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EDITORIAL |
Ms. DeWilde is Senior Policy Analyst, National Government Relations Department, American Cancer Society, Washington, DC.
Dr. Russell is Associate Professor of Medicine, Co-Director, Breast Cancer Center, University of Southern California, Los Angeles, CA.
Beginning January 1, 2005, Medicare will cover an initial preventive physical examination for all Medicare beneficiaries within 6 months of enrolling in Medicare. The "Welcome to Medicare" physical includes measurement of height, weight, and blood pressure, and an electrocardiogram "with the goal of health promotion and disease detection."1 The visit will also include education, counseling, and referrals for the other preventive services already covered under Medicare including breast, cervical, colorectal, and prostate cancer screening tests. Medicare beneficiaries will also be eligible for cardiovascular blood screening tests, bone mass measurements, and counseling on nutrition. Beneficiaries at risk for diabetes will be eligible for diabetes screening tests, glaucoma screenings, and diabetes outpatient management training.
The "Welcome to Medicare" prevention visit is a historic and very important step in the prevention and early detection of cancer. When the Medicare Program was first created in 1965, it was designed to fit the traditional insurance model of the time—it was designed to treat acute or chronic illnesses. (Medicare was also first created to provide health coverage for Americans 65 years of age and older, but coverage was later extended to some individuals with disabilities and permanent kidney failure.) At Medicare’s inception, little was known about the benefits of early detection and prevention methods—and we had few effective tools with which to detect cancer early and prevent it. Insurance models discouraged coverage for "broad and ill-defined" services, such as routine physicals and health education or counseling.2,3 Nevertheless, research has shown nearly 40 years later that many diseases, including cancer, can be prevented and successfully treated if detected early.
Fundamentally, Medicare has been a program for the sick. Services that are not medically "reasonable and necessary" and not provided to specifically treat illness are not covered by Medicare, unless otherwise specifically added by Congress through the legislative process (Section 1862(a)(1)(A) of the Social Security Act; 42 USC 1395y(a)(1)(A)). Thus, in large part because of the efforts of the American Cancer Society, Congress passed legislation in the 1990s that allowed Medicare to begin covering breast, colorectal, prostate, and cervical cancer screening tests.
Currently, Medicare beneficiaries only have coverage for physicians’ visits when they are sick or when they have signs or symptoms of an illness. Because Medicare does not cover any preventive visits such as a health checkup or examination, providers have to do risk factor counseling and promote screening during sporadic encounters related to treatment of acute and chronic diseases. Therefore, Medicare beneficiaries have to pay out-of-pocket for visits with their providers that include a prevention-oriented physical examination and discussion of general health, disease risks, and other preventive measures.
The American Cancer Society has long recognized that making coverage available for an initial physical for each individual entering the Medicare program is an important first step to improving screening rates and health outcomes for people aged 65 and older. The Society appreciated the value of a one-time visit that would be dedicated to prevention and early detection. The new initial preventive physical will allow patients and providers to spend time emphasizing prevention and screening during a visit when the Medicare patient is not preoccupied with symptoms or treatment plans for another health problem. The one-time preventive checkup will provide Medicare beneficiaries with the opportunity to talk with their health care providers about health risk factors, personal health and family history, screening and other cancer prevention strategies (such as smoking cessation), as well as discuss the important role nutrition and physical activity play in staying healthy. The American Cancer Society fought vigorously to get this "Welcome to Medicare" prevention benefit included under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) passed last year. It was one of the Society’s highest priority issues under the MMA—another priority was getting immediate coverage for oral anticancer drugs, a benefit that was also included in the final legislation.
It was particularly important for the American Cancer Society to get the "Welcome to Medicare" physical covered under Medicare because cancer is a disease that disproportionately affects the elderly. Cancer is the leading cause of death for Americans aged 60 through 79, and the second leading killer for those older than 80.4 This year alone, more than 2,000,000 Medicare beneficiaries will be actively treated for cancer5 and more than 390,000 will die from the disease,6,7 which translates to nearly 60% of all new cancer diagnoses and 70% of all cancer-related deaths in the 65 and older population.7 The benefit was also important to help increase screening utilization rates among Medicare beneficiaries, who have not been fully utilizing available cancer screening tests. For instance, 2002 data for colorectal cancer tests show that only 25.4% of people aged 65 and older reported having a fecal occult blood stool test in the last year, and 47.7% had either a sigmoidoscopy or colonoscopy within the preceding 5 years.8 Data from 1999 show that although 91% of female beneficiaries received at least one preventive service that year, only 10% were screened for cervical, breast, and colorectal cancer and immunized against both influenza and pneumococcus.9
This benefit further capitalizes on what other studies have shown, which is that a clinician’s recommendation is key to increasing cancer screening rates, particularly for older patients.10 In a study of 2,775 primary care patients, whether or not the patient had a specific visit for a health check-up in the previous year was identified as the strongest factor impacting whether the individual had undergone screening.11 Another study by the US General Accounting Office concluded that in many instances, beneficiaries may be simply unaware that these services are available or covered by Medicare.9 Therefore, this benefit can help by providing an opportunity for patients to see their providers and ensure that they are taking advantage of the cancer screenings already covered by Medicare.
The benefit can also provide a wise use of health care dollars. Mathematical models prepared by the Congressional Office of Technology Assessment and others have shown that the cost-effectiveness of colorectal screening is consistent with many other kinds of preventive services and is lower than some common interventions.12 For example, a polyp can be removed during screening for about $1,500, but if the patient is not diagnosed until symptoms are exhibited, the patient’s survival drops to 8% and the costs of care can add up to $58,000 over the patient’s lifetime.13 With sharp cost increases possible as new treatments are introduced, the cost-effectiveness of screening is likely to become even more attractive.14 Considering that 73% of newly diagnosed cases of colorectal cancer occur in persons aged 65 and older, the prevention and early detection of colorectal cancer can be a wise use of Medicare dollars.
There is no question that the physical examination will provide a great opportunity for patients and physicians to discuss health-promoting strategies—strategies that may prevent illness and save patients’ lives. Since one of the goals of the visit is to promote health and detect disease as defined broadly, it will be imperative to take time for a discussion of prevention strategies, including help to stop smoking, improve nutrition, and increase physical activity, and provide referrals for appropriate cancer screenings. The visit also provides for an education and counseling component that leaves the door open for physicians to provide this information to patients, whether it be through educational materials, counseling on healthy lifestyle choices, or follow-up interventions that can be effective for seniors in staying healthy and preventing disease. If used effectively, this benefit can be instrumental in increasing screening rates for cancer and other diseases, and in getting important information out to patients before they become sick.
We believe this "Welcome to Medicare" prevention visit provides a significant opportunity for improving the health of Medicare beneficiaries and reducing the burden of cancer. Our seniors have much to gain from a visit that will promote healthy lifestyles and disease prevention.
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