Evaluating the Effectiveness of Medicare's Preventive Visits

In this issue of the Journal of Women's Health, Salloum et al. ¹ look at whether a new preventive benefit offered by Medicare increased how many women received screening for cervical and breast cancer. The study highlights many issues about why women may or may not receive screening.

The study uses Medicare claims data to examine whether the introduction of the Welcome to Medicare Visit (WMV) resulted in more women having Pap smears and mammograms. Congress introduced the WMV in 2005 as a tool to offer more preventive services to beneficiaries. The extensive table in the article by Salloum et al. ¹ gives an outstanding overview of the history of when Medicare starting covering certain preventive services. The motivation behind offering the WMV was that it would provide physicians time for “preventive coordination,” including recommending and organizing preventive screenings. ² As many women reported not having a screening test because their physician did not recommend one, ³ this new visit supposedly would lead to more screenings.

The linked study shows, however, there was no increase in the provision of these services after the WMV was available. As the authors point out, the most likely reason for this is that few Medicare beneficiaries received the WMV. Several studies have shown that only about 3%–6% of Medicare beneficiaries received these visits. ³ If hardly anyone is receiving these visits, they are unlikely to have an effect on the delivery of any services. In addition, there are several weaknesses in the study design that the authors acknowledge.

Medicare already covered Pap smears starting in 1990; they covered mammograms starting in 1991. Therefore, it is unclear if adding another preventive visit would further expand these services. Women who do not already receive these services are likely not doing so because of other issues, such as lack of healthcare access, not having a primary care provider, perceived negative effects of screening, mistrust of the medical system, or other personal reasons.

The health policy community can learn from the experience of the WMV, especially as Medicare rolls out the yearly wellness visit. The wellness visit was passed as part of the Affordable Care Act and was offered starting in 2011. It allows patients to receive a yearly visit that includes a full medical and family history, screening for obesity, screening for cognitive impairment and depression, assessing the patient's level of safety, a written screening schedule, and voluntary advanced care planning. ⁴ This new visit seems like a great idea to ensure that beneficiaries are receiving appropriate services, but if the uptake is as low as that of the WMV, we will never know if it works to improve the delivery of preventive services.

If we want to know if dedicated preventive visits improve health, we first have to encourage patients to use these visits. Many senior citizens did not know about the availability of the WMV ³ for two reasons. First, medical providers may not have offered the visits to their patients. If this is the case, we need to determine what the barriers are to physicians recommending these preventive visits. In informal conversations, colleagues state that the new wellness visit has too many requirements and the investment in implementing them is not worth the reimbursement. Medicare should research why or why not implementation is a problem for these preventive visits. Physicians should use available tools that can help them implement the new visits. Second, Medicare has to encourage patients to receive this benefit. Their new consumer-friendly website provides some evidence that they are taking this approach. Other groups, such as Consumer Reports, are publishing pamphlets that encourage patients to take advantage of this new benefit. ⁵ Advocates for seniors, such as the American Association of Retired Persons (AARP), should aggressively promote this benefit to their members. The lack of any cost to the patient for such visits may also encourage more patients to receive them. Cost can clearly be an issue for prevention; for example, reduction of copays for mammograms has been shown to increase screening rates. ⁶

Until we improve the uptake of these preventive visits it is impossible to know if they are working. In the meantime, we must all remember that screening is only one part of preventing disease. Women can achieve optimal health by not smoking, eating a healthy diet, maintaining a healthy weight, being physically active, and not drinking too much alcohol. ⁷ These primary preventive measures are likely to be more powerful than any screening regimen the medical community designs.