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Statement by
Tom Grissom
Director, Center For Medicare Management
Centers For Medicare & Medicaid Services
on
Medicare and Preventive Services
before the
House Energy and Commerce Committee
Subcommittee on Oversight and Investigations

May 23, 2002

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:

• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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:

• 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.
• 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.
• 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:

• 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.
• 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.
• 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.
• 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.
• 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.
• 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.