Improving Preventive Health Care for Older
AmericansMarcel Salive, MD, MPH, FACPM
Division of Geriatrics and Clinical Gerontology, NIA
Coverage
"First we'll find out if your insurance covers the magic wand treatment.”
3
Medicare Preventive Services• One time “Welcome to
Medicare” physical exam• Physical Exam (yearly
“Wellness Visit”) Starts 2011
• Abdominal aortic aneurysm screening*
• Bone mass measurement• Cardiovascular disease
screenings• Colorectal cancer
screenings• Diabetes screenings
• EKG Screening*• Flu shots • Glaucoma tests• Hepatitis B shots• HIV Screening• Mammograms (screening)• Pap test/pelvic exam/
clinical breast exam• Prostate cancer screening• Pneumococcal shots• Smoking cessation
ACASection
4103
*When referred during Welcome to Medicare physical exam
2008 LAW: MIPPA, section 101Authority for Medicare to cover
additional preventive services that are
• Reasonable and necessary for the prevention or early detection of an illness or disability based on the national coverage determination process;
• “Strongly recommended” (A) or “recommended” (B) by the United States Preventive Services Task Force; and
• Appropriate for Medicare beneficiaries.
Medicare National Coverage Timelines
5
Staff Review
Draft Decision
Memorandum Posted
National Coverage Request
Medicare Evid Dev & Coverage Advisory
Committee
External Technology Assessment
6 months
Reconsideration
Staff Review
Public Comments
Final DecisionMemorandum
andImplementation
Instructions
30 days 60 days
9 months
Preliminary Discussions
Reasonable & Necessary?• Sufficient level of confidence that
evidence is adequate to conclude that the item or service:– improves health outcomes; prevents
disease – generalizable to the Medicare
population• Evidence assessed using standard
principles of evidence-based medicine
Affordable Care Act (2010)Medicare:
– 4103: Annual Wellness Visit Providing Personalized Prevention Plan Services
– 4104: Waives deductible and coinsurance for preventive service--UPSPSF A or B
Health Plans:– 2713: new plans must cover A/B
services, ACIP vaccines without cost sharing
Coordination in the health care system
(Woman at desk with a sign that says, 'Wait Coordinator.')
Wait Coordinator
Coordination of Preventive Services
• Annual Wellness Visit (proposed) and Welcome to Medicare Visit
• Coordinates the preventive services already covered by Medicare like cancer screenings, bone mass measurements and vaccinations– May be a written plan or checklist– Short/long term (5 yrs)
Translating recommendations into coverage policy
• Population• Frequency• Duration• Settings • Payment• Other
limitationsRemaining Gaps: Certain provider
typesNon-health services
Translation: Other LimitationsBased on the wording of the USPSTF
recommendation, with a grade of A or B by the USPSTF.
Some services have multiple recommendations, including other letter grades (C, D, I)
Possible prevention NCDsCOUNSELING• Alcohol Misuse Screening
and Behavioral Counseling Interventions
• Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing
• Diet, Behavioral Counseling in Primary Care to Promote a Healthy Diet
SCREENING• Depression• Hepatitis B Virus
Infection• Sexually transmitted
infectionsObesity in Adults (incl
counseling)CHEMOPREVENTION• Breast Cancer,
Chemoprevention counseling
• Aspirin to prevent CVD
How to Set Priorities?• Amount of disease
and premature death prevented in the U.S. population (5=best)
• Cost-effectiveness (5=best).
Am J Prev Med 2006; 31(1):52-61.
Top Ranked Clinical Preventive Services for the U.S. Population 10-Discuss daily aspirin use — men 40+,
women 50+Childhood immunizationsSmoking cessation advice and help to quit —
adults8-Problem drinking screening and counseling
— adultsColorectal cancer screening — adults 50+Hypertension screening and treatment—
adults 18+Influenza immunization—adults 50+7-Vision screening — adults 65+Cervical cancer screening — womenCholesterol screening and treatment — men
35+,women 45+Pneumococcal immunizations — adults 65+
Source: Maciosek MV, Coffield AB, Edwards NM, Goodman MJ, Flottemesch TJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med 2006; 31(1):52-61.
Prioritization: Other dimensions• Legal authority
– Is it a health service?• Impact
– Is it already available?– e.g. ASA to prevent CVD
• Feasibility of decision-making– How widespread is public support?– Generalizability of evidence of benefit
