Preventive care is an important part of the relationship between America's primary care physicians and their patients, including those who are eligible for Medicare.
Hence the interest of researchers at the Palo Alto Medical Foundation Research Institute in Palo Alto, Calif., in assessing the effect of expanded coverage for preventive services that the Patient Protection and Affordable Care Act (ACA) made available in 2011 to patients 65 and older.
The Agency for Healthcare Research and Quality funded the study, which was published in the January issue of Health Affairs in an article titled "Medicare Annual Preventive Care Visits: Use Increased Among Fee-For-Service Patients, But Many Do Not Participate."(content.healthaffairs.org)
Co-author Lenard Lesser, M.D., M.S.H.S., assistant research physician at the Palo Alto Medical Foundation and a clinical instructor in the Department of Family and Community Medicine at the University of California, San Francisco, understands all too well the advantages -- and challenges -- of adding prevention to the list of topics to address with patients.
"As a family physician, I know the difficulties of trying to fit preventive care into visits for acute and chronic care," Lesser said in an interview with AAFP News. "We (the researchers) wanted to figure out if the new preventive benefits of the Affordable Care Act were helping patients by allowing more time for physicians to address preventive health," he added.
The answer to that question is "Yes," but more about that and other study results later.
- New research suggests that the 2011 expansion of preventive care services to Medicare-eligible patients has led more patients to use preventive services.
- Use of preventive services nearly doubled among Medicare fee-for-service patients and was the largest increase among the four patient groups studied.
- Physicians benefit from the increase in scheduled preventive services because they have more time to discuss preventive health with patients when visits are dedicated exclusively to those issues.
Lesser also stressed the importance of preventive care in maintaining the health and well-being of older patients.
"Preventive medicine in those 65 and older can have clear benefits that can often be seen quickly. For instance, finding an early abnormality with colon cancer screening can save patients from more invasive treatments in the future," he said. "Physicians can also use preventive visits to discuss the most important aspects of health -- not smoking, being active and avoiding junk food," Lesser added.
Medicare Expansion of Benefits
Medicare did not provide beneficiaries with specific coverage for preventive visits until 2005, when the "Welcome to Medicare" exam was introduced as a one-time initial exam with a focus on prevention. The benefit is available to all patients within one year of beginning Medicare coverage.
According to the study authors, only about 3 percent of eligible patients took advantage of the benefit and physicians voiced concern about the documentation burden.
Then in 2011, the ACA gave patients another preventive care option: the Medicare annual wellness visit a yearly exam that requires no patient copay.
Also in 2011, the copayment for the Welcome to Medicare visit was eliminated.
For purposes of the study, researchers pulled data on active primary care patients seen at the Palo Alto Medical Foundation from 2007 to 2013. They compared trends in preventive visits and recommended preventive services among four groups: patients with Medicare fee-for-service coverage, patients in Medicare health maintenance organizations (HMOs), and non-Medicare patients ages 65-75 who either were covered by private fee-for-service plans or private HMO plans.
Researchers saw a "notable" increase in use of both Welcome to Medicare exams and annual wellness visits after implementation of ACA, with the biggest increase coming among Medicare fee-for-service patients. Among this group, the annual use of Medicare-covered preventive visits increased from 1.4 percent before the implementation of the ACA to 27.5 percent after implementation.
At the same time, the use of preventive visits not covered by Medicare decreased by two-thirds, from 16 percent to 5.5 percent.
When covered and non-covered preventive services were combined, preventive visits between 2011 and 2013 for the Medicare fee-for-service group nearly doubled from 17.3 percent to 32.8 percent.
Even so, the rates of annual preventive care visit use among this group of patients was 10 to 20 percentage points lower that of patients with Medicare HMO coverage (52.7 percent), private HMO coverage (43.5 percent) and private fee-for-service coverage (42.6 percent).
During the same period, researchers also observed significant declines in the frequency of visits that were not related to preventive care. They suggested that changes in practice patterns at the Palo Alto Medical Foundation -- changes that focused on effective care management outside of face time with patients -- may have influenced that decline.
Corresponding Author Weighs In
In an interview with AAFP News, corresponding author Sukyung Chung, Ph.D., an assistant investigator at the Palo Alto Medical Foundation's Research Institute, noted that before 2011, traditional Medicare fee-for-service beneficiaries had to pay for an annual preventive visit out of pocket or with supplemental private insurance.
On the other hand, Medicare HMO coverage for preventive care generally has been comprehensive with small, if any, copays, said Chung. Similarly, most private insurance covers annual preventive visits. Chung cited "lack of coverage" as the primary reason that rates of preventive visits had been low for Medicare fee-for-service beneficiaries.
Chung said study results suggested that a good percentage of patients would not have scheduled a preventive visit had it not been for the Medicare coverage expansion. "Uptake of annual wellness visits was slow in the first months of new coverage, but ramped up very quickly. By 2013, 32 percent of patients with Medicare fee-for-services received a preventive visit.
"Accordingly, uptake of recommended preventive services, particularly those that require substantial physician time and discussion with patients -- such as planning of an advance directive -- increased substantially," said Chung.
Did the study results reveal any surprises? Chung acknowledged that the low rate of annual preventive visits among seniors -- as well as the wide margin of differences in preventive service uptake based solely on patients' insurance coverage -- took her by surprise.
However, she described the magnitude of increase in the uptake of preventive visits and recommended preventive services after coverage expanded as nothing short of drastic.
"It is impressive to observe that relatively straightforward changes in coverage like this can have important and rapid effects on the use of preventive services," said Chung. "We anticipate that the rate among Medicare fee-for-service may continue to rise to the level among seniors with private insurance (44 percent) or with Medicare Advantage (52 percent)."
Chung said the research could have special value to family physicians because they regularly battle the time constraints of routine office visits.
"Prior to the Medicare’s preventive visit coverage, a family physician might try to address preventive and acute or chronic problems during a single non-preventive visit. But as coverage for annual wellness visits expanded, preventive issues could be fully addressed in the preventive annual visit and more chronic issues could be better handled during other problem-focused visits," said Chung.
Looking to the future, Chung pointed out one Healthy People 2020 goal -- a 10 percent increase in the proportion of older adults who receive a core set of preventive services.
"To achieve this goal, providers and patients will have to take full advantage of the Medicare coverage for preventive visits. Our hope is that through education, both providers and patients become more aware of available preventive services," said Chung.
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