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Improving Preventive Health Care for Older
Americans
Marcel Salive, MD, MPH, FACPM
Division of Geriatrics and Clinical Gerontology, NIA
3
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
ACASection
4103
*When referred during Welcome to Medicare physical exam
2008 LAW: MIPPA, section 101Authority 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; and
• Appropriate for Medicare beneficiaries.
Medicare National Coverage Timelines
5
Staff Review
Draft Decision
Memorandum Posted
National Coverage Request
Medicare Evid Dev & 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
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)
Medicare: – 4103: Annual Wellness Visit Providing
Personalized Prevention Plan Services– 4104: Waives deductible and
coinsurance for preventive service--UPSPSF A or B
Health Plans:– 2713: new plans must cover A/B
services, ACIP vaccines without cost sharing
Coordination in the health care system
(Woman at desk with a sign that says, 'Wait Coordinator.')
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
• Population• Frequency• Duration• Settings • Payment• Other
limitationsRemaining Gaps: Certain provider
typesNon-health services
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 NCDsCOUNSELING• 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
SCREENING• Depression• Hepatitis B Virus
Infection• Sexually transmitted
infectionsObesity in Adults (incl
counseling)CHEMOPREVENTION• 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).
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 immunizationsSmoking cessation advice and help to quit —
adults8-Problem drinking screening and counseling
— adultsColorectal cancer screening — adults 50+Hypertension screening and treatment—
adults 18+Influenza immunization—adults 50+7-Vision screening — adults 65+Cervical cancer screening — womenCholesterol 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?• Impact
– Is it already available?– e.g. ASA to prevent CVD
• Feasibility of decision-making– How widespread is public support?– Generalizability of evidence of benefit
Further Information
• Marcel Salive, MD, MPH– 301/435-3044– Marcel.Salive@nih.gov
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