Medicare Coverage of Clinical Preventive Services

Congress established the Medicare program in 1965 in response to concerns that many seniors did not have health insurance, or had insurance that only covered hospital inpatient services. Historically, Medicare covered only diagnostic and treatment services, not preventive services provided in the absence of illness. Generally, adding coverage of a preventive service required statutory authority. Since 1980, Congress has established Medicare coverage for several preventive services in law. Recently, Congress gave the Secretary of HHS limited authority to cover new Medicare preventive services administratively. While many view preventive services as a means to improve the quality of health care by preventing illness, disability, and death, some have touted prevention as a means to contain health care costs. However, whether expanding coverage or utilization of preventive services would actually save money for Medicare is a matter of debate. While these screenings may be effective in preventing premature death or other unwanted outcomes in some beneficiaries, their broad use may incur a net cost for the Medicare program, rather than savings.

Efforts have also been made to determine, for the purposes of coverage decisions, whether a given preventive service is effective, and whether its use in clinical practice is likely to benefit the patient, without posing potential risks from the procedure itself. Congress has in the past sought the advice of expert panels to make these assessments. These panels have had differing mandates, however, and none is explicitly charged with evaluating preventive services for the purposes of Medicare coverage. For example, current Medicare coverage of preventive services does not always comport with evidence-based recommendations of a prominent expert panel, the U.S. Preventive Services Task Force (USPSTF). A recent USPSTF recommendation regarding screening mammography has refocused congressional attention on the appropriate role of advisory panels with respect to Medicare coverage decisions.

Among those seeking to reform the nation’s health care delivery system, quality and cost of preventive services are key topics of discussion. In November 2009, the House passed the Affordable Health Care for America Act (H.R. 3962). Also in November, Senate Majority Leader Harry Reid introduced the Patient Protection and Affordable Care Act (an amendment to H.R. 3590). Each is a comprehensive proposal incorporating measures reported by multiple committees of jurisdiction in each chamber. Each proposal would reduce or eliminate most cost sharing for preventive services under Medicare. The proposals differ in certain other approaches, but each would, in general, expand Medicare coverage of preventive services. The Congressional Budget Office (CBO) has scored most of these proposals as incurring a net cost for Medicare.

This report first discusses the legislative and administrative history of Medicare coverage of preventive services. Then it discusses several advisory panels that have evaluated the effectiveness of preventive services, Medicare coverage of these services, or utilization of these services. Next, it discusses whether or not the use of preventive services would be cost-saving or cost-effective for Medicare, and whether utilization of preventive services can be improved. The report then presents relevant proposals in pending health reform legislation. Finally, the Appendix compares current Medicare coverage of preventive services with current USPSTF recommendations. This report will be updated to reflect legislative and other activity.

Date of Report: December 9, 2009
Number of Pages: 30
Order Number: R40978
Price: $29.95
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