inspector General:

Signed by Dara Corrigan: 

Enclosure:

The Office of Inspector General (OIG) is transmitting the Department's 
response to this draft report in our capacity as the Department's 
designated focal point and coordinator for General Accounting Office 
reports. OIG has not conducted an independent assessment of these 
comments and therefore expresses no opinion on them.

Comments of the Department of Health and Human Services on the General 
Accounting Office's Draft Report, "Medicare: Most Beneficiaries Receive 
Some But Not All Recommended Preventive Services" (GAO-03-958):

The Department of Health and Human Services (Department) appreciates 
the opportunity to review and comment on the above-referenced draft 
report. The General Accounting Office (GAO) report focuses on the 
preventive services Medicare beneficiaries receive through fee-for-
service or the managed care program.

Generally, we concur with the findings of the draft report and would 
note that prevention is a key goal for the Secretary. To support the 
Secretary's goal, the Centers for Medicare & Medicaid Services (CMS) 
have taken a number of steps to improve the delivery of preventive 
services for Medicare beneficiaries. The following are examples of CMS 
successes in promoting existing preventive services and in identifying 
strategies that might be used in future health promotion efforts:

* The Healthy Aging Project produced evidence reports on how to better 
promote existing Medicare preventive benefits, and explore other 
strategies for healthy aging. These include smoking cessation, health 
risk appraisal programs, falls prevention, chronic disease self-
management, and physical activity. These reports have allowed CMS to 
think prospectively about strategies to help older adults stay healthy.

* The requirement was removed from the providers' Conditions of 
Participation that a physician must write an individual order for each 
influenza and pneumococcal vaccination given in hospital and long term 
care settings and by home health agencies. Where allowed by State law, 
appropriate non-physician personnel can now provide these vaccinations 
under a facility-approved standing order protocol. This change to the 
Conditions of Participation was based on evidence generated by the 
Healthy Aging Project indicating that standing orders are effective for 
increasing immunization rates, and a CMS-Centers for Disease Control 
and Prevention pilot study, which implemented standing orders in 
nursing homes in 14 States.

CMS also increased Medicare payment rates for influenza / pneumococcal 
/ hepatitis B vaccine administration. Medicare's 2003 vaccine 
administration rate allowances average $7.72 for 2003, a 94% increase 
over 2002. The rates range from $5.34 to $10.98 depending on geographic 
location.

Recognizing that smoking is the single most preventable cause of 
disease and death in the United States, posing a significant health 
risk to the aged, CMS launched the Medicare Stop Smoking Program, a 
demonstration to identify the most effective strategy for helping older 
smokers help themselves to quit smoking. The evidence suggests that 
counseling by clinicians and by telephone, with and without smoking 
cessation medications have been effective in helping adults quit 
smoking. This demonstration tests these 
strategies in older adults to identify which strategies are most 
effective for helping older smokers help themselves to quit smoking. To 
date, this demonstration has enrolled 3,328 seniors, and according to 
experts, could possibly be the largest smoking cessation study to 
address the needs of older smokers.

* CMS is designing the Benefits Improvement and Protection Act (BIPA) 
mandated "Cancer Prevention and Treatment Demonstration for Ethnic and 
Racial Minorities." The purpose of this demonstration is to evaluate 
best practices; and design, implement and evaluate projects involving 
new and innovative intervention models that improve health, clinical 
outcomes, satisfaction, quality of life, and appropriate use of 
Medicare-covered services; and reduce disparities in cancer prevention 
and treatment for African American, Latino, Asian American/Pacific 
Islander, and American Indian/Alaskan Native beneficiary populations 
living in both urban and rural communities. The information gathered 
from this demonstration will inform efforts to reduce healthcare 
disparities.

* Colon cancer screening rates are low, with less than 50 percent of 
people age 50 and older receiving any screening test for colon cancer. 
CMS has funded Medical Review of North Carolina (MRNC), a Quality 
Improvement Organization, to analyze colon cancer screening rates. MRNC 
has an interactive website which displays State and county rates for 
the various Medicare-covered colon cancer screening tests, allowing 
organizations to target their efforts to increase rates. These data are 
currently being updated to include 2000-2002 data, and are the only 
comprehensive resource for both State and county data.

* There is collaboration between CMS and other agencies in the 
Department on public awareness campaigns to promote Medicare preventive 
and screening services, specifically colon cancer screening, 
mammography, and adult immunization.

CMS has initiated developmental work to design a study to evaluate the 
use of individual health risk assessments and tailored follow-up 
interventions to reduce health risks and promote the appropriate use of 
preventive services.

In the report, the linkage is drawn between the lack of knowledge of 
risk for health conditions with evidence that beneficiaries are not 
receiving the full range of preventive services. This linkage is 
presented specifically relating to high blood pressure. While we can 
see the correlation between the "lack of knowledge of health risk for 
that condition, additional evidence should be presented before 
extending this conclusion to the full range of preventive services.":

Two CMS initiatives are mischaracterized-the Medicare Stop Smoking 
Program and the design of a study to evaluate the use of health risk 
assessments and tailored follow-up interventions.

Several references are made to a study using health risk assessment and 
follow-up interventions to improve the delivery of preventive services. 
CMS has not yet decided whether it will conduct this study. If CMS 
decides to conduct this study, it will need to be approved by the 
Office of Management and Budget. The references to this study in this 
report imply that this study is underway when in fact no decision has 
been made about its conduct.

The description of the Medicare Stop Smoking Program implies that CMS 
will identify and cover a new benefit for smoking cessation. Congress, 
not CMS, makes coverage decisions regarding preventive services. In 
addition, the estimate of the project's budget is inaccurate.

We look forward to working with GAO on this and future issues.

FOOTNOTES

[1] We focused our work on the people covered by Medicare who are 65 
and older--about 86 percent of the entire Medicare population. Besides 
this age group, Medicare also covers about 5.8 million disabled persons 
younger than age 65. Throughout this report, except where otherwise 
noted, we use the term "Medicare beneficiaries" to refer only to those 
beneficiaries age 65 and older.

[2] U.S. General Accounting Office, Medicare: Beneficiary Use of 
Clinical Preventive Services, GAO-02-422 (Washington, D.C.: April 
2002).

[3] "Fee-for-service" is the Medicare arrangement sometimes referred to 
as the original Medicare plan. Under this option, Medicare pays a 
health care practitioner for each visit or procedure received by a 
patient, and a beneficiary can visit any hospital, physician, or health 
care provider who accepts Medicare patients. Medicare pays a set 
percentage of the expenses, and the beneficiary is responsible for 
certain deductibles and coinsurance payments--the portion of the bill 
that Medicare does not pay.

[4] These are health care options (like health maintenance 
organizations) in some areas of the country. In most programs, the 
beneficiary can go only to doctors, specialists, or hospitals on the 
program's list. Programs must cover all Medicare part A and part B 
health care but can also cover extras, like prescription drugs and 
periodic checkups.

[5] Besides the 84 percent of Medicare beneficiaries in fee-for-service 
and the 14 percent in Medicare + Choice (2002 data), a small percentage 
of Medicare beneficiaries receive services through such arrangements as 
prepaid group practice plans or Medicare demonstrations.

[6] The annual physical examination of healthy persons, in which a 
standard set of tests and procedures is performed, was first proposed 
by the AMA in 1922. For many years afterward, health professionals 
recommended routine physicals and comprehensive laboratory testing as 
effective preventive medicine. But in 1983, the AMA withdrew its 
support for a standard annual examination. Instead, the organization 
supported periodic visits in which patients receive preventive services 
depending upon the individual's unique combination of age, sex, and 
health risk.

[7] The surveys and other data sources from which we developed our 
information generally did not disaggregate the information into 
beneficiaries receiving care through fee-for-service and beneficiaries 
receiving care through Medicare + Choice programs. As a result, unless 
otherwise noted, the data reported include beneficiaries from both 
groups.

[8] CMS's Medicare Current Beneficiary Survey, 2000.

[9] To estimate the average number of physician visits, we used data 
from the National Ambulatory Medical Care Survey and the U.S. Bureau of 
the Census. See app. I for a description of our methodology. We believe 
that the result is a conservative estimate of the average number of 
physician visits, since the segment of the survey that we analyzed 
excluded visits made in hospital outpatient and emergency departments 
or other institutional settings and also excluded physicians in the 
specialties of anesthesiology, pathology, and radiology.

[10] Because Medicare's fee-for-service program does not cover routine 
physical examinations but does cover some preventive services, such as 
immunizations and certain cancer screening tests, it is possible that 
some of the nonillness visits in 2000 were to obtain such services. In 
addition, some fee-for-service beneficiaries may be paying for 
nonillness examinations through other means, such as employer-provided 
or other supplemental insurance. According to CMS's Medicare Current 
Beneficiary Survey, in the year 2000 about 41 percent of Medicare fee-
for-service beneficiaries had insurance from former employers to 
supplement their basic Medicare benefit.

[11] GAO-02-422. 

[12] In January 2003, the U.S. Preventive Services Task Force released 
new recommendations for the use of pap smears to screen for cervical 
cancer. The task force now "recommends against screening women 65 and 
older who have had adequate recent screenings with normal Pap smears 
and are not otherwise at increased risk for cervical cancer." 

[13] Anemia is a condition in which the blood is deficient in red blood 
cells, hemoglobin, or total volume. The hematocrit/hemoglobin test is 
used to test for anemia and to measure the concentration of packed red 
blood cells and hemoglobin in the blood. Hemoglobin is an iron-
containing respiratory pigment in red blood cells that helps transport 
oxygen from the lungs to the body tissues.

[14] Specifically, blood pressure measurements were provided at 56 
percent of visits for acute problems, 59 percent of visits for chronic 
problems, and 62 percent of nonillness visits. Diet counseling services 
were provided at 13 percent of visits for acute problems, 20 percent of 
visits for chronic problems, and 18 percent of nonillness visits. For 
both blood pressure measurement and diet counseling service estimates, 
the differences in these percentages were not statistically significant 
at the 95 percent confidence level. See app. I for a discussion of the 
methodology and specific results. Source: CDC's National Ambulatory 
Medical Care Survey, 2000.

[15] The source of data for this statement was CDC's National Health 
and Nutrition Examination Survey of 1999-2000. This survey oversampled-
-that is, included a larger number of persons age 60 and older in the 
sample, providing for a sample size that enabled us to focus our 
analysis specifically on the Medicare-age population for selected 
conditions. App. III contains a description of this survey and the 
specific results of our analyses.

[16] Medicare + Choice plans are required to make a "best effort 
attempt" to assess newly enrolled Medicare beneficiaries. 42 C.F.R. § 
422.122(b)(4)(i) (2002). 

[17] The risk assessment questionnaires for some plans are as brief as 
a one-page form, while others are as long as eight pages. A number of 
questions focus on identifying functional status, such as the ability 
to bathe independently; immunization status; current use of 
prescription medications; the history of screening tests, such as 
mammography; past health care use, such as the number of times 
enrollees saw their primary care physician in the preceding 6 months; 
behavior risks, such as smoking; and past illnesses or existing health 
conditions.

[18] CMS generally requires each Medicare + Choice plan to undertake 
one national quality assessment and performance improvement project per 
year to measure and improve its own performance in a CMS-defined 
national focus area. Past national focus areas include improving 
diabetes care and increasing vaccination rates for influenza and 
pneumonia.

[19] Angiotensin-converting enzyme. 

[20] Specifically, over the next decade, people designated as "frail" 
spent 800 percent more days in nursing homes than individuals who were 
not frail. K.K. Brody, R.E. Johnson, and L.D. Ried, "Evaluation of a 
Self-Report Screening Instrument to Predict Frailty Outcomes in Aging 
Populations," The Gerontologist, 37 (1997): 182-191.

[21] K.K. Brody et al., "A Comparison of Two Methods for Identifying 
Frail Medicare-Aged Persons," Journal of American Geriatrics Society, 
50 (2002): 562-569.

[22] Once frail people are identified, for example, Kaiser encourages 
medical providers to follow guidelines intended to detect conditions 
such as depression and to prevent outcomes such as injuries from falls. 


[23] Partnership for Prevention, A Better Medicare for Healthier 
Seniors: Recommendations to Modernize Medicare's Prevention Policies 
(Washington, D.C.: Partnership for Prevention, 2003), and Gilbert S. 
Omenn, "Historical and Current Policy Issues in Establishing Coverage 
for Clinical Preventive Services under Medicare," cited in the 
Partnership for Prevention's report. 

[24] C.H. Sox et al., "Periodic Health Examinations and the Provision 
of Cancer Prevention Services," Archives of Family Medicine, 6 (1997): 
223-230. This study reviewed a random selection of community general 
internists and family physician practices in New Hampshire and Vermont. 
Care was assessed for those who were patients of the study physicians 
for at least 1 year, were age 42 or older, had no life-threatening 
illness, and had recently visited the physician.

[25] See Congressional Budget Office cost estimate, H. R. Rep. 107-539, 
pt. 1, at 238. Beginning in 2004, the bill would have required Medicare 
to pay for a routine physical examination and associated services when 
furnished within 6 months of a beneficiary's enrollment in part B. 
Beneficiaries already enrolled would not have been eligible for this 
benefit. H.R. 4954, 107th Cong. (2d Sess. 2002). 

[26] A 4-year demonstration was mandated in the Consolidated Omnibus 
Budget Reconciliation Act of 1985, Pub. L. No. 99-272, § 9314, 100 
Stat. 82, 194 (1986), and extended for 1 year by the Omnibus Budget 
Reconciliation Act of 1990, Pub. L. No. 101-508, § 4164, 104 Stat. 
1388, 1388-100. At the time, CMS was known as the Health Care Financing 
Administration.

[27] Donna E. Shalala, Medicare Prevention Demonstration: Final Report, 
RC 87-172 (Washington, D.C.: Department of Health and Human Services, 
1998). The report tempered these results by pointing out that the 
relatively brief period during which the services were provided 
(roughly 2 years) and the limited number of provider contacts and 
follow-ups (one to two) may have been inadequate to achieve measurable 
outcomes. In addition, the grouping of the health risk assessment and 
preventive services into a preventive package may have obscured the 
relative effects of individual components of the package.

[28] A typical health risk assessment obtains information on 
demographic characteristics (e.g., sex, age), lifestyle (e.g., smoking, 
exercise, alcohol consumption, diet), personal health history, and 
family health history. In some cases, physiological data (e.g., height, 
weight, blood pressure, cholesterol levels) are also obtained, as well 
as a patient's status regarding cancer screens and immunizations.

[29] Southern California Evidence-Based Practice Center/RAND, Health 
Risk Appraisals and Medicare (Baltimore: Centers for Medicare & 
Medicaid Services, 2001). RAND identified 267 articles, unpublished 
reports, and conference presentations, of which 27 contained data that 
project staff deemed necessary to be included as evidence of the 
effectiveness of health risk assessments.

[30] According to CMS, the demonstration would also require approval 
from the Office of Management and Budget.

[31] Pub. L. No. 106-554, app. F, § 412, 114 Stat. 2763, 2763a-509.

[32] Annual performance targets will be established for each 
participating physician group, equal to the average Medicare 
expenditures of beneficiaries assigned to that group during the base 
period and adjusted for health status and expenditure growth.

[33] Pub. L. No. 105-33, § 4016, 111 Stat. 343, 345.

[34] Case management services would be provided to help manage general 
health, and disease management services would be provided to help 
manage a specific disease.

[35] The National Ambulatory Medical Care Survey is conducted by CDC's 
National Center for Health Statistics. See the Web site http://
www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm for details on the survey 
design.

[36] According to data from CDC's Behavioral Risk Factor Surveillance 
System, in 2000, almost 95 percent of adults age 65 and older reported 
having Medicare coverage.

[37] "Capitated" refers to a method of payment for health services in 
which an individual or institutional provider is paid a fixed amount 
for each person served, without regard to the actual number or nature 
of services provided to each person in a set period of time.

[38] Which examinations and blood tests a participant had depended on 
that participant's age and sex.

[39] Of the 9,282 individuals participating in both the NHANES 
interview and examination components, 1,196 were age 65 and older.

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