January 19, 2011 / 6:16 PM / 8 years ago

Medicare preventive coverage conflicts with experts

NEW YORK (Reuters Health) - The U.S. government’s Medicare health insurance program for older Americans does not always fully pay for preventive services recommended by government-appointed healthcare experts, yet Medicare does cover some screening tests those experts recommend against, a new study finds.

The results, researchers say, suggest that Medicare and Congress should revisit how the program reimburses for preventive services.

The study, reported in the Annals of Family Medicine, looked at how often Medicare reimbursement matched up with medical screening recommendations from the U.S. Preventive Services Task Force (USPSTF).

The USPSTF is an independent expert panel appointed by the federal government’s Agency for Healthcare Research and Quality to review the scientific evidence for various screening tests and procedures and other types of preventive medical care.

The Task Force recommends, for instance, that adults aged 50 to 75 get some form of colon cancer screening, and that women between 50 and 74 have mammograms to screen for breast cancer every two years.

In the new study, researchers found that as of 2009, Medicare at least partly covered 93 percent of the preventive services recommended by the USPSTF.

In most cases, though, Medicare only partly paid for the “coordination” of those services — including the visit to your primary care doctor to talk about what types of screening tests you need.

Even when that was covered, the payment was usually limited to the initial “Welcome to Medicare” visit beneficiaries have traditionally been allotted when they enter the program, the authors note.

The new healthcare reform legislation should resolve that particular issue, said Dr. Lenard I. Lesser, the lead researcher on the study.

As of this year, Medicare recipients will have coverage for a yearly “wellness” visit devoted to discussing preventive services, said Lesser, a family medicine specialist at the University of California, Los Angeles.

“The important thing for patients,” he said in an interview, “is that they take advantage of those visits.”

Still, there are also screening tests the USPSTF advises against because of a lack of good evidence that their benefits outweigh their harms — harms such as false-positive test results and unnecessary treatment.

Lesser and his colleagues found that of 16 such services, Medicare paid for seven. Those included screening for abdominal aortic aneurysm in women (it’s only recommended for older men with a history of smoking), and screenings for colon cancer in people older than 85 or for prostate cancer in men older than 74.

The reasons for the discrepancies are not clear. Medicare, Lesser noted, is not obligated to match its reimbursements to the USPSTF guides. And traditionally, it has been Congress — not Medicare — that authorized payments for specific preventive services.

That is also changing with healthcare reform, however. The new law allows the Department of Health and Human Services to remove Medicare coverage for services the USPSTF recommends against. (A 2008 law had already granted the department the power to add services.)

Lesser and his colleagues did not study the estimated costs of Medicare coverage for inadvisable screening tests. But they could be substantial, Lesser noted.

Even though the services are not recommended by the USPSTF, some doctors still perform them — because they believe the tests are beneficial, for instance, or because patients demand them.

“We as a society have to decide that we can’t pay for everything, for everyone — particularly for things that could harm patients,” Lesser said.

He suggested that people go to the USPSTF website (uspreventiveservicestaskforce.org) to find out which preventive services are recommended, or not recommended, for their age group. They can then discuss the information with their doctors.

SOURCE: bit.ly/fdFczu Annals of Family Medicine, online January 17, 2011.

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