On September 21, the House Energy and Commerce Subcommittee on Health held a hearing on the preventive health benefits included in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (P.L. 108-173).
Chair Mike Bilirakis (R-FL) said that “since the program’s inception in 1965, Medicare has paid the health care costs for beneficiaries when they are sick. In 1965, this was an appropriate approach to health care. Today, with rapidly increasing technology, health care is changing from diagnostic to preventative care. However, while the climate has changed, the Medicare program has dug its feet.” He explained that Medicare added some preventive benefits over the years, including mammography screenings in 1991 and pelvic exams and osteoporosis tests in 1997, but with the MMA, “beneficiaries’ access to preventative benefits has been brought to a whole new level.” Rep. Bilirakis praised the new “Welcome to Medicare” physical, explaining that Medicare “will now cover influenza and hepatitis B vaccines, mammograms, Pap smears and pelvic examinations and screening tests for prostate cancer, colon cancer, glaucoma and osteoporosis.”
Ranking Member Sherrod Brown (D-OH) called the new preventive benefits a “positive addition to Medicare,” but expressed his concern that they would add to the cost of beneficiaries’ premiums. He noted that Medicare premiums are expected to rise 17 percent next year, but the cost-of-living-adjustment for seniors’ social security benefits will be less than 3 percent.
Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy said that the United States Preventive Services Task Force is made up of private sector primary health care experts and methodologists and provides “the ‘gold standard’ regarding those preventive services for which there is good quality scientific evidence of effectiveness.” She explained that the task force solicits topics from its members, federal agencies, professional health organizations, and the public, and prioritizes these topics based on the magnitude of the problem. Once the task force has reviewed the research on a specific prevention method, such as postmenopausal hormone replacement therapy or obesity counseling, it establishes a recommendation by a formal vote.
Noting that “there is a large gap between what is known and what is done in practice,” Dr. Clancy stated that the MMA “challenges AHRQ to see that physicians and patients can access information on ‘what is known’ when they need it. We already have an innovative arrangement with the vendor, ePocrates, to provide physicians with fast access on their PDAs [personal digital assistants] to…recommendations from the Task Force.” She also noted that AHRQ “will soon be announcing a series of grant and contract awards to increase the deployment and use of health information technology precisely because health information technology can make the right thing to do the easy thing to do.”
Janet Heinrich, director of health care and public health issues at the Government Accountability Office, said that approximately 90 percent of Medicare beneficiaries visit a doctor at least once a year, and beneficiaries made an average of six visits in one year. “Despite how often Medicare beneficiaries visit physicians, relatively few beneficiaries receive the full range of recommended preventive services covered by Medicare,” she stated, adding, “As we reported in 2002, for example, although 91 percent of female Medicare beneficiaries in our analysis received at least one preventive service, only 10 percent were screened for cervical, breast, and colon cancer and were also immunized against influenza and pneumonia.” Ms. Heinrich said that the “Welcome to Medicare” physical could be beneficial in delivering preventive services, but alone “is not enough to ensure better health among beneficiaries…Primary care physicians typically cannot provide services such as mammography screenings for breast cancer or colonoscopies for colon cancer, because these services usually require specialists. It is also uncertain whether a one-time or periodic examination would be an effective way to improve beneficiaries’ health.” She concluded that ensuring that Medicare beneficiaries receive the services they need and follow-up care will remain a challenge.
Arguing that preventive services under Medicare remain “deficient,” Executive Vice President for Policy Development at the Partnership for Prevention Steven Woolf stated, “It is problematic that decisions about coverage of prevention under Medicare are determined by Congress, service by service. This is not the way that Medicare decides coverage for diagnostic tests and treatments: for those services, Congress directs CMS [the Centers for Medicare and Medicaid Services] to decide what to cover, in consultation with the nation’s leading medical experts.” He added, “Requiring an ‘act of Congress’ to cover each preventive service is inefficient and slows the delivery of preventive care to America’s seniors compromising their health and costing the system money. A bill to introduce coverage of Pap smears was introduced annually for 15 years before the benefit was added in 1989.” Dr. Woolf also noted that the rules become outdated before Congress can pass new legislation. “For example, in 1991, Congress authorized Medicare to cover ‘baseline mammograms’ to be performed on all women at age 35, a practice advocated at the time by the American Cancer Society. But today, no major medical group (including the American Cancer Society) advocates baseline mammograms,” he stated, adding, “In 1998 coverage was extended to osteoporosis screening for high-risk women, the group that seemed most likely to benefit. By 2002, the U.S. Preventive Services Task Force had begun recommending screening for all women over age 65, but in 2004, Medicare coverage remains restricted to women at high risk.”
Dr. Woolf also noted that Medicare does not cover many preventive services that could prevent cardiovascular disease and diabetes. He stated, “The recent decision by CMS to cover obesity treatment is welcome, but tobacco use remains the leading cause of death in the United States. Physical activity and unhealthy diets cause cancer and other diseases, even in people who are not obese, and they are essential to prevent obesity. Counseling about tobacco use, regular physical activity, and healthy diet are therefore urgent public health priorities, but Medicare does not provide coverage.” Finally, Dr. Woolf argued that Congress must ensure that preventive services are delivered well, explaining, “As of 2001, only 60% of beneficiaries over age 65 had received pneumococcal vaccinations, and only 44% had received sigmoidoscopy screening for colorectal cancer. Only 10% of older women were up-to-date on cervical, breast, and colorectal cancer screening. If what Congress has done to expand coverage is to realize its full benefits, both beneficiaries and providers must be educated about the importance of prevention and how to make use of the services that Medicare covers, and systems must be in place to expedite the delivery of these services.”
