Medicaid's high marks on preventive care contrary to its stingy image

Some states appear to be covering fewer recommended preventive services than others, but screenings may be getting bundled with other care.

By — Posted Oct. 8, 2012

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A new study indicates that most state Medicaid programs are doing an above-average job of covering needed preventive services for beneficiaries.

States generally aren't required to cover preventive services for Medicaid adults at the same levels as they do for children. But in surveying 48 states (Hawaii, Wisconsin and the District of Columbia did not participate), the Kaiser Commission on Medicaid and the Uninsured found that most state Medicaid programs covered the bulk of 42 recommended services for nonelderly adults through fee for service, particularly for cancer and sexually transmitted infection screenings as well as pregnancy care.

Medicaid, with its reputation for low payment rates and fiscal instability, is far from perfect, said Stacey Mazer, senior staff associate for the National Assn. of State Budget Officers. Budget officers in particular continue to have concerns about the fact that health care spending is outpacing other services.

Kaiser's findings highlight all of the positive benefits that Medicaid can provide, Mazer said. “The states did very well in terms of the number of preventive services that they covered, and even the states that didn't cover as many still covered the majority of them.”

In 2010, 44 states reported they were covering at least 30 of these 42 services, which consist of preventive care recommended by the U.S. Preventive Services Task Force and immunizations recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. Nearly all of the states surveyed said they covered screenings for hypertension and cholesterol abnormalities, and 31 said they covered all recommended health promotion services, such as obesity screenings and tobacco use counseling. Almost all of the states surveyed by Kaiser also reported covering four recommended adult immunizations.

Some variation does exist among states on what they do and don't cover, or exactly how they cover these services. Although 13 said they were covering all of these services, the survey reported that four states — Florida, Georgia, Louisiana and Nebraska — were covering fewer than 30.

State-to-state differences

There may be explanations for some of these differences, said Michael Scott Applegate, MD. He is immediate past president of Nebraska's chapter of the American Academy of Pediatrics and former chair of the Nebraska Medical Assn.'s Medicaid committee. (See correction)

In Nebraska, some of the screening services that don't appear to be covered in Kaiser's research actually are getting bundled with other services — meaning that the test is covered for patients, but the state isn't paying separately for these services, Dr. Applegate said. This may be good news for beneficiaries, but there can be financial downsides for the physicians providing the services.

Nebraska covers certain stand-alone services, such as influenza immunizations, hypertension and osteoporosis screenings, and mammograms. But it does not separately cover such items as breast cancer counseling and depression screening. That's because breast cancer counseling is included in the payment for the genetic screening test, and depression screening is considered part of a routine physical, Dr. Applegate said. This has been a sticking point with Nebraska doctors, as there's a CPT code a physician could use for counseling services after breast cancer genetic screening, he said.

“The physicians in Nebraska bear the brunt of the noncovered service,” Dr. Applegate said. “They do it; they perform the service. They're just not getting reimbursed for it separately.” Nebraska's Medicaid program pays doctors at 82% of what they receive for the same services under Medicare, although primary care physicians nationwide will experience a temporary pay bump in Medicaid rates for primary care services in 2013 and 2014.

In Georgia, a similar issue arose regarding preventive services not being covered by Medicaid but instead being bundled with other services. A Pap smear, for example, is billed as part of the patient visit, said Pamela Keene, spokeswoman for Georgia's Dept. of Community Health. Although Kaiser's data may show that Georgia doesn't fund various health promotion services, “in reality, many of our physicians do counsel their patients on tobacco use, obesity and alcohol,” she said.

But Sandra B. Reed, MD, president of the Medical Assn. of Georgia, said the study's findings underscored the challenges her state faces in resourcing Medicaid.

The program “is at real risk of becoming too heavily weighted on cost savings instead of patient care, given the budget crisis in the state. It is, therefore, imperative for state leaders to adequately fund the Medicaid program in Georgia to ensure that patients in the state have access to medical care they need,” Dr. Reed said.

Patients pay part of the bill

States differed even more significantly on cost-sharing requirements, the Kaiser study reported, with at least 25 requiring adult Medicaid beneficiaries to pay for part of at least one of the recommended preventive services it covered. The federal government limits how much states can charge these beneficiaries to protect them from access-to-care barriers and high out-of-pocket costs.

Of the 13 states that said they covered all preventive services and immunizations for nonelderly Medicaid adults, only five said they did so without any cost-sharing requirements.

The health system reform law, which authorizes a major program expansion starting in 2014, “provides several opportunities for states to increase the role Medicaid plays in providing access to preventive services,” the Kaiser study said. For example, Medicaid programs in January 2013 can gain a percentage point in their federal matching funds rate, provided they cover recommended immunizations and preventive services without charging beneficiaries extra for these services.

For now, it's a hopeful sign that states are offering the majority of these recommended services, which contribute to better health and more affordable Medicaid programs in the long run, said Bruce Siegel, MD, MPH. He's president and CEO of the National Assn. of Public Hospitals and Health Systems and spoke at a recent Capitol Hill event on Medicaid.

He cautioned that some legislative proposals to turn Medicaid into a block grant program that pays a fixed amount to states for patient care probably would undo the progress states have made in offering these types of preventive services. Rep. Paul Ryan (R, Wis.), the GOP vice presidential nominee, has floated a proposal of this type that would cap block grants at much lower levels than Medicaid's current federal spending levels and give states more latitude to adjust coverage and eligibility.

In the event block grants were enacted, “you could be looking at a future where [preventive services] aren't necessarily offered,” Dr. Siegel said. “Given who's on Medicaid, it would be penny-wise and pound-foolish to lose things like immunizations and mammograms.”

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How states cover preventive services

The Kaiser Commission on Medicaid and the Uninsured reported that 44 states in 2010 offered at least 30 out of 42 recommended preventive services for nonelderly, adult Medicaid beneficiaries, and 13 states covered all of them. About half of the states, however, required co-payments from patients for at least one service.

Service States covering service States requiring co-pay
Mammography screening 48 11
Cholesterol screening 46 14
Diabetes screening 46 15
Influenza immunization 46 10
Td booster/Tdap immunization 41 9
MMR immunization 40 9
Obesity screening and counseling 37 15
Prophylactic aspirin 37 19
BRCA screening and counseling 29 8

Note: Hawaii, Wisconsin and the District of Columbia did not participate in the survey.

Source: “Coverage of Preventive Services for Adults in Medicaid,” Kaiser Commission on Medicaid and the Uninsured, Sept. 21 (link)

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State Medicaid experiment shows quality gains

A select population of low-income, uninsured adults given the opportunity to enroll in Oregon's Medicaid program reported higher utilization of care, better care and lower out-of-pocket expenses than other uninsured adults, according to a report on the effort's first year.

This experiment, the Oregon Health Study, began in 2008, when the state procured enough funding to expand its Medicaid program to 10,000 additional adults, said Heidi Allen, PhD, an assistant professor at Columbia University's School of Social Work in New York. She is co-author of a study in the August Quarterly Journal of Economics discussing the outcomes of the initiative. Allen spoke at a Sept. 28 policy briefing hosted by the Partnership for Medicaid coalition in Washington.

Oregon officials knew there would be several hundred thousand people eligible for the expansion, which applied to adults ages 19 to 64 who were below the federal poverty line but not normally eligible for the program. So the state held a lottery and randomly chose names from among the 85,000 to 90,000 people who applied.

The study compared outcomes for people who were selected in the lottery with people who were not selected, Allen said. Because the study sample was completely random, any differences between the two groups would demonstrate the effects of the health insurance.

One year into the initiative, researchers found that expanding coverage improved care in several areas, Allen said. “It increased people's use of health care appropriately. It led to improvements in metrics of quality and access, including the use of preventative services. It decreased financial strain and medical debt, meaning providers were also getting paid, and we found significant improvements in physical and mental health.”

Researchers also noticed a 10% decrease in the probability of covered individuals screening positive for depression.

The expansion didn't pay for itself, however, Allen noted. “We did see an increase in costs of about $777 per person per year.” She said it would be up to each state to decide if such a Medicaid expansion would have benefits that outweighed the costs. The more frequent use of preventive services by the covered participants points to possible longer-term savings.

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External links

“Coverage of Preventive Services for Adults in Medicaid,” Kaiser Commission on Medicaid and the Uninsured, Sept. 21 (link)

“The Oregon Health Insurance Experiment: Evidence from the First Year,” The Quarterly Journal of Economics, August (link)

“What the Oregon Health Study Can Tell Us About Expanding Medicaid,” Health Affairs, August 2010 (link)

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This article originally misstated Nebraska Medicaid's policy on covering prophylactic aspirin. According to the Nebraska Dept. of Health and Human Services, the state covers over-the-counter medications with physician prescriptions. American Medical News regrets the error.

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