Health reform law can help align Medicare with preventive care recommendations

A significant gap exists between a government-commissioned task force's recommendations on preventive health services older Americans should receive and Medicare coverage for those services, a new UCLA-led study has found. But the researchers say the new health care reform law should be able to help mend the disconnect.

In particular, they say, there is a need to improve coordination between assessing risk for certain illnesses, on one hand, and providing the appropriate tests and follow-up medical services recommended by the U.S. Preventive Services Task Force (USPSTF), on the other.

The USPSTF is an independent expert panel appointed by the federal government to review and recommend various screenings and preventive health care procedures.

Alarmingly, the researchers say, there continues to be a lack of Medicare coverage for obesity and nutritional services, both of which are recommended by the USPSTF and which are important for maintaining good health.

The findings appear in the January–February issue of the journal Annals of Family Medicine(Link is external).

The study, which was led by Dr. Lenard Lesser, a UCLA family physician and a researcher with the Robert Wood Johnson Foundation Clinical Scholars program at UCLA, examined how well the USPSTF's recommendations were aligned with Medicare coverage before implementation of health care reform in January 2011.

The researchers looked at recommended services (those rated "A" or "B"), as well as services the task force didn't recommend (rated "D"). They then divided Medicare coverage for those services into two delivery components: (1) preventive coordination, which includes risk-assessment and arranging for appropriate services, and (2) preventive services, which include testing, as well as counseling.

A-rated services for adults over 65 included screenings for cervical cancer, colon cancer, high blood pressure, lipid disorders (for men and women, each listed separately) and tobacco. B-rated services included screenings for abdominal aortic aneurysm, alcohol (including counseling), breast cancer genetic risk, depression, diabetes, obesity (including counseling) and osteoporosis, as well as breast cancer mammographies and counseling on healthy diets.

The researchers found that of these 15 recommended preventive interventions, only one — abdominal aortic aneurysms — was fully covered by Medicare for both coordination and service. Most of the rest received either partial funding for one component and full funding for the other, or only partial funding for each.

For example, preventive services for osteoporosis, such as getting a bone-density scan, were fully funded, but preventive coordination, including risk-assessment and other elements, was only partially funded. For depression, services and coordination each received only partial funding.

In addition, researchers found that Medicare reimbursed clinicians for 44 percent of non-recommended, D-rated services, spending valuable tax dollars on unsupported health care. These services included screening for cervical cancer in women who no longer needed screening; screenings for ovarian cancer and colon cancer in those older than 85; and heart disease screenings for those at lower risk.

The expanded coverage provided under the new health care reform law, Lesser said, should have the effect of helping Medicare bring its coverage better into line with the USPSTF's recommendations.

Prior to the law's enactment, Medicare covered only one preventive health visit — the "Welcome to Medicare" visit, or WMV — which was to be ultilized within the first year of coverage. Reimbursement for this visit accounted for the majority of coverage for preventive services under Medicare. Yet these visits have been largely underutilized, with only 6 percent of beneficiaries actually receiving a WMV.

The new law has expanded coverage to include an annual wellness visit that would involve several aspects of prevention, including an assessment of disease risk and the development of a personalized prevention plan for beneficiaries.

"By expanding coverage for the preventive health visit, the health care reform law provides avenues to align Medicare payments with the recommendations of the USPSTF and for better coordination between screenings and clinical services," Lesser said. "For these reforms to be effective, however, Medicare beneficiaries must take advantage of the expanded coverage and get their annual check-ups."

The researchers concluded that although the health care reform law provides new initiatives to improve the delivery of preventive services, it is now up to Medicare to align itself with the USPSTF recommendations to improve quality of care through effective prevention. They also urged Congress to simultaneously increase support for research on the delivery and effectiveness of preventive services.

In addition to Lesser, study co-authors included Alex H. Krist of Virginia Commonwealth University, Douglas B. Kamerow of RTI International and Andrew W. Bazemore of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

The Pisacano Leadership Foundation, the Robert Wood Johnson Foundation Clinical Scholars program and the Robert Graham Center funded Lesser's time.

The Robert Wood Johnson Clinical Scholars(Link is external) program has for more than three decades fostered the development of physicians who are leading the transformation of health care in the United States through positions in academic medicine, public health and other leadership roles. Through the program, future leaders learn to conduct innovative research and work with communities, organizations, practitioners and policy-makers on issues important to the health and well-being of all Americans.

The UCLA Department of Family Medicine(Link is external) provides comprehensive primary care to entire families, from newborns to seniors. The department also provides low-risk obstetrical services and prenatal and in-patient care at Santa Monica–UCLA Medical Center and Orthopedic Hospital and out-patient care at the Les Kelley Family Health Center in Santa Monica and the Mid-Valley Family Health Center, located in a Los Angeles County Health Center in Van Nuys, Calif. The department is also a leader in family medicine education, for both medical students and residents, and houses a significant research unit focusing on geriatric issues and health care disparities among immigrant families and minority communities in Los Angeles and California.