2.  Improving Preventive Benefits and Eliminating Cost Sharing

Overview. Older Americans are the fastest growing age group in the United States, with an increasing number of older Americans surviving to age 85 and older. They carry the greatest risk of dying from cancer and heart disease as well as the highest rates of chronic disease and disability. For example, 88 percent of those over the age of 65 have at least one chronic health condition, and large numbers of older adults suffer from impaired functioning and well-being. Early detection, risk factor reduction, and health screening programs and appropriate follow-up care can result in a significant reduction in morbidity.

a.  Eliminating all preventive services cost sharing

Policy: This proposal would waive the Part B deductible and 20 percent coinsurance rate for preventive services for which cost sharing is not already waived under current law. The deductible would be waived for hepatitis B vaccinations, colorectal cancer screening, bone mass measurements, prostate cancer screening and diabetes self-management benefits. Coinsurance would be waived for screening mammography, pelvic exams, hepatitis B vaccinations, colorectal screening, bone mass measurements, prostate cancer screening and diabetes self-management benefits. For the rest of the preventive services covered by Medicare, cost sharing is already waived.

Background/rationale: The Balanced Budget Act of 1997 added many new preventive benefits (e.g., colorectal cancer screening and diabetes self-management training). According to recent studies, Medicare preventive services are underutilized. For example, the 1999 Dartmouth Atlas of Health Care found that, in 1995-1996, only one in four women in their sixties were tested as often as recommended for breast cancer. In the first two years that Medicare covered screening mammography, only 14 percent of eligible women without supplemental insurance received a mammogram. Waiving cost sharing for preventive benefits should increase utilization of these services.

b.  Information campaign on prevention

Policy: The Department of Health and Human Services (HHS) would launch a two year, nationwide education campaign beginning in 2001 to promote the use of preventive health services by older Americans and people with disabilities. The campaign would have three parts:

• Educating all Americans over age 50 and people with disabilities about the importance of preventive health care. The Department of Health and Human Services, the Social Security Administration, and private sector partners would combine public service announcements and a print media campaign to raise awareness of the value of prevention. HHS would distribute brochures and other information on health promotion and disease prevention activities through the State Health Insurance Assistance Programs and the Area Agencies on Aging. HHS would also place brochures in the Social Security Administration's (SSA) 1,300 field offices. SSA would include information on the importance of preventive health care on the Cost Of Living Adjustment (COLA) notice, which is sent to the approximately 6 million people with disabilities who receive SSA or SSI benefits. Information on the importance of preventive health care will also be included on the Personal Earnings and Benefit Estimate Statement and in currently produced brochures on retirement and survivors' benefits. Finally, SSA would expand the section in its Medicare brochure to include a fuller discussion of the importance of health promotion activities and the benefits offered under Medicare.
• Encouraging Medicare beneficiaries to use its preventive benefits. This campaign would provide Medicare beneficiaries information about the importance of regularly receiving preventive health care benefits, such as vaccinations and mammograms, and would encourage individuals to access these benefits under Medicare. This would be done in several ways:

• Distribute comprehensive information on preventive benefits to all 39 million Medicare beneficiaries. HHS would (1) expand the section on preventive benefits in the Medicare and You handbook to include information on the importance of receiving mammograms, diabetes monitoring, colorectal cancer screening, bone mass measurements, and regular vaccinations; (2) instruct fiscal intermediaries and carriers to include preventive benefits messages on the Medicare Summary Notice statement and the Explanation of Medicare Benefits; (3) include prevention messages regularly on the Medicare Part B benefits statement; and (4) work with the other agencies and the private sector, including senior centers, the Cooperative State Research Education and Extension Service, the Meals on Wheels programs, and religious organizations, to deliver information to Medicare beneficiaries about the importance of preventive benefits and which ones are covered under the Medicare program.
• Development of health status assessment tool for Medicare beneficiaries. HCFA, together with the Centers for Disease Control (CDC) and Agency for Health Care Policy and Research (AHCPR), would develop a health status assessment tool for beneficiaries. This self-assessment tool would help the beneficiary identify important health information, risk factors, or significant symptoms that should be acted upon or discussed with their health care provider. HHS would train the State Health Insurance Assistance Program staff to assist Medicare beneficiaries with the completion of the self assessment form so that they can raise the health issues identified to their health care provider.

• Launching an education and awareness campaign to prevent falls in the elderly. HHS would launch a nationwide campaign to educate older Americans about the best way to modify their home environment in order to avoid potentially harmful and debilitating falls. The campaign would utilize radio advertisements and print media, and would emphasize the following messages: use anchor rugs; minimize clutter on floors; use nonskid mats; install handrails in bathrooms, halls, and along stairways; light hallways, stairwells, and entrances; and wear sturdy shoes.

Background/rationale: Loss of function can begin for people in their 50s, arguing for preventive approaches starting in middle age as a means of promoting health and limiting disability in the later years of life.

Increasing the venues through which Medicare beneficiaries and older Americans will be educated about the importance of preventive benefits and how to access them under the Medicare program will increase the likelihood that beneficiaries will use these services. A recent study indicates that Medicare beneficiaries do not understand that Medicare covers preventive benefits. Almost 70 percent of beneficiaries who stated that they knew about the range of Medicare services were unable to answer questions about Medicare's coverage of preventive benefits correctly. However, studies indicate that repeated short, simple, print media messages enhance the target population's recall and retention of health promotion messages. These messages have also been shown to have a greater impact on individuals at higher risk.

In addition to educating beneficiaries about the importance and availability of preventive services, this proposal would address one of the major public health problems facing the elderly: the high incidence of falls. In 1995, more than 7,700 people over the age of 65 died as a result of a fall. For people aged 65 to 84, falls are the second leading cause of injury-related death; for those aged 85 or older, falls are the leading cause of injury-related death. Falls are the most common cause of injuries and hospital admissions for trauma among the elderly, accounting for 87 percent of all fractures among people aged 65 years or older and are the second leading cause of spinal cord and brain injury. For people aged 65 years or older, 60 percent of fatal falls occur in the home. This education campaign aims to reduce the risk of falls, thereby improving the quality of life and reducing Medicare costs.

c.  U.S. Preventive Services Task Force study on new preventive services for older Americans

Policy: The Secretary would direct the U.S. Preventive Services Task Force to conduct a series of new studies to identify preventive interventions that can be delivered in the primary care setting that are most valuable to older Americans. In addition, it would include evaluation of services of particular relevance to older Americans in the mission statement of the Task Force.

Background/rationale: Despite the potential for preventive services to improve the quality of life for older Americans, few clinical guidelines focus on preventive care for older Americans.

The U.S. Preventive Services Task Force, an independent panel of preventive health experts, together with the Agency for Health Care Policy and Research, is charged with evaluating the scientific evidence for the effectiveness of a range of clinical preventive services, including common screening tests, immunizations, and counseling for health behavior change and producing age-specific and risk-factor-specific recommendations for these services. The task force focuses primarily on preventive interventions that can be delivered in the primary care setting, are widely available, and for which scientific evidence exists to assess efficacy and effectiveness.

d.  Demonstration of smoking cessation drugs and counseling