medicare preventive services
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Medicare Preventive Services
Marcel Salive, MD, MPH, FACPM
Coverage and Analysis Group, OCSQDirector, Division of Medical and
Surgical Services
Overview of talk
• Medicare preventive services– MMA and earlier– MIPPA
• National Coverage Determination process
• HIV Screening national coverage analysis
Medicare Preventive Services• “Welcome to Medicare”
initial preventive physical exam
• Abdominal aortic aneurysm screening
• Bone mass measurement• Cardiovascular disease
screening blood tests• Colorectal cancer
screening• Diabetes screening,
services, and supplies
• Glaucoma screening• Medical nutrition therapy• Pap test and pelvic exam
with clinical breast exam• Prostate cancer
screening• Screening mammogram• Smoking cessation
counseling• Vaccinations
New Preventive Services (2005)
MMA sections 611-613• Initial Preventive Physical
Examination– Commonly “Welcome to Medicare” visit
• Cardiovascular Screening Blood Tests
• Diabetes Screening Benefits
“Welcome to Medicare” Physical Exam for New Enrollees
• One-time preventive physical exam within 12 months of a beneficiary's initial Part B enrollment
• Includes screening, education & counseling, and referral
• Coordinates the preventive services already covered by Medicare like cancer screenings, bone mass measurements and vaccinations
Preventive Examination Overview• Medical History• Social History• Depression Screening• Review of Functional Ability• Review of Home Safety• Physical Examination• Written plan or checklist provided to
patient for obtaining age appropriate screening tests
Components for Functional Ability/Level of Safety
• Screening for Hearing Impairment– The US Preventive Services Task Force Recommends
questioning older adults about their hearing and making referrals for further evaluation when appropriate.
• Activities of Daily Living• Discussion about Falls Risk
– The US Preventive Services Task Force Recommends counseling elderly patients on specific measures to prevent falls
• Discussion about Home Safety– The US Preventive Services Task Force Recommends
counseling adults about preventing household and recreational injuries
Physical Examination
• Height, Weight, Blood Pressure, EKG– Required by statute– New for 2009: EKG optional; BMI added
• Visual Acuity Screening– The US Preventive Services Task Force recommends
screening elderly persons for diminished visual acuity using the Snellen Eye Chart
– CMS does not specify instrument/test
• Other physical examination measures as appropriate
Examination Conclusion• End of life planning (added 2009)
• Patients should receive appropriate follow-up based on any needs identified during the preventive examination
• Patients should also receive a written plan or checklist– Outlining Medicare covered screening
and preventive services for which they are eligible
MIPPA, section 101 (2008)Gives the Secretary authority to extend
Medicare coverage to 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.
Coverage
Social Security Act 1862(a)(1)(A-B)
“…no payment may be made…for items or services - which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,… which are not reasonable and necessary for the prevention of illness,”
Reasonable & Necessary
How Do We Apply R&N Today?• Sufficient level of confidence that
evidence is adequate to conclude that the item or service:– improves health outcomes – generalizable to the Medicare
population
• Evidence assessed using standard principles of evidence-based medicine (EBM)
Internal Technology Assessment
Draft Decision
Memorandum Posted
National Coverage Request
Medicare 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
Benefit Category
Department Appeals Board
CMS National Coverage Decision (NCD) Process
What prompts NCDs?
• Internal or external requeste.g., technological advance, new study, inappropriate use
•May reconsider non-coverage•May address variation in local
coverage policies
What decisions are made?
• National Coverage • National Noncoverage• National Coverage with restrictions
– Specific populations– Specific providers/facilities– Evidence development
NCD Guidance Documents
Factors CMS considers in:•Opening an NCD review•Referring an NCD to:
-- Advisory committee (MEDCAC)-- External technology assessment
HIV screening
• Analysis opened: March 13, 2009• Proposed Decision released: Sept 9
– Annual voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per USPSTF guidelines
– Voluntary HIV screening of pregnant Medicare beneficiaries
USPSTF Recommendations: HIV screening
• All adolescents and adults at increased risk for HIV infection. Rating: ‘A’
• routine screening adolescents and Adults who are not at increased risk for HIV infection. Rating: ‘C’
• All pregnant women for HIV. Rating: ‘A’
Screening test analytic framework
• Simplicity• Acceptability• Accuracy• Cost• Precision• Sensitivity/Specificity
Consideration of cost: HIV Screening• Sanders, et al. (2008) published cost-
effectiveness analysis reported that screening costs $50,000-$100,000 per QALY gained where HIV prevalence is between 0.1% and 0.5%.
• One published study places HIV prevalence in this range for persons age 65-74 years. (Owens et al. 2007)
• Not a major consideration in the decision for HIV screening, but helped develop capacity for this type of analysis.
Limitation
CMS believes that statute and regulations only permit expanded coverage of additional preventive services that identify medical conditions or risk factors for individuals, such as voluntary HIV screening, which have been recommended with a grade of A or B by the USPSTF.
Possible prevention NCDs• Tobacco cessation
counseling• Alcohol Misuse Screening
and Behavioral Counseling Interventions
• Breast Cancer, Chemoprevention counseling
• Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing
• Chlamydial Infection, Screening
• Depression, Screening • Diet, Behavioral
Counseling in Primary Care to Promote a Healthy Diet
• Gonorrhea, Screening • Hepatitis B Virus
Infection, Screening • Obesity in Adults,
Screening & counseling• Syphilis Infection,
Screening • Aspirin to prevent CVD
Further Information
• http://www.cms.hhs.gov:
• Marcel Salive, MD, MPH– 410/786-0297– Marcel.Salive@cms.hhs.gov
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