MEDICARE: Widespread Failure in Preventive Care
The elderly are not receiving a wide range of preventive care covered by Medicare, according to a new study. The latest edition of the Dartmouth Atlas of Health Care, to be released today, reports that less than one-third of women between the ages of 65 and 69 obtain mammograms every two years, fewer than 25% of Medicare beneficiaries receive recommended colon cancer tests, and exams and treatments for glaucoma, diabetes and pneumonia are "similarly underutilized." Dartmouth Atlas Editor Dr. John Wennberg said, "These are cheap services and the benefits are obvious. There is no system of quality in place to insure that these simple things get done." Dr. Christine Cassell, chair of Mount Sinai Medical Center's geriatrics department, said, "Doctors know they are supposed to provide these services, and they don't. But it isn't just that they are sloppy or ignorant. The health care system is way behind in setting up reminders. ... We need to figure out how we can make this a no-brainer" (Winslow, Wall Street Journal, 4/19). "It is evidence of massive inefficiencies. We end up with a very, very unhappy picture," Wennberg said (Goldstein, Washington Post, 4/19). He added that HMOs, "although they are targets of criticism on some issues, almost always have better performance records when it comes to screening tests than the traditional fee-for-service Medicare system," thanks to their centralized information systems (Rubin/Rosenblatt, Los Angeles Times, 4/19). The Washington Post reports that "[e]ven when the federal government largely shoulders the bills, it is difficult to motivate doctors and patients to pay attention to how much and what kind of care is best" (Post, 4/19).
Where You're From
The Dartmouth Atlas' "The Quality of Medical Care in the United States: A Report on the Medicare Program," published by the American Hospital Association, also found that where beneficiaries live is the major determinant as to what care they receive. For example, the likelihood that beneficiaries would spend a week or more in intensive care ranged from less than 3% in Eugene, OR, to more than 25% in Munster, IN, and Miami, FL; the rate of radical prostatectomy ranged from 0.5 per 1,000 in Binghamton, NY, compared with 4.7 per 1,000 in Baton Rouge, LA. Women in the Northeast, Florida and Michigan between the ages of 65 and 69 were most likely to receive mammograms. AHA COO Jonathan Lord said, "the underlying theme of 'geography is destiny' has been consistent. That is a hard message for people in health care to swallow. It's tough to deal with the fact that there doesn't seem to be any real system of care in the country" (Manning, USA Today, 4/19).
The Wall Street Journal reports that researchers used Kaiser Permanente plans in California as a benchmark, with Kaiser's 82% mammogram rate nearly double that of the top performing geographic region (4/19). Kaiser's Joel Hyatt said, "We have reminder systems in place. When a woman comes in for an appointment, there's a history of her mammogram schedule, there's an immediate process where it checks her pap smear records, and if she's not had (the tests), it is flagged for the nurse or the physician" (Los Angeles Times, 4/19).
What's to be Done
Wennberg said the report was not an indictment of fee-for-service medicine per se, as Medicare could be efficient "if there were somebody accountable for reminding doctor and reminding patients. ... The problem is, who should be doing it?" HCFA Administrator Nancy-Ann Min DeParle noted that her agency has begun "two significant initiatives to educate patients and health care providers about the importance of preventive care, with a special focus on minority communities." She predicted that future reports would show "significant" improvements. The report drew from 1995 and 1996 Medicare data (Post, 4/19). The Institute of Medicine and the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry have also launched care improvement initiatives, the Wall Street Journal reports (4/19).