PRESIDENT'S PLAN TO STRENGTHEN AND MODERNIZE MEDICARE
2. Improving Preventive Benefits and Eliminating Cost Sharing
Overview. Older Americans are the fastest growing age group in the United States, with an increasing number of older Americans surviving to age 85 and older. They carry the greatest risk of dying from cancer and heart disease as well as the highest rates of chronic disease and disability. For example, 88 percent of those over the age of 65 have at least one chronic health condition, and large numbers of older adults suffer from impaired functioning and well-being. Early detection, risk factor reduction, and health screening programs and appropriate follow-up care can result in a significant reduction in morbidity.
a. Eliminating all preventive services cost sharing
Policy: This proposal would waive the Part B deductible and 20 percent coinsurance rate for preventive services for which cost sharing is not already waived under current law. The deductible would be waived for hepatitis B vaccinations, colorectal cancer screening, bone mass measurements, prostate cancer screening and diabetes self-management benefits. Coinsurance would be waived for screening mammography, pelvic exams, hepatitis B vaccinations, colorectal screening, bone mass measurements, prostate cancer screening and diabetes self-management benefits. For the rest of the preventive services covered by Medicare, cost sharing is already waived.
Background/rationale: The Balanced Budget Act of 1997 added many new preventive benefits (e.g., colorectal cancer screening and diabetes self-management training). According to recent studies, Medicare preventive services are underutilized. For example, the 1999 Dartmouth Atlas of Health Care found that, in 1995-1996, only one in four women in their sixties were tested as often as recommended for breast cancer. In the first two years that Medicare covered screening mammography, only 14 percent of eligible women without supplemental insurance received a mammogram. Waiving cost sharing for preventive benefits should increase utilization of these services.
b. Information campaign on prevention
Policy: The Department of Health and Human Services (HHS) would launch a two year, nationwide education campaign beginning in 2001 to promote the use of preventive health services by older Americans and people with disabilities. The campaign would have three parts:
Background/rationale: Loss of function can begin for people in their 50s, arguing for preventive approaches starting in middle age as a means of promoting health and limiting disability in the later years of life.
Increasing the venues through which Medicare beneficiaries and older Americans will be educated about the importance of preventive benefits and how to access them under the Medicare program will increase the likelihood that beneficiaries will use these services. A recent study indicates that Medicare beneficiaries do not understand that Medicare covers preventive benefits. Almost 70 percent of beneficiaries who stated that they knew about the range of Medicare services were unable to answer questions about Medicare's coverage of preventive benefits correctly. However, studies indicate that repeated short, simple, print media messages enhance the target population's recall and retention of health promotion messages. These messages have also been shown to have a greater impact on individuals at higher risk.
In addition to educating beneficiaries about the importance and availability of preventive services, this proposal would address one of the major public health problems facing the elderly: the high incidence of falls. In 1995, more than 7,700 people over the age of 65 died as a result of a fall. For people aged 65 to 84, falls are the second leading cause of injury-related death; for those aged 85 or older, falls are the leading cause of injury-related death. Falls are the most common cause of injuries and hospital admissions for trauma among the elderly, accounting for 87 percent of all fractures among people aged 65 years or older and are the second leading cause of spinal cord and brain injury. For people aged 65 years or older, 60 percent of fatal falls occur in the home. This education campaign aims to reduce the risk of falls, thereby improving the quality of life and reducing Medicare costs.
c. U.S. Preventive Services Task Force study on new preventive services for older Americans
Policy: The Secretary would direct the U.S. Preventive Services Task Force to conduct a series of new studies to identify preventive interventions that can be delivered in the primary care setting that are most valuable to older Americans. In addition, it would include evaluation of services of particular relevance to older Americans in the mission statement of the Task Force.
Background/rationale: Despite the potential for preventive services to improve the quality of life for older Americans, few clinical guidelines focus on preventive care for older Americans.
The U.S. Preventive Services Task Force, an independent panel of preventive health experts, together with the Agency for Health Care Policy and Research, is charged with evaluating the scientific evidence for the effectiveness of a range of clinical preventive services, including common screening tests, immunizations, and counseling for health behavior change and producing age-specific and risk-factor-specific recommendations for these services. The task force focuses primarily on preventive interventions that can be delivered in the primary care setting, are widely available, and for which scientific evidence exists to assess efficacy and effectiveness.
Policy: HCFA would launch a demonstration project to evaluate the most successful and cost-effective means of providing smoking cessation services to Medicare beneficiaries, including testing incentive systems for both providers and beneficiaries to optimize "quit" rates. The demonstration would be based on the latest scientific evidence regarding smoking cessation strategies and guidelines. These guidelines suggest that the most effective smoking cessation strategies include an initial patient assessment, counseling services, and nicotine replacement therapy. Non-Medicare providers could participate in the demonstration since part of its purpose will be to determine the most cost-effective providers for delivering smoking cessation services. Medicare rules would be waived to the extent necessary to allow such providers to bill for these services. Providers would be reimbursed for the lesser of 100 percent of the cost of the service or the amount determined by a fee schedule established by the Secretary.
Background/rationale: The four leading causes of death heart disease, cancer, cardiovascular disease, and chronic obstructive pulmonary disease (COPD) are strongly related to smoking. The risk of death due to coronary heart disease in smokers is two to four times greater than in non-smokers; the risk of stroke is 1.5 times greater in smokers than in non-smokers; and mortality and serious morbidity related to COPD occurs almost exclusively in smokers. Studies from the last three decades have shown that when people stop smoking, their risk of tobacco-related morbidity and mortality decreases significantly. For example, the risk of myocardial infarction (heart attack) diminishes by almost one third after the first year of smoking cessation and reaches the level of people who have never smoked by the third or fourth year of quitting. In addition to its health benefits, smoking cessation may reduce costs.