Tuesday, January 12, 2010

Preventive Services for Medicare

Medicare policies are followed by most private insurance companies. Medicare sets the standard in what is covered and in payment rates. Currently, preventive health services are not adequately covered. Currently, some tests and treatments that are not proven to improve health ARE covered. Health Care Reform is our chance to put policies in place that will invest in preventive care that works to improve quality of life and eliminate things that do not work.

The Center for Medicare Services (CMS) authorizes 14 services that are given an "A" or "B" rating by the US Preventive Services Task Force (USPSTF). (This was the impartial task force that created the bruhaha about eliminating screening mammograms for women age 40 last month.) These screenings include: high blood pressure, mammogram, pap tests, colon cancer screen, lipid testing, osteoporosis testing and diabetes screening if at risk.

Medicare will pay for a colonoscopy or cholesterol test or mammogram. The primary care physician who coordinates the testing, encourages the tests, gives the feedback explanation and counseling for these tests receives no payment. It is a significant amount of work for the physician and her office staff , to ensure patients receive this care, but that work is not reimbursed. Only the "procedure" is reimbursed.

What else is not covered? They pay nothing for counseling for obesity and diet, despite it being one of the largest health problems facing Americans. Although there are proposals for a "Medical Home", where nurses and dietitians are involved in patient care and counseling, there seems to be no payment mechanism to cover these services.

I am not campaigning for more expense to be added to the bankrupt Medicare Bank. Some of the screening they pay for now are not value added to anyone. We have evidence that doing pap tests in monogamous women over age 70 does not improve longevity. EKGs in patients who are low risk for cardiovascular disease does not make any difference in outcome. Colon Cancer Screening in patients over age 85 is not meaningful for longevity. Prostate screening tests in elderly men increases costs and disability without any survival benefit.

Primary Care Physicians lack any incentive to use evidence to make decisions and coordinate real care for patients. We do it without payment because it is the "right" thing to do and because it is part of our job. We will not reap the benefits of Health Care Reform until we really tackle the issues of reimbursement, value, and the "guts" to say no to procedures that are of no use.

(Credit given to Dr. Lesser and Robert Woods Johnson Foundation for info used in this blog)


KM said...

My insurance does not cover flu shots, physicals, or blood tests or UA that go with them because they say it is preventative and not a covered benefit. Without doing these you don't know if your health is good or there are early problems that can be detected and resolved or controlled by treatment, before turning into more dangerous potential problems.

CountryMidwife said...

To be blunt, it all just makes me want to go bound my head against a wall.