Medicare reimbursed for only a fraction of the services recommended by government task force, study finds

Health care reform should be able to mend a disconnect that has existed between the recommendations of the U.S. Preventive Services Task Force (USPSTF), a task force charged by the government to review clinical preventive health services for older adults, and Medicare coverage for those services, a new UCLA-led study finds.

In particular, 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, according to the study, which is published in the January/February issue of the Annals of Family Medicine. Alarmingly, there also 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.

Prior to January 2011, Medicare covered one preventive health visit, the Welcome to Medicare Visit (WMV), within the first year. Reimbursement for this visit comprised the majority of coverage for preventive coordination under Medicare but has been largely underutilized with only 6 percent of beneficiaries actually receiving a WMV. The health care 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.

"By expanding coverage for the preventive health visit, the health care reform law provides avenues to align Medicare payments with the recommendations of the USPSTF, and for better coordination between screenings and clinical services, said Dr. Lenard Lesser, 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."

The study authors conclude that although the 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. They urge Congress to simultaneously increase support for research on the delivery and effectiveness of preventive services.

The researchers sought to examine how well the task force's recommendations were aligned with Medicare coverage before implementation of health care 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 these 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. getting 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.

In addition, Medicare reimbursed clinicians for 44 percent of the non-recommended services, spending valuable tax dollars on unsupported health care 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 screening in those who are at lower risk.