Three Ounces Of Prevention
New Medicare Screening Benefits Kick In
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"Medicare's coverage and Medicare's expenses have historically focused on paying to treat costly health problems after they occur," said Mark McClellan, administrator of the Center for Medicare & Medicaid Services (CMS), in a December statement. "With Medicare's new support to help seniors use recommended preventive care and prescription drugs to avoid these costly and debilitating problems, that's going to change."
The new services "could save many thousands of lives and billions of dollars in avoidable medical expenses for preventable complications associated with heart disease, diabetes, cancer, weak bones, high blood pressure, smoking, inactive lifestyles and other illnesses and unhealthy behavior," according to the CMS statement.
CMS estimates the new preventive benefits will cost Medicare approximately $2.1 billion from fiscal 2005 to 2013.
As for the anticipated savings and the health benefits for those eligible to participate, CMS has made no firm estimates, and some experts are dubious. "The results of a CMS demonstration conducted in the late 1980s and early 1990s indicated that offering Medicare beneficiaries packages of broad-based preventive services slightly improved the use of some services, such as immunizations and cancer screenings, but did not consistently improve health or lower costs," Janet Henrich of the Government Accountability Office told a congressional panel in September.
Offering preventive services doesn't guarantee seniors will use them. For example, in 2000, 30 percent of Medicare beneficiaries didn't get a flu shot, and 37 percent had never received a pneumonia vaccination (both of which were already recommended, and paid for, by Medicare), Henrich testified. "A one-time preventive care examination will add a dedicated opportunity for delivering preventive care and could help reduce the gap in the preventive services that Medicare beneficiaries receive. At the same time, it is not a panacea. Ensuring that beneficiaries receive needed services and follow-up care is likely to remain a challenge."
Such challenges and uncertainties aside, here's a look at Medicare's new features:
"Welcome to Medicare" Preventive Physical Exam
Who qualifies? New Medicare Part B beneficiaries
whose coverage began on or after
What's covered? A thorough physical.
How often? Only once, within the first six months of enrolling in Medicare Part B.
What will it cost me? In the
What are they looking for? Obviously, the doctor will be looking for any medical problems that have not been detected yet. But the exam is also aimed at having the doctor counsel you on measures you should take to preserve your health.
What can I expect at the visit? A pretty thorough exam. Your practitioner (this could be an MD, a doctor of osteopathy, nurse practitioner, physician's assistant or clinical nurse specialist) is likely to ask you about:
• your medical history, including any surgeries, hospital stays, illnesses, allergies, injuries and treatments;
• your family's medical history, especially any diseases that may run in the family;
• medications and/or supplements you currently take;
• your diet and exercise habits;
• your history of alcohol, tobacco or illicit drug use;
• current or past problems with depression;
• hearing problems;
• trouble getting around, unsteadiness on your feet or trouble maneuvering around your home.
The practitioner should also:
• check your height, weight, blood pressure and vision.
• perform an electrocardiogram (EKG), a painless procedure to check your heart for irregularities.
• counsel you on Medicare benefits that may be appropriate for you, such as: flu, pneumonia, and hepatitis B shots; mammograms; screenings for diabetes, glaucoma, cardiovascular disease and prostate and colorectal cancer; diabetes outpatient self-management training services; and bone mass measurements.
Why is this exam important? Some people pooh-pooh checkups, but you can
spot lots of things in a thorough physical that you just won't find in a short
visit, said gerontologist Joanne Crantz of Novamed Associates in
While listening with her stethoscope during physicals, Crantz has picked up the murmurs of abdominal aortic aneurysms (bulges in blood vessels that can rupture) and the whooshing "bruits" (abnormal sounds) that indicate fatty buildup in the carotid artery, which brings blood to the head.
Crantz said a thorough physical gives the doctor time to really talk to the patient and reflect on the answers. Some patients, she said, don't like to complain: "a little shortness of breath" described by one person was actually a sign of congestive heart failure. Others might be having difficulties with depression or memory loss that they won't mention without prompting. Odds are, the doctor's not going to pick up on everything if she only sees you when you come in for a sinus infection. "A little prevention goes a long way," said Crantz.
Cardiovascular screening blood tests
Who qualifies? All Part B Medicare beneficiaries, regardless of when they joined the program.
What's covered? Blood tests that measure total cholesterol, HDL ("good") cholesterol and triglyceride levels.
The tests can be done individually or all together as a "lipid panel." If the triglyceride level is high, the doctor can order a measurement of LDL ("bad") cholesterol as well.
How often? Once every five years.
What will it cost me? Nothing.
What are they looking for? Risk of heart attack or stroke. While HDL cholesterol helps remove fat deposits from your blood vessels, LDL cholesterol can build up in your arteries, reducing the flow of blood. If a blood clot forms in one of these narrowed arteries, you're in big trouble: The blockage can cut off the flow of blood to the heart, causing a heart attack, or to the brain, causing a stroke. A high triglyceride level not only signals higher risk of heart attack, but also may indicate diabetes.
What can I expect at the visit? All that's required is a simple blood draw. You may be asked to fast for nine to 12 hours beforehand.
Why are these tests important? You can't control many of the risk factors for heart disease, such as family history, race and age. But you can control cholesterol. If the tests show your cholesterol count is too high, your doctor will advise you on what you need to do to get it back down. (You may just need to improve your diet and exercise habits, but you may need medication as well.) Many seniors already get regular cholesterol tests, because Medicare has paid for them in the past for people who already had a diagnosed cardiovascular problem, such as high blood pressure or a past heart attack, said Novamed's Crantz. But you can have high cholesterol even though you display no other symptoms. With these screening tests, your doctor can catch the high cholesterol before the other problems develop.
Diabetes screening
Who qualifies? Only beneficiaries considered at risk for developing diabetes. Medicare defines "at risk" as having any of these risk factors:
• hypertension (high blood pressure);
• dyslipidemia (off-balance blood lipids, such as high LDL cholesterol, high triglycerides and/or low HDL cholesterol);
• obesity (a body mass index, or BMI, of 30 or more);
• pre-diabetes.
You also qualify for diabetes screening if you have a combination of any two of these characteristics:
• age 65 or over (i.e., most people on Medicare);
• overweight (BMI greater than 25 but less than 30);
• a family history of diabetes;
• a history of gestational diabetes (diabetes during pregnancy) or delivery of a baby weighing more than nine pounds.
What's covered? A fasting blood glucose test and post-glucose challenge test.
How often? If you've been diagnosed with pre-diabetes, twice per year. If not, once per year.
What will it cost me? Nothing.
What are they looking for? Diabetes or pre-diabetes. Diabetes is a metabolic disorder in which glucose, a form of sugar, fails to move from your bloodstream to your cells. Over time, high blood sugar can cause damage to your heart, nerves, eyes and kidneys.
In pre-diabetes, blood glucose is higher than normal but not high enough to be diagnosed as diabetes. According to the American Diabetes Association's Web site, researchers believe that even pre-diabetes can cause long-term damage to the body, especially the heart and circulatory system.
What can I expect at the visit? For the fasting blood glucose test, blood is drawn from your arm after you have gone at least eight hours without eating. For the second test, you'll be asked to drink a sugary solution (which "challenges" your system with sugar) and wait two hours, after which your blood will be drawn again.
Why are these tests important? "Prevention and early detection mean
everything," said Cathy Tibbetts, president of health care and education
for the American Diabetes Association. No
one wants to hear that they have diabetes or even pre-diabetes. But the earlier
they're detected, the easier they are to control. If your blood test indicates high blood sugar,
"the follow-up to that screening is critical," said Tibbetts, who
manages the
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