Improving Preventive Health Care for Older Americans (Text Version)
On September 29, 2010, Marcel Salive made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (510 KB).
Improving Preventive Health Care for Older Americans
Marcel Salive, MD, MPH, FACPM
Division of Geriatrics and Clinical Gerontology, NIA
Image: Cartoon of a doctor with patient. The doctor is holding a sparkly magic wand and saying, "First we'll find out if your insurance covers the magic wand treatment."
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
*When referred during Welcome to Medicare physical exam.
2008 LAW: MIPPA, section 101
Authority 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.
- Appropriate for Medicare beneficiaries.
Medicare National Coverage Timelines
Image: A flowchart of Medicare National Coverage Timelines shows the following steps:
- Preliminary Discussions
- National Coverage Request
- Staff Review:
- External Technology Assessment
- Medicare Evid Dev & Coverage Advisory Committee
- Staff Review
- Draft Decision Memorandum Posted
The timeline allots six months from "National Coverage Request" to "Draft Decision Memorandum Posted." 30 days is alloted between "Draft Decision Memorandum Posted" and the next step, "Public Comments." 60 days is alloted between "Public Comments" and the next step, "Final Decision Memorandum and Implementation Instructions."
After "Final Decision Memorandum and Implementation Instructions," the final step is "Reconsideration"; an arrow points from "Reconsideration" back to "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)
- 4103: Annual Wellness Visit Providing Personalized Prevention Plan Services
- 4104: Waives deductible and coinsurance for preventive service—UPSPSF A or B
- 2713: new plans must cover A/B services, ACIP vaccines without cost sharing
Coordination in the health care system
Image: A woman is seated at a desk with a sign that says, "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
- Other limitations
Remaining Gaps: Certain provider types, Non-health services.
Image: A photograph of a doctor with stethoscope is shown.
Translation: Other Limitations
- Based 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 NCDs
- 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
- Hepatitis B Virus Infection
- Sexually transmitted infections
- Obesity in Adults (incl counseling)
- 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).
Image: A street sign that reads "Changed Priorities Ahead" is shown.
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 immunizations
- Smoking cessation advice and help to quit—adults
- 8-Problem drinking screening and counseling—adults
- Colorectal cancer screening—adults 50+
- Hypertension screening and treatment-adults 18+
- Influenza immunization-adults 50+
- 7-Vision screening—adults 65+
- Cervical cancer screening—women
- Cholesterol 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?
- Is it already available?
- e.g., ASA to prevent CVD
- Feasibility of decision-making:
- How widespread is public support?
- Generalizability of evidence of benefit
- Marcel Salive, MD, MPH