<DOC>
[107th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:80672.wais]
ASSESSING AMERICA'S HEALTH RISKS: HOW WELL ARE MEDICARE'S CLINICAL
PREVENTIVE BENEFITS SERVING AMERICA'S SENIORS?
=======================================================================
HEARING
before the
SUBCOMMITTEE ON
OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
MAY 23, 2002
__________
Serial No. 107-110
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
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COMMITTEE ON ENERGY AND COMMERCE
W.J. ``BILLY'' TAUZIN, Louisiana, Chairman
MICHAEL BILIRAKIS, Florida JOHN D. DINGELL, Michigan
JOE BARTON, Texas HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia SHERROD BROWN, Ohio
RICHARD BURR, North Carolina BART GORDON, Tennessee
ED WHITFIELD, Kentucky PETER DEUTSCH, Florida
GREG GANSKE, Iowa BOBBY L. RUSH, Illinois
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
BARBARA CUBIN, Wyoming BART STUPAK, Michigan
JOHN SHIMKUS, Illinois ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico TOM SAWYER, Ohio
JOHN B. SHADEGG, Arizona ALBERT R. WYNN, Maryland
CHARLES ``CHIP'' PICKERING, GENE GREEN, Texas
Mississippi KAREN McCARTHY, Missouri
VITO FOSSELLA, New York TED STRICKLAND, Ohio
ROY BLUNT, Missouri DIANA DeGETTE, Colorado
TOM DAVIS, Virginia THOMAS M. BARRETT, Wisconsin
ED BRYANT, Tennessee BILL LUTHER, Minnesota
ROBERT L. EHRLICH, Jr., Maryland LOIS CAPPS, California
STEVE BUYER, Indiana MICHAEL F. DOYLE, Pennsylvania
GEORGE RADANOVICH, California CHRISTOPHER JOHN, Louisiana
CHARLES F. BASS, New Hampshire JANE HARMAN, California
JOSEPH R. PITTS, Pennsylvania
MARY BONO, California
GREG WALDEN, Oregon
LEE TERRY, Nebraska
ERNIE FLETCHER, Kentucky
David V. Marventano, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Oversight and Investigations
JAMES C. GREENWOOD, Pennsylvania, Chairman
MICHAEL BILIRAKIS, Florida PETER DEUTSCH, Florida
CLIFF STEARNS, Florida BART STUPAK, Michigan
PAUL E. GILLMOR, Ohio TED STRICKLAND, Ohio
RICHARD BURR, North Carolina DIANA DeGETTE, Colorado
ED WHITFIELD, Kentucky CHRISTOPHER JOHN, Louisiana
Vice Chairman BOBBY L. RUSH, Illinois
CHARLES F. BASS, New Hampshire JOHN D. DINGELL, Michigan,
ERNIE FLETCHER, Kentucky (Ex Officio)
W.J. ``BILLY'' TAUZIN, Louisiana
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Bratzler, Dale, Principal Clinical Coordinator, Oklahoma
Foundation for Medical Quality, Inc., the American Health
Quality Association........................................ 31
Clancy, Carolyn, Acting Director, Agency for Healthcare
Research and Quality, U.S. Department of Health and Human
Services................................................... 26
Fleming, David W., Acting Director, Centers for Disease
Control and Prevention, U.S. Department of Health and Human
Services................................................... 20
Gold, Marthe R., Logan Professor and Chair, Department of
Community Health and Social Medicine, City University of
New York Medical School.................................... 57
Grissom, Tom, Director, Centers for Medicare Management,
Centers for Medicare and Medicaid Services................. 14
Gruman, Jessie C., President and Executive Director, Center
for the Advancement of Health.............................. 68
Heinrich, Janet, Director, Health Care--Public Health Issues,
U.S. General Accounting Office............................. 7
Himes, Christine, Director of Geriatrics, Group Health
Cooperative................................................ 63
Quirion, Viola, on behalf of Alliance of Retired Americans... 53
Material submitted for the record:
American Heart Association, prepared statement of............ 84
College of American Pathologists, prepared statement of...... 88
(iii)
ASSESSING AMERICA'S HEALTH RISKS: HOW WELL ARE MEDICARE'S CLINICAL
PREVENTIVE BENEFITS SERVING AMERICA'S SENIORS?
----------
THURSDAY, MAY 23, 2002
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Oversight and Investigations,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m., in
room 2322, Rayburn House Office Building, Hon. James C.
Greenwood (chairman) presiding.
Members present: Representatives Greenwood, Burr, Bass, and
Fletcher.
Staff present: Joe Greenman, majority professional staff
member; Brendan Williams, legislative clerk; Karen Folk,
minority professional staff member; Bridgett Taylor, minority
professional staff member; and Chris Knauer, minority
investigator.
Mr. Greenwood. Good morning. The hearing will come to
order.
We are the--good morning to the witnesses. One of the
benefits of you and all of those in attendance, we expect that
there will be members coming and going, and we're going to
begin now, because we ought to.
I've scheduled this hearing today to examine the importance
of incorporating wide-ranging preventive practices into common
patient care and in particular into the Medicare program.
Health care experts expend a lot of time and energy addressing
this issue, and Members of Congress have voiced their interest
in encouraging the use of preventive medical services by their
constituents. Yet there still appear to be some gaps in our
knowledge about the effectiveness of these programs and about
what programs are most appropriate for inclusion in Medicare.
We're all familiar with the phrase ``an ounce of prevention
is worth a pound of cure.'' Beyond conventional wisdom, this is
something health care providers have come to recognize as a
valuable part of medical care. Preventive services which entail
not only the early detection of disease but also practices that
actually prevent the onset of disease have been associated with
a substantial reduction in morbidity and mortality. Despite
these widely acknowledged benefits, a gulf exists between the
potential health gains from delivering the most innovative
forms of prevention and the gains we presently achieve for
beneficiaries of U.S. public health care programs.
Bear in mind that extending Medicare coverage to any
service that aims to prevent disease requires an act of
Congress. This means that the ongoing evaluation of the best
practices and the prevention of chronic illness is the
responsibility of Members of Congress. Since most of us in this
body are not medical providers, let alone clinical researchers,
we must rely on others to provide us with the information that
will form our decisions on what benefits should be covered by
Medicare.
Since 1980, Congress has amended Medicare law several times
to add coverage for certain preventive services. Preventive
services currently available to Medicare beneficiaries are
primarily used for the early detection of noncommunicable
diseases like cancer or the immunization of beneficiaries from
common sicknesses like influenza and pneumonia.
We know there are other preventive services that could be
offered to beneficiaries. Many of us read the news articles
that are appearing on a more and more routine basis that report
the results of preventive care studies. These studies have
continued to support the notion that the most promising role
for prevention in current medical practice may lie in changing
personal health behaviors of patients long before clinical
disease develops.
The importance of this aspect of clinical practice is
evident from a growing body of literature linking some of the
leading causes of sickness and death in the United States, such
as heart disease and cancer, to a handful of personal health
behaviors. Yet the Medicare program does not cover services
designed to improve the health status of most at-risk
beneficiaries. The most common behaviors related to the onset
of chronic illness cannot be addressed by benefits currently
available in the Medicare program, although these benefits are
becoming more widely available through private health coverage.
To improve the performance of the Medicare program in this
regard, Congress must find the most effective means of
incorporating these benefits that demonstrate an ability to
improve the health status of older Americans. Medical research
and technology has expanded the body of options available for
addressing the prevention and treatment of chronic illness.
Prevention can play a role in improving the health of medical
beneficiaries, as well as offer the potential for controlling
health care costs if the preventive services are soundly
structured.
Today we will hear from a number of witnesses who are
experts in the fields of public health, prevention programs and
medical research.
In an effort to obtain the best information in
understanding how best to achieve these reforms, I have asked
the U.S. General Accounting Office to assist us. The GAO has
prepared a study on the current state of preventive services
available in the Medicare program. This will be helpful in
reminding us what is and is not covered by Medicare.
Additionally, the GAO will tell us what it has learned
about the initiatives that the Centers for Medicare and
Medicaid Services, CMS, has conducted to encourage utilization
of the preventive benefits already offered by Medicare and how
the rates of utilization of these services have changed over
time.
I'm pleased to announce that the GAO will be assisting us
by preparing a follow-up study that will address issues related
to the challenges of evaluating and crafting preventive
services for the benefit of those served by U.S. public health
programs. I look forward to seeing the positive results that
this partnership will yield in the months to come.
Let me stress, finally, that, given the complexities
inherent in this issue, today's hearing is the beginning of a
process on prevention promotion in our public health programs.
Before we know how best to act, we will have to answer
difficult questions, such as what is the role of government in
trying to change the health-related behavior of the general
public? Are these efforts beneficial? Are they ethical? Who
will be trusted to generate the evidence, and who will be
responsible for using this evidence to implement policy?
Today we will hear from witnesses who bring a great deal of
expertise to this important topic and will help us begin to
address these questions. I thank all of the witnesses for their
testimony today.
[The prepared statement of Hon. James Greenwood follows:]
PREPARED STATEMENT OF HON. JAMES GREENWOOD, CHAIRMAN, SUBCOMMITTEE ON
OVERSIGHT AND INVESTIGATIONS
Good morning. I have scheduled this hearing today to examine the
importance of incorporating wide-ranging preventive practices into
common patient care--and, in particular, into the Medicare program.
Health care experts expend a lot of time and energy addressing this
issue and Members of Congress have voiced their interest in encouraging
the use of preventive medical services by their constituents. Yet there
still appear to be some gaps in our knowledge about the effectiveness
of these programs, and about what programs are most appropriate for
inclusion in Medicare.
We're all familiar with the phrase ``an ounce of prevention is
worth a pound of cure.'' Beyond conventional wisdom, this is something
health care providers have come to recognize is a valuable part of
medical care.
Preventive services--which entail not only the early detection of
disease, but also practices that actually prevent the onset of
disease--have been associated with a substantial reduction in morbidity
and mortality. Despite these widely acknowledged benefits, a gulf
exists between the potential health gains from delivering the most
innovative forms of prevention and the gains we presently achieve for
beneficiaries of U.S. public health programs.
Bear in mind that extending Medicare coverage to any service that
aims to prevent disease requires an act of Congress. This means that
the ongoing evaluation of the best practices in the prevention of
chronic illness is the responsibility of Members of Congress. Since
most of us in this body are not medical providers, let alone clinical
researchers, we must rely on others to provide us with the information
that will inform our decisions on what benefits should be covered by
Medicare.
Since 1980, Congress has amended Medicare law several times to add
coverage for certain preventive services. The preventive services
currently available to Medicare beneficiaries are primarily used for
the early detection of noncommunicable diseases, like cancer, or the
immunization of beneficiaries from common sickness, like influenza and
pneumonia.
We know there are other preventive services that could be offered
to beneficiaries. Many of us read the news articles appearing on a
more-and-more routine basis that report the results of preventive care
studies. These studies have continued to support the notion that the
most promising role for prevention in current medical practice may lie
in changing personal health behaviors of patients long before clinical
disease develops. The importance of this aspect of clinical practice is
evident from a growing body of literature linking some of the leading
causes of sickness and death in the United States, such as heart
disease and cancer, to a handful of personal health behaviors.
Yet the Medicare program does not cover services designed to
improve the health status of most at-risk beneficiaries. The most
common behaviors related to the onset of chronic illness cannot be
addressed by benefits currently available in the Medicare program--
although these benefits are becoming more widely available through
private health coverage.
To improve the performance of the Medicare program in this regard,
Congress most find the most effective means of incorporating those
benefits that demonstrate an ability to improve the health status of
older Americans. Medical research and technology has expanded the body
of options available for addressing the prevention and treatment of
chronic illness. Prevention can play a role in improving the health of
Medicare beneficiaries as well as offer the potential for controlling
health costs, if the preventive services are soundly structured.
Today, we will hear from a number of witnesses who are experts in
the fields of public health, prevention programs and medical research.
In an effort to obtain the best information in understanding how best
to achieve these reforms, I have asked the US General Accounting Office
(GAO) to assist us. The GAO has prepared a study on the current state
of preventive services available in the Medicare program. This will be
helpful in reminding us what is, and is not, covered by Medicare.
Additionally, the GAO will tell us what it has learned about the
initiatives that the Centers for Medicare and Medicaid Services (CMS)
has conducted to encourage utilization of the preventive benefits
offered by Medicare and how the rates of utilization of these services
has changed over time.
I am also pleased to announce that the GAO will be assisting us by
preparing a follow-up study that will address issues related to the
challenges of evaluating and crafting preventive services for the
benefit of those served by US public health programs. I look forward to
seeing the positive results that this partnership will yield in the
months to come.
Let me stress, finally, that, given the complexities inherent in
this issue, today's hearing is the beginning of a process on prevention
promotion in our public health programs. Before we know how best to
act, we will have to answer difficult questions such as what is the
role of government in trying to change the health related behavior of
the general public? Are these efforts beneficial? Are they ethical? Who
will be trusted to generate the evidence and who will be responsible
for using this evidence to implement policy?
Today, we will hear from witnesses who bring a great deal of
expertise to this important topic--and will help us begin to address
these questions. I thank all the witnesses for their testimony today.
Mr. Greenwood. I note that there is a vote pending, and
there are no other members to make opening statements. However,
we have a written statement submitted by Mr. Dingell which will
be made a part of the official record.
[Additional statements submitted for the record follow:]
PREPARED STATEMENT OF HON. ERNIE FLETCHER, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF OKLAHOMA
Chairman Greenwood, I am pleased you are having this hearing today
to look into the health of our Nation's Seniors. We have an obligation
to ensure that Medicare's clinical preventive benefits are serving all
our Seniors and to ensure that the preventive medical treatments are
incorporated and promoted in a comprehensive Medicare system that will
not bankrupt our children and grandchildren and will allow Medicare to
be around for a long time to come.
Medicare has provided health care security to millions of Americans
since 1965. Almost 400 new drugs have been developed in the last decade
alone to fight diseases like cancer, heart disease, and arthritis.
However, Medicare has not kept up with rapid advances in medical care.
Congress has a moral obligation to fulfill Medicare's promise of health
and security for America's Seniors and people with disabilities. It is
essential that Congress take steps to improve preventive care.
Preventive care has proven to be highly effective in reducing the
seriousness of many diseases and in improving the recovery time and
quality of life for those who suffer from them. At the same time as we
consider improving preventive benefits, we must fundamentally reform
Medicare to ensure that it is a strong and viable system for our
Seniors.
At a time when health care costs are soaring and the number of
uninsured Americans is approximately 40 million, Congress must be
careful to not place health care mandates on Medicare that will force
our young workers to pay more for the benefits than they can afford.
President Bush reminded us in his State of the Union Address that
health care reform was a domestic priority for his Administration.
Congress must turn attention to Medicare and Medicaid reform, the
problem of the uninsured and high costs now. We have a ripe opportunity
to improve the health of all Americans and make health insurance more
affordable for all Americans.
Some say an ounce of prevention is worth a pound of cure. In this
case access to preventive health care services is the prevention that
will cure many problems we face today in our health care system. Noted
businessman and presidential advisor Bernard M. Baruch once stated:
``There are no such things as incurables; there are only things for
which man has not found a cure.'' This statement is just as true for
illness as it is for problems with America's health care system
including Medicare. While we cannot solve all ills overnight, it's
important for Congress and the President to work together to provide
common sense and creative cures for improving health care to benefit
all Americans.
______
PREPARED STATEMENT OF HON. W.J. ``BILLY'' TAUZIN, CHAIRMAN, COMMITTEE
ON ENERGY AND COMMERCE
Thank you Chairman Greenwood, and let me commend you for holding
this oversight hearing on the role of preventive medicine in our
nation's public health programs.
Americans today enjoy better overall health care than at any time
in the nation's history. Rapid advancements in medical technologies,
increased understanding of the genetic foundations of health and
illness, improvements in the effectiveness of pharmaceutical
treatments, and other developments have helped to develop cures for
many illnesses and to extend and improve the lives of Americans,
especially those with chronic diseases.
These steady improvements are certainly a blessing. But by
themselves, they cannot address some of the most significant challenges
to improving the health of the coming generation of Medicare
beneficiaries.
Just this week, The Washington Post reported a recent AARP study
that showed Americans over 50 are living longer and suffering with less
disability than previous generations of midlife adults. But they are
more likely to be overweight or obese, live with multiple chronic
health conditions and depend more on prescription drugs.
If we are to realize the full potential of the investments we have
made to improve the quality of health care in this country, we must
undertake a serious effort to assess not only how best to treat these
chronic diseases but also how to implement what we know about changing
the behaviors that cause these diseases.
Fortunately, over the past decade, a growing body of evidence has
emerged that shows that behavioral and social interventions offer great
promise to reduce disease morbidity and mortality. But as yet, this
potential to improve the public's health has been poorly tapped.
Today, we have an opportunity to begin to address how to improve
the performance of programs such as Medicare through the use of
preventive health services that address the behaviors that lead to the
onset of chronic diseases. These preventive health services, in fact,
could play an important role in our effort to modernize the Medicare
program.
We are beginning to see some good examples of what will emerge in
the marketplace. Private sector health plans are showing how best to
incorporate cutting edge and nontraditional benefits for the patients
they serve. There are numerous examples of Medicare+Choice
Organizations that have improved health care for their Medicare
beneficiaries through innovations focused on nutrition screening,
exercise and fitness programs, and disease management programs, for
example, which craft interventions to cater to beneficiaries with
specific chronic illnesses. These services are provided without any
additional reimbursement, as value added services.
Today, we will hear from a representative from one such
Medicare+Choice Organization that has implemented these types of
programs. I look forward to hearing about the benefits seen in offering
such a program to Medicare beneficiaries.
Let me also add that, if we are to succeed, eventually, in
improving the quality of health care for our Medicare beneficiaries, we
must focus on the need to enact comprehensive reforms. Our public
health programs must coordinate efforts to conduct and gather research
on the most effective means of preventing chronic diseases. Health
policy leaders must begin to work together to determine how best to
offer as sound benefits those clinical preventive services that have
been proven effective. Providers and health plans, both public and
private, must work together to develop uniform guidelines for working
with beneficiaries to guide them to the usage of the medical services
that will truly improve their health status.
Undertaking an effort to achieve comprehensive Medicare reform
should ultimately lead to the systemic changes necessary for
strengthening the longevity of this vital program--and bringing 21rst
Century style health care to Medicare. We can begin this important
process by taking measures this year to strengthen the Medicare+Choice
program and add a prescription drug benefit. Creating a wider variety
of health plan options, along with access to affordable prescription
drugs, will begin to provide Americans with the innovation and choices
needed to ensure their long term health.
We can also make major improvements to the Medicare Program by
moving towards a more competitive method of delivering health care
services to beneficiaries. Our Committee has spent a great deal of time
thinking through how the Federal Employees Health Benefits Program
(FEHBP) may be replicated in Medicare. FEHBP, unlike traditional
Medicare, doesn't require a statutory change to incorporate important
new preventive services into its benefit package. One of the principal
reasons why Medicare currently covers such few preventive benefits is
because seniors need to wait for an Act of Congress. This could change
if we move aggressively toward an FEHBP style, competitive model of
delivering health care to seniors.
I look forward to hearing the presentations of the witnesses today
and I thank you all for your testimony.
______
PREPARED STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
I would like to thank Chairman Greenwood for convening a hearing on
the important topic of improving Medicare for seniors and the disabled.
This hearing will focus specifically on increasing seniors' use of
preventive services, including cancer screenings and immunizations. We
should not, however, lose sight of the one preventive benefit that we
all agree must to be added to Medicare--prescription drug coverage.
Prescription drugs can prevent seniors with diseases from getting
sicker and enable others to manage chronic illnesses so they can live
productively. In short, prescription drugs are the most important
preventive benefit we can give seniors and the disabled.
Although there is consensus that Congress needs to create a
Medicare drug benefit, some may argue that we cannot afford to add a
comprehensive benefit at this time. At one point, there may have been
arguments that adding preventive services to Medicare was too
expensive. But we did it. We don't need more study, more evaluation, or
more demonstration projects to determine whether prescription drugs are
really the right way to improve the Medicare program. I hope that my
colleagues will join me this year and create a dependable,
comprehensive, defined prescription drug benefit that is affordable to
all seniors, regardless of whether they choose to participate in
Medicare+Choice or fee-for-service.
Today's witnesses will inform us about the progress that has been
made since Congress added a number of preventive services to Medicare
several years ago. The American Health Quality Association will testify
that their member organizations that contract with Medicare have
increased utilization rates of these benefits in the fee-for-service
program. Still, more work needs to be done to ensure that all seniors
can take advantage of these services. In particular, we need to examine
whether the 20 percent coinsurance rate is keeping seniors from getting
the preventive care they need.
Some people may argue that the best way to increase coverage for
preventive services is to pay Medicare+Choice plans extra dollars to
provide them. It is important, however, to remember that over 85
percent of seniors are enrolled in the fee-for-service program. Some of
these seniors have no Medicare+Choice plans available to them, while
others choose to stay in the traditional plan because it better meets
their needs. Relying solely on Medicare+Choice plans to provide more
preventive services would not improve care for the majority of seniors.
Worse yet, this approach would create a deliberate inequality in a
program that owes its success to its universality.
I look forward to the testimony from today's distinguished panels
and working with Chairman Greenwood to improve the Medicare program.
Mr. Greenwood. Okay, I should also advise you that it looks
like we may be in for some procedural battling today. I will
hope that these disruptions will be at a minimum, but I need to
run over and vote now. So we will recess only for about 15
minutes, and then we'll look forward to your testimony. Thank
you.
[Brief recess.]
Mr. Greenwood. The subcommittee will come to order. It
appears that we have about an hour before the next dilatory
move.
So we welcome our witnesses. The first panel consists of
Dr. Janet Heinrich, who is the Director of Health Care and
Public Health Issues at the U.S. General Accounting Office. Mr.
Tom Grissom is the Director for the Centers for Medicare
Management, Centers for Medicare and Medicaid Services; Dr.
David W. Fleming, Acting Director of the Centers for Disease
Control and Prevention; Dr. Carolyn Clancy, Acting Director,
Agency for Healthcare Research and Quality; and Dr. Dale
Bratzler, Principal Clinical Coordinator of the Oklahoma
Foundation for Medical Quality, Incorporated, on behalf of the
American Health Quality Association.
We welcome all of you. I assume that you are aware that
this is an investigative hearing, and it is our custom in this
committee to hold--take our testimony under oath. Do any of you
object to giving your testimony under oath? Okay.
Now, pursuant to the rules of this committee and pursuant
of the rules of the House, you're entitled to be represented by
counsel during your testimony. Do any of you wish to be
represented by counsel?
Seeing no such requests, then I would ask that you rise and
raise your right hands.
[Witnesses sworn.]
Mr. Greenwood. Okay. You are under oath, and you may give
your testimony.
We will begin with Dr. Heinrich. Welcome. Good morning.
TESTIMONY OF JANET HEINRICH, DIRECTOR, HEALTH CARE--PUBLIC
HEALTH ISSUES, U.S. GENERAL ACCOUNTING OFFICE; TOM GRISSOM,
DIRECTOR, CENTERS FOR MEDICARE MANAGEMENT, CENTERS FOR MEDICARE
AND MEDICAID SERVICES; DAVID W. FLEMING, ACTING DIRECTOR,
CENTERS FOR DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES; CAROLYN CLANCY, ACTING DIRECTOR,
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES; AND DALE BRATZLER, PRINCIPAL
CLINICAL COORDINATOR, OKLAHOMA FOUNDATION FOR MEDICAL QUALITY,
INC., THE AMERICAN HEALTH QUALITY ASSOCIATION
Ms. Heinrich. Good morning. Mr. Chairman, we're very
pleased to be here as you review the existing preventive health
care services offered in the Medicare program and consider
proposals for expanding these benefits. At your request, we are
issuing a report today that examines beneficiaries' use of
preventive services and actions taken by the Centers for
Medicare and Medicaid Services, CMS, to increase utilization.
As originally conceived, the Medicare program covered only
services for the diagnosis and treatment of illness and injury;
and, as you noted, since 1980 Congress has amended the Medicare
law several times to add coverage for certain preventive
services. These services include immunizations for pneumonia,
hepatitis B, influenza screening for five types of cancer, as
well as screening for osteoporosis and glaucoma. Except for flu
and pneumonia immunizations and laboratory tests, Medicare
requires some cost sharing by beneficiaries.
In our review of preventive services offered under
Medicare, we found that utilization has increased over time,
but it really does vary significantly by service. Beneficiaries
received screenings for breast and cervical cancer at high
rates, less so for immunizations, and the lowest screening
rates were for colorectal cancer.
Relatively few beneficiaries receive all of the services
that are covered. For example, although 91 percent of female
beneficiaries receive at least one service, only 10 percent
received the whole array of covered preventive services, for
example, cancer, breast and colon cancer screening, as well as
the immunizations.
In considering the strategies for improving utilization, it
is clear that targeting specific population groups can be
effective. Our review of utilization rates also showed
variation by State, ethnic group, income and education level.
Although the national breast cancer screening rates are about
75 percent--at least they were in 1999--rates for individual
States range from a low of 66 to a high of 86 percent. Among
ethnic groups, the biggest differences occurred in use of
immunization services, with over half of whites receiving
immunization against pneumonia and only about a third of
Hispanics and African Americans.
Beneficiaries with higher incomes and levels of education
tend to use preventive services more than those at lower
levels. It is evident from the work that CMS has conducted thus
far that a variety of efforts are needed to increase the use of
services.
CMS has sponsored reviews of studies to identify
interventions that are most effective at increasing
utilization. While these studies suggest no one approach works
in all situations, several show promise. For example, allowing
health care providers to forgo some compensation by waiving
deductibles has been successful, and reminders to physicians or
patients can effectively improve cancer screening rates.
Another positive step CMS has taken is to contract with the
quality improvement organizations to increase use of three
services. These are the immunizations for flu and pneumonia and
for breast cancer screening. These organizations are developing
reminder systems and conducting activities to educate patients
and providers. They are also starting demonstrations to
increase use of preventive services by minorities and low-
income beneficiaries. Evaluating these efforts to identify the
most effective approaches will be extremely important for
further improvements in the Medicare program.
As the Congress considers broadening Medicare's coverage of
preventive services, you will likely consider the
recommendations of the U.S. Preventive Services Task Force, a
group of experts who evaluate evidence to determine
effectiveness of preventive services for different age and risk
groups. Medicare covers many but not all of the services
recommended by the task force. For example, the task force
recommends blood pressure and cholesterol screening, services
not explicitly covered by Medicare now.
This is true for a variety of counseling services as well.
Older people do report that they are having their blood
pressure and cholesterol checked. It is not clear, however,
that counseling intended to change unhealthy behaviors is
occurring during regular office visits, nor has research
established the effectiveness of well-defined clinical
counseling to actually change risky behavior.
In conclusion, it is important to recognize the difficulty
of translating some of the preventive service recommendations
into covered benefits. Nevertheless, we believe that it is
important to regularly review Medicare coverage of preventive
services as information on effectiveness of these services
becomes available. It is also important to continue to explore
approaches to encourage older Americans to use existing covered
services.
Thank you. I'm happy to answer any questions.
[The prepared statement of Janet Heinrich follows:]
PREPARED STATEMENT OF JANET HEINRICH, DIRECTOR, HEALTH CARE--PUBLIC
HEALTH ISSUES, UNITED STATES ENERAL ACCOUNTING OFFICE
Mr. Chairman and Members of the Subcommittee: We are pleased to be
here today as you review existing preventive health care services
offered in the Medicare program and consider proposals for expanding
these benefits. At your Subcommittee's request, we have been examining
several issues related to preventive services and have prepared a
report that is being released today.<SUP>1</SUP> My statement today
highlights some of the key aspects of that report.
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\1\ U.S. General Accounting Office, Medicare: Beneficiary Use of
Clinical Preventive Services, GAO-02-422 (Washington, D.C.: April 12,
2002).
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Preventive health care services, such as flu shots and cancer
screenings, can extend lives and promote the well-being of our nation's
seniors. Medicare now covers 10 preventive services--3 types of
immunizations and 7 types of screening--and legislation has been
introduced to cover additional services.<SUP>2</SUP> However, not all
beneficiaries avail themselves of Medicare's preventive services. Some
beneficiaries may simply choose not to use them, but others may be
unaware that these services are available or covered by Medicare.
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\2\ A bill introduced last year proposes adding visual acuity,
hearing impairment, cholesterol, and hypertension screenings as well as
expanding the eligibility of individuals for bone density screenings.
See H.R. 2058, 107th Cong. Sec. 203 (2001).
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You asked us to examine two questions regarding preventive services
for older Americans:
<bullet> To what extent are Medicare beneficiaries using covered
preventive services?
<bullet> What actions have the Centers for Medicare and Medicaid
services (CMS), which administers Medicare, taken to increase
beneficiaries' use of preventive services?
Our data on the extent to which beneficiaries are using covered
services are taken primarily from a survey conducted by the Centers for
Disease Control and Prevention (CDC), another agency that like CMS is
within the Department of Health and Human Services. The survey collects
information on the use of several preventive services covered under
Medicare, including immunizations for influenza and pneumococcal
disease, and screening for breast, cervical, and colon cancer.
In summary, although use of Medicare covered preventive services is
growing, it varies from service to service and by state, ethnic group,
income, and level of education. For example, in 1999, 75 percent of
women had been screened within the previous 2 years for breast cancer,
compared with 55 percent of beneficiaries who had ever been immunized
against pneumonia. However, even for a widely used preventive service
such as breast cancer screening, state-by-state usage rates ranged from
66 to 86 percent. Among ethnic groups, differences were greatest for
immunizations. For example, 1999 data show that about 57 percent of
whites and 54 percent of ``other'' ethnic groups had been immunized
against pneumonia, compared to about 37 percent of African Americans
and Hispanics.<SUP>3</SUP> Among income and educational groups,
variation was greatest for cancer screening.
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\3\ ``Other'' ethnic groups include survey respondents who reported
an ethnicity other than African American, Hispanic, or white.
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To help ensure that preventive services are being delivered to
those beneficiaries who need them, CMS sponsors activities--called
``interventions''--aimed at increasing use. CMS currently funds
interventions aimed at increasing the use of three services--breast
cancer screening and immunizations against flu and pneumonia--in each
state. CMS also pays for interventions that focus on increasing use of
services by minorities and low-income beneficiaries who have low usage
rates. The techniques being used in some of these interventions, such
as allowing nurses or other nonphysician medical personnel to
administer vaccinations with a physician's standing order, have been
found effective in the past. CMS is evaluating the effectiveness of
current efforts and expects to have the evaluation results later in
2002.
TYPE OF SERVICES COVERED
When the Medicare program was established in 1965, it only covered
health care services for the diagnosis or treatment of illness or
injury. Preventive services did not fall into either of these
categories and, consequently, were not covered. Since 1980, the
Congress has amended the Medicare law several times to add coverage for
certain preventive services for different age and risk groups within
the Medicare population. These services include three types of
immunizations--pneumococcal disease, hepatitis B, and influenza.
Screening for five types of cancer--cervical, vaginal, breast,
colorectal, and prostate--are also covered, as well as screening for
osteoporosis and glaucoma. Except for flu and pneumonia immunizations,
and laboratory tests, Medicare requires some cost-sharing by
beneficiaries. Most beneficiaries have additional insurance, which may
cover most, if not all, of these cost-sharing requirements.<SUP>4</SUP>
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\4\ U.S. General Accounting Office, Medigap Insurance: Plans Are
Widely Available but Have Limited Benefits and May Have High Costs,
GAO-01-941 (Washington, D.C.: July 31, 2001).
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For a number of reasons, not all Medicare beneficiaries are likely
to use these services. For some beneficiaries, certain services may not
be warranted or may be of limited value. Screening women for cervical
cancer is an example. Survey data show that 44 percent of women age 65
and over have had hysterectomies--an operation that usually includes
removing the cervix.<SUP>5</SUP> For these women, researchers state
that cervical cancer screening may not be necessary unless they have a
prior history of cervical cancer.<SUP>6</SUP> Also, patients with
terminal illnesses or of advanced age may decide to forgo services
because of the limited benefits preventive services would offer.
Research has shown, for example, that the benefits of cancer screening
services, such as for prostate, breast, and colon cancer, can take 10
years or more to materialize. Finally, the controversy over the
effectiveness of some services, such as mammography and prostate cancer
screening, may add to the difficulty in further improving screening
rates for these services.
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\5\ Data are from the CDC's Behavioral Risk Factor Surveillance
System (BRFSS), 2000.
\6\ CDC researchers report that among the general population, over
80 percent of hysterectomies are performed for noncancerous conditions
such as fibroids and endometriosis.
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To help determine which preventive services are beneficial among
various patient populations, the U.S. Department of Health and Human
Services established a panel of experts in 1984, called the U.S.
Preventive Services Task Force. The task force identifies and
systematically evaluates the available evidence to determine the
effectiveness of preventive services for different age and risk groups,
and then makes recommendations as to their use. Task force
recommendations were first published in the Guide to Clinical
Preventive Services in 1989, and are periodically updated as new
evidence becomes available. These recommendations are for screening,
immunizations, and counseling services that are specific for each age
group, including people 65 and older. See table 1 for the task force
recommendations for various preventive services including those
currently covered by Medicare.
Table 1: Preventive Services Covered by Medicare or Recommended by the Task Force
----------------------------------------------------------------------------------------------------------------
Task force Year first covered by
Service recommendation for age Medicare as preventive Medicare cost-sharing
65+ service requirement <SUP>a</SUP>
----------------------------------------------------------------------------------------------------------------
Immunizations
Pneumococcal......................... Recommended............ 1981................... None
Hepatitis B.......................... No recommendation...... 1984................... Copayment after
deductible
Influenza............................ Recommended............ 1993................... None
Tetanus-diphtheria (Td) boosters..... Recommended............ Not covered............ N/A
Screening
Cervical cancer--pap smear........... Recommended <SUP>b</SUP>.......... 1990................... Copayment with no
deductible <SUP>c</SUP>
Breast cancer--mammography........... Recommended <SUP>d</SUP>.......... 1991................... Copayment with no
deductible
Vaginal cancer--pelvic exam.......... No recommendation...... 1998................... Copayment with no
deductible <SUP>c</SUP>
Colorectal cancer--fecal-occult blood Recommended............ 1998................... No copayment or
test. deductible
Colorectal cancer--sigmoidoscopy..... Recommended............ 1998................... Copayment after
deductible <SUP>e</SUP>
Colorectal cancer--colonoscopy....... No recommendation...... 1998................... Copayment after
deductible <SUP>e</SUP>
Osteoporosis--bone mass measurement.. No recommendation...... 1998................... Copayment after
deductible
Prostate cancer--prostate-specific Not recommended........ 2000................... Copayment after
antigen test and/or digital rectal deductible <SUP>c</SUP>
examination.
Glaucoma............................. No recommendation...... 2002................... Copayment after
deductible
Vision impairment.................... Recommended............ Not covered............ N/A
Hearing impairment................... Recommended............ Not covered............ N/A
Height, weight, and blood pressure... Recommended............ Not covered............ N/A
Cholesterol measurement.............. Recommended............ Not covered............ N/A
Problem drinking..................... Recommended............ Not covered............ N/A
Counseling
Diet and exercise, smoking cessation, Recommended<SUP>f</SUP>........... Not covered............ N/A
injury prevention, and dental health.
Postmenopausal hormone prophylaxis... Recommended............ Not covered............ N/A
Aspirin for primary prevention of Recommended............ Not covered............ N/A
cardiovascular events.
----------------------------------------------------------------------------------------------------------------
<SUP>a</SUP> Applicable Medicare cost-sharing requirements generally include a 20 percent copayment after a $100 per year
deductible. Each year, beneficiaries are responsible for 100 percent of the payment amount until those
payments equal a specified deductible amount, $100 in 2002. Thereafter, beneficiaries are responsible for a
copayment that is usually 20 percent of the Medicare approved amount. For certain tests, the copayment may be
higher. See 42 U.S.C. Sec. 1395(a)(1).
<SUP>b</SUP> The task force found insufficient evidence to recommend for or against an upper age limit for pap testing, but
recommendations can be made on other grounds to discontinue regular testing after age 65 in women who have had
regular previous screenings in which the smears have been consistently normal.
<SUP>c</SUP> The costs of the laboratory test portion of these services are not subject to copayment or deductible. The
beneficiary is subject to a deductible and/or copayment for physician services only.
<SUP>d</SUP> The task force recommends routine screening for breast cancer every 1 to 2 years, with mammography alone or
along with an annual clinical breast examination, for women aged 50 to 69. The task force found insufficient
evidence to recommend for or against routine mammography or clinical breast examination for women aged 40 to
49 or aged 70 and older.
<SUP>e</SUP> The copayment is increased from 20 to 25 percent for services rendered in an ambulatory surgical center.
<SUP>f</SUP> The task force recommends these counseling services on the basis of the proven benefits of modifying harmful
or risky behaviors. However, the effectiveness of clinician counseling to change these behaviors has not been
adequately evaluated.
Source: U.S. General Accounting Office, Medicare: Beneficiary Use of Clinical Preventive Services, GAO-02-422
(Washington, D.C.: Apr. 12, 2002) and U.S. Preventive Services Task Force, Guide to Clinical Preventive
Services, 2nd ed. (Washington, DC, 1996) and related updates.
As table 1 shows, Medicare explicitly covers many, but not all, of
the preventive services recommended by the task force. However,
beneficiaries may receive some of the preventive services not
explicitly covered by Medicare. For example, even though blood pressure
and cholesterol screening are not explicitly covered under Medicare, in
1999, nearly 98 percent of seniors reported that they had had their
blood pressure checked within the last 2 years, and more than 88
percent of seniors reported having their cholesterol checked within the
prior 5 years.<SUP>7</SUP> Other task force recommended services--such
as counseling intended to change a patient's unhealthy or risky
behaviors--may also be occurring during office visits.<SUP>8</SUP>
Determining the extent to which these preventive counseling services
occur is difficult, in part, because the content of such services is
not well defined. It is also interesting to note that the task force
recommends these counseling services on the basis of the proven
benefits of a good diet, daily physical activity, smoking cessation,
avoiding household injuries such as falls, and avoiding dental caries
(tooth decay) and periodontal (gum and bone) disease. However, the
effectiveness of clinician counseling to actually change these patient
behaviors has not been established.
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\7\ Survey data are from the CDC's BRFSS 1999.
\8\ Counseling women regarding hormone replacement therapy, and all
beneficiaries regarding the use of aspirin for the prevention of
cardiovascular events is not necessarily intended to change behavior.
Rather, it is intended to provide the patient current information on
both the potential benefits and risks of these therapies. The task
force recommends that the decision to undertake these therapies should
be based on patient risk factors for disease and a clear understanding
of the probable benefits and risks of these therapies.
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USE OF PREVENTIVE SERVICES IS GROWING BUT VARIES WIDELY
Use of preventive services offered under Medicare has increased
over time. For example, in 1995, 38 percent of beneficiaries had been
immunized against pneumonia, compared with 55 percent in 1999.
Similarly, the use of mammograms at recommended intervals had increased
from 66 percent in 1995 to 75 percent in 1999. While these examples
show that use of preventive services generally is increasing, they also
show variation in use by service. Beneficiaries received screenings for
breast and cervical cancer at higher rates than they did immunizations
against flu and pneumococcal disease. Of the services for which data
are available, colorectal screening rates were the lowest, with 25
percent of the beneficiaries receiving a recommended fecal occult blood
test within the past year, and 40 percent receiving a recommended
colonoscopy or sigmoidoscopy procedure within the last 5 years.
Relatively few beneficiaries receive multiple services. While 1999
utilization data show progress in improving receipt of preventive
services, and in some cases relatively high rates of use for individual
services, a small number of beneficiaries access most of the services.
For example, although 91 percent of female Medicare beneficiaries
received at least 1 preventive service, only 10 percent of female
beneficiaries were screened for cervical, breast, and colon cancer, and
immunized against both flu and pneumonia.
Although national rates provide an overall picture of current use,
they mask substantial differences in how seniors living in different
states use some services. For example, the national breast cancer
screening rate for Medicare beneficiaries was 75 percent in 1999, but
rates for individual states ranged from a low of 66 percent to a high
of 86 percent. Individual states also ranged from 27 percent to 46
percent in the extent to which beneficiaries receiving a colonoscopy or
sigmoidoscopy for cancer screening.
Usage rates also varied based by beneficiary, income, and
education. Among ethnicity groups, the biggest differences occurred in
use of immunization services. For example, 1999 data show that about 57
percent of whites and 54 percent of ``other'' ethnic groups were
immunized against pneumonia, compared to about 37 percent of African
Americans and Hispanics. Similarly, about 70 percent of whites and
``other'' ethnic groups received flu shots during the year compared to
49 percent of African Americans. Beneficiaries with higher incomes and
levels of education tend to use preventive services more than those at
lower levels.
EFFORTS UNDERWAY TO INCREASE USE OF SOME PREVENTIVE SERVICES
CMS has conducted a variety of efforts to increase the use of
preventive services. These include identifying which approaches work
best and sponsoring specific initiatives to apply these approaches in
every state.
Studies Identify Effective Methods to Increase Use of Services
To identify how best to increase use of preventive services needed
by the Medicare population, CMS sponsors reviews of studies that
examine various kinds of interventions used in the past.<SUP>9</SUP>
Among the CMS-sponsored reviews was one that examined the effectiveness
of various interventions for flu and pneumonia immunizations and
screenings for breast, cervical, and colon cancer.<SUP>10</SUP> This
evaluation, which consolidated evidence from more than 200 prior
studies, concluded that no specific intervention was consistently most
effective for all services and settings.
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\9\ CMS also conducts a variety of health promotion activities to
educate beneficiaries about the benefits of preventive services and to
encourage their use. These include the publication of brochures on
certain covered services and media campaigns.
\10\ Health Care Financing Administration, Evidence Report and
Evidence-Based Recommendations: Interventions that Increase the
Utilization of Medicare-Funded Preventive Services for Persons Age 65
and Older, Publication No. HCFA-02151 (Prepared by Southern California
Evidence-based Practice Center/RAND, 1999).
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While no one approach appears to work in all situations, the CMS
evaluation concluded that system changes and financial incentives were
the most consistent at producing the largest increase in the use of
preventive services.
<bullet> System changes. These interventions change the way a
health system operates so that patients are more likely to receive
services. For example, standing orders may be implemented in nursing
homes to allow nurses or other nonphysician medical personnel to
administer immunizations.
<bullet> Incentives. These interventions include gifts or vouchers
to patients for free services. Medicare allows providers to use this
type of approach only in limited circumstances.<SUP>11</SUP> For
example, in order to encourage the use of preventive services,
providers may forgo some compensation by waiving coinsurance and
deductible payments for Medicare preventive services. In addition,
other types of incentives--such as free transportation or gift
certificates--are also allowed so long as the incentive is not
disproportionately large in relationship to the value of the preventive
service.
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\11\ Under regulations that became effective on April 26, 2000,
Medicare providers may offer certain incentives for preventive
services. Under no circumstances may cash or instruments convertible to
cash be used. See 42 CFR Sec. 1003.101.
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Other interventions found to be effective--though to a lesser
degree than the categories above--are reminder systems and education
programs.
<bullet> Reminders. These interventions include approaches to (1)
remind physicians to provide the preventive service as part of services
performed during a medical visit or (2) generate notices to patients
that it is time to make an appointment for the service. Studies show
that reminders to either physicians or patients can effectively improve
rates for cancer screening. However, if a computerized information
system is present in a medical office, computerized provider reminders
are consistently more cost-effective than notifying the patient
directly. Patient reminders that are personalized or signed by the
patient's physician are more effective than generic reminders.
<bullet> Education. These interventions include pamphlets, classes,
or public events providing information for physicians or beneficiaries
on coverage, benefits, and time frames for services. The review found
that while the effect of patient education is significant, it has the
least effect of any of these types of interventions.
CMS Is Sponsoring Efforts to Increase Use of Services
CMS contracts with 37 Quality Improvement Organizations (QIOs),
each responsible for monitoring and improving the quality of care for
Medicare beneficiaries in one or more states, in the District of
Columbia, or in U.S. territories.<SUP>12</SUP> QIO activities currently
aim to increase use of three Medicare preventive services--
immunizations against flu and pneumonia and screening for breast
cancer.
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\12\ CMS formerly referred to this program as the Peer Review
Organization program. During the course of our review CMS began
referring to these entities as Quality Improvement Organizations. CMS
officials told us that CMS plans to formalize the name change in a
future Federal Register notice.
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QIOs are using various methods of increasing the use of these
preventive services. For example, they are developing reminder systems,
such as chart stickers or computer-based alerts, that remind physicians
to contact patients on a timely basis for breast cancer screening. QIOs
are also conducting activities to educate patients and providers on the
importance of flu and pneumonia shots. CMS has taken steps to evaluate
the success of these efforts. CMS officials explained that the
contracts with the QIO organizations are ``performance based'' and
provide financial incentives as a reward for superior outcomes. CMS
officials expect information on the results by the summer of 2002.
CMS plans to expand these efforts by QIOs. While the current
efforts include only 3 of the preventive services covered by Medicare,
CMS is also planning to include requirements for the QIOs to increase
the use of screening services for osteoporosis, colorectal, and
prostate cancer in future QIO contracts. CMS is not currently planning
to include QIO contract requirements for the remaining preventive
services covered by Medicare--hepatitis B immunizations or screenings
for glaucoma and vaginal cancer.
Other specific efforts have been started to increase use of
preventive services by minorities and low-income Medicare beneficiaries
in each state. CMS-funded research on successful interventions for the
general Medicare population 65 and older concluded that evidence was
insufficient to determine how best to increase use of services by
minority and low-income seniors. To address this lack of information,
CMS has tasked each QIO to undertake a project aimed at increasing the
use of a preventive service in a given population. For example, the QIO
may work with community organizations, such as African American
churches, in order to convince more women to receive mammograms. CMS
expects to publish a summary of QIO efforts to increase services for
minorities and low-income seniors after the spring of 2002.
Finally, other studies or projects that CMS has under way aim to
identify barriers and increase use of services by certain Medicare
populations. For example, the Congress directed CMS to conduct a
demonstration project to, among other things, develop and evaluate
methods to eliminate disparities in cancer prevention screening
measures.<SUP>13</SUP> These demonstration projects are in the planning
stages. A report evaluating the cost-effectiveness of the demonstration
projects, the quality of preventive services provided, and beneficiary
and health care provider satisfaction is due to the Congress in 2004.
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\13\ See the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000, Public Law 106-554, Appendix F, Sec. 122, 114
Stat. 2763, 2763A-476 classified to 42 U.S.C. Sec. 1395b-1 nt.
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CONCLUDING OBSERVATIONS
Medicare beneficiaries are making more use of preventive services
than ever before, but there is still room for improvement. While most
preventive services are used by a majority of beneficiaries, few
beneficiaries receive multiple services. Also, disparities exist in the
rates that beneficiaries of different ethnic groups, income and
education levels use Medicare covered preventive services. CMS has
activities underway that have the potential to increase usage of
preventive services. However, the full effect of these activities will
not be known for quite some time.
As the Subcommittee and Congress consider broadening Medicare's
coverage of preventive services, it is important to recognize the
difficulty of translating some preventive service recommendations into
covered benefits. For example, inclusion of behavioral counseling
services may be beneficial, but reaching consensus on common
definitions of these services remains a major challenge. Establishing
Medicare coverage for some screening activities such as blood pressure
and cholesterol screening may not be necessary since most beneficiaries
already receive these services. Nevertheless, we believe that it is
important to regularly review Medicare's coverage of preventive
services as information on the effectiveness of such services becomes
available. It is also important to continue to explore new approaches
to encourage beneficiaries to avail themselves of the preventive
services Medicare covers.
This concludes my prepared statement, Mr. Chairman. I will be happy
to respond to any questions that you or Members of the Subcommittee may
have.
Mr. Greenwood. Thank you so much.
Dr. Grissom.
TESTIMONY OF TOM GRISSOM
Mr. Grissom. Thank you, Chairman Greenwood. It is a
pleasure to be here. Thank you for giving me the opportunity to
talk with you about coverage of preventive services within the
Medicare program. We, too, like you, believe that preventive
services and health screenings do extend lives and improve and
promote wellness throughout the country.
The President, the Secretary and the Administrator of CMS
strongly support preventive health care and recognize the need
to strengthen and improve the Medicare program by moving its
benefits package from the current reactive acute care model to
one which comprehensively and systematically emphasizes health
promotion and disease prevention.
When the program was established in 1965, it was
essentially and exclusively for the diagnosis and treatment of
illness or injury and is limited to this day by that Medicare
statute. The law then reflected the health care system at that
time. Since then Congress, recognizing the changes in health
practice, began to modify the law first--or most importantly in
the BBA and later in BIPA in 2000 to increase benefits for
preventive services, and over time has lowered the threshold,
increased the coverage and reduced copays and deductibles,
trying to make the Medicare program commensurate with or mirror
private health care.
In addition to the benefits offered under the original fee-
for-service, the Medicare law allows for private health plans,
Medicare+Choice and the risk plans, which give beneficiaries
expanded benefits especially in the area of vision care, dental
care, smoking cessation counseling, as well as disease
management and care coordination. The administration's goal is
committed to providing even greater availability of these
important preventive and innovative benefits by making these
private plans available more widely and to more beneficiaries.
Additionally, as part of his overall framework for Medicare
in the 21st century, President Bush has proposed giving seniors
better coverage of these benefits by making them cost-free. I'm
sure this morning we'll talk about the barriers to access and
the utilization rates of these services, and there is clear
evidence that cost may be an obstacle for certain kinds of
beneficiaries and dual eligibles.
We know that simply offering these benefits is not enough
to guarantee their utilization. We work at CMS with a variety
of other agencies, with our quality improvement organizations
to develop and use efficient approaches and methods to reach
out to beneficiaries. Education is absolutely essential to
improving utilization of these services. We include health
promotion information as part of our Medicare information
campaigns. We work with the National Cancer Institute, CDC, the
National Diabetes Institute, the National Eye Institute on
media campaigns at the local and the national level. We
integrate these messages in our promotional materials, our
Medicare and You handbook, and through the use of our 1-800
hotline. I have an example of those materials, Mr. Chairman,
and I would enjoy sharing them with you.
We are also utilizing increasingly tabs and insertions like
this from the carriers to beneficiaries in their summary of
notices so that they understand that they do have a benefit,
and we're trying to coordinate those with national campaigns
month to month throughout the year with the individual
preventive services.
The QIOs, which are groups of physicians in all of the
States, have a number of projects, Dr. Bratzler will testify
later, in which they are focusing on improving coverage of
the--the access to the benefits and utilization. There were
also focuses on working with minority groups and ethnic groups
and economically disadvantaged groups, where the utilization
rate is the lowest. Lots of those programs are innovative. They
are private-public partnerships, and we think that they are
quite effective.
Additionally, we're trying to change the way the
organizations work, and there is within our agency a regulation
under way that would alter the conditions of participation for
nursing homes, hospitals and home health that would allow
flexibility in standing orders, so that there were no
regulatory obstacles to beneficiaries receiving flu, hepatitis
B and pneumococcal vaccinations without having to go through a
physician's order.
There is the Healthy Aging Project, which we operate in
conjunction with AHRQ and the Centers for Disease Control, in
which we're trying to identify, test and disseminate evidence-
based approaches to promote health and functional decline in
older adults. We know that 70 percent of the decline in aging
is a result of environmental, behavioral, lifestyle causes, and
30 percent only by virtue of genetics. Thus, we are trying to
do risk appraisals, figure out the best way to identify risks
and to create educational programs that will have timely
follow-up and interventions that truly alter an individual's
behavior. Not much is known about this, certainly not enough,
and we are in partnership with Brandeis University to develop
pilot programs and to do so in a way which is education-based.
We also have a demonstration project about to launch in CMS
on smoking cessation. It is a result of BIPA 2000. It will
focus on seven States with four different treatment scenarios
for about 40,000 beneficiaries, for which we think there is a
great possibility and great opportunity for improvements.
Health risk appraisals focus on the area of diet and
physical activity. There is plenty of empirical evidence to
suggest that these are important. Secretary Thompson, both
personally and professionally, has talked about how a little
prevention won't kill you and is trying to give personal
leadership to changes in individual behavior as leading to
healthy lives. Again, our goal is to try increase access to and
in promotion of these efforts at CMS and in the Medicare
program.
We appreciate the opportunity to be here, and are thankful
for the attention that you're bringing to this. Thank you, and
I'll be glad to answer any questions.
[The prepared statement of Tom Grissom follows:]
PREPARED STATEMENT OF TOM GRISSOM, DIRECTOR, CENTER FOR MEDICARE
MANAGEMENT, CENTERS FOR MEDICARE & MEDICAID SERVICES
Chairman Greenwood, Congressman Deutsch, distinguished Subcommittee
members, thank you for inviting me to discuss Medicare coverage of
preventive services. Preventive care services can extend lives and
promote wellness among America's seniors. The President, the Secretary,
and CMS strongly support preventive health care services for Medicare
beneficiaries, and the Administration has proposed several initiatives
related to prevention that I will discuss in greater detail later in my
testimony. First, I would like to discuss the nature of preventive
health care benefits in the Medicare program and what benefits are
currently covered under Medicare.
BACKGROUND
When Medicare was established in 1965, the program covered only
those health care services necessary for the diagnosis or treatment of
illness or injury, as limited by the Medicare statute and reflecting
the health care system at that time. Consequently, Medicare, as a
general rule, did not cover routine screening or other purely
preventive benefits. However, Congress recently has expanded the
program to come closer to modeling the preventive care concepts in
private health care programs and has added a number of preventive and
screening benefits to the program. Both the Balanced Budget Act of 1997
(BBA) and the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA) significantly added to, or expanded, the
preventive benefits covered by Medicare. These benefits include:
<bullet> Screening Mammography: BBA expanded coverage to include an
annual screening mammogram for all women Medicare beneficiaries age
40 and over, and one baseline mammogram for women age 35-39. BIPA
moved payment for screening mammography to the physician fee
schedule and also specified payment for two new forms of
mammography that use digital technology.
<bullet> Screening Pap Smears and Pelvic Exams: BBA provided coverage
for a screening Pap smear and pelvic exam (including a clinical
breast exam) every 3 years, or annual coverage for women of
childbearing age who have had an abnormal Pap smear during the
preceding 3 years, or women at high risk for cervical or vaginal
cancer. BIPA increased the frequency of coverage for screening Pap
smears and pelvic exams (including a clinical breast exam) from
every 3 years to every 2 years for women at average risk.
<bullet> Colorectal Cancer Screening: BBA provided coverage for
colorectal cancer screening procedures including: (1) annual fecal-
occult blood tests for persons age 50 and over; (2) flexible
sigmoidoscopy for persons age 50 and over, every 4 years; (3)
colonoscopy for persons at high risk for colorectal cancer, every 2
years; and (4) other procedures the Secretary finds appropriate.
Barium enemas are also covered as an alternative to flexible
sigmoidoscopy or colonoscopy. BIPA expanded coverage of screening
colonoscopies to include all beneficiaries, not just those at high
risk for colorectal cancer.
<bullet> Prostate Cancer Screening: BBA provided coverage of annual
prostate cancer screening for men over age 50, including: (1)
digital rectal exams; (2) prostate-specific antigen (PSA) blood
tests; and (3) after 2002, other procedures the Secretary finds
appropriate.
<bullet> Glaucoma Screening: BIPA provided coverage of annual glaucoma
screening for individuals at high risk for glaucoma, individuals
with a family history of glaucoma, and individuals with diabetes.
<bullet> Diabetes Self-Management Benefits: BBA provided coverage for
outpatient diabetes self-management training in both hospital-based
and non-hospital-based programs, and for blood glucose monitors and
testing strips for all diabetics.
<bullet> Medical Nutrition Therapy Services: BIPA provided coverage of
medical nutrition therapy services for beneficiaries who have
diabetes or a renal disease. Covered services include nutritional
diagnostic, therapy and counseling services for the purpose of
disease management, which are furnished by a registered dietician
or nutrition professional, pursuant to a physician's referral.
<bullet> Standardization of Coverage for Bone Mass Measurements: BBA
provided coverage for bone mass measurement procedures, including a
physician's interpretation of the results, for estrogen-deficient
women at risk for osteoporosis, and persons: (1) with vertebral
abnormalities; (2) receiving long-term glucocorticoid steroid
therapy; (3) with primary hyperparathyroidism; and (4) being
monitored for response to an osteoporosis drug.
<bullet> Vaccines Outreach Extension: BBA extended, through FY 2002,
the existing Influenza and Pneumococcal Vaccination Campaign
conducted by our Agency in conjunction with CDC and the National
Coalition for Adult Immunization. Medicare covers influenza,
pneumococcal, and hepatitis B vaccinations, including payment for
the vaccine plus payment for a physician's administration of the
vaccine.
The BBA and BIPA also required CMS to conduct analyses of Medicare
preventive benefits. Under the BBA, we worked in conjunction with the
Institute of Medicine and the U.S. Preventive Services Task Force to
conduct a study of short- and long-term costs and benefits of expanding
or modifying preventive or other services covered by Medicare. This
analysis was completed in December 1999. Similarly, we are currently
working with the National Academy of Sciences in conjunction with the
U.S. Preventive Services Task Force to conduct, as required under BIPA,
a study on the addition of coverage of routine thyroid screening using
a thyroid stimulating hormone test as a preventive benefit.
In addition to the prevention benefits added to the program since
1997, Medicare has begun to offer additional preventive health care
services through the Medicare+Choice program. Unlike the Medicare fee-
for-service program whose benefits are tied to statute, the private
companies that provide Medicare+Choice have the flexibility to cover
additional services, such as immunizations, exercise programs, cancer
screening, and health education, that are not covered under the
traditional Medicare benefits package. For example, one Medicare+Choice
plan in California has a successful outreach program to increase
influenza vaccination rates among their elderly and chronically ill
beneficiaries to reduce mortality and morbidity among these at-risk
populations. And a Boston Medicare+Choice plan has a comprehensive
disease management program for its enrollees with diabetes. The result
has been significant increases in the share of enrollees who receive
preventive treatments like annual retinal eye exams and kidney tests,
and better blood sugar control and cholesterol levels, all of which
prevent the life-threatening complications of diabetes. The
Administration is committed to providing greater availability of
innovative preventive benefits by making private plan options more
widely available to beneficiaries. This is key to improving beneficiary
access to preventive benefits and to strengthening the overall Medicare
program.
In addition, Medicare+Choice programs typically provide some form
of disease management or care coordination program, a service not
covered in traditional Medicare. Several studies have suggested that
case management and disease management programs can improve medical
treatment plans, reduce avoidable hospital admissions, and promote
other desirable outcomes. Coordination of care has the potential to
improve the health status and quality of life for beneficiaries with
chronic illnesses. We believe disease management has potential for
preventing the worsening of chronic health conditions, and we are
currently undertaking a series of disease management demonstration
projects to explore a variety of ways to improve beneficiary care in
the traditional Medicare plan.
THE ADMINISTRATION'S COMMITMENT TO PREVENTIVE CARE
Obviously, Medicare's coverage of preventive benefits has come a
long way since the statute was written in the 1960s when the positive
impact of preventive services was not fully understood. However,
Medicare's coverage of preventive services can be improved. Under
current law, Congress must enact legislation authorizing Medicare to
cover specific preventive benefits. This approach can lead to
fragmentation, and may not be consistent with a comprehensive,
evidence-based approach to health promotion. The President recognizes
the need to improve and strengthen the Medicare program by moving its
benefits package from a reactive, acute care model to one that
comprehensively and systematically emphasizes health promotion and
disease prevention. As part of his principles for strengthening
Medicare, the President has proposed to give seniors better coverage of
preventive treatments by making existing preventive benefits cost-free
for seniors.
Secretary Thompson has reinforced the Administration's commitment
to disease prevention by promoting healthy behavior as a priority for
his Department, and even discussing in recent weeks his personal
efforts to adopt a healthier lifestyle. To this end, HHS supports a
number of programs to promote better health for all Americans,
including:
<bullet> Healthy Communities Innovation Initiative. President Bush's
fiscal year 2003 budget includes $20 million for a new Healthy
Communities Innovation Initiative, an effort to bring together
community-wide resources to help prevent diabetes, asthma and
obesity.
<bullet> Healthy People 2010. Healthy People 2010, a comprehensive set
of objectives for the nation to meet by the end of this decade,
identifies the most significant preventable threats to health and
establishes national goals to reduce these threats.
<bullet> Leading Health Indicators. The first annual report on the 10
leading health indicators, critical factors that have a profound
influence on the health of individual communities and the nation,
will be released this year. They represent the major public health
concerns in the United States where individuals and communities can
take action to realize significant health improvements.
HEALTH PROMOTION ACTIVITIES
Secretary Thompson, Administrator Scully, and I support the
President's commitment to expand beneficiary access to preventive
health services, and we are working on ways to improve health quality
for America's most vulnerable citizens. As you may know, simply
offering coverage for preventive health care services is not always
enough to guarantee that Medicare beneficiaries take advantage of the
benefits. That is why we strive to use efficient and cost effective
approaches by partnering with other agencies and organizations,
utilizing Medicare contractors to educate people with Medicare about
covered preventive services and encouraging beneficiaries to use these
services. To this end, we include health promotion information as a
part of many education campaigns that address different aspects of the
Medicare program or Medicare+Choice options. We have established
partnerships with other HHS agencies, such as the Centers for Disease
Control and Prevention (CDC) and the NIH's National Cancer Institute
(NCI) to carry out health promotion initiatives, distribute outreach
kits, and produce multi-media, multi-year campaigns involving numerous
partners at the local and national level.
In addition, we integrate communications about preventive services
with other Medicare educational initiatives, such as:
<bullet> The Medicare and You handbook, which is distributed to all
beneficiary households, includes information on Medicare-covered
preventive services. We also publish and distribute a brochure
entitled, Medicare Preventive Services . . . To Help Keep You
Healthy that provides more detailed information about Medicare's
preventive benefits, plus reminder cards showing how often
beneficiaries should receive screenings.
<bullet> Medicare carriers and intermediaries include messages on the
importance of preventive services when they send out Medicare
Summary Notices. These messages are sent during certain months of
the year to correspond with health themes, such as Colorectal
Cancer Awareness Month. The carriers and intermediaries also
discuss these services and distribute materials to Medicare
beneficiaries when they give talks on other Medicare issues. And
they include articles on preventive services in their newsletters
and on their websites.
<bullet> Our regional offices also are involved in outreach. They
disseminate information on preventive services during other
information campaigns, such as during our successful Regional
Education About Choices in Health (REACH) campaigns.
<bullet> Our 1-800-MEDICARE help line and Medicare.gov Internet site
also include information on preventive health services, including
coverage, screening techniques, and where to locate additional
information.
<bullet> We also use targeted promotions to educate beneficiaries about
particular preventive services. For example, we have produced and
distributed more than 23,000 ``Screen-for-life'' posters with tear-
off sheets that beneficiaries can take with them to their physician
as a reminder to discuss colorectal cancer screening options.
<bullet> Another example of a coordinated national activity was the
presentation of ``Beyond the Barriers: Effective Breast Cancer
Early Detection Strategies for Older Women.'' This national
satellite videoconference was broadcast live last year to 133 sites
in 40 states across the country.
In addition, we emphasize the importance of prevention in education
campaigns on the radio and through television public service
announcements, print materials and media kits, websites, and articles
in journals and newsletters. Through these campaigns, we are targeting
high-risk populations and health care practitioners whom we know have a
tremendous influence in encouraging healthy behavior.
We are actively working to find out how best to increase use of
preventive services needed by the Medicare population. We are studying
a variety of successful interventions to test their effectiveness in
the elderly population. In addition, we are working closely at the
state level with our Quality Improvement Organizations (QIOs, formerly
Peer Review Organizations) to monitor and to improve usage and quality
of care for Medicare beneficiaries. We have set a goal for the QIOs of
improving the utilization of flu and pneumonia vaccinations and breast
cancer screening. To this end, the QIOs are actively reaching out to
Medicare beneficiaries to increase the use of these three preventive
services. They are also targeting racial and ethnic groups that have
low rates of use. We are currently evaluating the success of these QIO
efforts, and expect results later this year.
Through our work with the QIOs and through other research, we know
that compelling evidence exists that race and ethnicity correlate with
health disparities. We are exploring a demonstration project to
identify and test cost-effective models of intervention that have a
high probability of positively impacting one or more health outcomes;
including health status, functional status, quality of life, health-
related behavior, consumer satisfaction, health care costs, and
appropriate utilization of covered services. We have contracted with
Brandeis University to report on interventions that could be used among
the targeted ethnic and racial minority populations. At the conclusion
of the demonstrations, we will deliver a report to Congress on the
cost-effectiveness of the projects, as well as the quality of
preventive services provided and beneficiary satisfaction.
CMS' INNOVATIONS IN PREVENTIVE CARE SERVICES
A growing body of literature indicates that chronic disease and
functional disability can be measurably reduced or postponed through
lifestyle changes, and that healthy behaviors are particularly
beneficial for the elderly. We have addressed some of the clinical
preventive services that contribute to a healthy aging experience, and
are just beginning to explore how to address behavioral risk factors,
which account for 70 percent of the physical decline that occurs with
aging, with the remaining 30 percent due to genetic factors. To this
end, we developed the Healthy Aging Project in collaboration with the
Agency for Healthcare Research and Quality, the Centers for Disease
Control and Prevention, the Administration on Aging, and the National
Institutes of Health. The Healthy Aging Project aims to identify, test,
and disseminate evidence-based approaches to promote health and prevent
functional decline in older adults.
We contracted with RAND to produce several reports synthesizing the
evidence on how to improve the delivery of Medicare clinical preventive
and screening benefits and exploring how behavioral risk factor
reduction interventions might be implemented in Medicare. We have been
using these reports to guide demonstration projects testing ways to
improve Medicare beneficiaries' health--and have already identified
ways to change our policies for the better. The first report,
Interventions That Increase the Utilization of Medicare-funded
Preventive Services for Persons Aged 65 and Older, states that
organizational changes are effective in improving the delivery of
preventive services. As a result of this research and a 14-state pilot
conducted in collaboration with CDC, we are making regulatory changes.
These changes will promote vaccinations, and encourage the use of
standing orders for flu and pneumococcal vaccinations in all health
care settings. Standing orders permit appropriate non-physician staff
to offer these services.
In addition to the regulatory changes for standing orders that have
come out of the Healthy Aging Project, we are using the research
gleaned from this project to explore methods to encourage behavioral
changes in the Medicare population, which could form the basis for the
``next generation'' of Medicare benefits.
Additionally, we, along with our partners at NIH and AHRQ, have
developed a demonstration to test the most effective strategies for
achieving smoking cessation in Medicare beneficiaries. The
demonstration will compare the impact of offering three different
approaches to smoking cessation on quit rates. We expect to start
recruiting smokers to participate in the demonstration this fall. The
study will be completed in 2004.
We also are developing a potential project that would examine the
use of health risk appraisal programs with targeted follow-up
interventions. We have reviewed evidence related to health risk
appraisal programs and their effectiveness in achieving positive
behavior change, particularly in the areas of diet and physical
activity. There is evidence that these programs improve physical
activity levels and reduce blood pressure. We are in the process of
developing a test of how health risk appraisal programs could improve
Medicare beneficiaries' health. We look forward to working with
Congress as we continue to develop groundbreaking ways to integrate
preventive health care services into the Medicare program.
CONCLUSION
Empirical evidence shows that preventive health care services are
vital for improving the quality and duration of life. Just last month,
Secretary Thompson, speaking at the National Press Club, emphasized his
philosophy, ``a little prevention won't kill you,'' and noted that even
modest behavioral changes and increased attention to health can prevent
or control myriad diseases and chronic conditions. We here at CMS,
along with the Secretary and the President recognize the benefits that
preventive health services provide. We are working to improve access to
these services and to develop innovative ways to offer prevention-
related health services to the Medicare population. In closing, I would
like to thank Congressman Greenwood for his interest in preventive
health care and the Committee for inviting me to testify today. We look
forward to Congress' continued interest and support for this vital
issue. I am happy to answer any questions.
Mr. Greenwood. Thank you, Mr. Grissom.
Dr. Fleming.
TESTIMONY OF DAVID W. FLEMING
Mr. Fleming. Thank you, Mr. Chairman, for providing CDC the
opportunity to be here with our colleagues today. We appreciate
being given the time to talk with you about the prevention
opportunities that are available to improve the health of
America's seniors.
You know, unfortunately, there is one thing that links
everybody in this room, and that is that we're all getting
older, and we're not alone. The population of older adult in
this country, both in number and in proportion, is increasing
at a much faster rate than we've ever experienced before. And
we have yet to encounter that rapidly rising tide of baby
boomers that will begin to reach age 65 just 8 years from now.
We have a potential health crisis on our hands, but the
operative word is ``potential.'' Poor health is not an
inevitable consequence of aging. While we can't live forever,
the evidence is overwhelming that prevention works for older
adults. We can postpone illness and disability so that the need
for long-term care is reduced and our seniors are able to enjoy
full, independent and healthy lives as long as possible.
And Medicare has brought the benefits of prevention to
millions of older adults by capitalizing on research, by
evaluating interventions, like you're going to hear about in a
minute, with the Guide to Preventive Services, and covering
services with preventive health care benefits.
So what role does CDC and public health have in this health
care arena? You know, there is still much work to be done, and
public health has a role in four of our most important
strategies: First, to make sure that covered benefits are
received. Unfortunately, just knowing what works and providing
it isn't enough. If you build it, everyone doesn't come. Today,
for example, instead of needlessly taking thousands of lives of
otherwise healthy Americans each winter, influenza can be
largely prevented. There is a highly effective vaccine which
has been recommended for use and is provided under Medicare,
but millions of America's seniors don't receive it. Public
health and epidemiological expertise can be used to identify
system solutions, like reminder recall in providers' offices
that you've heard about, like standing orders in nursing homes,
like immunization registries at the local level that can be
used within the health care system to improve the delivery of
preventive services.
And we can work on the patient side, too. In the last flu
season I called my 85-year-old dad and asked if he got his flu
shot. He said ``no;'' and I said, ``why?'' He said, ``no one
offered it to me.'' And I said, ``Did you think about asking
for it?'' He said, ``no.'' And I said, give that a try. One
week later he called and said, ``I asked for it, I got it, and
now I'm immunized.''
Public health can play an important role in community
education so that not only the medical system is trying to
deliver preventive services, but the patients out there are
actively trying to receive them as well. One successful model
is a model called SPARC. That is a public-private partnership
in Massachusetts, New York and Connecticut, and it serves a
role of serving as a catalyst, as the glue to bring together
seniors, health care providers and existing community
resources. These kinds of programs have dramatically increased
the use of Medicare-covered preventive services, and older
adults around the country should have access to the same kinds
of services that SPARC, for example, provides.
Now, second, we need to go beyond the medical services that
can be provided in the physician's office. We need to use tried
and true public health methods to help people make healthy
choices, as you said in your opening statements, because
contrary to widespread perception, it is never too late to
start healthy habits and gain benefits.
Even the most frail elderly are capable of increasing their
strength, balance and fitness. Just walking several days a week
yields significant health benefits. In fact, physical activity
may be the closest thing we have to a silver bullet against
aging. Not only can seniors improve cardiovascular fitness, but
exercise can reduce the impact of serious conditions like
diabetes, the risk of falling and costly hip fractures, and
help anxiety and depression.
Yet nowhere is the gap wider between what we know how to do
and what we can provide in this area. Few seniors engage in
regular activities that improve balance and strength, and
seniors have too few opportunities to do the beneficial
activities they like to do, like safe walking and gardening.
But, programs that influence these behaviors pay off. In
heart disease, for example, medical interventions reap
substantial benefits in added life expectancy, estimated by the
Institute of Medicine at 4 to 1 when costs are considered. But
interventions and behavioral change produce remarkable returns
at the 30-to-1 investment level.
Third, we need to engage our partners in this. We need to
take advantage of the aging network's resources. The
Administration on Aging, for example, reaches into virtually
every community in this country with its network of over 600
area Agencies on Aging. AOA has the mandate through the Older
Americans Act to address health promotion and disease
prevention, yet much of the expertise in how to do that rests
in public health. We need to work together, and some creative
integration could lead the medical system, public health and
the aging network, working together in communities and in the
home, to provide prevention services such as how to prevent
falls, reviewing medicines that our seniors are taking, and
vision screening. We know that these interventions work. We
just need to make use of the potential delivery systems that
are already in place.
Fourth and finally, we need to look upstream. Those of us
in this room who because of age are not yet Medicare-eligible
hopefully someday will be, and if each of us were successful at
just three things, maintaining healthy weight, engaging in
moderate physical activity and not smoking, we could delay the
onset of disability for a decade on average. Wise prevention
investments today in our younger adult population will yield a
generation of healthier seniors in the future.
So in conclusion, the science is compelling. We know that
it is never too late to take advantage of the promise of
prevention, but as a Nation, we focus primarily on providing
quality health, really illness care, for our older adults. Our
challenge now is to ensure that as life span lengthens, the
added years are quality years, and we need to create a
sustainable health care system that provides the very best
opportunities and incentives to stay healthy for our seniors as
long as possible.
I'd like to thank the committee for its leadership and
commitment in this arena, and I wanted to let you know we think
you're making a wise investment. Thank you very much.
[The prepared statement of David W. Fleming follows:]
PREPARED STATEMENT OF DAVID W. FLEMING, ACTING DIRECTOR, CENTERS FOR
DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Thank you, Mr. Chairman, and Members of the Committee, for the
opportunity to speak to you today about an issue that is of critical
and increasing importance at the Centers for Disease Control and
Prevention (CDC), and indeed for the American people. We at CDC are
pleased to join our federal and non-federal partners in addressing the
challenges facing Medicare, and identifying opportunities to improve
the health of older.
Before talking more specifically about improving the health of
older adults, I would like to provide some context. Chronic diseases
account for nearly 75 percent of the deaths in this country, are the
leading causes of disability and long-term care needs, and represent
nearly 75 percent of all health-related costs. Although chronic
diseases are not limited to older adults, these conditions, such as
cardiovascular disease, cancer, diabetes, and arthritis are heavily
concentrated in adults age 50 and over. Among the 10 leading causes of
death, the top six are concentrated in older adults. Premature death
and much of the illness and disability associated with these diseases
is preventable, even among older adults.
This is critically important because we are now entering the time
in our nation's history when the population of older adults--both in
number and in proportion--is increasing at a much faster rate than we
have ever experienced. The current anxiety and debate around Medicare
costs is motivated by the aging of the baby boomers. The baby boom
generation's leading edge is currently 56 years old. As this segment of
the population ages, the proportion of adults age 65 and over in the
U.S. will more than double, such that by 2030, 20 percent of all
Americans will be older adults. If we don't take some steps now to do
what we can to influence the health habits of the baby boomers, we may
never catch up to the upcoming demands on the health care system.
Current health and aging trends may have enormous implications for
the public health system, the health care system, and our existing
network of aging and social services. The cost of health care for a 65-
year-old person is four times as much as that for a 40-year old. People
age 65 and over even now consume 33 percent of our health care dollars,
or more than $300 billion each year. By 2030, those costs will increase
by 25 percent, for the sole reason that our population will be older--
even before inflation and the costs of new technology are taken into
account.
Recent CDC projections of just one major disease--diabetes--
illustrate the magnitude of what we face if we don't act. Today
diabetes alone accounts for about 6 percent of Medicare costs. The
number of people with diabetes is expected to almost triple from 11 to
29 million by 2050. Aging baby boomers will contribute to the increased
number of cases, but what's alarming is that among adults, diabetes
rates increased 49 percent between 1990 and 2000, in large part due to
unhealthy lifestyles. Clearly, we may not be able to sustain our
current health care system unless we address in a more aggressive
manner the prevention of chronic diseases and injuries. Until now, we
have not maximized our prevention opportunities among older Americans.
Too many believe the myth that older adults have lived beyond the time
when prevention can be beneficial.
The evidence is convincing that prevention is worth the investment
for the health and safety of older adults. A recent Institute of
Medicine report noted that the return on investment in medical care for
cardiovascular disease reaped benefits at 4 to 1, but investment in
behavioral change returned a remarkable 30 to 1 advantage. We should
bring the health advantages of prevention to older adults across the
country.
We at CDC, together with Centers for Medicare and Medicaid Services
(CMS), National Institutes of Health (NIH), the Administration on Aging
(AoA), and others are committed to improving health and independence,
and reducing long-term care needs among older adults. Medicare coverage
has a critical role to play here--and we should maximize the use of
currently covered services and identify additional effective prevention
and control measures that can enhance the health of Medicare
beneficiaries.
Through basic research at NIH and other institutions, CDC's
prevention research programs, and other institutions, we know quite a
lot about how to prevent or postpone illness, injury, and disability
experienced by older adults today. Unfortunately, just knowing what
works is not enough. Even when covered by Medicare, older adults often
may not be receiving recommended preventive services.
For example, only two-thirds of adults age 65 and older reported
receiving a flu shot in the previous year, and more than half report
that they have never been vaccinated against pneumococcal disease--even
though Medicare covers the cost of both immunizations.
Despite the lifesaving benefits of screening and early detection
for chronic disease, one in five women age 65-69 has never had a
mammogram, and half of older adults do not receive recommended
screening for colorectal cancer. Again, Medicare covers both of these
screening services.
It is clear that solving the basic research problem--developing
proven prevention measures--is just the first step. There are
significant gaps in getting what we know about prevention to
individuals who can benefit. We are likely close to the limits of what
the health care system as currently structured can do to increase
preventive services. Research conducted at RAND with support from CMS
showed that immunizations and screening improve when health care
organizational changes are made and patients are involved in their own
management. Clearly, improvements in prevention services for older
adults will require creative approaches that support new ways of
delivering preventive services and links to the community.
We can do better. To help ensure prevention benefits currently
covered through Medicare reach beneficiaries, we would propose more
closely linking CDC's public health expertise in disease prevention and
health promotion with the aging expertise and extensive outreach
capability of the aging network--the Administration on Aging and its
state and local counterparts. This network, analogous in ways to the
public health network but with a specific population focus, reaches
into virtually every community in the country with its network of over
600 area agencies on aging and associated senior centers. CDC and AoA
are currently working with state chronic disease directors and state
units on aging to stimulate local prevention activities. To commemorate
Older Americans Month in May, mini-grants of $5,000 to $10,000 will be
announced that will allow state and local representatives to develop
prevention programs that reflect local priorities.
While Medicare has made preventive services a priority through the
PROs, some creative approaches for increasing preventive services have
been tested that link the health care system to community-based
resources.
At CDC, we provided some funding to a program aptly named SPARC, or
Sickness Prevention Achieved through Regional Collaboration. This
program, serving counties where the borders of New York, Connecticut,
and Massachusetts meet, acts as a broker to bring together existing
health care and community resources. SPARC does not deliver services;
instead, it consolidates and coordinates, serving as the missing
catalyst, or the glue. Because providers do not see SPARC as a
competitor, they welcome a service that helps them and their patients.
SPARC has helped the communities it serves achieve dramatic results
in extending critical preventive health services to older adults. For
example, Medicare data shows that in 1997 in Litchfield County,
Connecticut, a community served by SPARC, pneumococcal immunizations
increased at twice the rate compared to seven surrounding counties
without the benefit of SPARC. The SPARC model has demonstrated its
value in bringing lifesaving preventive services to older adults.
Communities around the country could benefit from innovative and
successful models like SPARC.
CDC also participated in CMS's recent effort to permit ``standing
orders'' that allow institutions like nursing homes to routinely
provide immunizations without requiring providers and staff to
coordinate new written orders annually for individual patients. Support
for this type of systems change is critical in improving prevention
under Medicare.
While there are real gains to be achieved through the broader use
of covered preventive services, Medicare has just begun to support
benefits that target lifestyle issues so critical to reducing the toll
of chronic illness.
Research has shown that practicing a healthy lifestyle is more
influential than genetic factors in helping older people avoid the
deterioration traditionally associated with aging. Several weeks of
inactivity take a greater toll on the body than decades of aging.
People who are physically active, eat a low-fat, high-fiber diet, and
do not use tobacco products significantly reduce their risk for chronic
disease, such as cardiovascular diseases, diabetes, chronic obstructive
lung disease and arthritis, as well as for injuries related to falls.
Perhaps more important, practicing just these three healthy habits
delays the onset of disability by more than a decade on average. For a
society concerned about the public and private costs of long-term care,
delaying disability has enormous potential economic implications.
For the purposes of today's hearing, I'd like to focus on physical
activity as a preventive tool that deserves Medicare's support. Besides
reducing the risk for a variety of chronic diseases, regular activity
also helps older adults reduce their risk of falling, alleviate anxiety
and depression, maintain a healthy body weight, and improve joint
strength and mobility. And yet, nowhere is the gap wider between what
we know and what we do.
Two-thirds of older adults do not get regular physical activity.
Less than half of older adults served by Medicare say that their
healthcare provider asks them about physical activity. The potential
exists to reverse this by ensuring that older adults have access to
physical activity programs that address their unique health, lifestyle,
functional, and motivational needs. Even the frailest of elders can
benefit from low-stress activities tailored for their needs, such as
gardening ``which, by the way, is the third most popular physical
activity among seniors. All individuals, and particularly older adults,
should receive counseling from their health care providers on the
benefits of physical activity.
Let me give you an example of what moderate physical activity can
mean for people at high risk for diabetes, with its debilitating
complications and enormous Medicare costs each year. In a recent NIH
study, in which CDC collaborated, overweight adults with above-normal
glucose levels who walked five times a week and lost as few as five
pounds were able to reduce their risk of developing diabetes by nearly
60 percent. People in the study aged 60 and older were among those most
successful in reducing their risk.
There is a groundswell of interest across the country in promoting
physical activity among older adults. Over 800 candidate communities
recently registered their intent to apply for funding available from
the Robert Wood Johnson Foundation for the ``Active for Life'' program.
Unfortunately, only eight sites will receive funding for this program
to increase physical activity among older adults. Given the benefits of
physical activity, CDC is currently working with the National Institute
on Aging (NIA) and the Older Women's League to evaluate the
effectiveness of NIA's recently developed physical activity materials
in getting older adults to exercise.
There is recognized, science-based value in physical activity
programs, but they aren't reaching older adults. Learning how to get
the benefits of such programs out to seniors in communities across the
country should be a national priority.
Physical activity also plays a key role in reducing an older
person's risk of falling. One of every three older Americans--about 12
million seniors--falls each year, with devastating consequences. More
than 10,000 will die from the fall; another 340,000 will sustain a hip
fracture. Half of the older adults who break their hip in a fall are
never able to return home and live independently again. The risk of
falling and loss of independence has been shown to be a primary concern
for older adults. A recently-published study involving women age 75 and
older found that 80 percent would rather be dead than experience the
loss of independence and quality of life from a bad hip fracture and
admission to a nursing home.
Risk factors for falls include: a previous fall, muscle weakness,
problems with balance and walking, being underweight, vision and
hearing loss, taking four or more medications or psychotropic drugs
(such as sleeping pills and tranquilizers). Reducing the risk of falls
would make an enormous impact on reducing disability and long-term care
needs. Every year, falls among older people cost the nation more than
$20 billion, and these costs will rise to an estimated $32 billion by
2020.
Weight resistance exercises and regimens such as Tai Chi help
seniors maintain and improve balance, strength, and coordination at any
age. Other means to address fall risk include insuring proper
medication management for older people--a current priority of the
Assistant Secretary for Health, Dr. Slater; making physical changes in
the home environment; and educating seniors and their caregivers,
formal and informal, about factors that contribute to falls. Simple
changes in an older person's home, such as securing rugs and adding
grab bars in bathrooms can quickly and easily reduce fall risk. Because
vision problems can increase a person's risk for falling by as much as
60 percent, improved lighting in the home is also an effective strategy
for preventing falls. Despite the known benefits of such measures, more
than two million older Americans live in homes that have not had simple
modifications that can reduce their risk of falls. One-fourth of older
adults have an outdated or wrong eyeglass lens prescription,
contributing to poor vision and the increased likelihood of falls.
Screening older adults for fall risk should be a routine part of
medical care, just as we screen for cancer or diabetes complications.
Such screening should include identifying adults who have previously
fallen or who have multiple fall risk factors as I cited above,
followed by appropriate and necessary treatment, for example, training
to improve balance and muscle weakness, medication review and
management, vision screening and correction, and assessment of and
education on needed home modifications. Such efforts are already
underway in other developed nations, where collaboration between
government agencies and aging networks are providing easily accessed
and effective physical activity and falls prevention programs for
seniors.
Another area of importance to Medicare beneficiaries is medical
errors occurring while hospitalized or as a resident of a long-term
care facility. Based on a landmark report by the Institute of Medicine,
medical errors are responsible for 44,000 to 98,000 deaths each year
with additional healthcare costs of 17 to 29 billion dollars each year.
CDC is working with several partners including the Agency for
Healthcare Research and Quality, the Veterans Administration, and the
Centers for Medicare and Medicaid Services, along with private sector
partners, to better understand why these events occur, and to implement
programs to prevent them.
Finally, I'd like to address one last area today that holds
considerable promise in improving seniors' health and quality of life,
and in reducing the demands on the health care system. That area is
self-care for those with chronic diseases or for those at increased
risk for disease or complications.
Self-care can be undertaken in a variety of ways and for a variety
of conditions, from diabetes to arthritis. We know that people will
``self-manage'' their disease even when they are pursuing remedies with
no known health benefits. Programs are widely available, but no
criteria exist to determine what the programs should include. The
challenge, and the opportunity, is to ensure that older adults receive
the quality education they need to become knowledgeable about what they
can do to take responsibility for their own health and disease
management.
For an individual with diabetes, this might mean optimally managing
blood glucose levels. The individual not only fares better physically
but derives benefit and satisfaction from being an active participant
in his or her own care. Self-management has been shown to be of
particular value for people with arthritis, the leading cause of
disability and a problem for almost two-thirds of Medicare enrollees.
In selected states and in cooperation with the Arthritis Foundation,
CDC supports an arthritis self-management education program that
teaches people how to better manage their arthritis and lessen its
disabling effects. This six-week course has been shown to reduce
arthritis pain by 20 percent and physician visits by 40 percent. Again,
however, there is a gap in getting the benefits of this program out to
individuals. Currently, less than one percent of the 43 million
Americans with arthritis participate in such programs and courses are
not offered in all areas.
In conclusion, I would like to thank the Committee again for its
leadership and commitment in the important area of older adult health.
While the risk for disease and disability clearly increases with
advancing age, poor health does not have to be an inevitable
consequence of aging. Far from being too old for prevention, Medicare
recipients offer some of our most promising prevention opportunities.
The science base is compelling, but we should refocus our attention on
the real barriers to implementation and financing. Priority needs are
evaluating promising programs in real-world settings and making the
system flexible enough to accommodate the new types of benefits that
are required. Our nation has contributed to an unprecedented increase
in the human life span during the 20th century through improvements in
public health and medical care. Since the 1960s we have been committed
to providing health care for older adults. Our challenge now is to
insure that added years are quality years and to create a sustainable
health care system that provides the very best opportunities and
incentives to stay healthy and independent as long as possible.
Thank you. I'd be happy to answer any questions.
Mr. Greenwood. Thank you very much.
Dr. Clancy. I probably should have said earlier, since we
don't have a bevy of members here waiting to answer questions,
don't worry too much about the red light. Just speak until
you're finished.
TESTIMONY OF CAROLYN M. CLANCY
Ms. Clancy. Good morning, Mr. Chairman, members of the
subcommittee. I'm very pleased to be here today to discuss the
work of the U.S. Preventive Services Task Force and the role of
the Agency for Health Care Research and Quality, or AHRQ, which
provides the task force with scientific and administrative
support.
You might have seen Tuesday's Washington Post article this
week about the task force's new recommendations urging primary
care physicians to screen their adult patients for depression,
or you may have seen this week's Newsweek article highlighting
a recommendation recently released by the task force on the use
of aspirin to prevent heart disease. Indeed, we could never
have planned this, but it turns out that as we speak, people
are calling in to hear more about aspirin and heart disease as
well. These are both excellent examples of the work of the task
force and AHRQ as its sponsor to improve the scientific basis
in the quality of clinical preventive services.
The task force itself is an independent private sector
panel of experts in prevention and primary care who review the
scientific evidence and make recommendations on clinical
preventive services. These services specifically include
screening tests, immunizations and counseling. The work of the
task force is a natural fit with AHRQ's mission to support
research designed to improve the quality of health care, reduce
its costs, improve patient safety, address medical errors and
broaden access to essential services.
In 1999, the Congress directed AHRQ to provide scientific
and administrative support to the task force, and in 2000,
legislation required AHRQ to produce an annual report to the
Congress on preventive services for older adults, and a copy of
that has been submitted for the record.
I'd like to note since you're hearing from all of us who
work together that the work of AHRQ and the task force
complements the preventive services at the NIH and the Centers
for Disease Control and Prevention. While AHRQ studies the use
of clinical preventive services in everyday practice, NIH
research identifies preventive interventions that work under
ideal conditions, and for its part, CDC assesses the
effectiveness of community-based public health interventions,
as Dr. Fleming has just noted before.
I'd like to now describe briefly how the task force
formulates its recommendations and the support that we as an
agency provide.
The recommendations of the task force are based on state-
of-the-science evidence in health care. This is an interative
process. This is actually the third task force to make
recommendations based on evidence or on preventive services.
The first such task force was convened in 1984, and the
recommendations were released in 1989. A subsequent update was
completed by the second task force in 1996 after 5 years of
work.
To formulate its recommendations, the task force conducts
comprehensive reviews of the scientific evidence regarding the
effectiveness, risks and benefits of specific preventive
services. Because reviewing all of this evidence is a
significant task that requires specialized expertise, the task
force works with two of AHRQ's 12 evidence-based practice
centers, or EPCs, to do the analysis and synthesis. The task
force reviews the evidence synthesized by the evidence-based
practice centers and then makes recommendations.
Unlike its predecessors, the current task force is issuing
its recommendations serially rather than a single update--a
single volume at the end of its term. This allows them to
provide updated information in a much more timely fashion. To
date, this task force has released recommendations on screening
for depression, on breast cancer, chlamydia, bacterial
vaginosis in pregnancy, skin cancer, newborn hearing problems,
cholesterol and the use of aspirin to prevent heart disease.
But it is very important that we believe that AHRQ's work
on preventive services doesn't end with the task force
recommendations. As part of our effort to translate research
into practice, AHRQ also sponsors something called the Put
Prevention Into Practice program, which translates the
recommendations of the U.S. Preventive Services Task Force for
clinicians, health systems and patients in order to increase
the delivery of recommended preventive services.
Task force recommendations and the products of Put
Prevention Into Practice are used widely throughout the health
care system to improve the preventive services provided to the
Nation's citizens. So just by way of example, I have here two
booklets, one in English and one in Spanish, Staying Healthy
Over 50, which is done in partnership with the AARP to try to
get the message out broadly.
I'd like to now take a brief moment to discuss the
important issue of clinical preventive services in the elderly.
Just to echo what Dr. Fleming said, contrary to common
misperception, you're never too old to benefit from effective
preventive interventions, and prevention is especially
important for older Americans, since the risk for many
preventable conditions such as heart disease and cancer does
rise steadily with age. The challenge, of course, is
identifying which services are most effective for which
patients and finding ways to make sure that those patients get
the services from which they're likely to benefit.
Over the years the U.S. Preventive Services Task Forces
have documented the scientific evidence that preventive
services can significantly improve health. For older patients
they have found compelling evidence to recommend screening for
a long list of conditions included with my written testimony.
We're pleased and gratified that the importance of clinical
preventive services is now increasingly recognized throughout
the health care system, and we feel that the impartial
evidence-based recommendations of the task force have played a
major role in this development.
As AHRQ notes in its report to Congress on preventive
services, Medicare now covers nearly all of the screening
recommendations provided--recommended by the task force.
However, there is clearly more work to be done. A report on
clinical priorities and prevention from the Partnership for
Prevention documented the number of preventive service that,
although of great benefit, are received by less than half of
elderly patients in this country. They include, for example,
smoking cessation counseling, colorectal cancer screening and
pneumonia vaccinations.
AHRQ, which helps support the Partnership for Prevention
report, is working to improve the provision of these services
to the elderly and other underserved patients. In addition to
our Put Prevention Into Practice program, we're working with
other Federal agencies to support research and to identify and
overcome barriers to the use of appropriate preventive care.
In conclusion, AHRQ and the U.S. Preventive Services Task
Force are helping to ensure that the American public is
receiving high-quality, evidence-based clinical preventive
services. While we have achieved a great deal, and we're proud
of that, we know that a lot more needs to be done. And I'd be
happy to answer any questions.
[The prepared statement of Carolyn M. Clancy follows:]
PREPARED STATEMENT OF CAROLYN M. CLANCY, ACTING DIRECTOR, AGENCY FOR
HEALTHCARE RESEARCH AND QUALITY, DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Mr. Chairman, I appreciate this opportunity to discuss the work of
the U. S. Preventive Services Task Force (Task Force) and the role of
the Department of Health and Human Services's (HHS) Agency for
Healthcare Research and Quality (AHRQ), which provides the Task Force
with scientific and administrative support. Because the Task Force
chair and vice chair were unable to attend today's hearing, I have been
asked to provide an overview of AHRQ's role in developing scientific
evidence of the effectiveness of preventive health care services and
how the Task Force, an independent group of prevention experts, uses
that scientific evidence.
role of the agency for healthcare research and quality (ahrq)
The primary focus of the Agency for Healthcare Research and Quality
(AHRQ) is on clinical services--the care patients receive from health
care providers--and the health care systems through which those
services are provided. AHRQ research provides the scientific evidence
to improve the outcomes, quality, and safety of health care, reduce its
cost, broaden access to effective services, and improve the efficiency
and effectiveness of the ways we organize, deliver, and finance those
services.
Clinical preventive services--which include common screening tests,
immunizations, preventive medications like aspirin to prevent heart
attacks, and counseling about lifestyle that are delivered by
clinicians--are an important focus of AHRQ research. Our research
develops new scientific evidence regarding their effectiveness and
cost-effectiveness, synthesizes existing scientific knowledge, and
assesses strategies for facilitating their delivery and appropriate
use.
AHRQ's focus on the effectiveness of clinical preventive services--
what works best in daily practice--complements the research at the
National Institutes of Health (NIH) and Centers for Disease Control and
Prevention (CDC).
In addition, in 1999, the Congress directed the agency to provide
scientific and administrative support to the U.S. Preventive Services
Task Force, and legislation enacted in 2000 requires AHRQ to produce an
annual report to Congress on what preventive services are effective for
older Americans. A copy of our first report is attached to my
testimony.
THE STRENGTHS AND LIMITATIONS OF EXISTING SCIENTIFIC EVIDENCE
To ensure that Americans benefit from our existing knowledge, AHRQ
supports Evidence-based Practice Centers (EPCs) that undertake
comprehensive reviews of the scientific evidence regarding the
effectiveness, risks, and benefits of specific health care services.
The evidence reports they produce provide unbiased summaries of
existing knowledge without recommendations, so that those who need to
make decisions about health care and health systems, such as patients,
providers, health plans, insurers and policy makers, can make more
informed decisions. In response to requests from the Task Force, AHRQ
relies primarily upon two of these EPCs to assess the scientific
evidence regarding clinical preventive services.
How do they do that? Before the EPCs can begin to synthesize the
findings of available studies, they undertake a rigorous methodological
review of each study, asking questions such as: Did the investigators
use an appropriate research design for the question being asked? Did
they control for other factors that might affect the outcome (what
researchers call ``threats to validity'')? Did they use the right
statistical tests and calculate them properly? Did they examine health
outcomes that are most important to patients? Not surprisingly, there
are many studies that do not survive scrutiny; they were poorly
designed, poorly executed, or both. Unfortunately, the number of solid,
well-designed, well-executed research studies is often smaller than
policy makers would prefer.
Because a determination of effectiveness often has significant
implications in controversies over coverage or reimbursement, it is
critical that policy makers understand one important distinction. A
conclusion that there is not evidence of the effectiveness of a service
is different from a conclusion that the service is ineffective. ``No
evidence of effectiveness'' can simply mean there are no studies on the
subject, the studies that exist are flawed and cannot be trusted, or an
existing good study involved so few patients that it is not
generalizable. No judgment is implied regarding the effectiveness or
ineffectiveness of the service; it simply means there are too few good
scientific studies on the subject to guide your decision-making.
In its obligation to provide scientific support for the Task Force,
AHRQ follows this same approach and identifies the strengths and
limitations of the existing knowledge base but makes no
recommendations.
THE U.S. PREVENTIVE SERVICES TASK FORCE
The U.S. Preventive Services Task Force is in its third
incarnation. The HHS first convened a Task Force of independent
prevention experts in 1984; their report was released in 1989, and then
completely updated by the second Task Force in 1996. In 1999, Congress
established the Task Force as an ongoing body so that it could
regularly review and update its recommendations based upon new
scientific findings. A list of the current membership of the Task Force
is attached.
For each topic that the Task Force addresses, it requests an
updated evidence report, which AHRQ then commissions from one of its
EPCs. After reviewing the evidence report, the Task Force develops
recommendations based upon the strength of the scientific evidence and
their collective expert judgment regarding the balance of benefits and
harms of a specific service. These recommendations are then circulated
widely for comment from Federal agencies and private organizations, but
the final recommendations reflect the conclusions of the independent
Task Force, rather than policy decisions of HHS or any organization.
Task Force recommendations are not binding on public or private sector
providers or funders of care.
The Task Force requires evidence that a given intervention will
actually improve important health outcomes, such as lowering morbidity
or mortality, not simply detecting more disease or improving some
laboratory test result. As a result, Task Force recommendations are
sometimes more conservative than those of specialty groups. The
principle that clinical recommendations should be based on careful and
objective assessments of the evidence, rather than simply the opinions
of experts, is at the heart of the movement known as ``evidence-based
medicine''. These principles are especially important in prevention,
because an intervention, such as testing for colon cancer, will be
offered to large populations of healthy people.
The Task Force experience has demonstrated we still have
substantial room for progress in providing preventive services that are
supported by good evidence. Often the Task Force concludes that the
existing evidence is not sufficient to prove or disprove whether a
service is effective, indicating that more good scientific studies are
needed and that clinicians must use their own judgment with individual
patients until more definitive research is completed.
Since its first report, the Task Force has been recognized for
producing rigorous and unbiased assessments of what works in clinical
prevention. As a result, the influence of its recommendations goes far
beyond its primary mission, which is to make recommendations for
doctors and nurses to guide clinical practice. In fact, its
recommendations have formed the basis of prevention guidelines of the
American Academy of Family Physicians and other professional societies,
are used by health plans and insurers in developing their prevention
policies, and have figured prominently in the development of health
care quality measures and national health objectives. Finally, the Task
Force's Guide to Clinical Preventive Services is used widely in
undergraduate and post-graduate medical and nursing education as the
definitive reference for teaching preventive care.
CLINICAL PREVENTIVE SERVICES AND THE ELDERLY
Primary care clinicians play a central role in prevention for older
Americans. The average Medicare recipient makes 13 medical visits per
year, providing opportunities for doctors and nurses to deliver a range
of clinical preventive services, including screening tests, counseling,
immunizations, and advice about preventive medications such as aspirin
or hormone therapy.
Contrary to common misperceptions, one is never too old to benefit
from effective preventive interventions. Prevention is especially
important for older Americans, since preventive measures even at this
age can help delay the onset of disease. The challenge in prevention is
identifying which services are most effective for which patients and
finding ways to ensure they are delivered to all eligible patients.
In its comprehensive 1996 report, and in updates released over the
past 2 years, the Task Force has documented the scientific evidence
that preventive services can significantly improve health. For older
patients, it found compelling evidence to recommend that clinicians
regularly provide the following services: screening for high blood
pressure and high cholesterol; screening for cancers of the breast,
colon, and cervix; screening for vision and hearing problems;
immunization against influenza, pneumococcal disease and tetanus; and
discussions with patients about aspirin to prevent heart attacks. In
addition, the Task Force has noted the importance of counseling to
reduce tobacco and alcohol use, to promote healthy diets and physical
activity, and to prevent injuries. The general conclusions of the Task
Force urge clinicians to be more selective in their use of some
screening tests, pay more attention to behavioral health issues, and
find opportunities to deliver preventive services outside of the
traditional ``annual check-up. ``
MEDICARE COVERAGE
Thanks to the combined efforts of the Task Force and many other
agencies and organizations committed to prevention, the landscape for
prevention in 2002 is dramatically different from the one facing the
first Task Force in 1984. At that time, delivery of preventive care was
uneven, insurance coverage was rare, and attitudes of patients and
providers were often skeptical.
As AHRQ notes in its report to Congress on preventive services,
Medicare now covers nearly all of the screening services recommended by
the Task Force. The one exception, cholesterol screening, is often
covered as a part of follow-up care or treatment of other problems.
Similar progress has been documented in the private sector--among
employer-based health plans, over 90% cover mammograms and Pap tests,
and over 85% cover routine physicals and gynecological exams.
ENSURING THAT AMERICANS BENEFIT FROM PREVENTIVE SERVICES
Mr. Chairman, deciding what works is only the first step toward
quality preventive care. A report on clinical priorities in prevention
from the Partnership for Prevention, developed with support from CDC
and AHRQ, documented that a number of high priority services relevant
to older Americans are delivered to less than half of the population
nationally. These include smoking cessation counseling, colorectal
cancer screening, and pneumococcal vaccination.
Addressing this problem--facilitating the use of effective and
cost-effective health care services--is another aspect of AHRQ's
mission, which we term ``Translating Research into Practice.'' We do
this in two ways. First, we develop a variety of materials and tools
that help providers ensure that patients receive the right preventive
service at the right time. An example is AHRQ's ``Put Prevention Into
Practice'' effort that provides materials to help primary care
clinicians effectively deliver preventive services to patients,
educates patients about the services they should receive, and asks
patients to remind their physician if a useful service is not provided.
The second approach is through research designed to identify ways
to overcome barriers that may lead to under-use of effective preventive
services. For example, a recent research solicitation, co-funded by
AHRQ and the NIH's National Cancer Institute, solicits research to
identify the most effective ways to improve the delivery of preventive
colorectal cancer screening services in the clinical setting.
We are also working closely with our colleagues at the Centers for
Medicare and Medicaid Services (CMS) to increase the utilization of
clinical preventive services by Medicare beneficiaries. Through an
interagency agreement with CMS, we have funded our Evidence-based
Practice Center at RTI International to develop messages for patients
and providers about new preventive services covered under Medicare.
AHRQ is also funding several projects examining the best ways to
implement smoking cessation guidelines, and we support the ongoing
efforts of the CMS to fund demonstration programs to assess the costs
and benefits of expanding Medicare coverage for smoking cessation
CONCLUSION
In conclusion, Mr. Chairman, the effort to ensure that Americans
benefit from effective clinical preventive services is a multi-pronged
effort. It requires systematic scientific studies to fill the gaps in
our knowledge regarding existing and emerging preventive services,
objective assessments of what works by independent bodies like the Task
Force, and continuing research on how to improve the delivery and
quality of those services. In this way, we can continue the progress of
the past two decades in prevention for older patients and the American
public.
That concludes my testimony. I would be happy to answer any
questions.
Mr. Greenwood. Thank you, Dr. Clancy.
Dr. Bratzler, do you like that with a short A or a long A?
TESTIMONY OF DALE BRATZLER
Mr. Bratzler. Bratzler.
Good morning, Mr. Chairman, members of the subcommittee,
and thank you for inviting me here today. I am the principal
clinical coordinator of the Oklahoma Foundation for Medical
Quality, which is the Medicare quality improvement organization
for the State of Oklahoma, and I'm here today to testify on
behalf of the American Health Quality Association, or AHQA.
AHQA represents the national network of quality improvement
organizations that were formerly called peer review
organizations in the Medicare program.
The QIO's primary mission is to monitor and measurably
improve the quality of health care delivered to Medicare
beneficiaries. QIOs concentrate on systems of care rather than
care delivered to one patient at a time. A systems-based
approach improves the quality of care for all Americans
receiving services at health care facilities that are working
with the QIOs.
I want to make the point that QIOs are on the ground
promoting preventive services by taking evidence-based
preventive health practices from the bookshelf to the bedside.
QIOs promote and enhance the delivery of preventive services to
seniors and work to resolve barriers to greater utilization of
these services.
The Centers for Medicare and Medicaid Services, or CMS,
selects the clinical areas and the quality indicators that we
work on, and they are based on public health importance and on
the feasibility of measuring and improving quality on those
specific indicators. These clinical conditions are important
causes of morbidity and mortality among the Medicare population
and the U.S. population as a whole and account for substantial
numbers of hospitalizations and a large share of the health
care costs of this country.
QIOs work to improve care for both fee-for-service Medicare
beneficiaries as well as those enrolled in M+C plans. Although
the data-gathering phase of our quality improvement techniques
may differ depending on payment arrangements, in either case
the QIOs tend to employ systems-based approaches to improving
quality of care.
I'd like to give a few examples of ways the QIOs work to
promote primary prevention. With respect to immunizations,
we've heard a lot about immunizations already this morning.
There is certainly universal agreement among health care
providers regarding the value of immunizing seniors against
influenza and pneumonia, and yet we know that immunization
rates among our senior population are far below the Healthy
People 2010 goals, even for patients in institutional settings
that are very high risk, like nursing homes.
QIOs promote vaccination in two ways. First, QIOs educate
consumers on the importance of receiving these vaccinations for
both influenza and pneumonia. And second, QIOs promote
screening of patients to check if they have received them so
that doctors and nurses can provide vaccine when needed.
An example of one of the most successful interventions
employed by QIOs is to promote implementation of standing
orders to enhance vaccination rates. Regardless of the health
care setting, the use of standing orders allows appropriately
trained health care providers to administer vaccines to
patients in need. Now, there are barriers. Despite the evidence
that standing orders are sound intervention, I think Mr.
Grissom already mentioned this morning that there has been a
frustrating barrier in regulations in the Medicare condition of
participation which basically prevented institutions from
implementing standing orders without having an individually
signed physician order for each patient. I know there is work
ongoing now to correct that problem.
QIOs have also implemented programs to address barriers to
immunization with disparate populations. In Oklahoma we
surveyed African American and Caucasian beneficiaries to
determine the cause of disparity in immunization rates between
these two populations. We found that there were significant
differences in patient understanding and physician education
between the two groups regarding the need for pneumonia and
influenza immunizations. Attached to my testimony you'll find
table 1 and 2, which summarizes some of the key differences
that we found between African American beneficiaries and
Caucasian beneficiaries.
California's QIO also identified similar barriers to
immunization among African American populations living in
Alameda and Los Angeles Counties. They found that a
recommendation from a trusted physician was a key motivator for
vaccination, and they also found that the leaders of churches
and community centers can be effective partners in improving
awareness and building trust among African American seniors.
With respect to diabetes, we've heard of its real important
role in terms of morbidity in the Medicare population. QIOs are
directed by CMS to focus on prevention initiatives with
diabetics. Examples would include prevention of blindness by
promoting regular retinal examinations, and prevention of
cardiac complications by promoting regular testing of lipid
levels.
One of the barriers to patients receiving regular
screenings is that many physicians do not have medical record
information systems that allow them to access a list of their
diabetic patients that ought to be receiving regular reminders
for preventive care services. In many States, including
Washington, Oregon and Wisconsin, QIOs provide physician
offices with software that they can use to develop a disease
registry or a patient data base that tracks the provision of
preventive care and services and can generate physician
reminders regarding preventive care. In many cases the QIO
staff in those States is working directly with the physician to
actually populate the data bases.
QIOs have also found disparities between racial groups and
diabetes care. The Florida QIO routinely analyzes part B claims
data by each zip code in the State and then takes this data to
providers to show them the care received in their communities.
The South Dakota QIO working with local Native American
reservation health facilities found that Native--the Native
language is primarily spoken and not written, particularly
among the elderly. So as a result of those interactions, the
QIO is working to educate Native American elderly through radio
and television messages translated into the local languages.
In my testimony is table 3 that summarizes the progress of
some of the QIOs to date on our primary prevention efforts.
Now, let me finish by talking about some of the secondary
prevention efforts. Mammography clearly is the gold standard
diagnostic tool for early detection of breast cancer. The
barriers associated with increased mammography rates may be due
to access, especially in rural areas. I recently met with the
primary care providers at a hospital in Harmen County in
Oklahoma. It is the far southwest corner of the State, and the
county's only resource for mammography is a mobile unit that
comes to the county twice a year.
Even in areas of the country where there is better access
to care, QIOs have found that patients may not be receiving
adequate education counseling and reminders about the
importance of getting a mammogram. My QIO delivered 3,000 tool
kits to primary care physicians throughout the State. The tool
kit contained educational resources including patient education
videotapes and materials to assist physician offices in setting
up mammography reminder systems.
Some populations are especially vulnerable to underusing
mammography screening. In some Hispanic communities it is
culturally inappropriate to speak about mammography. The
Colorado QIO created a project to overcome these social
barriers by having female leaders in the Hispanic community
speak to other women in the Hispanic Roman Catholic churches, a
place where they found that these conversations were safe to
have. The Colorado QIO is also working with the staff of area
clinics that care for largely Hispanic populations to make sure
that the messages are reinforced by health care professionals
that the patients trust so that patients are scheduled for
mammograms.
The QIOs are also directed to increase utilization of
certain pharmaceutical therapies that are known to decrease
rehospitalization, recurrence and progressive worsening of
diseases. We heard about the aspirin issue for heart disease
today. For example, patients who are discharged from the
hospital following a heart attack should be on at least beta
blockers and aspirin unless there are contraindications. These
medications reduce mortality and reduce hospitalization. In
table 4, we show some of the progress that QIOs have made in
this area.
The QIOs are specifically working with hospitals to ensure
that there are systems in place for every patient, including
putting checklists in the patient records to remind clinicians
of recommended practices, developing discharge screening
procedures to make sure patients do not leave the hospital
without appropriate prescriptions, and making sure that follow-
up appointments are scheduled before they leave the hospital.
Finally, one barrier to more effective use of
pharmacotherapy for secondary prevention is the lack of the
Medicare outpatient drug benefit. As you do think about
developing drug benefits for seniors, remember that the QIOs
could work with those data sets, including health claims,
medical records data and drug claims to improve continuity of
care. QIOs can do this new work under any drug benefit
structure, anything ranging from discount cards to a full
prescription drug benefit.
Mr. Chairman, I hope the subcommittee will look to the
national network of quality improvement organizations to expand
outreach to Medicare beneficiaries and their caregivers about
important preventive benefits under the Medicare program. Under
current law QIO activities to promote prevention may be funded
through the Medicare Trust Funds. I thank you for the time, and
I'll certainly be happy to answer questions.
[The prepared statement of Dale Bratzler follows:]
PREPARED STATEMENT OF DALE BRATZLER, OKLAHOMA FOUNDATION FOR MEDICAL
QUALITY CARE ON BEHALF OF THE AMERICAN HEALTH QUALITY ASSOCIATION
Good morning Mr. Chairman, Mr. Deutsch, and Members of the
Subcommittee. Thank you for inviting me here today. I am Dr. Dale
Bratzler, Principal Clinical Coordinator at the Oklahoma Foundation for
Medical Quality, the Medicare Quality Improvement Organization (QIO)
for the state of Oklahoma. I am here today testifying on behalf of The
American Health Quality Association (AHQA). AHQA represents the
national network of Quality Improvement Organizations (QIOs, formerly
known as Peer Review Organizations).
The QIOs' primary mission is to monitor and measurably improve the
quality of health care delivered to Medicare beneficiaries. QIOs
concentrate on systems of care, rather than the care delivered to one
patient at a time. This systems approach improves the quality of care
for all Americans receiving services at health facilities working with
QIOs. I am here today because the vast majority of the quality
improvement tasks assigned to QIOs are preventive in nature whether
they are primary prevention efforts, which prevent the onset of a
disease, or secondary prevention efforts, which prevent the recurrence
or progression of a diagnosed disease.
This panel already understands the importance of preventive health
services. I want you to know that QIOs are on the ground promoting
these services by taking evidence based preventive health practices
from the ``bookshelf to the bedside.'' I am here to tell you what QIOs
do to promote and enhance the delivery of preventive services to
seniors, and resolve the barriers to greater utilization of preventive
services. I will also describe some additional interventions that QIOs
are using to target vulnerable and underserved populations across
America. CMS requires every QIO to perform this additional, targeted
outreach.
The work of the QIOs in the Medicare program is defined by the
Centers for Medicare and Medicaid Services (CMS). CMS selects the
clinical areas and the quality indicators that the QIOs use based on
their public health importance and their feasibility in measuring and
improving quality. All of the clinical conditions discussed in my
testimony this morning are important causes of morbidity and mortality
among the Medicare population, and the U.S. population as a whole, and
account for substantial numbers of hospitalizations and a large share
of health care costs.
Here are some examples of what QIOs do to enhance the utilization
of services recognized by experts as best practices:
<bullet> We teach clinical staff how to abstract data from patient
medical records to evaluate performance and track progress in
improving care.
<bullet> We interpret a vast amount of medical information obtained
through medical records and health care claims data, as well as
develop interventions specific to a particular hospital or
doctor's patient population's needs.
<bullet> We develop ``toolkits'' with step-by-step instructions on how
to assess and change systems of care to make sure the right
things are done in certain ways all the time.
<bullet> We implement various kinds of reminder systems that not only
help prompt patients to seek care, but also prompt clinicians
to provide certain types of care.
<bullet> We develop software or paper-based tracking systems or provide
access to online services that a facility would not otherwise
have.
It is important to note that QIOs work in the fee for service
Medicare system as well as with Medicare+Choice (M+C) managed care
plans. Although the data-gathering phase of our quality improvement
techniques may differ depending on the payment arrangements, in either
case QIOs employ a systems improvement approach.
Here is the way QIOs work to promote primary prevention through
immunizations and diabetic care.
Immunizations
There is universal agreement among health care providers regarding
the value of immunizing seniors against community acquired pneumonia
and influenza. Yet, immunization rates among the senior population are
generally very low, especially in the institutional settings like
nursing homes. QIOs promote vaccines in two ways: First, QIOs educate
consumers on the importance of receiving vaccinations for pneumonia and
influenza. Second, QIOs promote screening of patients to check if they
have received these vaccines, so doctors and nurses can provide the
vaccine when needed.
One of the most successful interventions employed by the QIOs to
enhance immunization rates is the implementation of ``standing
orders.'' Regardless of the health care setting, the use of standing
orders allows appropriately trained health care providers to administer
immunizations to patients in need.
Despite the evidence that standing orders are a sound intervention
strategy, there are barriers to implementing standing orders programs
nationally. A particularly frustrating barrier is the regulatory
prohibition of standing orders contained in Medicare facility
``Conditions of Participation'' rules. Medicare CoPs generally prohibit
the use of standing orders in institutional settings. Another barrier
is manufacturers' recent inability to supply the market with adequate
quantities of vaccine doses.
QIOs have also implemented programs to address barriers to
immunization within disparate populations. My QIO in Oklahoma surveyed
African American and Caucasian beneficiaries to determine the cause of
the disparity between immunization rates for these two populations.
We found that there were significant differences in patient
understanding and physician education between the two groups regarding
the pneumonia and influenza immunizations. Attached to my testimony the
Subcommittee will find Table 1 and Table 2 that summarize the answers
to four key questions that our survey asked about each vaccine.
California's QIO, which is called CMRI, identified similar barriers
to immunization among the African American populations living in
Alameda and Los Angeles counties. Through discussion groups and a
telephone survey, CMRI identified barriers such as lack of awareness
about the need for vaccination and misconceptions about adverse effects
of vaccinations. They found that a recommendation from a trusted
physician is a key motivator for vaccination. They also found that
leaders of churches and community centers could be effective partners
in improving awareness and building trust among African American
seniors.
Diabetes
QIOs are directed by CMS to focus on two primary prevention
initiatives with diabetics: prevention of blindness through regular
retinal exams and prevention of cardiac complications through regular
testing of lipid levels. The QIOs are also engaged in a high priority
secondary prevention effort to decrease the progression of diabetes by
testing diabetics regularly for glycosylated hemoglobin (a blood test
that measures a diabetic's exposure to unacceptably high glucose levels
over a long period of time).
One of the barriers to patients receiving regular screenings is
that most physicians do not have medical record information systems
that allow them to access a ``list'' of diabetic patients that ought to
be receiving regular reminders for preventive care services. Medical
records are not filed by disease state, so patients who need reminders
cannot be easily identified. In many states, including Washington,
Oregon, and Wisconsin, QIOs provide physician offices with software
that they can use to develop a disease registry, or patient database,
that tracks the provision of preventive care and can generate physician
reminders regarding preventive care. In many cases, the QIO staff work
directly with the physician to populate the database and minimize the
burden on physicians when they start-up reminder systems.
QIOs have also found disparities between racial groups in diabetes
care. The Florida QIO, called Florida Medical Quality Assurance, also
uses the faith-based approach to community-wide education of the
African American population in the state. They developed educational
materials to train ministers and others within the church to help
parishioners recognize and manage their condition. At the same time,
FMQA analyzes Part B claims data by each zip code in the state and then
takes this data to providers to draw attention to the disparities in
diabetes care that exist in their communities.
The South Dakota QIO is working closely with local Native-American
reservation health facilities to increase diabetes hemoglobin testing.
During the development of relationships with diabetes educators in the
field, the QIO found that the native language is primarily spoken and
not written, particularly among the elderly. As a result, the QIO is
working to educate Native American elderly through radio and television
messages translated into local languages.
Attached to my testimony is Table 3 that summarizes the progress of
some of the QIOs to date related to our primary prevention efforts. The
table shows the median statewide ``failure rate'' for these QIO
indicators. The ``failure rate'' is the percentage of people who are
eligible for a particular kind of care, and are appropriate candidates
for the care, but were not receiving this care as of 1998. The results
of projects to reduce the failure rate are in from two-thirds of the
QIOs right now. We expect complete results later this summer.
QIOs also promote secondary prevention in mammography, heart
attack, and congestive heart failure.
Mammography
Mammography continues to be the gold standard diagnostic tool for
early detection of breast cancer. QIOs strive to increase the number of
cases of breast cancer diagnosed in ``Stage 1,'' when the cancer is
most responsive to treatment. The barriers associated with increased
mammography rates are primarily due to access, especially in rural
areas. In my state, Harman County is a rural county in the extreme
Southwestern portion of Oklahoma. This county's only resource for
mammography services is a van that visits that county only two days
each year. Even in areas of the country where there is better access to
care, QIOs have found that patients may not be receiving adequate
education, counseling, and reminders about the importance of getting a
mammogram.
My QIO delivered 3000 ``Mammogram Toolkits'' to practitioners
throughout the state. The toolkit contained instructions, which
included an educational video, to teach physician offices how to set up
mammogram reminder systems.
Some populations are especially vulnerable to underusing
mammography screening. In some Hispanic communities, it is culturally
inappropriate to speak about mammography. The Colorado QIO, the
Colorado Foundation for Medical Care, created a project to overcome
these social barriers by having female leaders in the Hispanic
community speak to other women in Hispanic Roman Catholic Churches--a
place where these conversations are safe to have. The Colorado QIO is
also working with the staff of area clinics that care for largely
Hispanic populations to make sure the messages are reinforced by health
care professionals that patients trust, so patients are scheduled for
mammograms.
In California, the QIO developed a multi-lingual, culturally
appropriate program targeted to Asian Pacific Islander women who suffer
high rates of breast cancer. Because one-third of this target
population is not proficient in English, CMRI developed educational
literature in Chinese, Tagalog, and Vietnamese. Both the National
Cancer Institute and CMS plan to conduct focus group tests across the
country to implement a nationwide rollout of this program.
Heart Attack and Congestive Heart Failure
The QIOs are directed to increase the utilization of certain
pharmaceutical therapies that are known to decrease rehospitalization,
reoccurrence, and progressive worsening of these diseases. For example,
patients who are discharged from the hospital following a heart attack
should be on at least beta-blockers and aspirin. When these medications
are administered together and appropriately, mortality rates (both 30
days and one year after their first heart attack) and the readmission
rates due to another heart attack can be reduced by up to one third.
Table 4, attached to my testimony, shows the failure rate in these
secondary prevention indicators and the progress that some of the QIOs
have made in reducing those rates. To improve these secondary
prevention failure rates, QIOs employ several techniques to assure that
a system is in place that helps every patient, including: putting
checklists in patient records to remind clinicians of the best
practices that should be followed; developing discharge screening
questions and checklists to make sure patients do not leave the
hospital without the appropriate prescriptions; making sure follow-up
appointments are scheduled with their doctors before they leave the
hospital.
Congress has a lot to say about one barrier to more effective use
of secondary prevention for heart attack. The work of the QIOs in the
area of pharmacotherapy is focused only on the inpatient setting right
now in the absence of Medicare outpatient drug data. As you develop a
drug benefit for seniors, remember that the QIOs are ready and willing
to extend their quality improvement work to the outpatient environment.
They can present physicians with a complete picture of their patient
populations, which will greatly improve the continuity of care in the
health care system. QIOs can do this new work under any drug benefit
structure from discount cards to a full prescription drug benefit. As
long as the QIOs have access to the claims data that will be generated,
they can expand their work to promote secondary prevention.
Mr. Chairman, I hope that the Subcommittee will look to the
national network of Quality Improvement Organizations to expand
outreach to Medicare beneficiaries and their caregivers about important
preventive benefits covered under the Medicare program. Under current
law, QIO activities to promote prevention may be funded through the
Medicare trust funds.
Table 1
Evaluating Disparity
Why didn't you get the flu shot?
------------------------------------------------------------------------
African
Americans Caucasians P
N=1252 N=660
------------------------------------------------------------------------
Didn't know I needed one...... 20% 9% <0.001
Afraid it will make me sick... 40% 26% <0.001
The doctor did not recommend 28% 17% <0.001
it...........................
I don't like needles or shots. 18% 8% <0.001
------------------------------------------------------------------------
*Based on a survey of 26,194 Oklahoma Medicare patients (31.4% response
rate).
Table 2
Evaluating Disparity
Why haven't you ever taken the pneumonia vaccine?
------------------------------------------------------------------------
African
Americans Caucasians P
N=1408 N=918
------------------------------------------------------------------------
Didn't know I needed one...... 43% 43% 0.724
Afraid it will make me sick... 21% 8% <0.001
The doctor did not recommend 42% 41% 0.567
it...........................
I don't like needles or shots. 13% 5% <0.001
------------------------------------------------------------------------
*Based on a survey of 26,194 Oklahoma Medicare patients (31.4% response
rate).
Table 3
QIO Primary Prevention
Increased Utilization of Flu/Pneumonia Vaccines
(data for 36 states)
----------------------------------------------------------------------------------------------------------------
Median State Median State Median State
Failure Rate At Failure Rate At Improvement in
Baseline Remeasurement Failure Rate
----------------------------------------------------------------------------------------------------------------
State Immunization Rates
Influenza............................................ 25.2 22.3 11.6
Pneumonia............................................ 52.6 41.1 21.9
Hospital Screening and Immunization Rates
Influenza............................................ 88.5 78.1 11.7
Pneumonia............................................ 81.4 72.1 11.4
----------------------------------------------------------------------------------------------------------------
Table 4
QIO Secondary Prevention
Increased Use of Preventive and Timely Services for Breast Cancer, Heart Attack, and Diabetes
(data for 36 states)
----------------------------------------------------------------------------------------------------------------
Median State Median State Median State
Failure Rate At Failure Rate At Improvement in
Baseline Remeasurement Failure Rate
----------------------------------------------------------------------------------------------------------------
Mammography............................................ 44.5 39.7 10.8
Heart Attack (AMI)
Aspirin at discharge................................. 16.5 14.3 13.3
Beta blocker at discharge............................ 24.7 16.9 31.6
Diabetes
Glycosylated hemoglobin blood test................... 43.0 30.7 28.6
Eye examinations..................................... 25.2 24.1 4.4
Measure lipid profiles (``cholesterol'')............. 39.4 23.2 41.1
----------------------------------------------------------------------------------------------------------------
Mr. Greenwood. Thank you, Dr. Bratzler.
Thank you all.
The Chair recognizes himself for 10 minutes for questions.
I think I'm fairly typical in that the only thing that
keeps me healthy is--the most important factor--I just turned
51. So I need to pay a little more attention to that. But the
most important factor is that somebody calls me and says that
it is time for your annual checkup, and when it is time for my
annual checkup, I go in and do all of the tests and the screens
and all of that. And without that, I mean, I certainly--I
certainly would not wake up one morning and say I think I need
and want a colonoscopy. It requires somebody to say, come in.
Okay. This is where you are on this milestone. This is what you
need to do.
And so the first question I have is what do we know? What
information do we have with regard to what percentage of
Medicare beneficiaries even get an annual physical, because I
just--I think to me intuitively that seems to be--if every
Medicare beneficiary had an annual checkup--and I know that
there are barriers to this. I know that physicians are rushed
and don't feel that they have the time to go through a
comprehensive checklist that I might get when I go over to the
Capitol for my physical. I know that there are--I don't think
beneficiaries are regularly notified unless they take the
initiative or unless they're already into a regime with a
physician about annual checkups.
What do we know, if anything, about how many beneficiaries
even get an annual exam?
Mr. Grissom. There are a lot of people looking at me.
The Medicare program and the way in which the claims
processing operates is based on the presentation by the patient
with a symptom or a problem. There is no covered benefit for
annual physicals. We have not done a screening of the entire
claims processing data base to ascertain whether or not people
are presenting for physicals. We would typically not pay for
that. They would have to present with a symptom or an illness
or an injury, and in the course of that, it follows, well,
would they be--would there be follow-up? Would the physician
ask, have you had your physical? Would the physician look at
the medical record? Would the physician have a way of indexing
the care received versus the benefits?
The answer to that question is some doctors do. Some
doctors don't. We do know this: That in all of our surveys of
beneficiaries, when we ask them, why did you not get a flu
vaccine, why did you not have colorectal screening, why have
you not had glaucoma, the reasons are always the same and in
the same proportion.
The second answer is, the doctor didn't tell me. The doctor
didn't say anything. I didn't hear from the doctor, which is
why our efforts have been focused on beneficiary education, and
through Dr. Bratzler's group, the QIOs on physician education.
Mr. Greenwood. Let me interrupt you, because it seems to me
to be a colossal mistake not a cover the basic annual checkup.
My understanding is that Medigap policies and Medicare+Choice
policies do, and my assumption is that they do that because
they have decided it saves them money to do that.
Ms. Clancy. Without getting into the issue of what the law
covers or not, I have been reminded that the average
beneficiary makes about 13 visits a year. So the real challenge
is, how do you ensure the provision of preventive care in the
visits they are already making.
This is not easy. For many people it is within the context
of something called the annual exam that they are likely to do
it. At the same time, the additional challenge for older
people, whether or not you cover the annual exam, is going to
be to make sure that they get the preventive care they need
because, as you get older, you have more competing illnesses,
and sometimes those acute needs tend to drive out paying
attention to preventive services.
Mr. Greenwood. The average beneficiary makes 13 visits to
some sort of health care provider a year?
Ms. Clancy. Usually many providers.
Mr. Greenwood. I can imagine that, as Dr. Grissom just
described, the way the fee-for-service program works
essentially is, you present with something wrong with you, and
you get reimbursed for that service; but there is no systematic
way of making sure that all your systems are checked.
If I didn't have an annual inspection on my automobile, I
just take it in every time it ran out of oil or when the tires
went bald and I went off the road, that would be a very
expensive way to maintain my automobile. Yet I would never take
it in for someone to do all of the preventive maintenance.
It seems to me to be an obvious reform that we ought to
make.
There ought to be incentives in the system for both the
health care provider and the beneficiary to get that annual
exam, and maybe they would be making seven trips to the
providers instead of 13 and would save a lot of money.
Mr. Bratzler. I would say your illustration is excellent.
Patients do not wake up thinking about what preventive services
they need. That is the limitation of consumer education
efforts. I don't think that they will work.
Also, when you go to the physician, particularly if the
patient has a lot of chronic medical problems, there are lots
of issues to deal with, and that is why we are focusing hard on
putting systems into place to build those reminder systems so
they think about routinely needed preventive services and,
perhaps, recall systems to bring patients back in to get those
services.
Mr. Greenwood. Dr. Grissom, you mentioned that CMS is
developing a potential project that would examine the use of
health risk appraisal programs with targeted follow-up
interventions. What stage is the project in? Is there anything
Congress can do to speed up the process of development of an
approval to get a project like this up and running?
Mr. Grissom. We are in the process of developing that. I
can't give you a specific deadline or timetable. We
commissioned a report from Brandeis on risk appraisals, which
we have received with recommendations from them on what to do
and how to go forward.
I can get you a specific answer. I am not aware of anything
that Congress can do that is keeping us from moving forward on
that project. But I will be glad to give you a written
response.
Mr. Greenwood. Is there data within or without the Medicare
system that would indicate whether or not, if we had a system
where there was a minimal incentive for an annual health check;
and it seems to me that it is covered. I could imagine other
incentive systems where you would have a different payment in
your Part B premium or your Social Security check would go up
or a different deductible for your hospitalization, if you got
the annual checkup; and it would seem to me, in order for that
to be a good and comprehensive health checkup, you would need
to reimburse physicians in such a way that they would be
incentivized to spend the time to go down a comprehensive list
of screens, et cetera.
What do we know in the whole history of health care as to
what data--where would I turn to find out whether that would,
A, significantly increase health, reduce expensive treatments;
and B, be less costly to the health care system as a whole?
Mr. Grissom. I asked this question of our clinicians at CMS
before I came over. Their answer is, and this is really
fortunate, is because there is no evidence, it is not
definitive. There is no scientific evidence that increased
physicals, by themselves, would improve health outcomes.
Mr. Greenwood. Is that because no one has done the study?
Mr. Grissom. It is because no one has done the studies. And
No. 2, it assumes that there are other ways that people can
obtain preventive services and immunizations and vaccinations
without having a physical.
The way the Medicare program works now is, you can call
your physician up and say it is time for my mammogram; or can I
come in for my flu shot. If the physician looks at your record
and you need it, and the physician offers a service, they have
an opportunity to bill.
Mr. Greenwood. We know most people do not do that, right?
Mr. Grissom. Not nearly enough people do that because not
nearly enough Medicare beneficiaries understand the benefits.
Mr. Greenwood. The best utilization for immunizations is
about a half among Caucasians, and it goes down to a third for
minorities, is my understanding.
Mr. Grissom. It is a little different. Let me give the
correct immunization rates. For pneumococcal vaccination, and
that is a lifetime vaccination, 63 percent of beneficiaries are
covered. Last year, 73 percent of beneficiaries had a flu shot.
Mammograms, in the 10-year baseline period it has gone from
37 percent mammograms, annual mammograms, up to 54 percent.
Pap smears and cervical pelvic exams is in the area of 35
percent.
AMA reported yesterday that in the last year, the rate of
mammograms has gone up in 43 out of 47 States. The rate for flu
vaccination is up in 44 out of 49. Pneumococcal up in 48 out of
49. Trailing is cholesterol which is not a covered benefit;
cholesterol screening only went up in 13 States. Cervical
cancer screening up in 13 of 49 States.
We are making improvements, but those are gross numbers, by
State, and they are not the same across all populations. The
rate of increase and the numbers of people getting those
screenings is not what it should be.
Mr. Greenwood. My time has expired, and I want to recognize
Mr. Strickland. It just seems to me that even the best of those
utilization rates are sort of rifle shots, whereas we know if
someone came in for a comprehensive physical exam, and if
someone talked to them about their physical activity and
getting a flu shot and talked to them about smoking.
Mr. Grissom. And exercise, right.
Mr. Greenwood. All of those things in a comprehensive form,
it would seem to me to be much more beneficial. That is what
people with good health care systems get.
Mr. Strickland is recognized for 10 minutes.
Mr. Strickland. Thank you, Mr. Chairman.
The managed care organizations seem to emphasize the fact
that one of the real advantages of the Medicare+Choice program
is that the beneficiaries are much more likely to get
preventive services. I am wondering, do we know that for sure?
Is there anything in the research that you are aware of that
would indicate that that, in fact, is the case?
If you are in a managed care plan, you are more likely to
get an annual physical, for example, than if you are in a fee-
for-service plan?
Ms. Heinrich. In the process of doing the work for this
report, we did come across studies that looked at managed care
organizations and utilization of preventive services as opposed
to fee-for-service. It is difficult, though, because there are
not many studies that actually target the 65-and-over
population. Much of the information is for younger age groups.
What we do find is that the strongest relationship in terms
of utilization of preventive services is economic level and
education level. Oftentimes, when you adjust for that, the
differences that you might see in use by people in managed care
as opposed to people in fee-for-service may disappear.
Others may have some information on that.
Mr. Strickland. Does anyone else have a desire to respond
to that question?
Mr. Bratzler. I can give you anecdotal data.
I am in a State that has relatively low managed care
penetration. And so when we go in and measure performance on
preventive services like immunizations, diabetic screening and
things like that, we look at a practice which includes both
managed care, Plus Choice, and Medicare fee-for-service. We do
not find much difference, mainly because we do not find that
physicians in their practices, particularly when they have a
mixed practice, treat the patients any differently based on
payer source. That is in a State with relatively low
penetration.
Mr. Fleming. Regardless whether someone is in managed care
or fee-for-service, the more approximate predictor is that the
receipt of predictive services is going to be whether or not
there is a reminder recall system in place so that when the
patient comes in, the physician knows the preventive services
that are needed, whether or not there is a copay or preventive
services can be delivered for free. There is a whole list of
interventions that are independent of whether they are fee-for-
service or managed care that you can put in place to increase
the likelihood that preventive services are being delivered.
Mr. Strickland. So is it a correct statement that although
we seem to accept the fact that managed care does provide
greater access to preventive services, we do not know that for
sure, based upon the research that is available to us?
Mr. Grissom. Based on our surveys of beneficiaries that are
in the risk programs, we know that they do get more preventive
services than the fee-for-service beneficiary. We also know
that the more managed the managed care program, the more likely
they are to get those preventive services.
The old Kaiser model of HMOs that existed still does exist,
but was more predominant years ago in which patients had a
long-term, standing relationship with a group of physicians in
a fixed facility, it did result in that.
Mr. Strickland. The reason I am smiling is some people may
find it surprising that I used to be a strong advocate of the
concept of an HMO because it seems to me that in the early days
of this movement, what you described was much more likely to
occur. There was an emphasis on keeping people well rather than
treating them when they get sick; and prevention was a big part
of the justification for the HMO movement.
But it seems to me that in recent times, perhaps because of
cost constraints or whatever, that there is less and less
emphasis on the preventive aspects of a managed care program.
Ms. Heinrich. One thing I would add is that managed care
organizations have changed over time, and there are a lot of
variations in how they are structured and the kind of services
that they do provide.
I know one study that was done by CMS, doing a comparison
of beneficiaries by managed care versus fee-for-service, was
really old data. I think it was data from 1996, and at that
point in time your fee-for-service Medicare system did not have
the same array of services that Medicare now offers. I don't
think it is so clear.
I think you are right, it is not clear that beneficiaries
in managed care necessarily receive more preventive services
than those in fee-for-service.
Mr. Strickland. If I can direct a question to Mr. Grissom,
I was struck by the chairman's question earlier regarding
whether or not, as I understood the question, we know for sure
that an annual exam, for example, is going to lead to cost
savings. I believe that was the gist of the question, and I
think your answer was that we don't know that for sure; is that
correct?
Mr. Grissom. My answer is, I am not aware of any science-
based evidence that an annual physical would either in the
short term or long term reduce health care costs or improve
health care outcomes.
Mr. Strickland. I just find that fascinating, because I
think that is such a basic bit of information that is crucial
to what we are trying to do in terms of provide the best, most
efficient care and treatment.
Is it possible, and I am wondering whether it is because
the research has not been done. Or is it because of the way
that we factor in cost savings under our system up here that
preventive care may not demonstrate a benefit for 10 or 15
years or 20 years into the future, and so as we look at
potential cost savings, we are looking more in the near-term
paradigm, and that we may be experiencing cost savings, but we
are unable to factor that into the scoring that we do here in
the Congress, or you do at CMS or whatever? Is that a
possibility?
Ms. Clancy. If I can jump in here, your comments and the
comments and the questions of the Chair have been focused on
the annual physical exam. In general, the focus of the U.S.
Preventive Services Task Force and other expert bodies has been
to focus on the specific components of what takes place within
a physical exam, specific services, because, for example, what
a 51-year-old man needs in terms of detecting disease early and
preventing future diseases is different than an 18-year-old man
or a 25-year-old woman.
For that reason, most of the literature is organized around
whether specific services are cost effective or not. There are
very specific examples. Some services save money, a small
subset. Immunizations generally fall into that category. Some
actually delay the onset of bad outcomes, and over the time
horizon, that is to say, they can be shown to be cost
effective.
Where possible, the Preventive Services Task Force actually
presents the information if cost effectiveness analyses have
been done, but they are not systematically and routinely done
when gathering the evidence on effectiveness.
Mr. Fleming. Just to follow up on that point, there is much
evidence that shows that the delivery of the preventive
services that we are talking about yield substantial returns on
that investment in terms of improving quality of life,
generally far more so than waiting until somebody becomes sick
and investing that same amount of money in acute medical care.
I think the issue is whether or not it is best to think
about delivering those preventive services all at once in some
sort of separate exam where we essentially divorce prevention
from routine medical care; or alternatively, looking toward a
system where preventive services are naturally integrated into
every visit that someone seeks.
If you are a smoker, hearing once a year at an annual exam
that you should not smoke will provide some incentive to quit,
but the better incentive is, every time you as a smoker come
in, including the times that you are in there for your
bronchitis or pneumonia as a result of your smoking, you hear
that message from your provider that you need to quit. That is
going to be the more effective way of delivering preventive
services.
Mr. Strickland. Thank you, Mr. Chairman. I yield back the
balance of my time.
Mr. Greenwood. Thank you.
I recognize the gentleman from New Hampshire, Mr. Bass, for
10 minutes.
Mr. Bass. Thank you, Mr. Chairman. I was not that
enthusiastic when I read the title for the hearing, which is
about half a paragraph long, but this is a very interesting
hearing.
The fundamental issue here obviously is how the Medicare
system is able to deal with issues that are not traditional to
its original mission, and it is a most interesting subject. Mr.
Strickland has gotten into the issue of Medicare+Choice versus
fee-for-service.
I would like to recount the first exposure I had to this
issue in 1996 or 1997 when our former Speaker walked into a
Republican Caucus in July and announced that every Member,
during the August recess, was going to do an event to support
the cause of finding a cure for diabetes, and that we were
going to increase the budget for NIH. The Medicare system was
going to be studied because we were going to do everything that
we could to make sure diabetics were properly treated, because
26 percent of the total cost of Medicare is associated with one
illness, which is diabetes. That is the answer, and we didn't
have to worry about anything else related to Medicare.
Dr. Coburn, a former Member, stood up and said, Mr.
Speaker, that makes a lot of sense, sort of; but the real issue
here is diet, and you can't legislate diet. A doctor cannot
guarantee that a potential diabetic follows a diet.
I will not go on to discuss the Speaker's response to that,
but suffice it to say that it was not government's issue to
determine what diet is.
What we are really talking about here is providing services
that have very little to do with, or may not have a lot to do
with, prescriptions or operations or annual physicals and so
forth, but being able to make a system such as the Medicare
system responsive and flexible enough to be able to work these
issues and do it successfully in light of the debate which is
occurring as to whether or not the traditional Medicare system
works as well as perhaps some other alternative health care
delivery systems that have been around for awhile.
My only question is: Is it possible that Medicare will have
to change some of its reimbursement policies to not only
provide reimbursements to qualified nonphysicians, outside of
the Medi-care+Choice program, who provide assistance to seniors
that may not be clinical in nature?
Does anybody want to answer that?
Mr. Grissom. Congressman, as you well know, in 1997 in the
BBA, there was a benefit for diabetes self-management written
into law which was to increase patient education, and it
reimbursed physicians for providing that service. And then in
2000 with BIPA, we had the first medical nutrition therapy
benefit, and it was to help people with their diet, and that
referral to a physician occurs because they are probably under
the care of a physician for diabetes. That benefit does allow
reimbursement directly to nutritional therapists or registered
dieticians and does not depend on a physician for that service.
Mr. Fleming. Just to reinforce that point, to get back to
your question about diabetes, studies recently done by NIH show
that the best way to prevent someone who is at risk of getting
diabetes is not through medication and not through legislation,
but through counseling about diet and physical activity and
creating circumstances in their home life and in their
environment where they can eat the right things and they can
exercise.
So if we really are looking for ways to reduce health care
costs from diabetes in the future, the place to focus now is on
people who are at risk and making sure that they have the
nutritional counseling that they need and advice about exercise
and they have an understanding about the kinds of things that
they need to do to prevent getting that disease in the future.
Mr. Bass. Mr. Grissom answered by saying there is indeed a
benefit or system or a way in which this issue, diabetes
specifically, can be addressed.
My question is: Is Medicare going to be able to be a
flexible enough system to address this issue in such a fashion?
First of all, the management of chronic illness, some seniors
have as many as 5 or 6 chronic illnesses to manage, and can
this system--that was established 35 years ago, I think, to
treat illness in one manner--going to be able to in its current
configuration, deal with this and do it successfully?
Mr. Grissom. We are authorized by Congress to do some
disease management and coordination-of-care demos, and we have
5 or 6 demos for which proposals are out on the street which
will do precisely what you are suggesting, which is disease
management, especially in the area of chronic diseases, mostly
congestive heart failure and diabetes; and they are going to be
available not only in the Medicare+Choice but in the Medicare
fee-for-service program, which is an effort by the Secretary,
the Administrator, to push these kinds of alternative treatment
schemes down into the fee-for-service area.
Additionally, we do at Medicare commit increasingly
significant sums of money to partnerships and educational
programs in this particular area with the Association of State
and Territory Officials, with the National Diabetes Foundation,
to try to reach out to significant groups responsible within
the family or within the individual subculture for care and
care-giving decisions to educate in the area of diabetes.
So both in demonstrations and in education, I think we have
the tools, and I think we are using them appropriately to
address the problems that you are concerned with.
Ms. Clancy. I think you are highlighting some very
important problems.
Last year, the Institute of Medicine published a report
called ``Crossing the Quality Chasm,'' and they used ``chasm''
instead of ``gap'' to signify a huge gap between the kind of
quality of care we could provide across the system, across the
life span, and what is actually being provided on average.
Medicare faces that problem, but it confronts all payers, and
it is a very big focus of the research that we are supporting.
One of the strategies that has been used that Medicare has
been very much part of, and is part of accreditation and so
forth, is actually reporting on how we are doing. Where health
plans do participate in accreditation, there are reports in
terms of clinical preventive services, they do have better
results than the State average.
Next year, my agency will be submitting to the Congress a
national report on the quality of care in this country, and I
think that can be an important lever to drive change. The
issues that you are identifying are fundamental to how we
deliver care, and most health care systems right now are
struggling.
Mr. Bass. This may not require an answer. I ask it anyway.
Does managed health care work better on providing preventive
services than fee-for-service or Medicare? Is that too simple a
question?
Ms. Clancy. No. It is breathtakingly clear.
The problem has been that the definition of managed care
has changed almost continuously over the past 10-20 years.
Overall, most studies would say that managed care systems have
an edge in terms of providing preventive services. I think
people disagree about what that means. Is that because the care
system is doing it, or because managed care tends to attract
people who are healthier and more interested in prevention and,
in some cases, the plans have less cost-sharing? In general,
their track record is pretty good.
Ms. Heinrich. Although there have been studies, I know we
did one, which was a comparison of managed care and fee-for-
service, on the treatment following cardiac arrest; there was
really no measurable difference. So the evidence is mixed.
Mr. Bass. Thank you. Mr. Chairman, I will end by saying I
wish I could compare in my own home State Medicare+Choice with
fee-for-service. Unfortunately, the reimbursement formula
discriminates against rural America.
I yield back the balance of my time.
Mr. Fletcher [presiding]. Thank you. I am sorry I wasn't
here for the testimony, I have reviewed most of them. I thank
you for coming here today, and I want to thank the chairman,
who is out just briefly, for hosting this hearing.
Prevention is one of the areas I was involved in in a
former life, and if the election goes well it will continue to
be a former life. I think it looks good so far. In any case,
thank you all for coming.
Let me make a statement and see if you concur with this or
not. Managed care, early on, changed probably the perspective
of physicians and the practice of medicine in the sense that a
lot more emphasis was put on prevention and chronic disease
management, and probably changed a little bit the way the
practice of medicine has evolved, particularly in the reports
that I used to get back on the vaccination rates for children,
the rates of mammograms on women that were of the proper age to
receive those under the recommendations, as well as other
issues.
Would you say--and I think it has already been stated--the
degree of prevention and screening depends more on the practice
than on the insurance product? However, if you reimburse for
those, things you are more likely to get them than not?
I just want to hear a few comments.
Mr. Bratzler. That is our experience in Oklahoma where, in
our metropolitan areas, we have managed care penetration; it is
practice dependent, it is not based on who is actually paying
for the care. I do think that incentivizing certain preventive
services would probably increase services. In our State, we do
not find differences between managed care patients and fee-for-
service patients. We see differences, though, between
practices.
Ms. Clancy. In general, the literature is pretty consistent
that knowing the right thing to do on the part of providers or
patients does not necessarily mean that it gets done. Knowing
it is the first step; the next step is having a supportive
practice environment and an incentive for change, which can be
financial and otherwise.
Mr. Grissom. The reason that CMS in the Medicare program
has focused on outreach to minority groups, ethnic groups, and
economically disadvantaged groups is because the evidence is
overwhelming that there is a high association between certain
demographic groups and their access or utilization of these
benefits and services.
Underlying that data is probably also a subset of providers
to whom certain individuals go by demographic, ethnic and
economic group, and thus, there is a high degree of correlation
between types of providers with their practices and types of
patients.
None of that has much to do with who is paying for it.
Mr. Fletcher. It seems to be a pretty good consensus there.
Let me ask a specific question. Dr. Fleming, I think it is
in your report on page 5, you say a recent Institute of
Medicine report noted that the return on investment in medical
care for vascular disease reaped benefits, four to one, but
investments in behavioral change returned a remarkable 30 to 1
advantage.
What is the scale? What are the units there?
Mr. Fleming. I will be happy to provide that report to you
as well. The bottom line of what the Institute of Medicine was
saying, medical therapy to treat an illness, once someone has
heart disease, does provide that person improved quality of
life, but it is fairly expensive and in general cannot remove
the symptoms entirely.
In contrast, if you can work with that person on preventive
measures by changing their behavior--stopping smoking, diet,
exercise, for example--such that they never develop heart
disease in the first place, first, those interventions tend to
be less expensive; and second, the return on them, which is the
absence of symptoms versus reduced symptoms, is far greater.
So if you have a fixed number of dollars to spend and your
goal is to improve quality of life, investing those dollars in
behavioral interventions early to prevent illness is going to
yield a better return than investing those dollars late once
illness has occurred.
Mr. Fletcher. Is this four to one?
Mr. Fleming. We can provide the report, but to do these
economic analyses, you have to look at what the cost of
intervention is and then look at the quality of life that is
produced and assign some economic value to that improved
quality of life.
Mr. Fletcher. It is an estimated economic value due to the
quality of life and the ability of the individual to continue
in the workplace, et cetera?
Mr. Fleming. Continue in the workplace and carry out day-
to-day activities, yes.
Mr. Fletcher. Dr. Clancy, when I was practicing, it was
always very difficult to decide what screening tests were good
and cost effective. We also were concerned at one time on the
liability because we had posted in our charts, we went through
the prevention task forces and posted what we needed, and if we
missed someone, we documented our own record of not getting
something done.
Let me ask you, and you mentioned, obviously there is some
very clear evidence on some studies, or on some diagnostic
procedures or clinical procedures that shows a tremendous
advantage; and others, it is rather murky. And I think this
goes to the physical exam, which is something that we are all
familiar with, but the content of that is really important, and
it is tailored to the individual person and risk factors as
well.
What are you doing as far as what you see on the horizon?
And you mentioned in here some studies that are not clear, that
are not effective, maybe not good studies in general. What do
you see coming in a way of being able to more pinpoint
diagnostics, clinical interventions, et cetera, for prevention
and disease management?
Ms. Clancy. You have highlighted something that I think
gives people great angst about the use of evidence to inform
practice, which is that lack of evidence of effectiveness is
not the same thing as saying that something does not work; and
that makes people very nervous, especially if we start to tie
payment to evidence and so forth.
The evidence the Task Force considers in making their
recommendations generally comes out of an evidence report,
which is a systematic review of the available scientific
evidence, on that particular service. Frequently they will
review services for which the evidence is indeterminate. Part
of that report actually articulates priorities for research
which we try to share with our colleagues at NIH and so forth,
to try to make sure that for areas where there are important
questions and great concerns and issues of public health, that
they are aware of what the specific questions are that need to
be addressed by research.
PSA may be one, for example. The U.S. Preventive Services
Task Force has not recommended it as effective because the jury
is still out. The studies are being done right now, but that is
the process.
Mr. Fletcher. In light of that, though, we are all doing
PSAs because of the hopeful fact that the studies may indicate
that we do save lives and decrease morbidity and mortality.
Mr. Grissom, it is good to have you here from Kentucky, and
let me ask you, I was looking through what particular
preventive measures and diagnostic tests are available on
Medicare. Just looking at this, it looks like we in Congress
tend to practice a lot of medicine here. We have to look at
your evidence data, weigh it, and see what it is going to cost,
and every time we want something new on the regular Medicare
fee-for-service, we say let us authorize that or not.
Let me ask you how effective that is, given what Dr. Clancy
and Dr. Fleming have mentioned, and I am sure some of the
others, in the fact that medicine is evolving very quickly. The
questions are not easy, and the answers are even more
difficult.
Does a program where you have the flexibility like the
Federal employees health plan or Medicare+Choice, does that
give you a lot more flexibility to have plans that meet the
needs and evolve with the science of medicine, rather than the
typical Medicare situation where we have to come up here and
fight politically to get things done?
Mr. Grissom. I was doing good on a panel of doctors until
the chairman became a doctor.
You are absolutely right. The fee-for-service program is a
disease diagnostic and treatment program, and the Secretary is
authorized by that statute to make decisions and has great
discretionary authority to decide what is an appropriate
service for the treatment and diagnosis of those illnesses and
diseases.
In the preventive area, there is no discretion, and so it
is Congress telling us specifically when they want this to be
covered as a benefit, when screening is appropriate. And I am
sure it gives clinicians great pause to see that in 1997 the
recommendation was for every 3 years, and for women at high
risk or child-bearing age; and 3 years later the threshold goes
down, and it is every 2 years, or all persons regardless of
age.
What you are seeing is a progression, expansion, increase
of the universe, increase in frequency.
I think there are those--I don't think there are any
problems, but I think there are those that think that this
process could be improved upon, and that legislation is not
ordinarily science-based and that these are very heavy
decisions that the Congress is making and that there may well
be opportunities to give others some authority or discretion to
make those decisions.
I am unaware, in those payment plans that you referred to,
whether or not they routinely have those benefits or that there
is greater utilization of them than there is in the fee-for-
service or Medicare+Choice program. But we are bound by
statute, and the discretion and flexibility in the prevention
area does not exist as it does for diagnosis and treatment
procedures.
Mr. Fletcher. I was going to get some comments from the
rest of the panel because the fee-for-service Medicare, which
has been a tremendously effective program, is probably the
ultimate managed care program when you have 535 folks up here
managing every preventive measure that is reimbursed.
I wonder, from your comments, do the other possibilities
that I mentioned and some other ways of managing Medicare seem
a little more positive and better, to be sure that we are able
to address the needs of our seniors regarding disease
prevention and chronic disease management?
Ms. Heinrich. Certainly in our work we did not actually
examine the process that Congress uses to determine coverage
for preventive services. I know that there have been
suggestions that various groups in the private sector, or CMS,
consider evidence, the evidence phase that is developed by the
U.S. Preventive Services Task Force; that these organizations
could make recommendations based on evidence to the Congress,
and then the Congress could consider them as one possibility.
I think it is really important that we understand that not
all the recommendations from the Preventive Services Task Force
are so easily translated into a benefit for the 65-and-over
population. I think we have to think through very carefully the
evidence and differentiate, for example, the difference between
a behavior being good and healthy and reducing risk, and
understanding that we do not necessarily know how best to
counsel people to achieve that behavior.
Mr. Fleming. The fact is that the reality of these issues
that we are confronting is changing. This is an evolving time.
The numbers of people that are elderly are increasing. Our
understanding of what works and does not work is changing, and
our knowledge regarding preventive services is growing. I don't
know what the right system is for incorporating that into
Medicare.
I do know whatever system you choose to put in place is one
that is going to have to deal with these complex issues. It is
going to have to be flexible and adapt to changing knowledge
over time, and it is going to have to be knowledge-driven.
There is science that can tell us what to do, and whatever
system you put in place needs to be able to take that knowledge
and incorporate it into policy.
Ms. Clancy. I like the image of ``535 managers of the
Medicare program.'' You have alluded to managing what the
program covers and what is the scope. I think that is one part
of the puzzle, and I know Dr. Gold is going to speak to that.
The second thing is what happens at the level of practice.
That is a local phenomenon, and that is where the quality
improvement organizations are important. With the help of
science, to help clinicians know how to make sure that they get
the preventive services delivered is important.
For example, we know from a lot of studies that people with
multiple chronic illnesses are far less likely to get
prevention. Why should that be? The very people you would like
to reach and are in there all the time are the people least
likely to get recommended preventive services.
There are a lot of factors that contribute to that, but I
don't think that is something that is going to be dictated at
the level of the scope of the program or what the structure and
the financing is. I think that is going to be much more local.
Mr. Bratzler. I am not going to try to make recommendations
about what Congress should do about changing the Medicare
program for preventive services, but there needs to be
flexibility to have pilot projects to test some of these
preventive measures to see if they work. I think the Medicare
stop-smoking program is an outstanding example of a pilot that
is coming up that may result in recommendations for a new
preventive service that should be provided to all Medicare
patients, if it is a successful project--so continuing to have
flexibility to the pilots when there is evidence from AHRQ and
others.
Mr. Fletcher. I thank you, and I will turn the hearing back
over to the chairman.
Mr. Greenwood. Just a few additional questions.
Mr. Grissom, you mentioned a couple of times that Medicare
is statutorily structured for the diagnosis and treatment of
diseases, and does not have a mandate on prevention. What would
happen if we went into that statute and added preventive
services to the mandate?
Mr. Grissom. I looked at the literature, and I do not think
that there is any preventive service or screening that is
absolutely--that all clinicians would say, this is the next
thing or that this is what we need to do.
I think Dr. Clancy probably can speak to the
recommendations from the United States Preventive Services Task
Force. I believe probably that cholesterol screening is one
that is in play. However, I think what we are seeing for a
variety of reasons, blood pressure screening and cholesterol
screening, because they can be done in a shopping center, are
increasingly being done, being accessed by a lot of seniors. I
think, except for cholesterol screening and some thyroid
monitoring, there is no consensus on what else ought to be
covered.
The issue, though, that I think you are maybe also alluding
to is, if it could be shown that an annual physical, because it
either increased access to preventive services or it was, in
itself, a preventive service--if it could be shown to be
beneficial, would the Secretary use authority or discretion to
implement that, is a good question. I must say I don't have the
answer. I know that we don't have scientific evidence upon
which to make the determination.
Those are the things that I think in the area of preventive
screening are next steps or in play.
Ms. Clancy. I think there is a very solid body of
literature that says that economic barriers are a very
important deterrent to the receipt of effective clinical
preventive services, so higher cost-sharing and not having
coverage for the service actually do effect people not getting
the service. To that extent, there is an opportunity if
preventive services are covered.
At the same time, in addition to focusing on quality of
care prevention, we also have a lot of economists who study
economic behavior. So if Congress were simply to say, we will
cover preventive services, I think you could set your watch
until new things people wanted covered would be defined as
prevention, so you would need to be specific about what you
mean by ``preventive services.''
Mr. Greenwood. According to GAO's report, CMS's current
efforts to increase beneficiary utilization of Medicare-funded
preventive services for persons 65 and older centered around
four components reviewed in a 1999 evidence report prepared by
RAND. These are systems change, financial incentives, reminders
and education.
The key conclusion that the report drew was that
organizational and systems change, such as the use of standing
orders, which has been referred to, and the use of financial
incentives, were the most consistent at producing the largest
increase in the use of preventive services.
What kind of financial incentives were the most effective?
Are you familiar with that, Dr. Grissom?
Mr. Grissom. I think the financial incentives were, A,
reimbursement for those services for physicians; and, B, the
existence of copays and deductibles.
As you are aware, the President has recommended removing
the remaining barriers to copays and deductibles. Since the
start of this administration, we have tried to address
physician fees on the administration of vaccines as well as all
preventive services. Secretary Thompson has specifically
addressed the issue of mammography, mammograms, and we have
increased coverage for different kinds of digital
mammographies, and we intend to address that issue again this
year in the physician fee schedule.
I think those are the kinds of incentives that our report
has focused on and referred to.
Ms. Heinrich. Just one comment.
There were some other examples, for example, travel
reimbursement or gift certificates that have been used; but
again you have mixed evidence about how effective they are. But
there are some other examples of what you can do.
Mr. Greenwood. When we have health fairs back home, we give
a spaghetti lunch and people come in and get their blood
pressure tested.
Ms. Heinrich. Right. It seems logical that removing
economic barriers should be a very effective strategy, but when
you look at utilization, you see that the use of immunizations
is relatively low. There is no copay formula.
Mr. Greenwood. It goes back to the comment made earlier,
which is when you ask, why didn't you utilize this service,
nobody told me that I could. Nobody said that it was out there.
Mr. Grissom. We need to get all of the rates up, but the
rates are highest for those screenings for which there is no
copay or deductible.
Mr. Greenwood. I thank each and every one of you for
spending the last couple of hours with us.
We will call forward the next panel which consists of Dr.
Marthe Gold, Logan Professor and Chair, Department of Community
Health and Social Medicine, City University of New York Medical
School; Dr. Christine Himes, Director of Geriatrics, Group
Health Cooperative in Seattle; Viola Quirion, on behalf
Alliance for Retired Americans in Washington; and Dr. Jessie
Gruman, President and Executive Director, Center for the
Advancement of Health, also in Washington.
Welcome to all of you, and thank you for being with us this
afternoon. If you were here when we began the hearing, you
heard me say that this is an investigative hearing and it is
our custom to take testimony under oath.
Does anyone object to giving your testimony under oath? And
you are entitled to be represented by counsel. Do any of you
wish to be represented by counsel?
Nothing to hide, okay.
In that case, I will swear you in.
[Witnesses sworn.]
Mr. Greenwood. We will start with Ms. Quirion.
TESTIMONY OF VIOLA QUIRION, ON BEHALF OF ALLIANCE OF RETIRED
AMERICANS; MARTHE R. GOLD, LOGAN PROFESSOR AND CHAIR,
DEPARTMENT OF COMMUNITY HEALTH AND SOCIAL MEDICINE, CITY
UNIVERSITY OF NEW YORK MEDICAL SCHOOL; CHRISTINE HIMES,
DIRECTOR OF GERIATRICS, GROUP HEALTH COOPERATIVE; AND JESSIE C.
GRUMAN, PRESIDENT AND EXECUTIVE DIRECTOR, CENTER FOR THE
ADVANCEMENT OF HEALTH
Ms. Quirion. Thank you, Chairman Greenwood and members of
the subcommittee, for this invitation to testify today. I am
Viola Quirion from Waterville, Maine. I am a member of the
Alliance for Retired Americans.
Before I go further in my testimony, I would like to stop
all distractions or anything. I figure you might wonder why I
have a hat which says Washington, DC, and that is because I
forgot my wig at home. I decided to buy a hat, and I bought one
with Washington, DC, because I love Washington.
Although I have been fighting for this for 9 years, for
affordable health care and prescription drugs, and it is pretty
discouraging we have not gone very far with it; but I am still
confident and I have hope in all you people that this year it
will come.
Mr. Greenwood. And you look great in your cap.
Ms. Quirion. Thank you.
I am accompanied today by John Carr, the President of the
Alliance for Retired Americans, which was established in
January 2001. It now has 2.5 million members across the Nation.
Retirees from affiliates of the AFL-CIO, community-based
organizations and individual seniors have joined the Alliance
to create a strong, new voice for retired workers and their
families.
I want to congratulate you for holding this hearing, as I
believe that preventive services under the Medicare program are
very important. Because of Medicare coverage of pap smears,
mammograms and flu shots, many lives have probably been
extended. I think physical exams also should be considered a
preventive service. For many people on limited income, however,
that 20 percent copayment for preventive services may be an
immediate luxury they cannot afford even though it may
ultimately be life-saving.
It is not in my testimony, but I believe that preventive
service and mammograms were not always covered by Medicare, and
physical exams were not. In my case, it would have saved a lot
of illnesses. I will go, later on, and you will see it would
have helped me a lot if I would have had these.
I am from Waterville, Maine. I worked in the Hathaway shirt
factory for 44 years until I retired in 1994. I live on two
small pensions and Social Security, which comes to $1,466 a
month. I never had to worry about health care expenses until I
retired. I now have a supplemental plan to cover some of the
costs Medicare does not cover, but it is not sufficient for
everything.
I was diagnosed with ovarian cancer in late December 2000,
and had surgery in January 2001. The surgeons who operated
found that different parts of the cancer had cemented together
my ovaries and many parts, so they could not cut into it
because I would have bled to death.
Consequently, I took a series of chemotherapy treatments
lasting 5\1/2\ hours each time. It took 7 days for me to
recover after each of these treatments. For these treatments, I
was in a nursing home for 6 months.
In December of 2001, I had knee surgery. While recovering
at home, I suffered from a number of infections. I needed
intravenous transfusions, but since Medicare does not pay for
those at home, I had to go into a skilled nursing home facility
for 6 weeks where they are covered. Consequently, Medicare paid
for the skilled nursing care and the IVs which were much more
costly than the $400 treatments I could have received at home.
Although IV transfusions may not be considered a preventive
service, it does not make sense to me to spend extra money
unnecessarily.
Currently, I am taking 1\1/2\ hour chemotherapy treatments
for the ovarian cancer and don't experience negative
aftereffects. The blood test shows that the mass is dissolving.
I am happy to say that Medicare does cover the chemo
treatments, but follow-up is just as critical to survival as
preventive service.
I am here today primarily to tell you the importance of
prescription drugs as a preventive measure that has extended
and enhanced everyday life for millions of Americans.
Technological advances in treating disease include use of new
drugs that can arrest or cure many cancers, heart disease, high
blood pressure and other life-threatening conditions.
Prescription drugs save costs in reducing surgeries in
hospitals and nursing home care. However, new drugs are more
expensive than old drugs and three times more costly than
generic drugs.
Because of my--they give me blood work before every chemo,
and at one point my blood was low; they talk about giving me a
drug that would have cost me $2,000 for a cancer drug. That is
more than I earn every month. So if it ever comes to that, I'll
just have to wait and die, because there is no way even the
Canadian drugs would pay for something as heavy as that.
I have taken seven bus trips to Canada over the past years,
which were sponsored by the Maine Council of Senior Citizens
and the Alliance for Retired Americans. I take Prilosec for
stomach ailments, which in the U.S. costs me $5 a pill, and
Relafin for my back and knees. I estimate that I save $1,000
every trip.
Unfortunately, it took me a week to recover from the last
trip because of my knees. I probably won't be able to make any
more trips, but I'm not alone. There are so many people who
could benefit from these trips, but are physically unable to
board a bus.
And the last trip that I made, it was January when I came
out of the nursing home. I needed prescription drugs, but I
also had some new ones, and of course I wasn't in a condition
to go to Canada. So I had one drug that cost me $301.54, one
$264.78, $34.98, $16.78, which is a total of $558.08. My
monthly expenses are my rent, $271; my supplement insurance,
$113.50; phone, $25; cable, $23; a total of $432.50. So with my
income of $1,466, that left me for the month for food $125.58.
And, of course, I couldn't buy it for the month because they
keep changing my prescriptions, and I had to make sure that I
had extra money to pay for something in case they changed them,
because I couldn't make the trip to Canada.
So the real point, however, is that we should not have to
make these trips at all. Prescription drugs should be one of
the benefits of the Medicare program.
Despite all of the hopes placed in the Medicare Choice
program, it is not a solution. The share of Medicare Choice
enrollees with prescription drug coverage declined from 84
percent in 1999 to 67 percent in 2001. At the same time,
premiums, copayments are more costly. In half of the 33 States,
Medicare Choice plans that provide drug coverage, the average
premium rose more than 100 percent in the past 3 years.
Sadly for Maine's residents, even if some were able to
afford these increases, it doesn't make any difference. There
is no Medicare Choice program in Maine. So trying to add
preventive service coverage here would be no help either.
The Alliance for Retired Americans has developed a set of
principles for comprehensive Medicare prescription drug
program. The program should provide full access to all
medically necessary medications. Most importantly, the benefits
should be affordable. It should include a monthly premium of no
more than $25, 20 percent coinsurance, a $100 deductible, and a
$2,000 out-of-pocket annual cap.
Mr. Chairman and members of the committee, I would like to
close by telling you about a husband and wife that I met on the
bus trips who both take a number of medications. However, they
can't afford them. They have ``resolved'' this dilemma by
taking turns buying their medications. One month, they pay for
the husband's prescription drug; the next month, it is his
wife's turn and so on. Neither bus trips nor cutting back on
medication that are necessary not only for health but for life
itself are the answer.
As you probably know, the State of Maine has taken steps on
behalf of its citizens to ensure affordable prescription drugs
because of inaction on the Federal level. However, the Maine Rx
Program has been challenged in the courts by the pharmaceutical
companies all the way up to the Supreme Court.
While we in Maine support our State's action, we also
believe this is a national policy problem. The real solution is
within the power of Congress, and that is to add a prescription
drug benefit to the Medicare program, as well as increase
access to the preventive services.
And I would also encourage you to go after the general
attorney to get our bill out of captivity and bring it to Maine
so at least we would be covered until something else is done.
Thank you very much.
[The prepared statement of Viola Quirion follows:]
PREPARED STATEMENT OF VIOLA QUIRION, ALLIANCE FOR RETIRED AMERICANS
Thank you, Chairman Greenwood and all of the Members of this
subcommittee, for this invitation to testify today. I am Viola Quirion
from Waterville, Maine and a member of the Alliance for Retired
Americans. I am accompanied today by John Carr, president of the Maine
Council of Senior Citizens. The Alliance for Retired Americans, which
was established in January 2001, now has 2.5 million members across the
nation. Retirees from affiliates of the AFL-CIO, community-based
organizations and individual seniors have joined the Alliance to create
a strong new voice for retired workers and their families.
I want to congratulate you for holding this hearing as I believe
that preventive services under the Medicare program are very important.
Because of Medicare coverage of pap smears, mammograms and flu shots,
many lives have probably been extended. I think physical exams also
should be considered a preventive service. For many people on a limited
income, however, the 20 percent co-payment for most preventive services
may be an immediate luxury they cannot afford even though it may
ultimately be life-saving.
As I mentioned, I am from Waterville, Maine. I worked in the
Hathaway shirt factory there for 44 years until I retired in 1994. I
live on two small pensions and Social Security, which comes to $1,466 a
month. I never had to worry about health care expenses until I retired.
I now have a supplemental plan to cover some of the costs Medicare does
not cover, but it is not sufficient for everything.
I was diagnosed with ovarian cancer in late December 2000, and had
surgery in mid-January, 2001. The surgeons who operated found that
different parts of the cancer had cemented together in my ovaries and
if they tried to cut it out, I would have bled to death. Consequently,
I took a series of chemotherapy treatments lasting 5 + hours each time.
It took 7 days for me to recover after each of these treatments. For
these treatments and my recovery, I was in a nursing home for six
months.
In December of 2001, I had knee surgery. While recovering at home,
I suffered from a number of infections. I needed intravenous
transfusions but since Medicare does not pay for those at home, I had
to go into a skilled nursing facility for six weeks where they are
covered. Consequently, Medicare paid for the skilled nursing care and
the IVs which was much more costly than the $400 treatments I could
have received at home. Although IV transfusions may not be considered a
preventive service, it does not make sense to me to spend extra money
unnecessarily.
Currently, I am taking 1\1/2\ hour chemotherapy treatments and
don't experience negative after effects. And the numbers on the blood
tests show that the mass is dissolving. I am happy to say that Medicare
does cover the chemo treatments. Follow-up is just as critical to
survival as preventive services.
I am here today to tell you of the importance of prescriptions
drugs as a preventive measure that has extended and enhanced the
quality of everyday life for millions of Americans. Technological
advances in treating diseases include use of new drugs that can arrest
or cure many cancers, heart disease, high blood pressure and other
life-threatening conditions. Prescription drugs have saved costs in
reducing surgeries and hospital and nursing home care. However, new
drugs are more expensive than old drugs and three times more costly
than generic drugs.
I have taken 7 bus trips to Canada over the past few years which
were sponsored by the Maine Council of Senior Citizens and the Alliance
for Retired Americans. I take Prilosec for stomach ailments, which in
the U.S. costs me $5 a pill, and Relafin for my back and knees. I
estimate that I saved $1,000 every trip. Unfortunately, it took me a
week to recover from the last trip because of my knees. I probably
won't be able to make any more. But I am not alone, there are so many
people that could benefit from these trips but are physically unable to
board a bus.
The real point is, however, that we should not have to make these
trips at all. Prescription drugs should be one of the benefits of the
Medicare program. Despite all the hopes placed in the Medicare+Choice
program, it is not a solution. The share of Medicare+Choice enrollees
with prescription drug coverage declined from 84 percent in 1999 to 67
percent in 2001. At the same time, premiums and co-payments are more
costly. In half of the 33 states with Medicare+Choice plans with drug
coverage, the average premium rose more than 100 percent in the past 3
years. Sadly for Maine residents, even if some were able to afford
these increases, it doesn't make any difference--there is no
Medicare+Choice plan in Maine. So trying to add preventive services
coverage here would be no help either.
The Alliance for Retired Americans has developed a set of
principles for a comprehensive Medicare prescription drug program. The
program should provide full access to all medically necessary
medications. Most importantly, the benefit should be affordable. It
should include a monthly premium of no more than $25, 20 percent co-
insurance, a $100 deductible, and a $2,000 out-of-pocket annual cap.
Mr. Chairman and members of the committee, I would like to close by
telling you about a husband and wife that I met on the bus trips who
both take a number of medications. However, they can't afford them.
They have ``resolved'' this dilemma by taking turns buying their
medications. One month, they pay for the husband's prescription drugs,
the next month, it is his wife's turn and so on. Neither bus trips nor
cutting back on medications that are necessary, not only for health but
for life itself, are the answer. As you probably know, the state of
Maine has taken steps on behalf of its citizens to ensure affordable
prescription drugs because of inaction on the federal level. However,
the Maine Rx Program has been challenged in the courts by the
pharmaceutical companies all the way up to the Supreme Court. While we
in Maine support our state's actions, we also believe this is a
national policy problem. The real solution is within the power of
Congress and that is to add a prescription drug benefit to the Medicare
program as well as increase access to other preventive services.
Thank you.
Mr. Greenwood. Well, thank you, Ms. Quirion, and you're a
courageous woman to come here and be with us and wait for your
turn, and I thank you for it. I'm proud of you for doing it.
Ms. Quirion. You're welcome.
Mr. Greenwood. We're going to try like heck, and we'll
succeed here in the House, in moving a bill out to expand
Medicare+Choice funding. It should never have been allowed to
drop down in reimbursements so that it couldn't cover
prescription drugs; and we're going to have a prescription drug
benefit in that bill and fight like heck to get it through the
Senate after we get it through here. But I'm pretty sure we
will get it through the House and that will happen next month.
Dr. Gold.
TESTIMONY OF MARTHE R. GOLD
Ms. Gold. Good afternoon. Thank you for inviting me to
testify today, Mr. Chairman, and members who are not here.
My name is Marthe Gold. I'm Logan Professor and Chair of
the Department of Community Health and Social Medicine at the
City University of New York Medical School, and I served as a
member of the Institute of Medicine's Committee on Medicare
Coverage Extensions, whose report was issued in 2000. I'm
pleased to be here.
My comments today will draw from conclusions of the IOM
report that are relevant to this hearing, and I'm also going to
draw from my own background in cost-effectiveness analysis,
clinical preventive services and patient care as a practicing
physician at Settlement House in New York City Community Health
Center.
As you've heard and as you know, primary prevention is
directed toward averting health problems. Secondary prevention
is aimed at discovering existing abnormalities before they do
harm. And tertiary prevention, which is really a form of
treatment, is intended to prevent worsening of complications in
individuals who have an established disease. Some of us in the
prevention community don't think that there is too much of a
difference; it is just a matter of a continuum.
By definition, preventive interventions are administered to
people who are not experiencing illness, and therefore the
possibilities of side effects, false positive findings and
costs of care must always be weighed against the health
improvements the interventions provide. On a population basis,
preventive services should, at minimum, create more good than
harm.
Medically delivered prevention has been undersubscribed in
this country as other insurers, along with Medicare, have
increased their coverage. We've seen that uptake of the
services has improved. Insurance is certainly necessary, but
not sufficient for increasing uptake of preventive services.
This uptake has particularly benefited the low-income
individuals whose health is known already to be poorer and
whose life expectancy is shorter than other Americans.
Medicare extends coverage to Americans age 65 or over and
to some individuals with disabilities or permanent kidney
failure. With certain exceptions, Congress explicitly excluded
coverage for primary and secondary prevention and outpatient
prescription drugs, among other services.
Over the years selective preventive services have been
added on a case-by-case basis through congressional action. As
a result, Medicare now covers many, but not all secondary and
tertiary preventive services that would be of value to its
beneficiaries. Medicare also covers some services whose value
is unproven.
For example, in 2000, Congress extended Medicare coverage
to prostate-specific antigen and digital rectal exam, to screen
for prostate cancer, despite evidence-based recommendations by
some scientific and professional bodies to the contrary. In the
case of PSA, the combination of yet unproven survival advantage
and the not-infrequent serious side effects associated with
treatment of prostate cancer led the U.S. Preventive Services
Task Force, the American College of Physicians and the American
College of Preventive Medicine to specifically recommend
against the use of routine screening by PSA. Two studies
conducted early in the 1990's estimated that an initial
screening of PSA would cost between $6 to $28 billion.
From the other side, Medicare fails to cover a number of
effective preventive services. For example, the Task Force
recommends blood pressure screening and screening for vision
and hearing impairment, depression and problem drinking. In
addition, it recommends that patients be educated and/or
counseled about tobacco cessation, diet, alcohol, dental
hygiene, physical activity, fall prevention and other safety-
related issues. None of these are currently covered by
Medicare.
In 2001, Partnership for Prevention sponsored a
prioritization project which had contributions from scientists
from CDC, CMS and AHRQ. That prioritization project ranked
preventive services on the basis of the burden of disease they
prevented and their cost effectiveness, and they placed
tobacco-cessation counseling and screening for vision
impairment among adults age 64 and over as two of the top three
most valuable services, neither of which is included. Childhood
immunizations were ranked No. 1, just so you understand the
continuum there.
Blood pressure and cholesterol screening had priority
scores that were equivalent to those of vaccination for
influenza, a Medicare-covered service. Priority scores for
screening for blood pressure and cholesterol were predicated on
pharmaceutical treatment of elevations of blood pressure and
cholesterol to bring them to normal levels. Obviously,
medication is not covered by Medicare.
Prevention wisely accomplished should save pain, mental
anguish and cost. Why then would a public program like Medicare
pay $75,000 for coronary artery bypass surgery in some
situations and decline to pay for the smoking cessation
counseling and blood pressure and cholesterol-lowering agents
that would obviate the need for some of these surgeries? Why
would Medicare pay for the hip fractures suffered by elderly
Americans and not cover the screening and counseling of elders
that could substantially decrease the falls that cause the
fractures?
The IOM report on Medicare coverage of clinical preventive
services made several points about the coverage decisionmaking
process. In brief, the cost accounting framework that supported
IOM committee recommendations and is used by the Congressional
Budget Office looks at costs and offsets over a 5-year period
of time, a period that is too short for many preventive
interventions to achieve their benefit. Formal cost-
effectiveness analysis where the health effects of differing
interventions are compared over an appropriate timeframe and
evaluated along with their costs would provide a truer picture
of both the economic and the health impact of medical care.
Second, the IOM committee strongly endorsed the utility of
evidence-based reviews of health services for guiding clinical
and policy decisions. Reviews guide clinicians and health care
organizations to abandon practices that are clearly not
beneficial and to apply and recommend practices that are
identified as worthwhile. They support governments and others
who pay for care in revising coverage, reimbursement, quality
assessment and related policies to discourage nonbeneficial
services.
The committee also favored more extensive reliance on
formal cost-effectiveness analysis for informing coverage
determinations. The status quo coverage apparatus makes it
difficult to compare the expected benefit's harms and costs of
different health care decisions. The procedure relied on by
Congress for estimating the cost to Medicare of covering a new
service provides an incomplete picture of the value for money
for such an action.
Finally, the committee suggested that methods toward
rationalizing coverage policy for preventive and other Medicare
services should be pursued. For example, Congress could
encourage and provide funding support for AHRQ, CMS and other
relevant agencies in preparing evidence evaluations and cost-
effectiveness analyses. Congress could also direct CMS to
assess the services recommended by the U.S. Preventive Services
Task Force in the context of the Medicare program and to make
coverage recommendations. The systematic analysis of the
potential benefits, harms and costs of covering additional
services would protect against the piecemeal addition of less
valuable services at the expense of more valuable ones.
To conclude, more systematic evaluations of the
effectiveness and cost effectiveness of health care
interventions and using that information to inform coverage
decisions will create a more effective and efficient health
care system that better meets the needs of Americans. For those
of us in the prevention community who have long been troubled
by the practice of scrupulously holding preventive
interventions to stringent standards of accountability and
cost-saving while leaving many other interventions unexamined,
a more systematic approach to coverage policy would indeed be a
breath of fresh air.
[The prepared statement of Marthe R. Gold follows:]
PREPARED STATEMENT OF MARTHE R. GOLD, ARTHUR C. LOGAN PROFESSOR AND
CHAIR, DEPARTMENT OF COMMUNITY MEDICINE AND SOCIAL MEDICINE, CITY
UNIVERSITY OF NEW YORK MEDICAL SCHOOL AND MEMBER, COMMITTEE ON MEDICARE
COVERAGE EXTENSIONS, DIVISION OF HEALTH CARE SERVICES, INSTITUTE OF
MEDICINE
Good morning, Mr. Chairman and members of the Committee. My name is
Marthe Gold. I am Logan Professor and Chair of the Department of
Community Health and Social Medicine at the City University of New York
Medical School and served as a member of the Institute of Medicine's
Committee on Medicare Coverage Extensions. The Institute of Medicine is
part of the National Academy of Sciences, a private, nonprofit
organization that was chartered by Congress in 1863 to advise the
government on matters and technology. The committee report on its
findings and recommendations was published in 2000.
My closing comments (``Report Findings'') will cover certain
conclusions of the IOM report that are relevant to this hearing. I will
also draw on my background in cost-effectiveness analysis, clinical
preventive services, and patient care as a family practitioner,
currently seeing patients in a community health center in East Harlem,
in New York City.
Preventive Services
It would be lovely if we could live long lives without disability
or illness, and slip off softly in our sleep somewhere in our 9th or
10th decade. Second best is to catch illness early, and intervene in a
manner that reasonably maintains health and longevity. Prevention
supports both of these scenarios. Primary prevention is directed
towards averting a health problem, e.g., we immunize to prevent
infectious illness, we fluoridate to prevent tooth decay, we stop
people from smoking and avoid heart and lung disease. Primary
prevention can occur at the population health level--in communities
through public health educational campaigns--or it can occur in
clinical settings. Primary prevention leads us toward scenario one.
Secondary prevention is aimed at discovering existing abnormalities
before they do us harm; hopefully before they interfere too much with
quality of life and life span. We catch cervical cancer early with Pap
tests, or decrease the risk of heart disease by lowering cholesterol or
blood pressure. Secondary prevention occurs in the medical care
setting. Tertiary prevention, in reality a form of treatment, aims to
prevent worsening of complications for patients who already have a
specific disease. Examples of tertiary prevention include controlling
blood sugar in diabetic patients and performing coronary artery bypass
grafting on individuals with narrowed coronary arteries to prevent
heart attacks.
Medically delivered prevention has been under subscribed in this
country. There are many reasons for this, a number of which will have
been discussed by others at this hearing, but certainly a major factor
historically has had to do with insurance coverage. As insurance
coverage has improved through Medicare and other insurers, so has
uptake of preventive services. Low income individuals and uninsured
persons whose health is known to be poorer and whose life expectancy
shorter, have lower levels of uptake of preventive services. We know
from the health services research literature that as insurance covers
preventive services, more low income persons make use of them.
Although an ounce of prevention is held to be worth a pound of
cure, there is always fine print to be read. Preventive interventions,
by definition, occur in asymptomatic people. They can cause
uncomfortable side effects (e.g. pain or perforation associated with
colonoscopy, untoward effects of immunizations); precipitate worry,
pain and unnecessary further testing in association with false positive
results (e.g., a mammogram detects a mass that after biopsy turns out
not to be malignant); interfere with peoples' self perception by
assigning them a disease ``label'' (people assigned a diagnosis have
been found to miss more work post-labeling); and use up financial
resources. On a population basis, preventive services should, at
minimum, create more good than harm. In addition, they should represent
a reasonable investment of resources. Money used in one place is not
available for use elsewhere. Certainly the IOM committee was mindful
during its deliberations of Congress's budget rules for itself that
require that decisions to increase most types of federal spending be
accompanied by explicit decisions to reduce spending elsewhere, or to
raise taxes.
Medicare Coverage (and lack thereof) of Preventive Services
Medicare extends coverage to Americans age 65 or over and to some
individuals with disabilities or permanent kidney failure. From the
outset, the program has focused on coverage for hospital, physician and
certain other services that are ``reasonable and necessary for the
diagnosis or treatment of illness or injury, or to improve the function
of a malformed body member'' (section 1862 of the Social Security Act.)
With certain exceptions, Congress explicitly excluded coverage for
primary and secondary prevention and outpatient prescription drugs,
among other services. Over the years, selected preventive services have
been added on a case-by-case basis through Congressional action.
Given the considerations outlined, sensible policy making would
favor that all services that are insured and promoted by Medicare are
ones that are known to be appropriate and effective in increasing the
health of Americans. This is not currently the case. For example, in
1998, Congress extended Medicare coverage to bone densitometry (to
screen for osteoporosis) and in 2000, to prostate-specific antigen
(PSA) and digital rectal examination (to screen for prostate cancer)
despite evidence-based recommendations by scientific and professional
bodies such as the U.S. Preventive Services Task Force (USPSTF), the
American College of Physicians, the American College of Preventive
Medicine, and the Canadian Task Force on Preventive Health Care. In the
case of PSA, for example, the combination of no known survival
advantage and the not infrequent serious side effects associated with
treatment of prostate cancer, led the USPSTF to specifically recommend
against the use of routine screening by PSA. Two studies conducted a
decade ago estimated that an initial screening of PSA would cost 6 to
28 billion dollars (Kramer et al, 1993; Optenberg SA and Thompson IM,
1990.)
From the other side, sensible policy would favor Medicare coverage
of all appropriate and effective preventive services. This, also is not
the case. For example, the USPSTF recommends blood pressure screening,
and screening for vision and hearing impairment, depression and problem
drinking. In addition it recommends that patients be educated and/or
counseled about tobaccos cessation, diet, alcohol, dental hygiene,
physical activity, fall prevention and other safety-related issues.
None of these are currently covered by Medicare. A 2001 prioritization
project that ranked preventive services on the basis of burden of
disease prevented and cost-effectiveness placed tobacco cessation
counseling and screening for vision impairment among adults aged >64 in
the top three services. The report was co-authored by prevention
specialists and researchers from the Centers for Disease Control, the
Agency for Healthcare Research and Quality, and Partnership for
Prevention (Coffield et al, 2001.)
The priorities project ranked blood pressure and cholesterol
screening equivalently with vaccination for influenza--a Medicare
covered service. Priority scores for screening for blood pressure and
cholesterol were predicated on pharmaceutical treatment of elevations
of blood pressure and cholesterol to bring them to normal levels. And
yet, as you are well aware, Medicare does not provide coverage for
drugs. Low and moderate income individuals are often left with highly
treatable risk factors for diseases that they lack the economic
wherewithal to control.
Prevention, wisely accomplished, should save pain, mental anguish,
and cost. Why then would a public program pay $75,000 (Peigh, 1994) for
coronary artery bypass surgery and decline to pay for the smoking
cessation counseling and blood pressure and cholesterol lowering agents
that would obviate the need for some of these surgeries. Why would
Medicare pay for the hip fractures suffered by elder Americans, and not
cover the screening and counseling that could substantially decrease
the falls that cause the fractures?
Coverage Determinations
Coverage determinations for the Medicare program currently take in
a range of considerations, many of them non-aligned. When Congress
considers preventive care and other interventions that are now
statutorily excluded from Medicare coverage, costs are routinely
weighed as part of the decision making. When CMS makes coverage
determinations about new technologies that fit under existing
categories of covered services, its decisions are not directly governed
by the ``budget neutrality''' rules that Congress has adopted for
itself. Instead, CMS applies criteria of effectiveness. These, in turn,
are not applied to established technologies and interventions.
Congress has been restrained in its addition of new services to the
Medicare package. A major component of the Balanced Budget Act of 1997
was a set of measures intended to slow the growth in program spending
and at least delay the date at which Medicare spending is projected to
exceed revenues. The cost-accounting that supported IOM committee
recommendations on coverage of the services we examined was that used
by the Congressional Budget Office, which looks at costs and off-sets
over a five year period of time. Often, however, a short time horizon
will not permit an adequate evaluation of the long-term costs or
savings associated with an intervention. For example, smoking cessation
treatment or cholesterol lowering medications may not show their
benefit till a decade or two after the intervention has occurred.
Formal cost-effectiveness analysis, where the health effects of
differing interventions are compared over an appropriate time frame and
evaluated along with their costs, provides a truer picture of both the
economic and health impacts of medical care.
During the first three decades following the establishment of
Medicare, Congress was highly sensitive to issues of clinical
effectiveness and cost-effectiveness. For example, at the behest of
Congress, the now defunct Office of Technology Assessment (OTA)
undertook state-or the-art analyses of the cost-effectiveness of
several preventive services. A study of congressional coverage
decisions from 1965-1990 identified evidence of favorable cost-
effectiveness ratios as one factor differentiating preventive services
approved for coverage from those not approved.
Report Findings
The IOM committee strongly endorsed the utility of evidence-based
reviews of health services for guiding clinical and policy decisions.
For both new technologies and current practices, these reviews help
make clear the extent to which there is good evidence about the
benefits and harms of a particular intervention. At the same time they
highlight important health problems for which good evidence is still
missing and point the way toward needed research. Reviews place
pressure on clinicians to abandon practices that are clearly not
beneficial and to apply and recommend practices that are identified as
worthwhile. They support governments and others who pay for care in
revising coverage, reimbursement, quality assessment, and related
policies to discourage nonbeneficial services and encourage effective
care.
The committee also favored more extensive reliance on formal cost-
effectiveness analyses for informing coverage determinations. Our point
was not that cost-effectiveness analyses should be conducted on all
currently covered services Medicare services (a massive task) nor that
cost-effectiveness should be the only criterion for coverage decisions.
It was, rather, that the status quo coverage apparatus makes it
difficult to compare the expected benefits, harms, and costs of
different health care decisions. The procedure relied on by Congress
for estimating the costs to Medicare of covering a new service--the one
adopted for the report of the committee--provides an incomplete picture
of the value for money of such an action.
The committee's endorsement of the tools of evidenced-based
medicine and cost-effectiveness analysis led it to be strongly
concerned by the fluctuating policy support for technology assessment
and evidence-based recommendations for clinical practice and coverage
policy. Ironically, at a time when the methodology for assessing
effectiveness and cost-effectiveness has been strengthened by the
health services research community, the coordination of decision making
for coverage appears to have eroded.
The committee believed that it is possible to take some steps
toward rationalizing coverage policy for preventive and other services.
For example, a modest step in this direction would be for Congress to
encourage and provide funding support for AHRQ, CMS, and other relevant
agencies in preparing evidence evaluations and cost-effectiveness
analyses. With respect to preventive services, Congress could direct
CMS through the Secretary of Health and Human Services to assess the
services recommended by the USPSTF in the context of the Medicare
program and to make coverage recommendations. The systematic analyses
of the potential benefits, harms, and costs of covering additional
services would protect against the piece-meal addition of less valuable
services at the expense of more important ones. At the clinical level,
this is likely to play out with doctors and other health professionals
placing emphasis on higher priority services for their patients.
Enlarging the apparatus for systematic evaluations of the
effectiveness and cost-effectiveness of health care interventions and
using that information to inform coverage decisions will create a more
effective and efficient health care system that will better meet the
needs of Americans. For those of us in the prevention community, who
have long been troubled by the practice of scrupulously holding
preventive interventions to various form of accountability, while
leaving many extant interventions unexamined, a more systematic
approach to coverage policy would indeed be a breath of fresh air.
Thank you for the opportunity to present these views. I would be
pleased to answer any questions.
References Cited
Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among
recommended clinical preventive services. Am J Prev Med 2001;21:1-9
Institute of Medicine. Extending Medicare Coverage for Preventive
and other Services. Field MJ, Lawrence RL, Zwanziger, L (eds). 2000.
National Academy Press. Washington, D.C.
Kramer BS, Brown ML, Protok PC et al. Prostate cancer screening:
what we know and what we need to know. Ann Intern Med 1993;119:914-923
Optenberg SA and IM Thompson. Economics of screening for carcinoma
of the prostate. Urol Clin North Am 1990;17:719-737
Peigh PS, Swartz MT, Vaca KJ, et al. Effect of advancing age on
cost and outcome or coronary artery bypass grafting. Ann Thorac Surg.
1994;58:1362-1366
Mr. Greenwood. Thank you, Dr. Gold.
Dr. Himes.
TESTIMONY OF CHRISTINE HIMES
Ms. Himes. Thank you very much.
It is amazing to me when I came here. I'm a primary care
doc. I'm the way other side of the spectrum. I'm the person who
sits in the room with patients every day and talks about these
kinds of issues.
I'm also the Director of Geriatrics for Group Health
Cooperative, and it has been interesting to me to listen this
morning to all of the comments about the good old guys in
managed care and how the days used to be. And the truth is,
having been first birthed in 1947, group health, I think, is
still one of the old guys, and we've benefited tremendously
from our relationships with the Medicare program.
In 1976, we became the first demonstration project for
Medicare risk, and in 1982, became one of the first-ever risk
contracts. So I've enjoyed a very long history of relationship
not only with Medicare but the ability afforded by risk
contracts, and now Medicare+Choice, to really take a systems
view and look at, how do we take care of our patients.
Our charge to ourselves has always been, if we said we were
the very best health care organization for seniors in the
world, what would that look like and how do we try to get
there? And as I listen today, I've been--I've never been to
Congress before.
This area is a personal area of passion of mine, healthy
aging. We were asked to come and talk primarily because of some
physical activity programs we have, which are my biggest
passion areas, and I brought some--so you all could benefit
from having some little exercise--tools while you sit here for
these long hours, I think. So I'll make a few comments about
that in your everyday practice a little while later.
But I want to talk about, I think, two things that have not
been mentioned so far today.
We depend--our system depends on being able to step back
and look at all of the evidence that is available. We look at
all of the wonderful reports that are put out by all of the
folks who have been on this panel, as well as all of the
literature in general; and the geriatric literature over the
past 15 or 20 years has really provided us with a really clear
way, I think personally, of where to go.
And when I look at you all here on this committee and hear
about your responsibilities and how you think about them in
terms of Medicare, I think we're the same. I think you have the
same charge on the national level that I have for our 60,000
Medicare recipients at Group Health. So I'll share what I know.
I'll be happy to share anything in the future that I can be
helpful or that Group Health can be helpful in clarifying, and
really am very happy and privileged that you all are taking
such a close look at preventive services for seniors.
Prevention is an interesting idea that really changes as we
get older. In our 50's, it is different than it is for people
who are 65 or than it is for people who are 75, 85, 95. Many of
the cancer screens that you've heard about earlier today and
even many of the medications that are used, whether it is
aspirin or whether it is beta blockers, et cetera, as people
get older and older, there is not clear evidence anymore about
the efficacy of those interventions on the prevention scale,
partly because we think of prevention traditionally in our own
minds as preventing premature disease.
What is premature disease when you are 85 or 95 or 100
years old? Hard to know. So the truth is, really prevention as
we get older and older is a question of how do we prevent our
life from falling apart? How do we prevent a downward spiral
where our quality of life is the pits? How are we to live our
lives the best ways that we can for all of our lives?
The geriatric literature shows us really clearly something
about prevention. There is a set of syndromes, called the
``geriatric syndromes,'' which include urinary incontinence,
depression, all of those really obnoxious things that totally
screw up quality of life. All of them lead you in an amazing
downward spiral, and all of them have some very clear evidence-
based interventions that can really make a difference in
people's quality of life.
There is a wonderful report that was just put out,
sponsored by the Robert Wood Johnson Foundation and AAHP,
called ``Improving Care of Older Adults With Common Geriatric
Conditions''; and it is probably the best literature and most
current literature review around the geriatric conditions.
But if we talk about getting older, we want to focus on
geriatric conditions. The most important geriatric condition is
lack of physical activity. If there is one prescription
physicians can write in their office that is the most important
prescription, it is a prescription for regular physical
activity. At Group Health, we've developed a series of physical
activity programs that we'll be happy to talk about more in the
question-and-answer time, if you'd like--or they are in the
written testimony--that really address that one problem, and in
doing so, improve very clearly not only the costs and
utilizations for seniors, but also quality of life and allowing
or helping seniors to be the best they can be for all of their
lives.
Thank you.
[The prepared statement of Christine Himes follows:]
PREPARED STATEMENT OF CHRISTINE HIMES, GROUP HEALTH COOPERATIVE, GROUP
HEALTH PERMANENTE MEDICAL GROUP
I. INTRODUCTION
Mr. Chairman and members of the Subcommittee, thank you for
inviting me to testify today on the important topic of preventive
benefits offered under the Medicare program. I am Dr. Chris Himes,
primary care physician and Director of Geriatrics for Group Health
Cooperative, based in Seattle, Washington. I also am a member of the
Group Health Permanente Medical Group, which with 1,217 physicians, is
among the largest medical groups in the state of Washington. Group
Health Permanente contracts exclusively with Group Health Cooperative.
Founded in 1947, Group Health is a not-for-profit and with nearly
600,000 members, is the nation's largest consumer-governed health care
organization. Group Health has a long-standing commitment to serving
Medicare beneficiaries. Shortly after Medicare's creation, we began
working with the government to design a program that would allow
Medicare to work with prepaid health care organizations like Group
Health. In 1976, we were the first organization to partner with the
government under what was then referred to as the Medicare risk
program. At present, we serve nearly 60,000 Washington state
beneficiaries under Medicare+Choice.
Since our founding, Group Health has focused on preventive care
programs to help people stay healthy, while at the same time making
sure people receive the comprehensive care they need when they are ill.
Pre-payment has been fundamental to our ability to pursue both of these
objectives simultaneously. Pre-payment allows us to direct resources to
areas of greatest need and to be creative and innovative in designing
programs. Simply stated, when you are not paid on an encounter-by-
encounter or procedure-by-procedure basis, you can shift your focus to
include longer-term improvement in health outcomes.
Group Health has developed programs related to chronic illnesses
common in the elderly including depression, diabetes, and heart
disease. We also have initiatives in prevention and acute care for
conditions such as breast, cervical, and colorectal cancer. At present,
work is underway to unify these initiatives with other special needs of
seniors, such as fall prevention. Although the programs span a wide
spectrum of health care conditions and approaches, they all reflect the
collaborative relationships between an organization, patients,
clinicians, and other providers.
II. PROMOTING HEALTHY AGING: PREVENTIVE CARE MODEL
Today, I'd like to focus on the concept of ``healthy aging''--a
topic that has long been a passion of mine. The concept of ``healthy
aging'' is not a magical or fanciful quest for the ``fountain of
youth'', but rather a clearly attainable road to being the ``best we
can be''--physically, mentally and spiritually. Healthy aging is not
dependent on high cost medical technology--although certainly,
technology can sometimes extend the length of life, improve functional
ability and overall quality of life.
To achieve healthy aging, individual relationships between patients
and their providers must take center stage; providers need to
understand fully their patients needs, desires and things that most
impact their ability to live their lives well. Patients need to have
confidence that their providers will listen and partner with them to
make the best choices for their own lives and circumstances.
With the baby boomers aging and individuals over age 85 becoming
our nation's fastest growing population segment, the definition of good
preventive health care models are changing and expanding. In addition
to disease prevention, the focus is gradually shifting to include a
greater emphasis on helping people live with chronic illness and
maintaining and improving functional abilities and quality of life.
Helping our providers keep up with changes and the best approaches
to care--including ways to promote healthy aging--is one of the most
important contributions of Group Health's care delivery model. Our
focus on evidence-based medicine--a systematic approach to collecting
and critically evaluating available scientific evidence on treatment
options--seeks to offer practitioners and patients the information they
need to make informed decisions about treatment options. It also helps
ensure that health care dollars are being spent on treatments that have
proven benefits.
For today's--and tomorrow's--Medicare beneficiaries, the growing
body of geriatric literature clearly points the way. In achieving
healthy aging, studies point to the need for regular geriatric
assessments and evidence-based interventions in areas known to threaten
functional ability, commonly called the ``geriatric syndromes'' (e.g.,
physical inactivity, depression, urinary incontinence, falls, cognitive
impairment, medication-related complications and poor nutrition). For
the most part, these interventions are low cost and do not involve
advanced technologies. Yet, studies have clearly shown that
assessments, certain interventions and close follow-up of these
syndromes can help avoid deterioration in health and costly
complications, while dramatically improving the quality of life for
seniors in six to twelve months. From a medical perspective that is a
relatively fast timeframe for improvement, especially when considering
that beneficiaries often experience geriatric syndromes for lengthy
periods of time.
III. GROUP HEALTH'S WORK TO IMPROVE BENEFICIARIES' HEALTH AND WELL-
BEING THROUGH EXERCISE
Today, I want to focus on perhaps one of the best examples of a
low-cost, low-technology intervention that can have a dramatic impact
on seniors' health and well-being: Group Health's simple, but
pioneering research and resulting strategies in promoting senior
fitness.
Group Health not only has focused on learning from the geriatric
literature, but also has made significant contributions to it over the
last twenty-five years. In the 1980s, researchers from Group Health's
Center for Health Studies and their colleagues at the University of
Washington examined key determinants of overall health outcomes for
seniors. The results were quite clear. There are only two statistically
significant predictors: social isolation has a negative impact on
health, while regular physical activity had a very positive effect on
health. In assessing the types of physical activity, the researchers
found--and many others have since validated--that in addition to
endurance activity, such as walking, gardening, swimming, muscle
strengthening and flexibility exercises are also important, especially
for seniors with functional deficits or balance problems as they age.
The joint Group Health-University of Washington work led to the
development of an exercise program known as Lifetime Fitness, offered
by Group Health at local senior centers through a community partnership
with Senior Services of Seattle-King County. Group Health paid the
start-up costs for the weights used for muscle strengthening and the
training and salaries for the exercise instructors. Senior centers
provided the space and logistics for the classes, which were offered to
all comers in the community, three times a week in five-week sessions.
Each class has segments that focus on improving balance,
flexibility, and aerobic capacity. Participants perform exercises both
standing up, holding the back of a chair for balance, as well seated in
chairs. In addition to the actual exercise components, the class offers
participants a chance to socialize--they talk about their weekends,
their grandchildren, and visits with their families. Couples exercise
together; group lunches are occasionally arranged after class.
Based on the positive response from participants, Group Health soon
expanded the availability of classes throughout our entire service area
by partnering not only with community senior centers, but also with
YMCA's. Lifetime Fitness is now offered in 34 locations.
To further contribute to the evidence-base in healthy aging, the
same Group Health Cooperative-University of Washington research team,
in partnership with Senior Services of Seattle-King County Health
Enhancement Project, developed and tested a model of geriatric
assessment with accompanying interventions and follow-up by a nurse
practitioner. Over the study period, a nurse practitioner stationed in
a senior center that offered Lifetime Fitness classes performed regular
assessments on patients 70 years and older from Group Health and
Pacific Medical Center who participated in Lifetime Fitness. The
improvements in health and well-being were dramatic as evidenced by
reductions in ``geriatric syndrome visits.'' The nurse practitioner,
along with a social worker, was able to demonstrate significant cost
and utilization savings--a 72 percent reduction in six to twelve
months.
It became clear that regular exercise was key to the intervention's
success. The study's positive findings with respect to avoided
deteriorations in health and costly complications served as a catalyst
for Group Health to move regular assessment and intervention support
into all primary care settings. Senior Services, a local not-for-profit
organization, also expanded the Health Enhancement Program to senior
centers around the country.
IV. INTEGRATING FITNESS INTO GROUP HEALTH'S MEDICARE+CHOICE PLAN
Once we understood that increasing physical activity for all
seniors was the most important key to healthy aging, Group Health began
to develop a ``full spectrum'' of exercise opportunities that could be
individualized according to patient preference and ability. Whether
robust and healthy or frail, living independently or in nursing homes,
Group Health is working to bring the benefits of exercise to all our
Medicare members. Today, in addition to Lifetime Fitness, Group Health
offers Medicare+Choice enrollees a benefit called ``Silver Sneakers''
which enables them to join local health clubs and YMCA's at which they
can take senior-focused fitness classes. At present, 1,300 Medicare
beneficiaries participate in Lifetime Fitness, of whom 1,000 are Group
Health Medicare+Choice members. Nearly 10,500 Group Health
Medicare+Choice members have participated in Silver Sneakers. In April
alone, 3,748 Group Health Medicare beneficiaries--6.3 percent of our
membership--used their Silver Sneakers benefit.
In addition, Group Health is ``rolling out'' our new geriatric
assessment protocol to all primary care clinics. Physicians will be
asked to write ``exercise prescriptions'' for all of their senior
patients and to conduct regular follow-up on their progress. We have
developed a set of tools and supports, as well as planned training for
all practitioners in addressing and monitoring geriatric syndromes. The
key message in this training is that recommending exercise is among the
most important prescriptions to write, individualize, and assure
compliance.
While these two exercise programs have been overwhelmingly
successful in improving quality of life, they are beyond the ability of
many seniors with disabilities and multiple chronic diseases. These
seniors, however, often have the most to gain from increasing physical
activity. Virtually all guidelines and care coordination programs for
conditions such as diabetes, heart disease, chronic obstructive
pulmonary disease, hypertension, depression, osteoporosis, arthritis,
to name a few, call out exercise as a central strategy to improve
health.
Let me give you a few examples of why this can be so effective and
life changing for the most frail among us. Group Health currently has
an exercise program beginning at our nursing home, Kelsey Creek, and
has started our first program in a retirement community next to one of
our clinics. For several years in my own practice, I have written
exercise prescriptions based on individual needs and preferences for
all senior patients, promoting the value of regular exercise in
managing virtually every medical condition and disability. In doing so,
there was a particular group of patients who caught my attention--my
patients who visited me often with various ailments and complaints that
did not have a specific etiology. Simply stated, they were in
``downward spirals''.
As I did with all my patients, I encouraged them to exercise and
get out socially but they just couldn't. They lacked the motivation and
will, and they had real obstacles--chronic pain, significant medical
diseases and functional deficits, depression, social isolation, lack of
transportation; the list goes on. Perhaps most importantly each of
these people was facing huge losses--death of their spouse, a move from
their life long home to a retirement apartment. They felt like they
were simply burdens on their families and friends. They most common
word they used to describe themselves was ``useless''.
I knew that these were the very people who would benefit most from
an exercise regimen so I decided to start a muscle strengthening and
flexibility program at Group Health's Northgate Medical Center, where I
practice, tailored specifically to their needs and disabilities. I
asked this group to commit to coming to class three times a week for
four and a half months, stay for lunch together once a week after
class, and participate in a community performance at the end to share
with their families and community all I knew they would accomplish.
Within weeks I could see them getting stronger, becoming an incredible
support group for each other, and perhaps most importantly, truly
embracing and enjoying life again.
It's been two and a half years since the first class, and they are
still coming. Some have died, they are old and frail. But at their
funerals, each of their families talked about how much better their
mom's last year of life had been as a result of the ``dancing ladies
and their few good men'' program. As for the rest, I don't see them as
much for these ``unspecified ailments'', though I regularly see them at
the lunches and in class where we talk about a whole range of healthy
aging issues. With sponsorship from Group Health, the group recently
made an exercise video of this class to be used as an inspiration and
entry-level in-home exercise option for our frail populations.
V. UPDATING MEDICARE TO INCLUDE BENEFITS THAT PROMOTE HEALTHY AGING
Limited health care resources mandate that physicians, health plans
and payers alike identify new and innovative ways to improve the
overall health outcomes for the Medicare population and control costs.
Care coordination programs for high-risk, high-cost conditions have and
continue to promote cost-effective delivery of services and avoid
deteriorations in health. That said, we as a nation must persist in
looking ``upstream'' for additional strategies. In my view, one such
strategy is the promotion of healthy aging.
Regular geriatric assessments and follow-up of geriatric syndromes
are key to healthy aging. The most important of these follow-up
activities is increasing regular physical activity for all patients,
whether they are healthy or frail. We know that fitness can make a
difference not only in terms of beneficiaries' physical and mental
well-being, but also in terms of expenditures. A recent controlled
analysis of health cost and utilization of 1,124 Group Health
Medicare+Choice members enrolled in Lifetime Fitness who were compared
to 3,342 age and gender ``matched'' control beneficiaries. The baseline
per year expenditures on members of the control group and individuals
who participated in more than 120 Lifetime Fitness Classes were
virtually the same: $3,932 and $3,940 respectively. However, the change
in the subsequent year's expenditures differed dramatically: costs for
individuals who did not participate in Lifetime Fitness increased by
$1,175, while costs for Lifetime Fitness participants decreased by $71.
The study also showed that costs for members who increased their
participation by just one time a week decreased by 14 percent, while
the annualized number of inpatient days fell by half a day.
Writing and assuring compliance with exercise prescriptions is the
single most important intervention physicians can do for their
patients. Health plans need to continue to develop a full spectrum of
exercise opportunities for their members and their communities, in
partnership with community, private and governmental organizations.
Toward this end a national effort, cosponsored by the Center for
Disease Control and the Robert Wood Johnson Foundation, is currently
underway bringing health plans, government agencies, seniors themselves
and community organizations together in support of the ``National
Blueprint on Increasing Physical Activity Among Adults Age 50 and
Older''. The Blueprint work will continue to support the development of
the exercise and behavior change literature base, as well as broadly
``spreading the word''. Group Health, as well as many others like us,
fully embrace and support this work, understanding its central
importance to the health of the health, our members, and ourselves.
VI. CONCLUSION
There is no doubt that the Medicare benefits package needs to be
updated. As a practitioner, I applaud Congress' work in recent years to
improve the availability of important preventive benefits for our
nation's Medicare beneficiaries. But as I have presented here today,
prevention of illness or deterioration in health does not always result
from a screening test, but rather it can result from even more simpler,
fundamental, low cost approaches like fitness programs. As Congress
continues its work in this important area, I urge you to continue to
think creatively and to take a broader perspective on seniors' health.
Our Medicare members have told us loudly and clearly that they want
to live life fully with dignity and grace. Group Health is committed to
fulfilling their request. As you can tell, we are proud of our
accomplishments, but we know that more can and must be done to ensure
that all Medicare beneficiaries achieve ``healthy aging.'' We again
want to thank you for the opportunity to share our work in this area
and to contribute to the Subcommittee's deliberations on this important
issue.
Mr. Greenwood. Thank you.
Dr. Gruman.
TESTIMONY OF JESSIE C. GRUMAN
Ms. Gruman. Thank you, Mr. Chairman. I represent the Center
for the Advancement of Health, which is an independent,
nonpartisan, nonprofit organization that promotes the greater
recognition of how nonbiological factors affect health; that
is, what we do and where we live and what we eat and what
resources are available to us influence health and illness. The
fundamental aim of the Center is to ensure that everything
we're learning about health through scientific inquiry, not
just what we're learning about physiology and genetics, is
applied and translated into policy and practice to improve the
health of individuals in the public. And it is that mission
that brings me here today.
As Dr. Fleming in the previous panel pointed out, no single
group of Americans more--has more to gain than the elderly from
putting into practice the medical--what medical evidence
strongly suggests, and that is that behavior matters. From
avoiding risky behavior to taking pills on time, to getting
appropriate medical screenings, a solid core of evidence exists
on how to stay healthy and productive for as long as we can.
In the past 5 years, Congress has doubled the funding for
the National Institutes of Health, and the payoff should be
seen in dramatically improved health outcomes in the years
ahead. Or maybe not. The investment we've made in basic science
is going to be diluted if we do not translate these advances
into use, and use implies systematic changes in the behavior of
doctors, of health systems and of individuals. Let me give you
an example of what I'm talking about.
Biomedical researchers tell us that we are on the verge of
seeing a new genetic test that will tell people their genetic
risk for colon cancer. This development is a triumph of
science. If anything, it vindicates our Nation's investment in
discovery of research at NIH by promising a tectonic shift in
the burden of colon cancer, the cause of 56,000 deaths a year
in the United States. But this incredible advance coming from
basic science necessitates a more powerful understanding of
behavior if we are going to make use of it.
From this one test alone, many new questions will need to
be answered in order to realize the promise of fewer colon
cancer deaths. For example, how do you persuade people to take
a test that may indicate with a pretty high degree of certainty
that they are going to get a deadly disease? What environmental
and behavioral factors influence whether people who test
positive actually get colon cancer or not?
And following on that, what life-style changes can
individuals make to reduce the probability that they will get
colon cancer? What constitutes good medical care for patients
who test positive on such a test? What are the implications of
this test for insurance generally and for Medicare in
particular to cover the cost of the test, to cover the cost of
monitoring and to cover the cost of treatment for those who
test positive? How will we train and deploy a workforce of
genetics counselors to introduce the entire U.S. population to
the idea that they ought to have a test that very well may
change their lives and prospects?
Now, these are questions that are not going to be answered
by geneticists or biochemists or biologists. Rather, they are
questions that will be answered by experts in learning, in
cognition, in human factors, organizational development, health
research, epidemiology, economics, psychology and sociology,
and others probably.
Basic biological science was the starting point of the
test, but scientific attention must then be paid to changes in
the behavior of patients, of doctors, of insurers, of managed
care executives and others if we are to successfully complete
the production arc from laboratory to living room. Without
systematic attention to these questions, the most sophisticated
genetic test is functionally as useless as a cell phone on the
dark side of the moon.
As the GAO report shows, even time-tested effective
technologies, mammograms and immunizations are not finding
their way often enough to the people who need them. Physicians
forget to recommend them, patients don't ask for them, they're
confused about how often they need them, they fail to comply
with their doctor's orders.
One recent action by the CMS is an important and,
unfortunately, too-rare instance of really attending to the
behavior that connects the technology to its target: CMS's
review that you mentioned earlier of the evidence on
interventions that are directed at doctors, health care
facilities and individuals to increase vaccine use. Based on
that review, CMS implemented standing orders to increase the
chances that the right immunizations get to the right seniors
at the right time.
But behavior doesn't just matter in realizing the health
benefits of clinical preventive services covered by Medicare.
There is overwhelming scientific evidence, as we discussed
earlier, that demonstrates the great gains to be had by
reducing behavioral risks, including smoking, increasing
physical activity, preventing falls. All are extraordinarily
important, but until quite recently have not been viewed by CMS
as part of the Medicare mandate for prevention.
The new CMS-sponsored stop-smoking demonstration project is
the agency's first effort to systematically address a major
behavioral risk factor for disease and disability, and evidence
has been gathered by the Healthy Aging Program on the
feasibility of pilot programs to assess risk, prevent falls,
better manage chronic conditions; and each of these might have
an important role to play in a Medicare program that aims to
help Americans live as well as they can for as long as they
can.
Mr. Chairman, it would be a terrible waste of the Nation's
health and wealth if the bulk of the health research that
Congress has sponsored sits in the file cabinets in Bethesda
and is not used to benefit the American public. The
pharmaceutical and technology industries are responsible for
bringing some of that knowledge to the marketplace, but they
are not responsible for ensuring that we know--that what we
know about quitting smoking or getting people to participate in
screening tests becomes part of routine health care and
community services.
There are several ways that Congress can act to make
certain that we realize the full benefits of all of our
investments in health research. First, by raising the priority
within CMS for addressing behavioral risks like physical
activities, reducing the impact of falls, assessing health
risks.
Second, by increasing the extent to which CMS makes use of
the evidence on how to overcome behavioral barriers in
implementing preventive services and other medical care
services, as the Agency did with it standing orders for
immunizations.
Third, by fostering better cooperation among Federal
agencies with responsibilities for senior health. Center for
Medicare and Medicare services, CDC, Administration on Aging,
AHRQ and NIH all have important roles to play to ensure that
the evidence drives the implementation of effective programs to
improve health and prevent disease.
And finally, by balancing the Federal research portfolio
better between basic and applied research. Just as we plan
retirement security in our investment portfolio, by creating a
mix of stocks and bonds and cash, the Nation's science
portfolio must also be balanced. Basic discovery research,
balanced by research on application, translation and behavior.
The challenge before us is to figure out how to make sure
that when medical breakthroughs are made, they get translated
at the right time by the right people in ways that are going to
make a difference. Because when it comes to health, biology
matters and drugs matter and genetics matter, but behavior
really matters, and it is not just the behavior of individuals,
it is the behavior of individuals, health care professionals
and systems.
Thank you.
[The prepared statement of Jessie C. Gruman follows:]
PREPARED STATEMENT OF JESSIE C. GRUMAN, PRESIDENT AND EXECUTIVE
DIRECTOR, CENTER FOR THE ADVANCEMENT OF HEALTH
Thank you, Mr. Chairman.
I represent the Center for the Advancement of Health, an
independent, non-partisan nonprofit organization funded by the John D.
and Catherine T. MacArthur Foundation. The Center promotes greater
recognition of how non-biological factors affect health--that is, how
what we do, where we live, what we eat, and the resources available to
us influence health and illness. The fundamental aim of the Center is
to ensure that everything we are learning about health through
scientific inquiry --not just physiology and genetics--is translated
into policy and practice to improve the health of individuals and the
public.
It is this mission that brings me here today. As Dr. Fleming has
pointed out in his testimony, no single group of Americans more than
the elderly has as much to gain from putting into practice what medical
evidence strongly suggests--that behavior matters.
From avoiding risky behavior, to taking your pills on time, to
getting appropriate medical screenings, a solid core of evidence exists
on how to stay healthy and productive for as long as we can. In the
past five years, Congress has doubled the funding for the National
Institutes of Health, and the payoff should be seen in dramatically
improved health outcomes in the years ahead. Or maybe not.
The investment we have made in basic science will be diluted if we
do not translate these advances into use--and use implies systematic
changes in the behavior of doctors, health systems and individuals.
Let me give you an example of what I am talking about. Biomedical
researchers say that we are on the verge of seeing a new genetic test
that will tell people whether or not they will get colon cancer. This
development is a triumph of science; for many, it vindicates the
nation's investment in discovery research at NIH by promising a
tectonic shift in the burden of colon cancer, the cause of 56,000
deaths a year in the United States. But this incredible advance coming
from basic science necessitates a more powerful understanding of human
behavior if we are to make the best use of it.
From this one new test alone, many new questions will need to be
answered to realize the promise of fewer colon cancer deaths. For
instance:
1. How do you persuade people to take a test that may indicate with
high certainty that they are going to get a deadly disease?
2. What environmental and behavioral factors influence whether people
who test positive actually get the disease? And following on
that, what lifestyle changes can individuals make to reduce the
probability that they would?
3. What programs can we put in place to help people change and maintain
those long-held habits?
4. What constitutes good medical care for patients who test positive on
this test?
5. How can we ensure that physicians routinely provide such care?
6. What are the implications of this test for insurance generally and
for Medicare in particular--to cover the cost of the test, to
cover monitoring and to cover treatment for those who test
positive?
7. How will we train and deploy a workforce of genetics counselors to
introduce the entire U.S. population to the idea that they
ought to have a test that may very well change their lives and
prospects?
These are questions that will not be answered by geneticists or
biochemists or biologists. Rather, they are questions that will be
answered by experts in learning, cognition, human factors,
organizational development, health services research, epidemiology,
economics, psychology and sociology.
Biological science was the basis of developing the test. But that
is only the first of several steps required to convert this discovery
into an effect on the health of the population. Scientific attention
must be paid to changes in the behaviors of patients, doctors, insurers
and managed care executives if we are to successfully complete the
production arc from laboratory to living room. Without systematic
attention to these questions, the most sophisticated genetic test is as
useless as a cell phone on the dark side of the moon.
Even time-tested, effective technologies--mammograms and
immunizations--are not finding their way often enough to the people who
need them. Physicians forget to recommend them, patients don't ask for
them, are confused about how often they need them and fail to comply
with their doctors' advice to get them. The technology is brilliant but
it requires human behavior to make it work.
One recent action by CMS is an important, and unfortunately too
rare, instance of attending to the behavior that connects the
technology to its target. CMS reviewed the evidence on interventions
directed at doctors, health care facilities and individuals to increase
vaccine use, and, based on this review, implemented with CDC an
effective pilot program in nursing home, creating standing orders to
increase the possibility that the right immunizations get to the right
seniors at the right time. CMS is proposing to take the next step to
facilitate the delivery of immunizations and the use of standing orders
in health care facilities.
But behavior doesn't just matter in realizing the health benefits
of the clinical preventive services covered by Medicare. There is
overwhelming scientific evidence demonstrating the great gains to be
had by reducing behavioral risks. Quitting smoking, increasing physical
activity and preventing falls, are extraordinarily important but until
quite recently have not been viewed by CMS as part of the Medicare
prevention mandate.
The new CMS-sponsored stop-smoking demonstration project is the
agency's first effort to systematically address a major behavioral risk
for disease and disability. And evidence has been gathered on the
feasibility of pilot programs to assess risk, prevent falls and better
manage chronic conditions. Each of these might have an important role
to play in a Medicare program that aims to help Americans live as well
as they can for as long as they can.
Mr. Chairman, it would a terrible waste of the nation's health and
resources if the knowledge generated by the health research sponsored
by Congress sits in file cabinets in Bethesda and is not used to
benefit the American public.
The pharmaceutical and technology industries are responsible for
bringing some of that knowledge to the marketplace, but they are not
responsible for ensuring that what we know about quitting smoking or
getting people to participate in screening tests becomes part of
routine health care and community services.
There are several ways Congress can act to make certain that we
realize the full benefit of our investment in health research. Congress
can:
1. Raise the priority within CMS for addressing behavioral risks in
the Medicare program, for example, by supporting demonstration projects
to help seniors increase physical activity, reduce the impact of falls,
manage chronic conditions, reduce alcohol and substance abuse and
improve nutrition. These risks are critically important for seniors,
and their health stands to gain from widespread availability of
services to support behavior change to reduce them. We applaud the
efforts of CMS to address expansion of prevention efforts to include
smoking and other risk behaviors based on careful scientific review.
Increased commitment on the part of CMS would expedite program and
benefit design and feasibility assessment that would ultimately result
in more effective prevention efforts.
But medical care, even with Medicare reimbursement, is neither
organized nor equipped to shoulder the entire burden for reducing risk
behaviors among seniors.
2. Foster better cooperation among federal agencies--CMS, CDC,
AHRQ, AoA and NIA--to ensure that evidence drives the implementation of
effective programs to improve health and prevent disease. Each agency
brings different knowledge and resources to solving the problem of the
health of seniors. Each agency is connected to seniors in different
ways--through state and local health departments, local senior services
or specialized research programs. More frequent communication and
stronger collaboration among these agencies would benefit those
individuals and families that each of these agencies claim to serve.
But the federal government is by no means the only advocate for the
health of seniors, and federal agencies play only a partial role in
ensuring that the prevention programs for seniors are widely available.
3. Encourage public-private partnerships among federal agencies
with responsibility for seniors and the organizations that can act on
evidence-based strategies to improve the health of individual seniors
in the communities in which they live. The most effective programs will
be ones that integrate the authority of health care with delivery
capacity of local services that support seniors in living full lives.
4. Increase the extent to which CMS makes use of evidence on how to
overcome behavioral barriers in implementing preventive services. In
implementing standing orders for immunizations, CMS showed that it
understood just covering a service as a benefit is not enough;
consistent policies and practices are necessary to get the right
preventive procedure to be used right. More attention must be paid to
ensuring that health care systems, group practices, physicians and
other health professionals are encouraged to act on the evidence of the
most effective means of ensuring that clinical preventive services
reach the right individuals in a timely manner.
5. Finally, by promoting better balance of basic and applied
research in the federal health research portfolio. Just as we plan
retirement security in our investment portfolio by creating a mix of
stocks and bonds and cash, the nation's science portfolio must also be
balanced--with an emphasis on application, translation and behavior.
Although it is not the direct responsibility of this subcommittee,
I would make the point that while funding for the NIH is going up by 16
percent this year, funding for the lead agency for translating
research--AHRQ--is being reduced by 16 percent. I am told that at CDC,
less than 1 percent of its budget is spent figuring out how to apply
what it spends the other 99 percent learning.
The challenge before us is to figure out how to make sure that when
medical breakthroughs are made, they get translated at the right time,
to the right people, in ways that will make a difference. Because when
it comes to health, biology matters, pharmaceuticals matter, genes
matter, but behavior really matters.
Thank you, Mr. Chairman.
Mr. Greenwood. Thank you. Appreciate it. All of you.
The Chair recognizes himself for 10 minutes for questions.
Ms. Quirion, you, in your comments, mentioned--sort of
referred to the fact that perhaps if you'd had some preventive
care early on, or some access to some advice, information, that
you might have spared yourself some of--you might have been
spared some of what has befallen you.
Ms. Quirion. I think I would have found out sooner that I
had ovarian cancer, and they might have did the surgery very
successfully. But because that I didn't have a pap smear,
because they didn't pay for them, or annual checkup, I had the
pain----
Mr. Greenwood. That's what I wanted to get at. You had no
idea that you----
Ms. Quirion. No idea whatsoever. I've always been active,
but I had abdominal pain that I knew there was something wrong.
So I went to see my doctor right away. She was very alarmed.
Mr. Greenwood. Were you going for any kind of regular--you
weren't going for regular physicals?
Ms. Quirion. I go once a year for a checkup, but not a
physical because they didn't pay for it. So right away she
suspected it wasn't good, and she sent me to all specialists.
She called me in her office the next day to tell me that I had
ovarian cancer. And there are four stages, and they found out
that my stage was 3.2. So it might not have been as serious if
I could have detected it before.
Mr. Greenwood. And when you said you had an annual checkup,
but not a physical, what do you mean?
Ms. Quirion. Well, they just checked the blood pressure and
the blood work for sugar and something like this.
Mr. Greenwood. But it wasn't a thorough physical exam?
Ms. Quirion. No, not a final one.
Mr. Greenwood. Let me address a question to Dr. Himes, if I
may.
Within the Medicare+Choice program that you work for, what
are the utilization rates of preventive services covered--that
are also covered by traditional Medicare, like flu and
pneumonia vaccine, breast cancer screening, for the Medicare
beneficiaries under your care?
Ms. Himes. We just looked that up because we heard that
question earlier. For flu shots, our latest available data is
84 percent; for mammograms, 83 percent; for cholesterol
testing, 78 percent for primary and secondary prevention of
heart disease.
Mr. Greenwood. I'm assuming that those rates are higher
than they are for--I don't know if you have that data, but
they're higher than they are for--they sound to be probably
much higher than they are for----
Ms. Himes. For the general community.
Mr. Greenwood. For the general community, certainly, for
the fee-for-service folks.
Which raises the question, of course, how did you get those
rates that high? What do you do that encourages----
Ms. Himes. We do several things on all kinds of levels. The
first is patient education and awareness about all of those
things, now on the Web site, but it used to be in a whole
variety of ways through pamphlets, through cards that we have
people carry around in their pocket that say what adult
screening schedules and preventive care schedules should be.
Mr. Greenwood. Let me interrupt you for a second. I
apologize for doing it, but I want to get something clear.
Ms. Himes. Please.
Mr. Greenwood. Do you have 60,000 lives?
Ms. Himes. Yes.
Mr. Greenwood. How do they compare demographically to the
country at large? Do they tend to be--because there's a self-
selecting process that goes----
Ms. Himes. Right. We have a Center for Health Studies
Research wing that works with the University of Washington,
and--oh, I think two times now, one in the early 1990's and one
in the late 1990's--we had CHS do a look at our community, the
western Washington area--catchment area and compare Group
Health patients, according to chronic disease scores, with our
community in general. And it looks like we're about the same.
So it doesn't look----
Mr. Greenwood. In terms of disease?
Ms. Himes. In terms of chronic diseases.
Mr. Greenwood. But I was referring to----
Ms. Himes. Oh, I'm sorry. Are you referring to weights?
Mr. Greenwood. The demographics--the educational, the
income demographics. Do your 60,000 folks tend to be younger,
healthier, wealthier, better educated than the average; or do
you think that they are fairly much a cross-section?
Ms. Himes. What we think is, their demographics in general
are essentially the same as the community in general. In part,
that is because most of our folks, 80 percent of our folks,
have been with us forever; and so originally joining the
program as young adults, aged into the program. We've been
around for 54 years.
So we've had a very stable number of Medicare recipients
over the years, and in recent years have added another, oh,
13,000 or 14,000 with the new influx of Medicare+Choice
enrollees, but essentially kept our stable population. It
appears to reflect demographically, and in terms of burden of
illness, our community.
Mr. Greenwood. Ms. Quirion, I should point out to you that
I believe your Congressman is here, Mr. Allen is here too.
Ms. Himes. We then have registries that allow us to follow
up on immunization registries and general disease registries
that allow us to follow up on patients through our primary care
practices. So we feed back to our primary care physicians and
nurses on a regular basis four times a year what their rates
are for all of these screening tests on mammographies,
immunizations, et cetera.
And finally, then, organizationally, we put systems in
place to remind patients so that, for example, patients get
postcards in the mail to remind them when their mammogram is
due; they get postcards about flu shots, et cetera. So there
are a whole variety of systems that get put in place.
That is really, in many ways, the benefit of the
Medicare+Choice program for us.
Mr. Greenwood. Is there a program for--a Healthy Aging
initiative, or is that something separate?
Ms. Himes. It is part of our, in general, preventive health
care promotion initiative. I mean, it includes the entire
organization, if that is the question.
Mr. Greenwood. Okay.
For any of you, I--Ms. Quirion, it was clear to me from
your response that you think that if Medicare covered--paid for
a regular physical examination, that you would have come in
regularly to get them, and that might have spared you a lot of
the suffering.
Let me ask the other three of you. You've listened to the
rest of this hearing. I'm interested in your views on that very
forward and simple question, because as I said earlier, it
seems intuitive to me that if Medicare, A, reimbursed
physicians for a fairly comprehensive annual physical exam,
like most people with good health care plans get, that a lot
of--there would be a lot of advantage to that, both in steering
people toward screening activities, toward looking at the
questions that have been raised here with things like blood
pressure, vision, hearing, depression problems, tobacco
cessation, dental hygiene, physical activity, fall prevention.
All of those things could be part of the questioning process
that went on in an annual physical exam, it seems to me.
I don't know in my own mind yet whether I think it actually
saves the Medicare program money in the long run or not, but it
seems it would promote a heck of a lot of well-being and
prevent a lot of suffering.
I'd like your thoughts on that, Dr. Gold, Dr. Himes and Dr.
Gruman.
Ms. Gold. The short answer is yes.
It is interesting. When you look at what the Task Force
suggests, they sort of say, every exam should be an opportunity
for prevention, and I think that that is great wisdom for a
practicing doctor. But I think the reality in today's world is
that you're seeing a lot of people who have a lot of
difficulties, and to actually seize that opportunity and create
that time to spend the time counseling, or to do some of the
risk assessment, just doesn't--it gets lost in the shuffle.
Mr. Greenwood. And that is true in any--when something is
bugging me, when I've got a headache or something is hurting
me, and I go see the doctor in the Capitol, he doesn't take
that opportunity to ask me 25 questions about the rest of my
health care. He gives me what I need, and I'm out of there. And
I would assume that is the same with Medicare beneficiaries as
well.
Ms. Gold. I think that is exactly right.
A number of years ago--I was in Washington for a number of
years, and we did a study for Health and Human Services that
looked at the cost of sort of bundling preventive services into
an annual visit, and did some costing out for Medicare; and
that might be an interesting report to get to you folks. It
really added, at that time, perhaps $18 or $20 a year, as I
recall, to the overall expenditure per capita; and that seems
like a pretty good deal.
The only other thing I want to say, and it is just sort of
a throwaway line, is the notion that prevention should be cost
saving is one that really sticks in my craw a little bit. That
is not--the design of health care is not to be cost saving. The
design of health care is to promote health.
I think the whole notion of cost-effectiveness analysis,
which is a different issue--how much health do you buy for the
money you invest--is actually a lot more useful way to be
thinking about Federal investments.
Mr. Greenwood. If I can interrupt you on that, I quite
agree with that. It helps, because of the straitjacket of
budget tiering around here, if we can show that something pays
for itself. So it just makes our life a heck of a lot easier.
But the fact of the matter is that, A, if preventive health
care keeps our parents and eventually ourselves happier and
healthier and avoids Ms. Quirion's suffering, that is what the
whole system is supposed to be there for; and that is justified
in itself.
But there are so many other related costs that can be
prevented. For instance, wage loss. I mean, you think of how
many people are not out in the world earning a living because
they've lost their wages. But if Dr. Himes and Dr. Gruman can
respond as well----
Ms. Himes. A couple of points: The first is that, just for
your information, we do, of course, pay for--or there is no
extra, added expense, except for copay in some cases, and often
not that--for a physical exam; and we get 25 percent of our
seniors who self-select for a physical every year. So just to
let you know in kind of a general way in our population.
But a second part of all of this is this big bugaboo of a
question of what is entailed in a complete physical. And that
is a very interesting question, and what I would argue here,
and the one point I really want to make that I tried to make
earlier and made in my written statement, is that what we do
know from the literature--and some of this literature, we've
contributed at group 2 at Group Health--is that if, as people
get older, you focus the preventive care or health promotion
visit on the geriatric syndromes that really interfere with
functional status and that include physical activity, et
cetera, smoking cessation and all of the things we've talked
about today--if you focus on those things, rather than
distracting your time on the millions of complaints you could
possibly talk about, then in only--we have really clear data
that in only 6 to 12 months you can make huge decreases in
costs, in utilization; so that physicals for seniors, if you
will, that are done in the geriatric assessment model really do
show very quick results, quicker than any other preventive care
work that we do around diabetes or anything else--so something
to very seriously take a look at covering.
Thank you.
Mr. Greenwood. Thank you.
Ms. Gruman. I have two comments, kind of add-on to those.
One is that it strikes me that all these questions about a
physical exam kind of raise the problem of something that has
just been a really important health policy issue for a while,
which is what is the role of the primary care physician, and
particularly for older people, what is the role of the
geriatrician in serving that role of the primary care
physician, which is not only to coordinate prevention care, but
also, once you find something, to coordinate the rest of the
care?
And, you know, this is an issue that managed care tried to
kind of manage into place, and I think with not too much
success. Raising the capacity of primary care physicians to
serve as--in this very care-coordinated role, as well as
professional, in a 7-minute office visit has been a really
tough thing.
And that actually raises----
Mr. Greenwood. Let me interrupt you. What drives--I mean,
this is somewhat of a--I think I know the answer to this
question, but what drives it to be 7 minutes instead of 20
minutes?
Is it not what Medicare will pay for that?
Ms. Gruman. No. I think it probably has more to do with how
people are organizing their patients these days; and, you know,
probably also how much time they spend complaining about being
in managed care programs. You know, it cuts down on the medical
visit.
Anyway, I think that it does raise another--two--that kind
of raises two other issues. And one is that it is possible that
there is a need to really expand the kind of people who deliver
those--who help to deliver the kinds of preventive services
that we're talking about, primarily if you move into the zone
of doing counseling or referring people to other kinds of
expertise, for example, with smoking cessation.
I think a more creative approach to what is covered--I
mean, is a telephone call covered to coordinate care versus
only an office visit? Can Medicare--can CMS support telephone
counseling lines and nurse advice lines that would help to cut
down on some of the kind of extra time that physicians might
take to take care of their patients and to really address all
of these preventive issues that are important?
And I think that the final point that your question raises
is something that actually came up in your first question. You
said something, your first question to the first panel when you
said something about, well, you know, if I could just go to the
doctor and get my exam, then I would be healthy. And I'd just
like to remind us all that going to the doctor and having an
exam once a year is not the thing that is going to make us
healthy, that that hour is one tiny piece of time when you're
under the supervision of a physician, but the things that you
do every day--what you eat and how you exercise, or don't--
really make much more of a difference than that 1 hour.
So just to kind of keep that in perspective, I think, is
important.
Mr. Greenwood. Well, I think it is exactly the case. I
think what I'm trying to get at is this recurring information
that we hear that if you look at the people with the worst
health outcomes, they seem to be the ones who are not availing
themselves of any of the preventive modalities--not the
screenings, not the--and not the smoking cessation and not the
diet and not the activity.
And if you ask, why is that, it seems to me that the
recurring answer is--in large measure is because nobody has
suggested it to them. Nobody counseled them about it. Nobody
pointed them in that direction.
And obviously there are a lot of ways we can try to
communicate with these beneficiaries, other than in the
doctor's office, but it is just my intuitive sense that having
that regular opportunity to know that you can go in and spend
some quality time with your primary care physician or
geriatrician and cover a variety of issues, it would seem to be
a very effective way at steering people to all of these, both
tests and behaviors.
Ms. Gruman. I think that you're right, that there's an
incredible authority that that still resides with physicians
and the ability of physicians to use that, to not only say, you
know, you need to take these drugs in this way, but also there
are other things that you need to be thinking about.
And to help people set priorities is really critically
important. I think there need to be other ways of linking that
advice to individuals--individuals to services in the
community, that it's not just--it can't just be a one shot,
gee, I think you should stop smoking, and not be able to give
people other ways to kind of act on that advice.
Mr. Greenwood. Thank you.
The Chair recognizes the gentleman from Kentucky, Dr.
Fletcher, for 10 minutes.
Mr. Fletcher. Well, thank you, Mr. Chairman, and I thank
the panelists. I wasn't here for all of it; I had some
constituents come to visit. But again, thank you for your
testimony.
One of the things--let me address this to--I think, Dr.
Himes, you talked about physical fitness, and I know we have
referenced here the New England Journal of Medicine. There was
a study that was reported in the New England Journal of
Medicine that talked about poor physical fitness as an
indicator of poor outcomes and even a stronger indicator than
some of the other things we usually look at--whether it is
smoking or some of the other high potential for risk things.
And I know you mentioned in the Medicare+Choice--are there
plans that provide for physical fitness, and what can we do,
and what are the roadblocks that we face here in, say, in the
typical Medicare fee-for-service from trying to put more
emphasis on the physical fitness programs?
Ms. Himes. The literature clearly shows that if you look at
all of the indicators or all of the things that we commonly
think of as screwing up people's lives as they get older, that
physical fitness, on the very positive side, is the one thing
that statistically, significantly is relevant in terms of
positive health care outcomes for all seniors, if you look at
the entire Medicare population.
The only other thing that is statistically significant
actually is social isolation on the very negative side.
So physical activity then becomes a real mainstay. It is
the biggest bang for the buck, as I personally look at it,
individually for my patients and for others.
The question then becomes, what do we do about that as an
organization? If I look at Group Health's 60,000 seniors, what
do I say we're going to do about that? In the--for us, once we
understood that literature base, we then went on to look at,
okay, what kind of exercise is the most important? It turns out
that not only aerobic or endurance exercise, but muscle-
strengthening and flexibility is really important. And it also
turns out that actually, as with everything, people who are the
most disabled or the most frail are the folks who have the most
to benefit.
So in looking at those populations, then how do you develop
exercise programs that health care organizations can sponsor to
send people to? Because you're exactly right, if you don't have
programs to send people to, I can talk until I'm blue in the
face to an individual patient in my office about starting to
exercise, but if I don't have some specific ways for that
person to exercise, especially the more disabled they are, it
rarely does any good.
So we developed a program called the Lifetime Fitness
Program, which we actually just finished doing some outcome
studies around, and showed about a 20 percent decrease over 1
year for a Lifetime Fitness participant as compared to our
senior Medicare population in general, in terms of both overall
costs and health care utilizations. And 3 or 4 years ago, we
decided that we would start to cover as a Medicare benefit some
exercise programs.
We contracted with local health clubs for a program called
Silver Sneakers, and with local senior centers for our Lifetime
Fitness Program and started to offer those two programs as
benefits for our Medicare recipients. Since that time, I've
sent a lot of my--I write prescriptions for patients, and I
send a lot of my patients to those programs.
A lot of folks won't go, especially my most disabled
people, so I started a program, actually in my own clinic just
for my folks, to see what would make a difference for them and
what would get them to exercise; and we just made a video of
these guys there called ``The Dancing Ladies and Their Few Good
Men,'' and they've become an inspiration to many people. So we
are making a home exercise video.
So I think that bottom line here is that health care
organizations, Medicare--Medicare programs in general need to
be promoting, but not only promoting, really developing and
sponsoring physical activity programs for the entire range of
folks, whether they live in nursing homes, whether they live at
home, whether they can go to a health club, or whether they
live in an assisted living facility. We need to figure out ways
to get people exercising across the board.
And just for you all's information, there is a brand-new
effort that has just started called the ``National Blueprint on
increasing Physical Activity in Folks 50 Years and Older,''
that is sponsored by the Robert Wood Johnson Foundation and the
CDC. And we are going to make a difference.
Mr. Fletcher. Okay. Thank you.
Let me ask, one of the--you know, in my practice, one of
the problems I had--and the chairman mentioned this. When a
patient comes in with an acute problem, the last thing they
want to hear is a lecture on probably something else, because
they are not feeling well, they've got a problem, their family
is concerned about that, and it's just--you know, not now, this
is not the time.
So I think the utilization of a lot of extenders, or other
individuals that can help in the educational process, is very
important. Physicians do, and studies seem to have a certain
degree of credibility that is very important to emphasize those
things.
One of the things that we were never able to implement--and
I'm very interested in what I call e-medicine--is the fact of
having information come up that's specific for the patient,
based on evidence, but additionally in what's probably
considered some of the best practices, so that that pops up
electronically to provide information to the patient, can be
some reinforcement.
And Dr. Gruman, let me ask you, what work is being done in
that regard? And what can we look forward to, or some of the
things we could do in Medicare to help implement some tools for
practitioners to really start putting a greater emphasis on
prevention?
Ms. Gruman. I think there's a tremendous amount of work
that is being done to try to develop different technologies,
using the Web, using various kinds of search engines to find
the best--to match the right information to the right person at
the right time.
Right now, there's a bit of a forest-and-the-trees problem
in that consumers have one sense of what information they need
and how to set the sort--set the--kind of the filter; and
physicians have another--another set of concerns that may--in
many cases, includes keeping a lot of that information out of
the physician-patient relationship because it's just too
confusing. They'd much rather have the old-fashioned
relationship, where physicians get to tell the patients what to
do and what not.
So I think we actually are in a time of great change right
now. I think that--in terms of the Medicare program, I think
that looking at the range of ways that patients can interact
with authoritative sources and ensuring that those
authoritative sources really are good and having some
flexibility about how those things are covered and what kind of
access people have is really important.
For example, I know that the demonstration project on
smoking cessation that CMS is going to be sponsoring features a
1-800 QUIT LINE; and, you know, if they can generate enough
demand through physicians telling their patients that they
should stop smoking and that they should use this, that could
be a really wonderful extender.
I think that there are lots of other kinds of technologies
that are available, like that, that just--that really haven't--
haven't even really been considered. Because no one has really
said to CMS, you know, you've got to figure out a way to help
physicians use their time better; and what are the central
things that we could support, we could control quality on, that
wouldn't involve kind of licensing a whole other guild to
deliver services, but would in fact serve to make accessible to
individuals information that they need in order to stay
healthy?
And I think kind of liberalizing, or asking CMS to really
look at some of those technologies, would be a really wonderful
thing.
Mr. Fletcher. Thank you.
Ms. Quirion, you mentioned that if some of the preventive
measures would have been available and paid for and things,
that it would have helped you tremendously.
One of the things I noticed--or one of the things in my
experience--it's probably been presented here in the last
couple of panels--is, it's extremely difficult to get
information out to the general population on the importance of
prevention in a way that will spur them to actually act in
common and do something about it. And I wondered, since you
represent a lot of folks on behalf of this--a lot of retired
Americans, what can we do?
And let me just throw out something. You know, when we go
get a driver's license, there are certain things we have to
know before we get the privilege of driving on the roads. What
can we do to make sure that there is some personal
responsibility here for seniors, but we do what--through
Medicare, whatever, to make sure that there's a certain
educational level regarding the prevention and their
responsibility for the health care, to make sure they get
there?
I'm just wondering if you have any ideas on that for us.
Ms. Quirion. Well, all that they say here is true, about
smoking and drinking, and that's something I've never done. And
I exercised, and I worked. After I stopped working and I
retired, I took another job, a second job, and I've been
working hard for 12 years. So I did all those things.
I try to eat well. But that did not prevent the fact that
if I would have had a physical, anything like this, it would
have prevented it from being--being in the state that I was,
and I would have had a better chance really of recovering
better from this. I might have had the surgery, no chemo.
And there's a lot of people that die of those things, and I
think never even know what they have. They don't tell their
physician the reason--I went there because I started to have
abdominal pain, and I knew that there was something wrong, but
some don't do that. They just--once they discover it, it's too
late for them, period.
Mr. Fletcher. Dr. Gold, would you have some comments on
that, as far as educating the general population and the
responsibility there that might be included in some Medicare
programs, whether it's some educational things that encouraged
or incentivized or required?
Ms. Gold. It's interesting. I've been thinking about
incentivizing, but I've been thinking about it in a slightly
different way. I was thinking about the UK experience where
physicians are actually incentivized to deliver preventive
services, so in your panel you get paid your per capita rate.
But if you can bring more people in for preventive services
because that is seen as a social good--which, I would argue, is
the same in the United States as in the UK--it might be worth
thinking about setting priorities of clinicians and physicians
more toward prevention.
Medicare has been sort of heavy-handed in the way it
reimburses for technological procedures, and so light-handed in
the way it deals with the sort of less technological and more
behaviorally based kinds of things. So that is one reflection.
The other thing I would say, having spent my clinical
career really serving low-income populations--first, rural and
now, urban--some of the notion of education, I think, is a
tricky one. You know, how many lower-income Americans sit in
their living room with computers? How many less-educated
people, you know, have had that benefit? You know, 30 years
from now, we may be fine, but that is not where we are now.
And I think that there is something else also about health
which is very intimate, and the whole notion of the
relationship one develops with a primary care provider and the
sort of power-of-the-profession thing is a real one, and so it
is fine. I mean, I think it's enhancements you plug into your
computer, and up comes your--you should do this thing. But the
reality is that a lot of people are pushed toward taking action
because somebody is concerned about them and makes a specific,
tailored point about them, the individual.
Mr. Fletcher. So let me sum up. Do you think something
where incentivizing the providers or the physicians is going to
have a greater impact than a direct response to the general
population; for example, making sure that there's--that they
become familiar with preventive measures that have been shown
to be effective?
Ms. Gold. I think that would be a great thing, and I think
that particularly in underserved populations or underinsured
populations, where there's an excess of morbidity anyway, when
the patients are coming in, you're sort of riveted on the
diabetes out of control, the hypertension out of control. To
get those practices and those doctors to find ways--innovative
ways, different programs at the grass-roots level that bring
people in--takes some extra work on the part of those
organizations and those providers; and I think if you can build
in that kind of incentive, that is a great policy piece to
think about.
Mr. Fletcher. Thank you. My time has expired.
Mr. Greenwood. We thank the gentleman.
And I think--ultimately, as I grapple with this issue, I
think you need to have incentives for the provider. I think you
have to pay providers a decent reimbursement for a good,
thorough examination, and I think that we need to think of the
incentives for the patients.
I mentioned earlier--you know, I'm just playing around with
these thoughts--but whether your premium changes or you lose--
you have a benefit in terms of a deductible for hospitalization
because you've avoided hospitalization by doing certain things,
I think you can keep it pretty simple and figure out some ways
to attract people in to get these exams.
Let me just--one final question. And we've covered the fact
that we all think it is in the best interest of us as a
society, out of just pure compassion and quality of life, to do
these things so that the people live longer, healthier, happier
lives; but we do have to, here in Washington, deal with this
darn issue of cost effectiveness and does it save us money in
the long run.
It seems that there is a dearth of really good information
on that subject and it is shocking to me. It is shocking to me
that not CMS, not CDC, no one has really been able to say, yes,
this is such an obvious question, it has been asked a thousand
times and the answer is very clear with regard to how
preventive services do or do not save dollars, and how to
maximize that.
My question is: What do you think we ought to do about this
dearth of knowledge? Is this something that the CMS ought to be
tasked to, in a very comprehensive way with supercomputers, be
gathering all of this information from the field and doing
longitudinal studies; or do you think we need to pay for
somebody like the Academy of Sciences or GAO to do a massive
study? Is the data all sitting there and we just need to
collect it from insurance companies? What do you think we ought
to do so we can be real smart about this question of cost
effectiveness?
Ms. Gold. Let me go back to this whole notion of the
continuum between primary, secondary, and tertiary prevention.
Tertiary prevention is real treatment.
One question which arises when beginning to scrutinize
everything in terms of its cost effectiveness is will you do
everything; and the answer is you can never do everything
because it would take a lot of person-power hours. The analytic
piece itself would be challenging. There are lots of procedures
that we do in medicine which have been grandfathered and
grandmothered in. We will never really know how effective they
are. They just sort of state what goes on.
I am very much a proponent of thinking about how effective
what we do in medicine is. Evidence-based medicine has been
extremely helpful to me on a personal practitioner basis and
also in the teaching that I do.
I do think that incorporating the cost piece is really
important. There have been some sort of major breakthroughs in
standardization of cost-effectiveness analysis over the last
several years. I think in reality many of the Federal agencies
are not adequately funded to be able to incorporate some of
those kinds of evaluations. If there were a concerted effort
from the Congress to say we really would like to know as we
begin to grow the Medicare program in different ways, what the
health effect we are getting for the investment is, that would
be an extremely large contribution to sane policymaking.
Again the problem we have to solve is to think smartly
about what set of services we are going to put that charge
around, and how are you going to make those decisions. We can
look at top medical conditions for which Medicare is paying,
and say is there effectiveness information? I think it is a
large charge. I think it is a very, very important one, but
will be a difficult one to figure out exactly how you want to
approach.
Ms. Himes. I think there are two issues. Essentially one
is, what is good preventive care? Coming up with that idealized
model, if you will, of what we want to be telling seniors or
docs that they should be doing for seniors in the preventive
care mode is essential. I don't think there is clear agreement
on that, overall, at this point in time. There is lots of
individual evidence around individual preventive measures but I
think you are right, the overall piece is not there.
Then my personal bias is that CMS and Congress ought to
sponsor a series of demonstration projects to just look very,
very clearly at how can systems do this. In my own system the
question of our network model versus our group model, where we
have got physicians out there in the world who have very few
group health practitioners and other physicians who contract
exclusively with group health, we have learned a lot from those
two separate models. We focus much more on patient education in
that external world; much more on physician education, and
patient, in the internal world.
So I think a series of demonstration projects really
looking at what is good preventive care, No. 1, and then how do
you put it out there. And what, not only money does it save,
but what changes does it make in the quality of life of folks.
Ms. Gruman. I think it is a really interesting question
that you would raise, and especially the assumption that
someplace out there, there should be all of this information.
It is not like prevention is just a new thing that we do not
know anything about.
I think this goes back to a point that I made earlier which
is that the NIH budget for this year is $23 billion; and the
budget for the Agency for Health Care Research and Quality,
which is the federally mandated organization whose role it is
to translate research into policy and practice, has a budget of
$307 million. That is slightly over 1 percent of the NIH
budget.
We have this huge bonus of new science coming down the
pike, and we don't even know what the right preventive services
package is. I think we need to really think about balancing the
research portfolio so that some of these questions can be
answered, and not just for the Medicare population. These are
questions that really need to drive health care generally in
this country.
Mr. Greenwood. Okay. I want to thank each of you,
particularly you, Mrs. Quirion, for your courage in being with
us. We will take your words to heart.
I thank each of you for your testimony, and the hearing is
adjourned.
[Whereupon, at 1:20 p.m., the subcommittee was adjourned.]
[Additional material submitted for the record follows:]
Prepared Statement of the American Heart Association
Mr. Chairman and distinguished members of the Subcommittee on
Oversight and Investigations: The American Heart Association commends
you for holding this hearing entitled ``Assessing America's Health
Risks: How Well Are Medicare's Clinical Preventive Benefits Serving
America's Seniors? How Will the Next Generation of Preventive Medical
Treatments be Incorporated and Promoted in the Health Care System?'' on
May 23, 2002. The Association presents to the subcommittee the
following statement, and we appreciate the opportunity to be heard on
this important topic.
The American Heart Association works to reduce disability and death
from heart attack, stroke and other cardiovascular diseases through
research, the development and distribution of consumer education
materials, and grassroots advocacy. The American Heart Association
currently spends over $380 million of its own resources annually on
research support, public and professional education, and community
programs. The Association does not accept government funding.
Nationwide, the organization has grown to include more than 22.5
million volunteers and supporters who carry out its mission in
communities across the country. The Association is the largest
nonprofit voluntary health organization fighting heart disease, stroke
and other cardiovascular diseases, which annually kill about 960,000
Americans.
Heart disease, stroke and other cardiovascular diseases have been
America's number one killer since at least 1919, and today these
diseases account for more than 40 percent of American deaths. These
conditions are a major cause of disability as well. Heart disease
alone, for example, is the major cause of premature, permanent
disability of American workers and accounts for nearly 20 percent of
Social Security disability payments.
Nationwide nearly 62 million people, or 1 in every 5 Americans,
live with one or more of these diseases. Both genders and all age
groups suffer from these diseases, and in many cases, cardiovascular
diseases strike down otherwise healthy individuals for reasons not yet
fully understood.
Tens of millions of Americans have major risk factors for these
diseases that can be modified with appropriate interventions: an
estimated 50 million have high blood pressure, more than 41 million
adults have elevated blood cholesterol (240 mg/dL or above), 48 million
adults smoke, more than 108 million adults are overweight or obese and
nearly 11 million have physician-diagnosed diabetes. Clearly, as the
``baby boomer'' generation ages, the number of Americans afflicted by
these often lethal and disabling diseases will increase substantially.
What is perhaps most shocking is the cost of cardiovascular
diseases. These conditions cost Americans more than any other disease--
an estimated $330 billion in medical expenses and lost productivity in
calendar year 2002 alone. Three of the top five hospital costs for all
payers (excluding childbirth and its complications) and three of the
top five Medicare hospital costs are cardiovascular diseases.
While the American Heart Association strives to find breakthroughs
in the treatment for these conditions through our support of research,
the organization is also devoted to the prevention of cardiovascular
diseases as well. We strongly believe that mortality rates can be
drastically lowered, and disability from cardiovascular diseases can be
greatly reduced through scientifically proven prevention methods.
Congress has discussed preventive measures in recent months and has
passed many into law in recent years. While the Association supports
breast, vaginal, prostate and colon cancer screenings, glaucoma
screenings, bone mass measurements, pneumococcal and influenza
immunizations, and all of the other preventive measures that Congress
has enacted on behalf of Medicare beneficiaries since 1981, none of
these measures focus on the number one and number three killers in the
nation--heart disease and stroke.
Periodic cholesterol screenings, healthy diets combined with even
moderate amounts of exercise, and kicking the cigarette habit for those
who smoke have all produced dramatic results. It is important to note
that scientific studies have shown these results can be achieved in
both young and elderly individuals alike, and that it is never too late
to have an impact on your long-term health outcomes through preventive
measures.
CHOLESTEROL AND LIPID SCREENING
Perhaps the best example of a preventive benefit that Congress
should add to the Medicare Program as quickly as possible is coverage
for periodic screening of cholesterol and lipid levels. The American
Heart Association urges Congress to add coverage for this important
preventive test. Consider the following:
<bullet> In separate federal initiatives conducted by NIH and AHRQ
(discussed below), both agencies published recommendations over
a year ago stating that all elderly Americans should undergo
periodic screening of their cholesterol and lipid levels.
<bullet> In relation to other health care costs and preventive
benefits, the annual cost of adding this coverage to the
Medicare Program would be relatively modest (even without
considering the potential financial savings of preventing acute
events such as heart attacks and strokes).
<bullet> Cholesterol screening is becoming more widely recognized by
Americans as an important aspect of basic health care, and as
such, Medicare coverage of cholesterol and lipid screening
would be meaningful to Medicare beneficiaries.
The need for covering cholesterol and lipid screening as a
preventive service under Medicare has never been clearer. In May of
2001, two separate panels from the National Institutes of Health (NIH)
and the Agency for Healthcare Research and Quality (AHRQ) concluded
that elderly individuals of all age ranges can substantially lower
their risk of heart attack by aggressively treating abnormal
cholesterol and lipid blood levels. Previously, these agencies had
established upper age limits within their federal cholesterol screening
guidelines, but they changed these recommendations last year in the
face of overwhelming scientific evidence. Nonetheless, although these
federal recommendations highlight the importance of cholesterol
screenings for elderly patients, many Medicare beneficiaries are not
able to benefit from these simple tests under current Medicare coverage
policy.
Currently, Medicare beneficiaries are only covered for cholesterol
and lipid testing if they already suffer from known illnesses such as
heart disease, stroke, diabetes or other disorders associated with
elevated cholesterol levels. In many cases, seniors eligible for these
tests are already victims of a condition cholesterol screening might
have caught and helped prevent. By adding cholesterol screening as a
covered benefit for ALL seniors enrolled in the Medicare program,
Congress will enable Medicare beneficiaries and their physicians to
learn of otherwise silent problems and seek appropriate treatment in
advance of a disabling or deadly event. This will help drastically
reduce the number of cardiovascular disease and stroke deaths each year
and will greatly reduce the number of individuals disabled by these
conditions.
With this in mind, the American Heart Association is leading an
effort to enact H.R. 3278 and S. 1761--The Medicare Cholesterol
Screening Coverage Act of 2001. We ask that your committee consider
these bills as you investigate Medicare's preventive benefits.
Congressmen Dave Camp (R-MI) and William Jefferson (D-LA) introduced
this important bill in the United States House of Representatives late
in 2001. Senators Byron Dorgan (D-ND), Ben Nighthorse Campbell (R-CO)
and Jeff Bingaman (D-NM) introduced a companion bill in the United
States Senate. This legislation will guarantee Medicare coverage of
preventive screenings for cholesterol and other lipid levels.
SMOKING CESSATION COUNSELING
As the nation's largest health care purchaser, the federal
government has a vital role to play in promoting effective, affordable
tobacco use cessation services. Research consistently has shown that
smoking cessation saves lives, reduces smoking-related health care
costs, and is one of the most cost-effective health interventions
available. Unfortunately, some government financed health care
programs, including Medicare and Medicaid, do not provide reimbursement
for some of the most effective smoking cessation treatments recommended
by the Department of Health and Human Services' Clinical Practice
Guideline for treating nicotine addiction. The facts supporting
expanded coverage of effective smoking cessation treatments are
compelling.
Tobacco use is our nation's number one cause of preventable death.
Tobacco use causes more than 400,000 deaths each year among smokers and
contributes to profound disability and pain in many others.<SUP>1</SUP>
About half of all long-term smokers die prematurely of diseases caused
by smoking.<SUP>2</SUP> The U.S. Surgeon General has concluded that
reducing tobacco use is the single most important action this nation
can take to reduce death from heart disease and other chronic
diseases.<SUP>3</SUP>
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\1\ U.S. Department of Health and Human Services. Reducing Tobacco
Use: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department
of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2000.
\2\ Peto R, et al. Mortality from Smoking in Developed Countries,
1950-2000. New York, NY: Oxford University Press, 1994.
\3\ U.S. Department of Health and Human Services. Reducing Tobacco
Use: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department
of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2000.
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Tobacco users would like to quit but success rates are low.
Approximately 50 million Americans are now addicted to tobacco
products.\3\ More than 70 percent of all smokers report that they would
like to break their addiction, but have not been able to do so.\3\
Effective, therapies exist to double or triple successful quit-
rates but these life-saving measures are significantly
underused.<SUP>4</SUP> Research consistently demonstrates a sharp
increase in successful tobacco cessation among smokers who seek
assistance. In general, those who receive no assistance are about twice
as likely to fail in their quit attempts. When optimal professional
counseling and smoking cessation drugs (nicotine replacement therapy
and/or Zyban) are combined, success rates can triple.\4\
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\4\ Fiore MC, Bailey WC, Cohen SJ et al. Treating Tobacco Use and
Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department
of Health and Human Services. Public Health Service. June 2000.
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Smoking cessation is extremely cost-effective compared to health
interventions already covered by public and private health providers.
Smoking cessation coverage has been found to be more cost effective
than many widely accepted reimbursable medical interventions.\4\ For
pregnant women, smoking cessation interventions result in fewer low
birth weight babies and perinatal deaths, fewer physical, cognitive,
and behavioral problems during infancy and childhood, and also yield
important health benefits for the mother.\4\ Providing both counseling
and smoking cessation drugs is significantly more cost-effective than
providing either treatment alone because a much higher percentage of
patients will successfully quit using the combined approach.\4\ Over a
five to six year period, smokers experienced 30 to 45 percent more
hospital admissions than former smokers.<SUP>5</SUP>
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\5\ Wagner, EH et al. ``The Impact of Smoking and Quitting on
Health Care Use.'' Archives of Internal Medicine, 1995;155:1789-1795.
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Congress should act now to promote effective tobacco use cessation
therapies. The American Heart Association favors reimbursement of
tobacco use cessation treatments as part of all health care programs,
including those financed by the federal government.
Immediate priorities for congressional action include:
<bullet> Adding a smoking cessation counseling benefit for all Medicare
beneficiaries and ensuring that any prescription drug benefit
for Medicare beneficiaries includes coverage of smoking
cessation drugs. Smoking cessation provides significant health
benefits for smokers of all ages.\4\
<bullet> Providing prescription and non-prescription smoking cessation
drugs in the Medicaid program. Current Medicaid law allows
states to exclude FDA-approved smoking cessation therapies from
coverage. Moreover, less than half of the states provide
coverage for smoking cessation products in their Medicaid
program even though the states won $246 billion over the next
25 years from the tobacco industry in 1998 settlements of
Medicaid claims. Full coverage of smoking cessation is urgently
needed by the Medicaid population, which bears a
disproportionate burden of the death and disease caused by
tobacco. About 57 percent of Medicaid recipients are current or
former smokers.<SUP>6</SUP>
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\6\ Harris JE. Written Testimony Before the Senate Judiciary
Committee Hearings on the ``Proposed Global Tobacco Settlement: Who
Benefits?'' Washington, D.C., July 30, 1997.
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<bullet> Clarifying that the maternity care benefit for pregnant women
in Medicaid covers smoking cessation counseling and services.
This is critically important for the health of the mother and
child. Women who stop smoking before becoming pregnant or
during the first trimester of pregnancy reduce their risk of
miscarriage or of having a low birth weight baby to that of
women who have never smoked.\4\ A counseling benefit is
essential because use of smoking cessation medications may not
be appropriate for this population.
<bullet> Ensuring that the Maternal and Child Health (MCH) Program
funds may be used for smoking cessation counseling and
medications, and that smoking cessation is considered part of
quality maternal and child health services.
These proposals are based on the June 2000 clinical practice
guideline for treating nicotine dependence, which represents the state
of the art in tobacco use cessation.\4\ These proposals focus
exclusively on improving delivery of effective tobacco use cessation
through existing health programs and are contained wholly or in part in
H.R. 3676, the Medicare, Medicaid, and MCH Tobacco Use Cessation
Promotion Act of 2001, sponsored by Representatives Mary Bono and Diane
DeGette. Companion legislation was introduced in the United States
Senate (S. 622) by Senator Richard Durbin.
Costs for these benefits would be modest. For instance, ensuring
that Medicaid recipients have access to proven smoking cessation drugs
would cost $200 million over 10 years, according to a 2000 estimate by
the Office of Management and Budget.
disease management as an approach to confronting chronic illness
The incorporation of disease management benefits into the Medicare
program may improve health care quality for Medicare beneficiaries as
well as contain costs. Disease management is a promising and evolving
approach to confronting the challenges represented by chronic illness.
As government, health plans and clinicians have adopted disease
management models to fit their own needs and goals, the various
meanings of disease management have evolved and diversified. In
practice, it can cover a range of potential activities, from
distributing pamphlets to patients instructing them on self-management
techniques related to their particular condition to relying on a case
manager to develop patient-specific care plans.<SUP>7</SUP> Although
the term is widely and inconsistently used, all disease management
programs share the common goal of improving quality of life and care
outcomes for people with chronic illness.
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\7\ Jeff Tieman, Disease Management Making a Case for Itself
Clinically and Financially, Modern Healthcare, July 9, 2001.
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Increasingly, disease management is being offered as an approach to
health care management in the public and private sectors. Hundreds of
so-called ``disease management programs'' exist for a wide array of
chronic illnesses, including congestive heart failure, diabetes, asthma
and depression. Federal agencies are currently evaluating the cost
effectiveness and patient outcomes of programs that rely on disease
management techniques to deliver patient care; a number of states are
offering disease management services through their Medicaid programs;
key members of Congress are introducing legislation to fund new disease
management initiatives; and pharmaceutical benefit managers (PBMs) are
contracting with states to provide disease management services through
pharmaceutical assistance programs for seniors.
The American Heart Association finds the concept of disease
management promising, but also urges the Subcommittee to consider two
issues--
(1) any quality standards or performance measures for cardiovascular
disease and stroke must be based on appropriate, objective and
scientifically-derived evidence-based guidelines; and
(2) quality of care must be prioritized over cost-containment or other
financial incentives in all disease management initiatives.
Disease management should be primarily about improving patient
outcomes and only secondarily about cost containment.
For disease management to truly put patients first, clinical
guidelines must rely on a template that emerges from medical community
consensus. For example, appropriate clinical guidelines for some
disease states may require minimum staffing levels. Additionally,
appropriate disease-specific programs should reach low-risk patients as
well as high-risk patients to best serve long-term health needs. In
short, to focus on appropriate patient-centered clinical guidelines,
medical community standards must serve as the fundamental framework for
any disease management program that hopes to draw widespread approval
and acceptance.
In addition to the use of appropriate clinical guidelines, it is
critical to ensure that disease management programs are driven by the
clinical needs of patients rather than mere cost containment or
financial profit. While we recognize the need for cost containment and
careful allocation of health care resources, the improvement of quality
care must be the primary goal of any disease management program.
The American Heart Association is at the forefront of investigating
ways to improve the quality of care for patients with cardiovascular
disease and stroke. We have developed and are currently operating a
number of patient-centered programs. In essence, our existing programs,
when viewed together, represent a form of disease management. We are
extremely proud of the process through which our guidelines are
developed and place great emphasis on ensuring objectivity and sound
science.
Our work on disease management is ongoing. We are currently
reviewing various models of disease management, particularly in the
area of cardiovascular disease and stroke. We are analyzing the
effectiveness of these models and hope to use this information to
refine our current programs and efforts, if needed. The American Heart
Association considers disease management an important and timely issue
and looks forward to working with Congress as it continues to consider
the appropriate integration of disease management into the Medicare
program.
The American Heart Association is eager to work with your
subcommittee, with others in Congress, and with the Administration as
you work on these and other health care reforms. We invite you to call
upon our organization for any assistance you may need in these
endeavors. The Association feels strongly that Congress should enact
changes to Medicare and other federal programs that are based on sound
science, honor good medical practices, and are meant to provide
patients with the best possible care.
Again, we commend the subcommittee for holding this hearing and
greatly appreciate the opportunity to comment on a few of the items we
feel will greatly improve the clinical preventive benefits received by
the over 40 million seniors currently enrolled in the Medicare program.
______
PREPARED STATEMENT OF THE COLLEGE OF AMERICAN PATHOLOGISTS
The College of American Pathologists (CAP) is pleased to submit
this statement for the record of the Subcommittee on Oversight and
Investigation's hearing on issues associated with Medicare's Clinical
Preventive Benefits. The College is a medical specialty society
representing more than 16,000 board-certified physicians who practice
clinical or anatomic pathology, or both, in community hospitals,
independent clinical laboratories, academic medical centers and federal
and state health facilities.
The College is aware that much has been learned about providing a
robust approach to quality health care for seniors since 1965, when
Congress created the Medicare program and chose not to include coverage
of preventive benefits. Preventive services have become a cornerstone
of quality, cost-effective health care delivery and should be readily
available to our nation's seniors. A specific example of where Medicare
falls short on prevention is the need for all women who are or have
been sexually active to have an annual Pap test and pelvic examination.
Medicare lacks such coverage for many women in the program.
Medicare provides annual screening Pap test coverage only for women
defined by the program as being at ``high risk'' of cervical cancer. To
help women understand Medicare coverage policies for the Pap test, the
Centers for Medicare and Medicaid Services offers a 14-page brochure.
But this well-intentioned document is complicated and confusing. Given
this approach, it's not surprising that many Medicare beneficiaries are
not utilizing this valuable service. Simply adopting an annual Pap test
coverage policy for Medicare would go far toward clearing up this
confusion. Physicians, in consultation with their patients, should
decide how often to perform this test and not be restricted by anything
less than annual Pap test coverage. Reasons for this are detailed
below.
No cancer screening test in medical history has proved as effective
for early detection of cancer as the Pap test. Since the introduction
of the Pap test shortly after World War II, death rates from cervical
cancer have decreased 70 percent in the United States. But despite the
test's unparalleled record of success, thousands of American women
still fail to have an annual Pap examination. It is sad to note that of
those women who die of cervical cancer, 80 percent had not had a Pap
test in the five years preceding their deaths, studies show. The
benefits of annual Pap tests are clear: A 1999 report from the Agency
for Healthcare Research and Quality (AHRQ), titled ``Evaluation of
Cervical Cytology,'' showed that the lifetime number of cervical cancer
cases decreases from 506 to109 in a cohort of 100,000 women with annual
Pap test screenings and cervical cancer deaths decrease from 116 to 21
with annual Pap tests. The report concluded that annual Pap tests could
result in 65 percent fewer cervical cancer deaths compared with
screenings once every two years.
Access to annual Pap tests is particularly important to women in
the Medicare program. The 1999 AHRQ report revealed that 40 percent to
50 percent of all women who die of cervical cancer are older than 65.
Recognizing the limitations of Medicare's coverage policy and the
importance of annual Pap tests, the College has called for annual
screening Pap test coverage under Medicare. Congress responded by
passing the ``Medicare, Medicaid and S-CHIP Benefits Improvement and
Protection Act of 2000'' (BIPA), which, last year, improved Medicare's
coverage of Pap tests and pelvic and clinical breast examinations from
once every three years to once every two years for all women in the
program. While BIPA did much to expand Medicare access to the Pap test,
it fell short of ensuring that all women beneficiaries have access to
the test on an annual basis.
The College believes that lack of Medicare coverage for the annual
screening Pap test often precludes early detection and diagnosis of
disease and results in greater costs to the Medicare program for
treating serious medical conditions that could have been prevented. The
College is now supporting legislation that would provide annual
coverage for the screening Pap test and pelvic examination. The
``Providing Annual Pap Tests to Save Women's Lives Act of 2001'' (H.R.
1202, S.258) would establish an annual Pap test benefit for all women
in Medicare. Passage of the bill is crucial to preventing death and
disability among America's elderly women.
The College thanks the subcommittee for the opportunity to present
its views on this important issue and offers its support and continued
assistance as Congress works to improve women's health.