Healthcare reform could close the gap between recommendations of the U.S. Preventive Services Task Force, charged by the government to review clinical preventive health services for older adults, and Medicare coverage for those services, according to a new study.
According to the study, which is led by UCLA and published in the January/February issue of the Annals of Family Medicine, Medicare reimbursed for only a fraction of the services recommended by the government task force.
Study authors say there is a need to improve coordination between assessing the risk for certain illnesses and ensuring the patient receives the appropriate tests and follow-up medical services. There continues to be a lack of coverage for obesity and nutritional services, both of which are supported by the task force and important for maintaining good health.
The study authors conclude that although the healthcare 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 authors urge Congress to increase support for research on the delivery and effectiveness of preventive services.
"By expanding coverage for the preventive health visit, the healthcare reform law provides avenues to align Medicare payments with the recommendations of the USPSTF, and for better coordination between screenings and clinical services," said Lenard Lesser, MD, a family physician and researcher with the Robert Wood Johnson Foundation Clinical Scholars at UCLA and the study's lead author. "For these reforms to be effective, however, Medicare beneficiaries must take advantage of the expanded coverage and get their annual check-ups."
Prior to January 2011, Medicare covered one preventive health visit, the so-called Welcome to Medicare Visit, within the first year. Reimbursement for this visit comprised the majority of coverage for preventive coordination under Medicare but has been largely underused, with only 6 percent of beneficiaries actually receiving a WMV. The healthcare reform law expanded coverage to an annual wellness visit covering several aspects of prevention, including an assessment of risk for disease and developing a personalized prevention plan.
In the study researchers sought to examine how well the task force's recommendations were aligned with Medicare coverage before implementation of healthcare reform. They looked at the services that USPSTF recommended (these have an A- or B-rating) as well as those the task force did not recommend (D-rated). They then divided Medicare coverage for those services into two delivery components: preventive coordination, which includes risk assessment and arranging for appropriate services, and the preventive service itself, which includes the actual testing as well as counseling.
Services rated A by the USPSTF for adults over the age of 65 include screenings for cervical cancer, colon cancer, high blood pressure, lipid disorders for men and for women (each listed separately) and tobacco use. B-rated services comprise screenings for abdominal aortic aneurysm, alcohol (counseling also included), breast cancer genetic risk, depression, diabetes, obesity (also counseling) and osteoporosis as well as breast cancer mammographies and counseling for a healthy diet.
The researchers found that of the 15 recommended preventive interventions for older adults, only one – abdominal aortic aneurysms – was fully covered by Medicare for both coordination and service. Most of the rest received either partial funding on one side and full on the other, or only partial funding for each. For instance, osteoporosis services (i.e., a bone density scan) were fully funded while risk assessment and other elements of coordination were only partially funded, and depression services and coordination each got only partial funding.
Medicare reimbursed clinicians for 44 percent of the non-recommended services, spending valuable tax dollars on unsupported healthcare services. These non-recommended but covered services included screening for cervical cancer in women who no longer need screening, ovarian cancer, colon cancer in those older than 85, and heart disease in those who are at lower risk.