Medicare Matters:
Healthy Aging: What Will Medicare Pay For?
by Mary Elina Ferris, M.D., M.S.| Geriatric Times |  |
May/June 2000 | |
Vol. I | |
Issue 1 |
For many years, the notion of prevention in geriatric medicine seemed irrelevant. After all, death was inevitable, and older adults had missed the chance to prevent the premature mortality that was traditionally the focus of public health initiatives. Health economists suggested that dollars invested in prevention were better spent in the younger years. Thus, when the federal government created the Medicare program in 1965, coverage for medical expenses was allotted for acute illnesses only (Kang, 1999). Life expectancy in 1965 averaged 70 years, just five years past the eligible age for receiving Medicare benefits (National Center for Health Statistics, 1998).
Now, however, the landscape has changed considerably. Life expectancy for women in America is approaching 80 years, and the most rapidly growing segment of our population are those 90 years of age or older. Current estimates show that this population is increasing from approximately 1.2 million today to 9.6 million by the year 2050. An American reaching age 70 can now expect to live 12 to 15 additional years, and even at age 85 there are five to six additional years anticipated (National Center for Health Statistics, 1998).
This bulging wave of older adults has forced the Health Care Financing Administration (HCFA), which operates the Medicare program, to change its orientation and incorporate principles of disease prevention and health promotion (Kang, 1999). Even though death is inevitable, it is now thought that any terminal periods of disease and severe disability can be compressed into fewer years. This is known as the "compression of morbidity" or "squaring the morbidity curve" (Fries et al., 1989). Not only will this benefit the quality of life for Medicare recipients, it will also save the Medicare program and the American taxpayers lots of money otherwise spent in treating chronic diseases that could have been prevented or at least postponed.
"The challenge for us is how to modernize Medicare from a medical, acute care model to a comprehensive, health care model emphasizing successful and healthy aging through health promotion and risk factor reduction," said Jeffrey Kang, M.D., M.P.H., HCFA's chief clinical officer, in a recent speech to a congressional prevention coalition (1999). HCFA's first priority is to increase the use of the currently covered clinical preventive and screening benefits that the U.S. Congress has added in the years since Medicare began. Several new benefits mandated in the Balanced Budget Act of 1997 have been recently implemented.
Kang, a board-certified internist and geriatrician, is part of a new era at HCFA, as it recruits physicians with strong clinical and leadership skills to help guide it to a modern role as a beneficiary-centered purchaser of health care. HCFA is increasingly being held accountable by Congress and the public for measurable results (Kang, 1999). Although HCFA is a government agency, it is actually the nation's largest insurer, paying out $210 billion in benefits each year for 40 million Medicare beneficiaries. HCFA's coverage decisions on how preventive services for older adults will be reimbursed should have a major impact on geriatric medicine in the United States.
The actual preventive services now covered by Medicare are listed in Table 1. Immunization coverage for influenza and pneumococcal disease continues. For all women over age 40, mammography screening has been extended to a yearly exam. Pelvic and breast exams with Pap smears are now covered for screening every three years and annually for high-risk women. Diabetes glucose home monitoring supplies are now covered for all people with diabetes, not just those using insulin. Diabetic training by certified diabetes educators and dieticians can be ordered under a comprehensive-care plan by a physician. This training is now being expanded from hospital outpatient departments to non-hospital settings.
Entirely new benefits were created for osteoporosis and colorectal and prostate cancer screenings. These could previously be ordered only if disease was actually suspected. Bone density measurement is now covered once every two years or more often if medically indicated. Previously, this coverage varied depending on the decision of each regional Medicare billing contractor. A major promotion came from both HCFA and the Centers for Disease Control and Prevention (CDC) for early detection for colorectal cancer. Coverage now includes fecal occult blood testing every year, starting at age 50, and a screening flexible sigmoidoscopy every four years, starting at age 50 (or colonoscopy every two years if a patient is determined to be at high risk). A barium enema can be substituted for the direct endoscopic visualizations, but Medicare will not pay for both.
Prostate cancer screening coverage took effect in January, with payment for annual digital rectal examinations and prostate specific antigen blood tests for all men over 50. As with all new Medicare benefit coverages, the congressionally mandated effective dates can actually take longer to be nationally implemented, so billing and reimbursement problems sometimes arise. The country is divided into regions that are contracted with different billing intermediaries ("Part B carriers" for outpatient coverage), each of which must incorporate the new guidelines.
For many of Medicare's covered preventive benefits, deductible and co-insurance requirements have been eliminated to encourage beneficiaries to utilize the service without waiting until later in the year or not using it at all due to cost pressures. For example, a woman might not have her mammogram in January if she has to pay a large deductible before she receives any reimbursement. HCFA leaders and President Clinton's 2001 budget have proposed eliminating all cost-sharing (both deductibles and co-insurance) for preventive benefits (HCFA, 2000), since studies have shown that eliminating out-of-pocket costs will increase their use. As with all Medicare's coverage decisions, politics and congressional negotiation will play a role in any changes.
With these new preventive benefits, Medicare now covers the majority of the recommended screening strategies with strong evidence basis in older adults, as summarized in a recent update (Goldberg and Chavin, 1997) and available in Medicare & You 2000 at www.medicare.gov.
The most notably absent benefit is for tetanus vaccine prophylaxis, which has the highest grade of evidence to support its use (Goldberg and Chavin, 1997) but is still not covered by Medicare. Some screening recommendations that are often used but not strongly supported by evidence are also not covered: routine chest X-rays and electrocardiograms, glaucoma and hearing screenings, and lab testing for thyroid-stimulating hormone, glucose and cholesterol, in the absence of any disease suspicion (Goldberg and Chavin, 1997).
Despite the availability of Medicare's preventive benefits, there has been significant underutilization, possibly due to ignorance among both beneficiaries and providers about their availability and usefulness. No more than 60% of Medicare-eligible women received screening mammography every two years under the previous coverage, and only 1 million out of 39 million eligible used the new colorectal screening benefit in 1998, the first year it was available.
For physicians practicing in the last three decades, the shift toward preventive coverage is a new concept. Negative cultural beliefs about aging and the role of the older person in society may contribute to avoidance of health promotion by seniors. Medical research has traditionally neglected the very old, so evidence-based literature support for these services has also been lacking. All that is changing, however, as more support accumulates for instituting prevention in the later years, particularly the impact of early detection of cancer and diabetes complications on the subsequent quality of life.
HCFA's initial efforts to increase use of preventive services focused primarily on reaching beneficiaries directly and encouraging them to seek these services from their health care providers. As multiple studies have concluded that physician recommendations are the major determinants in the use of preventive screening, however, HCFA has begun to target the Medicare provider population for outreach and educational efforts. Each state's peer review organization has been instructed to increase the early detection of diabetes complications and raise rates of immunizations and mammography.
HCFA also has launched the National Provider Education Program, a combination of satellite broadcasts and computer-based training courses to educate providers about Medicare-covered preventive benefits. These programs are available free of charge at the Medicare Learning Network www.hcfa.gov/medlearn/default.htm.
So far, two satellite broadcasts, one promoting the use of influenza and pneumococcal immunizations and the other promoting the use of screening services by women for breast, cervical and colorectal cancers have been produced. These present a unique collaboration of various federal agencies and national organizations promoting the use of preventive services. Providers including physicians, hospitals, managed care plans and public health departments give examples of how to encourage and provide their Medicare beneficiaries with necessary immunizations or screenings. Both broadcasts also present Medicare coverage, billing and reimbursement issues related to the services. Finally, the programs acknowledge the importance of effective provider/patient communication and how lack of communication or miscommunication between the parties can seriously hinder a Medicare beneficiary's understanding of the importance of obtaining necessary preventive services.
This is certainly a new and improved role for HCFA, compared to its former role as a regulatory claims payer. Although it still maintains its vigilance against fraud and abuse of the Medicare program, its new preventive services benefits and educational outreach hold much promise for senior beneficiaries. As Kang acknowledged to Congress, "To ensure a healthier aging experience for our nation's 39 million elders, we need to work together across the Department of Health and Human Services and achieve a partnership between the private and public sectors. By working together, our chances of improving the health of all seniors are far greater."
Dr. Ferris is a geriatric consultant for CMRI, California's non-profit peer review organization funded by the HCFA.
References
Fries JF, Green LW, Levine S (1989), Health promotion and the compression of morbidity. Lancet 1(8636):481-483.
Goldberg TH, Chavin SC (1997), Preventive medicine and screening in older adults. J Am Geriatr Soc 45(3):344-354.
Health Care Financing Administration (2000), Medicare & You. Available at www.medicare.gov. Accessed May 3.
Kang J (1999), Medicare and Health Promotion. Presented at the Congressional Prevention Coalition meeting, July 27, 1999. Available at: www.hcfa.gov/quality/3b1.htm. Accessed April 27.
National Center for Health Statistics (1998), National Vital Statistics Report 47(13):10.