Thursday, February 24, 2011

Medicare Preventive Services - Are We Using Our Money Well?

I have written before about the importance of evaluating medical procedures to evaluate effectiveness. I’ve noted that this will be important under our new health care law, so that the Government and insurance companies pay for what works – and don’t pay for what doesn’t. But, as I’ve also noted, who of us really wants to receive a treatment that hasn’t been shown to work, much less one that has been shown not to work?

That has been the point of the US Preventive Services Task Force (USPSTF). The USPSTF is not in fact part of the new health care law. Instead, it is a program of the Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services (HHS). It’s a panel of primary care physicians and epidemiologists who review published research to assess what works and what doesn’t. The program has functioned for more than twenty five years, but last year rose to public attention when it suggested new recommendations for mammograms.

With all that in mind, I wanted to take note of a recent article. A group of physicians has published, “Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage,” (Lesser et al, Annals of Family Medicine, Vol.9, No.1 [January-February], 2011). The Center for Medicare Services (CMS) has published recommendations for preventive services for Medicare patients (in 2007 and revised in 2009). The researchers compared those with recommendations from USPSTF, and looked at what Medicare would pay for. They looked both at individual preventive services, and also at what they identified as “preventive coordination:” that is, for coordination in addition to the service there needed to be reimbursement for risk assessment, patient motivation, and/or arranging the service. Much of this would be covered by the Welcome to Medicare Visit, an initial preventive physical exam for new Medicare beneficiaries. On the other hand, many were only covered as a part of the Welcome to Medicare Visit, and not if needed later. As a result, they stratified their results in four categories. “Fully covered” meant that both the service and preventive coordination as recommended by USPSTF were covered by Medicare. “Partially covered” meant that the service was covered, and preventive coordination was covered, but only as part of the Welcome to Medicare Visit. “Partial coverage with inconsistent indication” meant that the Medicare did reimburse for some patients and not for others. “No coverage” meant that the preventive services recommended by USPSTF were not covered by Medicare.

The researchers identified 15 preventive interventions recommended by USPSTF. While Medicare provided partial payment for 93% of the procedures (14 of 15), they provided full payment of both the procedure and for preventive coordination for only one (7%). On the other hand, the researchers identified 16 procedures that USPSTF recommends against, either fully or after a certain age. Medicare reimbursed for seven (44%), regardless of age. The researchers also noted that both USPSTF and Medicare recommended preventive services for at-risk populations, but sometimes defined those populations differently (focusing in different risks).

This is an interesting study. Medicare is the largest institution reimbursing providers for health care. CMS is continually searching (under no small pressure from the Executive and Legislative branches) for ways to support and provide appropriate care, and get the best bang for the buck. Effectiveness has gotten attention in the recent passage of our new health care law, but it has actually been an issue for some time. One would think it important that two agencies, both within the HHS, to talk with each other about recommendations. And perhaps they do; but these differences between what USPSTF recommends, based on review of the literature, and what Medicare recommends functionally (by being willing to pay for it) raise a question about that.

These days we’re inundated with news about how little money Government has (at all levels), and the necessity of controlling costs. (Remarkably, there are no discussions about raising revenue; but that’s a topic for another day.) Comparative effectiveness of medical interventions and efforts at preventive care are both important for controlling health care costs for the long term. Perhaps coordination will get better with time. Unfortunately, this study suggests that we aren’t coordinating well enough with the tools we already have.

No comments: