Medicare Reimbursements Short-Changed Preventive Coordination

Study by RWJF Clinical Scholar identifies disconnect between preventive care recommendations and reimbursement that health reform may help alleviate.

    • March 8, 2011

The U.S. Preventive Services Task Force (USPSTF) offers up-to-date recommendations on the types of preventive care Americans should receive. This government authorized, independent panel of experts uses evidence-based research to evaluate preventive services that improve health and save lives—screenings for cancers, high blood pressure and heart disease, counseling for depression and tobacco use, and more.

But Medicare, the country’s largest payer for medical services, did not cover all of USPSTF’s recommended services prior to January 2011, according to a study by Lenard Lesser, M.D., Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2009-2011) and colleagues. Their findings were published in the January/February 2011 issue of the Annals of Family Medicine.

A family medical physician with the University of California, Los Angeles (UCLA) Health System, Lesser and his team compared the USPSTF’s 15 recommendations for adults age 65 and older to the corresponding reimbursements provided by Medicare. They distinguished, for the first time, between preventive coordination—when a doctor talks to a patient about his or her risk factors for colon cancer, for instance, and educates the patient on screening options—and the preventive services themselves, which are the screenings or counseling.

The research team found that most of the USPSTF recommended preventive services were fully covered by Medicare, but coordination for those services was only partially covered. In fact, Medicare only reimbursed fully for both preventive coordination and preventive service for one of USPSTF’s recommendations: screening for abdominal aortic aneurysm.

“Medicare was doing a good job of reimbursing for the actual services, but all the things a primary care provider does, including coordinating services, were only partially covered,” Lesser said. “We know that doctors try to fit [preventive care] in, but without being reimbursed for coordination, it’s going to fall by the wayside when other, more acute, health problems are present.”

Medicare also reimbursed for 7 of the 16 preventive services that USPSTF recommends against for people over the age of 65. USPSTF recommendations differ based on age, and some include ages at which screening should stop. But in some cases, the study notes, Medicare covered these services regardless of age.

While it’s not clear how many doctors actually order the tests that USPSTF recommends against, it would make sense for Medicare to stop covering them, Lesser said. “There can be adverse health effects from being inappropriately screened,” he added, including anxiety from false-positive test results, unnecessary follow-up tests and unnecessary complications from subsequent testing and treatment.

Preventive Care Under Health Care Reform

Lesser is optimistic that the new health reform law may improve the disparities the study identified. The law has a focus on preventive care. For instance, health reform will cover an annual wellness visit that is designed to create a personalized prevention plan for Medicare beneficiaries. Until now most coverage for preventive coordination was included as part of the “Welcome to Medicare” Visit, which is available to seniors during their first year in the program. But only 6 percent of seniors take advantage of this visit. The new annual wellness visit eliminates the time restriction and ensures that patients can get needed preventive care throughout their time in the Medicare program.

The health reform law also reinforces the authority of the U.S. Department of Health and Human Services (HHS) to add services to Medicare that receive a high enough rating from USPSTF, which Congress established in 2008, and also allows HHS to remove services that are poorly ranked.

“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,” the study says.

A focus on prevention can work to prevent or delay disease, Lesser said. “It’s the right thing to do for patients. Preventive care makes for healthier patients and a healthier American public.”