Graham Center Commentary Urges Greater Prevention Role for Medicare

The federal government can more effectively invest in prevention and wellness if it gives the Medicare system greater latitude to make coverage decisions and changes the Medicare payment system to reward the coordination of preventive care services. That's according to a recent commentary by family physician Lenard Lesser, M.D., a Robert Wood Johnson Clinical Scholar at the University of California, Los Angeles, and Andrew Bazemore, M.D., M.P.H., assistant director of the AAFP's Robert Graham Center in Washington.

The commentary, "Improving the Delivery of Preventive Services to Medicare Beneficiaries," which appeared in the Dec. 23/30 issue of the Journal of the American Medical Association, or JAMA, proposes three steps to expand Medicare preventive care:

The commentary points out that an investment in prevention and wellness is a hallmark of both the House and Senate health care reform bills. However, it goes on to say, "translating that commitment ... into improved health will require a strategy for separating effective prevention from that which is ineffective or even harmful and aligning payment strategies with practice supported by best evidence."

"Existing federal and private insurance coverage does not adequately support the delivery of clinical and preventive services associated with improved quality of life and reduced premature mortality."

As the largest payer of adult health services, Medicare serves as a model for other payers to follow, making it the logical choice to drive optimal coverage for preventive services throughout the entire health care system, according to the commentary. However, it notes, preventive services covered by Medicare also must be effective. Although the 2008 Medicare Improvements for Patients and Providers Act authorizes CMS to cover preventive services given an A or B rating by the U.S. Preventive Services Task Force, or USPSTF, there are some notable exceptions in what Medicare will cover.

For example, notes the JAMA commentary, CMS does not pay for USPSTF-recommended intensive dietary and behavioral counseling, even though poor nutrition and obesity are significant causes of morbidity and mortality.

In addition, says the commentary, coordination of preventive care services is vital and is a role often assumed by primary care physicians. Medicare pays these physicians for processing preventive tests and performing procedures, but it does not pay for preventive coordination, such as risk assessment, patient motivation and arranging the service itself.

For example, in the case of colon cancer screening, the commentary notes, "Laboratory-based clinicians, radiologists and endoscopists are reimbursed for performing the screening tests. However, there is no reimbursement for coordination of care (discussing and motivating patients to undergo screening procedures, assisting patients in deciding which screening test is most appropriate for them and ensuring that patients follow through and receive the screening) outside of the single welcome to Medicare visit."

The commentary assails the current fee-for-service payment system in particular for failing to provide incentives for the provision of preventive services. "The current system for coordinating preventive care is inadequate, amplifying the message that Medicare pays for many preventive tests but not for prevention," it says.

The commentary also urges Congress to pass legislation allowing CMS to discontinue payment for preventive services given a D recommendation by the USPSTF. Under current law, Medicare is required to cover many of these preventive services, even though a D rating by the USPSTF means there is a moderate or high certainty that the service has no net benefit or the potential harms outweigh the potential benefits.

"Potential harm aside, current Medicare spending on these preventive measures is unknown but likely significant," says the commentary. "One analysis of CMS spending on unnecessary 'preventive' chest X-rays, urinalyses and electrocardiography estimated annual costs between $47 and $194 million.

"Guidance to discontinue unnecessary and costly services that may be harmful to patients is essential as CMS embarks on a path toward innovative and effective preventive care for older patients."