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Many Medicare Recipients Not Getting Full Preventive Care

Study finds service varies widely between doctors

TUESDAY, July 26, 2005 (HealthDay News) -- Many Medicare beneficiaries are receiving below-standard preventive care that appears linked to certain characteristics of their doctors' practices, a new study contends.

In particular, beneficiaries were more likely to get recommended care if their doctor worked in a larger practice with a lower proportion of Medicaid patients, had graduated from a U.S. or Canadian medical school, and used computerized information technology in the office.

The study, appearing in the July 27 issue of the Journal of the American Medical Association, was released just as Medicare gets set to turn 40 this Sunday.

According to the study authors, research has already unearthed discrepancies in treatment linked to racial and socioeconomic differences between patients. More recently, however, data has suggested that differences in physician characteristics may also play a role.

For this study, the researchers combed through data from 3,660 U.S. physicians providing care to more than 24,500 Medicare beneficiaries aged 65 and up.

They concentrated on preventive care, looking at the proportion of eligible patients who received each of six preventive services during 2001: diabetes monitoring involving eye exams or blood measurements of hemoglobin A1c, screening for either colon or breast cancer, and vaccination against influenza or pneumococcus.

Overall, fewer than half the beneficiaries received the level of service outlined in national guidelines. Only 48 percent and 56 percent of diabetic beneficiaries received eye examinations and hemoglobin A1c blood tests, respectively. Only 47 percent of women aged 65 to 75 received mammograms, while 46.5 percent of all beneficiaries received a flu shot.

Various physician and practice characteristics accounted for many of the discrepancies, the strongest associations being with practice type and proportion of practice revenue coming from Medicaid.

Specifically, individuals who received care in practices that derived less than 6 percent of their revenue from Medicaid were more likely to receive preventive services than individuals visiting practices where more than 15 percent of revenue came from Medicaid.

The specific percentages were as follows: 48.9 percent of those in the practices receiving less from Medicaid got diabetic eye exams, versus 43 percent of those who in the higher Medicaid bracket; 61.2 percent received hemoglobin A1c monitoring versus 48.4 percent; 52.1 percent got mammograms versus 38.9 percent; 10 percent got screened for colon cancer versus 8.5 percent; 50.2 percent received flu vaccines versus 39.2 percent; and 8.2 percent got pneumococcal vaccines versus 6.4 percent.

Also, beneficiaries were more likely to get the appropriate preventive care if they saw a physician in a larger practice that had at least three doctors, who was a graduate of a U.S. or Canadian medical school, or who reported having information technology that could generate preventive care reminders or easily access treatment guidelines.

"For a long time, there's been conjecture that larger practices do better for a variety of reasons," said Dr. Hoangmai H. Pham, lead author of the study and senior health researcher at the Center for Studying Health System Change in Washington, D.C. He said large practices probably succeed because of a combination of better organization, being more oriented to quality improvement, having more specialists (who bring in more reimbursement dollars) and having more capital. Extremely large practices did not perform better than small practices, however.

There was also no association between the number of Medicare patients a doctor had and performance, the researchers noted.

And while information technology did improve service, its effects appeared to be limited. "You can lead the horse to water, but you can't make them drink it," Pham said. "You can have it in the office, but it doesn't mean they're using it. That has implications for the huge amounts of money being poured into IT [information technology] investment. We're not saying stop, but there's reason to be cautious about expectations."

The findings may have other public policy implications, as well.

"Because Medicare is now contemplating a pay-for-performance design, one of the positive steps they can take is to take into account the socioeconomic status of the beneficiaries that specific physicians are caring for and build that difference into the incentive design," Pham said.

Another step might be to pay subsidies for disadvantages in the outpatient arena, something Medicare already does for hospitals. "That's a much more dramatic step that people aren't ready to commit to, but it's worth discussing at this point," Pham said.

"The issue of looking at quality is relative new. It's in its infancy," said Hugh Long, a professor of health systems management at Tulane University School of Public Health and Tropical Medicine in New Orleans. "These kinds of studies are going to help bolster the case. We're just beginning to take the system-wide steps that can eventually move us towards rewarding quality as opposed to existing systems which, in some cases, reward bad quality. But this huge tanker is cruising along at 15 knots and trying to make it turn 90 degrees is going to take a while."

A research letter in the same issue of the journal found that negotiating drug prices with pharmaceutical companies -- a strategy currently used by the Department of Veterans Affairs -- would also dramatically lower Medicare's drug costs. If the Medicare Reform Act had permitted direct negotiation for Medicare patients, the authors of the letter estimated that a typical patient being treated for heart disease could have saved at least 50 percent each year on prescription drugs.

More information

For more on Medicare, head to the Center for Medicare & Medicaid Services.

SOURCES: Hoangmai H. Pham, M.D., M.P.H., senior health researcher, Center for Studying Health System Change, Washington, D.C.; Hugh W. Long, Ph.D., J.D., professor of health systems management, Tulane University School of Public Health and Tropical Medicine, New Orleans; July 27, 2005, Journal of the American Medical Association
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