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

GAO-12-81 Published: Jan 18, 2012. Publicly Released: Feb 17, 2012.
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What GAO Found

Use of some preventive services--cardiovascular disease screening and cervical cancer screening--by FFS beneficiaries generally aligned with clinical recommendations, but use of other cancer screenings for certain age groups, osteoporosis screening, and immunizations did not. In particular, among women aged 65 to 74, for whom breast cancer screening is recommended biannually by the Task Force, only two out of three received a mammogram in 2008 or 2009. Among beneficiaries aged 65 to 75, about one out of four received any of the Task Force recommended regimens for colorectal cancer screening from 2005 through 2009. Among men aged 75 or older, about two out of five received a Prostate-Specific Antigen test for prostate cancer--a test that required no cost sharing--from 2006 through 2009 even though the Task Force recommended against this service for that age group. Use of osteoporosis screening--for which Medicare coverage is limited--and influenza and pneumococcal immunizations was generally lower than recommended by the Task Force or ACIP. The Department of Health and Human Services has the authority to modify coverage of Medicare preventive services--such as osteoporosis screening--consistent with Task Force recommendations.

Fewer than 7 percent of FFS beneficiaries who became eligible for the WTM exam in 2008 received it. For FFS beneficiaries who became eligible in 2006 and received the exam, use rates for all of the selected preventive services GAO reviewed were higher than for beneficiaries who did not have the exam. Specifically, use of selected preventive services from 2006 through 2009 was greater by about 3 to 20 percentage points for women and about 4 to 17 percentage points for men.

Compared to beneficiaries in FFS, those in MA HMOs reported greater use of immunizations and cholesterol tests but not cancer screenings, holding demographic and geographic factors constant. There was no discernable difference in use rates between FFS beneficiaries and those in MA non-HMO plans. Overall, Medicare beneficiaries who did not receive certain preventive services commonly reported that they had limited information on prevention; had concerns about discomfort, side effects, or efficacy; or their doctor did not recommend the services.

HMO performance data from the Centers for Medicare & Medicaid Services' (CMS) Medicare Health Plan Compare ratings show that use varied substantially for the preventive services we examined. Representatives from higher-performing HMOs reported using tools such as clinical guidelines, performance monitoring and feedback, and financial incentives to encourage physicians to provide preventive services. HMO representatives also said they developed newsletters, phone messages, and websites to highlight the availability of preventive services and enhanced benefits to encourage enrollees' use of preventive care.

Why GAO Did This Study

Preventive care services have the potential to improve health outcomes and lower health care expenditures. This report examines (1) whether preventive service use by Medicare fee-for-service (FFS) beneficiaries aligns with recommendations from the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices (ACIP), (2) use of the Welcome to Medicare (WTM) exam and its association with use of preventive services, (3) preventive service use in Medicare Advantage (MA) relative to FFS, and (4) service use among MA health maintenance organizations (HMO) and efforts by high-performing HMOs to encourage preventive care. To do this, GAO selected eight preventive services that had Task Force or ACIP guidelines for the general Medicare population. GAO analyzed the most recently available data from Medicare claims, a beneficiary survey, and MA plan ratings. GAO also interviewed representatives of selected HMOs.

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Congress should consider requiring beneficiaries to share the cost of a service if the Task Force recommends against use of that particular service for those beneficiaries. The Administrator of CMS should provide coverage for Task Force recommended services, as she determines is appropriate considering cost-effectiveness and other criteria. CMS agreed that preventive service use could be improved, but stated that GAO likely undercounted use of some preventive services. The agency also pointed out that it has recently added coverage for several new preventive services.

Matter for Congressional Consideration

Matter Status Comments
To further align Medicare beneficiary use of preventive services with Task Force recommendations, Congress may wish to consider requiring beneficiaries who receive services with a grade of 'D" to share the cost, notwithstanding that cost sharing may not be required for other beneficiaries receiving the same services.
As of July 2022, Congress has not yet taken action to require beneficiaries who receive services with a Task Force grade of "D" to share the cost.

Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should take steps to better align Medicare beneficiary use of preventive services with Task Force recommendations, including providing coverage of services with an 'A" or 'B" grade for the recommended population and at the recommended frequency, as she determines is appropriate considering cost-effectiveness and other criteria.
Closed – Implemented
CMS extended Medicare coverage for several additional preventive services, and demonstrated that the agency continues to review the Task Force's recommendations. Specifically, the agency noted that it closely monitors Task Force updates and attends relevant meetings so that alignment with Medicare coverage can be considered. In addition, the agency identified certain legislative constraints on the bone mass measurement benefit, but noted that agency officials believe its current policy reaches virtually any beneficiaries for which the service is recommended. The agency also demonstrated that, when Medicare coverage is misaligned with Task Force recommendations, agency officials consider alignment based on the appropriateness for the Medicare population through the National Coverage Determination process. For example, in response to a March 2021 update to Task Force recommendations related to lung cancer screening, CMS has begun the process of reviewing the evidence base to determine whether Medicare coverage should be adjusted to align with the updated recommendations.

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