Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage

Lenard I. Lesser; Alex H. Krist; Douglas B. Kamerow; Andrew W. Bazemore

doi:10.1370/afm.1194

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Figure 1.
Proportion of services recommended by the US Preventive Services Task Force (USPSTF) and covered by Medicare.

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Table 1.

United States Preventive Services Task Force (USPSTF) Recommended Services and Medicare Coverage for Prevention in Adults 65 Years of Age and Older

Service	Rating	Details	Preventive Coordination: Risk Assessment, Patient Motivation, and Arranging the Service	Preventive Service: Test, Screening Instrument, or Counseling
Partially reproduced and reprinted with permission from: Lesser LI, Bazemore AW. Improving the delivery of preventive services to Medicare beneficiaries. JAMA. 2009;302(24):2699–2700.
BMD = bone mineral density; Pap = Papanicolaou; WMV = Welcome to Medicare Visit.
^aFor services where the USPSTF including screening and counseling in the same recommendation, the screening portion was considered as “risk assessment and arrangement.”
^bColonoscopy would be fully covered, as, if normal, would only need one-time screen. Sigmoidoscopy and fecal occult blood testing would not be, as repeated screenings would be needed.
Abdominal aortic aneurysm (screening)	B	One-time ultrasound for men ≥65 y who have ever smoked	Fully	Fully
Alcohol (screening and counseling)^a	B	Screen and counsel all adults	Partial: WMV only	Fully
Breast cancer, genetic risk assessment (screening)	B	Referral for genetic counseling with option for testing for women with a family history suggestive of breast cancer mutation	Fully	None
Breast cancer, mammography	B	Screen all women, ages 50–74 y, every 2 y	Partial: WMV only	Fully
Cervical cancer, at increased risk	A	Screen all women who have been sexually active and have a cervix. Recommends against screening women >65 y if they have had adequate recent screening with normal Pap smears and are at otherwise not at high risk	Partial: WMV only	Fully
Colon cancer ages 50–75 y	A	Screen with fecal occult blood testing, sigmoidoscopy, or colonoscopy, from the ages of 50 to 75 y	Partial: WMV only^b	Fully
Depression (screening)	B	Screen adults for depression, when care supports are available	Partial: WMV only	Partial: WMV only
Diabetes, if at risk	B	Screen adults with sustained blood pressure (either treated or untreated) >135/80 mm Hg	Partial: WMV only	Fully
Healthy diet, if at risk (counseling)	B	Intensive counseling (usually multiple sessions lasting 30 min or more) for adults with risks for cardiovascular or diet-related chronic disease	Partial: WMV only	Partial: inconsistent indication
High blood pressure	A	Check the blood pressure of all adults	Partial: WMV only  Partial: inconsistent indication	Partial: WMV only
Lipid disorders, men >35 y	A	Screen all, with an uncertain, but likely interval of every 5 y. Repeated screening less likely of benefit in those >65 y	Partial: WMV only	Fully
Lipid disorders, women >45 y at increased risk	A	Screen all, with an uncertain, but likely interval of every 5 y. Repeated screening less likely of benefit in those >65 y	Partial: WMV only	Fully
Obesity (screening with intensive counseling)^a	B	Screen all adults and offer high-intensity counseling for obese adults	Partial: WMV only	Partial: inconsistent indication
Osteoporosis, women at risk	B	Screen all women >65 y. Interval uncertain, but yield of repeated screening will be higher in older women, those with lower BMD at baseline, and those with other risk factors for fracture	Partial: WMV only	Fully
Tobacco use	A	Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products	Partial: WMV only	Fully

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Table 2.

Preventive Services Covered by Medicare Which the US Preventive Services Task Force (USPSTF) Recommends Against

Preventive Screening with D Recommendation	Medicare Coverage
ECG=electrocardiogram; WMV=Welcome to Medicare Visit.
^aMedicare covers a screening ECG as part of WMV, although it is optional.
^bSpecifically required as part of screening pelvic examination.
Abdominal aortic aneurysm, women	Yes
Asymptomatic bacteriuria	No
Bladder cancer	No
Breast cancer genetic testing, not high risk because of family history	No
Carotid stenosis	No
Cervical cancer, women >65 y and not at high risk, with adequate screening	Yes
Cervical cancer, women with hysterectomy for benign disease	Yes
Colon cancer aged >85 y	Yes
Chronic obstructive pulmonary disease	No
Coronary heart disease, in low-risk patients	Yes^a
Hemochromatosis	No
Ovarian cancer	Yes^b
Pancreatic cancer	No
Peripheral arterial disease	No
Prostate cancer, aged 75 y and older	Yes
Testicular cancer	No

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The Article in Brief

Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage

Lenard I. Lesser , and colleagues

Background A 2008 law allows Medicare to pay for medical services rated A or B by the US Preventives Services Task Force (USPSTF), a government-authorized and -sponsored independent panel of experts in primary care and prevention. This study compares preventive medical services offered by Medicare with those recommended by the USPSTF.

What This Study Found Of the 15 USPSTF recommended interventions for adults aged 65 years and older, Medicare reimburses fully for only 1 service. For most preventive services (60 percent), Medicare reimburses fully for the service or test, but only partially for the coordination of obtaining that service. For 4 services (27 percent), Medicare reimburses clinicians partially for both the preventive coordination and the actual service. For 1 service, Medicare reimburses fully for the coordination and assessment but not for the test/service itself. Further, instead of providing payment to clinicians for recommended preventive services, Medicare pays clinicians to provide 7 services that are not recommended, potentially increasing harm to patients as well as medical costs.

Implications

Medicare coverage for preventive services needs to be reassessed, with special focus on preventive coordination.
Current Medicare coverage will likely promote both inadequate and excessive delivery of preventive services. The new health care reform law, however, has the potential to improve the provision of preventive services to Medicare beneficiaries.
The authors call for Medicare to align itself with the USPSTF recommendations and usher in an era of improved quality of care through effective prevention.