Tight funds may hinder Bush move on Medicare prevention

Lawmakers propose expansion of Medicare's colon cancer screening benefit.

By Markian Hawryluk, amednews staff. Feb. 25, 2002.

Washington -- President Bush has called for an expansion of preventive benefits for Medicare beneficiaries in his 2003 budget plan. But facing deficit spending and controversy over an existing benefit, Congress may find the usual hurdles to passing preventive measures much higher this year.

Beginning in 1998, Medicare has added coverage for only a handful of preventive services, including mammograms, prostate cancer screenings, flu vaccines and colonoscopies. But in most cases, Medicare still imposes a 20% co-payment and kicks in only after beneficiaries exceed their $100 annual deductible.

"As a result, healthy Medicare beneficiaries can face costs in the hundreds of dollars each year, just to keep up with recommended preventive treatments," the White House said in its Medicare reform plan, released last year. By contrast, private plans have moved toward limiting the out-of-pocket costs for preventive health services, often providing screenings and tests for free.

The cost barrier has led to an underutilization of Medicare's preventive services. Last year, a General Accounting Office report said the addition of a new colon cancer screening benefit in 1998 increased the percentage of beneficiaries undergoing colonoscopies by only one percentage point, to 3.8%. Meanwhile, a study published by Dartmouth University said only 28% of women 65 to 69 get mammograms.

In his 2003 budget, Bush proposed $113 billion over five years for comprehensive Medicare reform, part of which would be used to exempt preventive benefits from the co-payment and deductible provisions.

Building on Bush's commitment, Sens. Joe Lieberman (D, Conn.) and Susan Collins (R, Maine) earlier this month introduced the Colon Cancer Screening for Life Act, aimed at increasing the number of Medicare-funded colonoscopies. It was introduced in the House by Reps. Ben Cardin (D, Md.) and Philip English (R, Pa.).

A new bill would increase pay for colonoscopies and reimburse for pre-test consultations.

The bill would increase Medicare payment for colonoscopies performed in hospitals and outpatient facilities by 30% and those done in doctors' offices by 10%. It would reimburse physicians for consultations with the patient before screening colonoscopies. Currently, Medicare pays only for the appointment before a diagnostic colonoscopy.

The legislation also would exempt screening colonoscopies from a senior's Medicare deductible, as Congress has done for screening mammography.

The sponsors say the bill would save Medicare money over the long term as colon cancer cases are caught in early and highly treatable stages. But they acknowledge that rules governing congressional debate mean the measure would be considered as an expense rather than a savings.

The Congressional Budget Office must estimate the budgetary impact of any bill before Congress and usually does so over a five- or 10-year period. That's well short of the time frame needed to realize the savings of most preventive measures.

"We think this is an important bill on its merits, and it will save money over any reasonable period of time," Cardin said.

Mammography dispute

Expanding preventive benefits also may be tougher this year because of a controversy over the long-term efficacy of mammograms in reducing the number of breast cancer deaths. The row was sparked not by a new study, but by two Danish researchers who reanalyzed data from seven large mammography studies conducted as far back as 30 years ago. They found that those studies didn't meet the standard for scientific research today. But clinical oncologists stress that doesn't mean mammograms aren't effective.

"Scientific debate on critical issues like this is common, but well-established guidelines must be followed unless there is compelling reason to alter them," said Larry Norton, MD, president of the American Society of Clinical Oncology.

In a letter to The New York Times, ASCO and 18 other health organizations, including the American Medical Association, urged women to follow the advice of their physicians and to continue to obtain mammograms under the original guidelines.

But the debate has some physicians concerned that Congress, facing a budget shortfall and rising Medicare costs, will be less willing to tack on new preventive benefits.

"I worry about the whole process of political decision-making because it's based on polls," said David L. Katz, MD, a professor at the Yale School of Medicine and chair of the annual meeting of the American College of Preventive Medicine.

Physicians also are concerned that private insurers may seek to cut back on mammography coverage even if Medicare does not. Senate hearings have been scheduled on the issue.

Dr. Katz said part of the problem is that the burden of proof for preventive health benefits is higher than for most therapeutic procedures.

"There are many things in all of medicine that we do because they make sense to us, that have never been proved and we reimburse for routinely," he said. "I don't think we should necessarily hold preventive medicine to a different standard."

Dr. Katz said that while everybody recognizes the value of paying for a surgical procedure that will save someone's life, a preventive benefit must be proven to be effective and a cost-saver.

"In general, prevention does save dollars," he said. "But there are times when it would save suffering at the cost of dollars, and I think that would be money well spent."

Some likely suspects

If lawmakers do decide to add new preventive benefits, they will likely rely on the U.S. Preventive Services Task Force, a panel of experts charged with taking an objective look at preventive health care services and recommending cost-effective measures to improve the health system.

Last year, Sens. Bob Graham (D, Fla.) and Jim Jeffords (I, Vt.) introduced the Medicare Wellness Act, which would add nine new preventive measures recommended by the task force. These include screening for hypertension, counseling for tobacco cessation, counseling for hormone replacement therapy, screening for vision and hearing loss, cholesterol screening, expanded screening for osteoporosis and nutrition therapy counseling for seniors with cardiovascular disease. The bill was never considered in committee, much less on the Senate floor.

A companion bill introduced by Rep. Sander Levin (D, Mich.) on the House side was also unable to move toward a vote.