Fascinating article, illustrating the dilemma facing primary care physicians attempting to provide true preventive care to our patients... jbwMD
Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage
Lenard I. Lesser, MD1, Alex H. Krist, MD, MPH2, Douglas B. Kamerow, MD, MPH3 and Andrew W. Bazemore, MD, MPH4
The study was setup like this...
"We undertook an analysis to assess a healthy senior American’s access to USPSTF-recommended preventive services if he or she were solely insured through Medicare, before the implementation of the new health insurance law."
The Results were as follows...
- The USPSTF recommended 15 preventive interventions for adults aged 65 years and older. Medicare reimbursed fully for the preventive coordination and the preventive service for 1 (7%) preventive service (screening for abdominal aortic aneurysm).
- The preventive coordination and associated screening need to be performed only once and is covered in conjunction with the WMV.
- For most preventive services (60%), Medicare reimbursed fully for the service or test, but only partially for the coordination of obtaining that service.
- For 4 services (27%) Medicare reimbursed clinicians partially for both the preventive coordination and the actual service. Finally, for 1 service (7%), breast cancer genetic testing,
- Medicare reimbursed fully for the coordination and assessment (as part of risk assessment in the WMV), but not for the test or service itself (intensive counseling by a trained genetic counselor).
- Most coverage for preventive coordination was included as part of the WMV. Although preventive tests were often covered beyond this visit, the risk assessment, coordination, and motivation of the patient were not.
- The USPSTF recommends against 16 preventive services that would apply to Medicare beneficiaries (excluding sexually transmitted infections and immunizations against hepatitis B and C). Medicare reimbursed clinicians for 7 (44%) of these services.
- USPSTF recommendations differed based on age and frequently included ages to stop screening. Medicare, by comparison, covered services for prevention for all beneficiaries regardless of age (eg, colon, cervical, and prostate cancer screening).
- The USPSTF and Medicare both recommend and covered, respectively, preventive services only for certain at-risk populations, yet there are several examples for which the 2 organizations define the at-risk population differently.
A portion of the discussion went like this...
"Our analysis shows that Medicare covered many USPSTF recommended preventive services. A substantial disconnect was evident, however, especially in 2 areas: coordination of care, and coverage of nonrecommended services.
"Congress first tried to increase coverage of preventive coordination in 2005, when it authorized the WMV, or Initial Preventive Physical Examination, which is the first time Medicare could specifically pay clinicians to coordinate prevention. In 2008, Congress tried to fix one of the problems with the WMV—that seniors could get a WMV only during the first 6 months of enrolling—by expanding the window to 1 year.
"Despite its intent, 3 realities undermined the WMV’s contributions to optimal preventive care: (1) only 6% of persons get their WMV6; (2) all USPSTF-recommended services applicable to adults for the rest of their lives cannot reasonably be covered in a single visit at the age of 65 years17; and (3), to be effective, many preventive services require periodic repetition beyond a single visit. The reasons for the low uptake of the WMV are unclear, but possible reasons are logistical issues and patients not being aware of the benefit.
"Although the new 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 and usher in an era of improved quality of care through effective prevention. Congress should simultaneously increase support for research on the delivery and effectiveness of preventive services."