AMA urges more Medicare coverage for preventive care

Delegates call for coverage of screenings for lipids disorders and diabetes.

By Markian Hawryluk, amednews staff. Dec. 24/31, 2001.

San Francisco -- With physicians already facing potential reductions in Medicare payments and increases in costs, the American Medical Association will pursue program coverage for Coumadin management and new preventive benefits.

At the recent Interim Meeting of the AMA House of Delegates, physicians voted to seek payment from Medicare and other insurers for the telephone contacts routinely used to evaluate and manage patients taking therapeutic anticoagulants, such as Coumadin (warfarin sodium, made by DuPont Pharma).

Because the dose needed for blood thinning is different for each patient, physicians must carefully monitor patients on Coumadin, especially in the early days of their therapy.

Before the vote, AMA policy already was to support and advocate for payment for case management services and telephone consultations. Many delegates said they thought reimbursement for Coumadin management could be an important first step in carrying out that policy, particularly in light of the growing prevalence of telephone and electronic communication with patients.

"In the future, we're going to have more telephone and e-mail communication and less face-to-face time with [patients]," said Steven Polsley, MD, an Urbana, Ohio, family physician. "More and more, we're going to need to be able to bill for these services."

Delegates also voted to begin a dialogue with the Centers for Medicare & Medicaid Services on screening for lipids disorders and diabetes, two common risk factors for cardiovascular disease. Although cardiovascular disease is the leading cause of death in the United States, Medicare does not pay for routine screenings except for certain congressionally mandated preventive health measures.

AMA says Medicare should pay physicians for telephone management of patients taking Coumadin.

"With patients on Medicare, we have no ability to screen for lipids disorders or diabetes unless the patient agrees to pay beforehand the cost of the test," said John Mangum, a Sanford, N.C., family physician. "In reality, if patients have to pay out of pocket for that screening, most of the time it's not going to occur."

Getting Medicare to pay for preventive benefits historically has been a difficult and expensive proposition. In 1997, President Clinton signed into law screening coverage for breast, cervical, vaginal, colorectal and prostate cancers at a cost of $8.5 billion over 10 years.

Jeff Terry, MD, a urologist from Mobile, Ala., said he thought Medicare must consider preventive medicine as a whole, rather than on a case-by-case basis. But, he warned, it's difficult to get any new tests funded.

"I remember the debates we had to try to get [prostate specific antigen tests] reimbursed as a screening," Dr. Terry said. "It was a heck of an issue and finally got approved only by a separate law by Congress. It's hard to get coverage for specific items."

But some doctors also said pursuing payment for the screenings may backfire, adding yet another unfunded mandate to the Medicare program.

"With respect to lipid and diabetes screening, you have to weigh the mandated benefits with what that does to the cost of care," Dr. Polsley said. "If that, in fact, is what our wishes are, we need to realize that will in some way reduce our reimbursement in other aspects of Medicare."