Medicare Preventive Services

1
Medicare Preventive Services

• Marcel Salive, MD, MPH, FACPM
• Coverage and Analysis Group, OCSQ
• Director, Division of Medical and Surgical
  Services

2
Overview of talk

• Medicare preventive services
• MMA and earlier
• MIPPA
• National Coverage Determination process
• HIV Screening national coverage analysis

3
Medicare Preventive Services

• Welcome to Medicareinitial 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

4
New Preventive Services (2005)

•  MMA sections 611-613
• Initial Preventive Physical Examination
• Commonly Welcome to Medicare visit
• Cardiovascular Screening Blood Tests
• Diabetes Screening Benefits

5
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

6
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

7
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

8
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

9
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

10
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.

11
Coverage
12
Social Security Act 1862(a)(1)(A-B)
Reasonable Necessary
no payment may be madefor 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,
13
How Do We Apply RN 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)

14
CMS National Coverage Decision (NCD) Process
Preliminary Discussions
Reconsideration
Benefit Category
6 months
30 days
60 days
Final Decision Memorandum and Implementation
Instructions
Draft Decision Memorandum Posted
Internal Technology Assessment
National Coverage Request
Public Comments
External Technology Assessment
Staff Review
Department Appeals Board
Medicare Coverage Advisory Committee
9 months
15
What prompts NCDs?

• Internal or external request
• e.g., technological advance, new study,
  inappropriate use
• May reconsider non-coverage
• May address variation in local coverage policies

16
What decisions are made?

• National Coverage
• National Noncoverage
• National Coverage with restrictions
• Specific populations
• Specific providers/facilities
• Evidence development

17
NCD Guidance Documents

• Factors CMS considers in
• Opening an NCD review
• Referring an NCD to
• -- Advisory committee (MEDCAC)
• -- External technology assessment

18
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

19
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

20
Screening test analytic framework

• Simplicity
• Acceptability
• Accuracy
• Cost
• Precision
• Sensitivity/Specificity

21
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.

22
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.

23
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

24
Further Information

• http//www.cms.hhs.gov
• Marcel Salive, MD, MPH
• 410/786-0297
• Marcel.Salive_at_cms.hhs.gov