Summary

Preventive care depends on identifying health risks and on taking steps to control these risks. In contrast, Medicare, the federal health program insuring almost 35 million beneficiaries age 65 or older, was established largely to help pay beneficiaries' health care costs when they became ill or injured. Congress has broadened Medicare coverage over time to include specific preventive services, such as flu shots and certain cancer-screening tests, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) added coverage for several preventive services, including a one-time preventive care examination for new enrollees, which will start in 2005. GAO's work, done before MMA, included analyzing data from four national health surveys to examine the extent to which Medicare beneficiaries received preventive services through physician visits. GAO also interviewed officials from the Centers for Medicare & Medicaid Services (CMS) and other experts and reviewed the results of past demonstrations and studies to assess expected benefits and limits of different delivery options for preventive care, including a one-time preventive care examination.

Most Medicare beneficiaries receive some but not all recommended preventive services. Our analysis of year 2000 data shows that nearly 9 in 10 Medicare beneficiaries visited a physician at least once that year; beneficiaries made, on average, six visits or more within the year. Still, many did not receive recommended preventive services, such as flu or pneumonia vaccinations. Moreover, many are apparently unaware that they may have conditions, such as high cholesterol, that preventive services are meant to detect. In one 19992000 nationally representative survey where people were physically examined and asked a series of questions, nearly one-third of people age 65 or older whom the survey found to have high cholesterol measurements said they had not before been told by a physician or other health professional that they had high cholesterol. Projected nationally, this percentage translates into about 2.1 million people who may have had high cholesterol without knowing it. A one-time preventive care examination may help orient new beneficiaries to Medicare and provide further opportunity for beneficiaries to receive some preventive services. Covering a one-time preventive care examination does not ensure, however, that beneficiaries will receive the recommended preventive services they need over the long term or consistently improve health or lower costs. CMS is exploring an alternative that would provide beneficiaries with systematic health risk assessments by means other than visits to physicians. A key component of this early effort involves the coupling of risk assessments with follow-up interventions, such as referrals for follow-up care.