1. Copyright 2015 American Medical Association. All rights reserved.
Medical News & Perspectives
Filling the Gaps in Preventive Care Services for Older Adults
Rita Rubin, MA
O
nElectionDay2012,votersatpoll-
ing places in 48 US states could
choosenotonlyapresidentialcan-
didate but whether to get a flu vaccination.
Morethan9000votersoptedtobeim-
munized through the “Vote and Vax” pro-
gram that year, and more than half of them
reported that they did not regularly get flu
shots (Shenson D et al. Am J Public Health.
doi:10.2105/AJPH.2015.302628 [pub-
lished online April 16th
2015]).
While likely not the first setting that
comes to mind, the polling place repre-
sents a logical location for efforts to boost
the rate of older individuals who are up-to-
dateoncorepreventiveservicessuchasim-
munization. After all, more than half of the
more than 120 million voters in a US presi-
dential election are 50 years or older, said
DouglasShenson,MD,MPH,nationaldirec-
tor of Vote and Vax.
There’s definitely room for improve-
ment,especiallyconsideringthe“silvertsu-
nami,” consisting mostly of aging baby
boomers. The US population 65 years or
older is expected to more than double be-
tween 2010 and 2050, when it will swell to
nearly 89 million (Ogden LL et al. Am J Pub-
lic Health. 2012;102[3]:419-425).
Today in the United States, fewer than
half of people aged 65 years and older are
up-to-dateonthecoresetofclinicalpreven-
tive services: screening tests, immuniza-
tions, health behavior counseling, and pre-
ventivemedications.Onlyaquarterofthose
aged 50 to 64 years meet preventive ser-
vices recommendations (http://1.usa.gov
/1MUJN7B). And black and Hispanic older
adultsareevenlesslikelytoreceivepreven-
tiveservicesthantheirwhitepeers(http://1
.usa.gov/1FsnzV8).
For example, the proportion of people
60 years and older in the United States
who reported receiving a herpes zoster
vaccination, as recommended for that age
group, was only 24.2% in 2013—below the
Healthy People 2020 goal of 30%,
according to a recent report from the Cen-
ters for Disease Control and Prevention
(CDC) (Williams WW et al. Morb Mortal
Wkly Rep. 2015;64[4]:95-102). Similarly,
for those 65 years and older, the recom-
mended age group for the pneumococcal
vaccine, 59.7% reported having gotten
that shot—again, far below the Healthy
People 2020 goal of 90%.
Some Healthy People 2020 goals re-
latedtopreventiveservicesforolderadults,
such as having a mammogram within the
past 2 years and having been screened for
colorectal cancer, have already been met.
ButtheUnitedStatesstillfallsshortofreach-
ing 2020 targets for other preventive ser-
vices, as well as the goal of having 46% of
menand43.1%ofwomen65yearsandolder
up-to-date on all of the core services (http:
//1.usa.gov/1NzFtYV and http://1.usa.gov
/1LGY5aA).
“When we’re less than 50%, we have a
long way to go,” Lynda Anderson, PhD, di-
rector of the CDC’s Healthy Aging Program,
said in an interview. “It’s interesting that
people who are getting some of these (ser-
vices) aren’t getting all of them.”
Research shows that only a minority of
Medicare enrollees take advantage of the
freeannualpreventivevisitstheprogrambe-
gan offering in 2011, and even those older
adultswhoseeadoctorregularlyarenotup-
to-date on preventive services.
Typically, chronic conditions get the
mostattentionatolderpatients’medicalap-
pointments,Andersonsaid.“Alotofthepre-
ventiveissuesdon’trisetothetop,”shesaid.
“Iftheirproviderisn’ttellingthemit’simpor-
tanttogetthatvaccination,inadvertentlyit
does send the message that it’s not impor-
tant.”
Shenson, an associate clinical profes-
sor of epidemiology at the Yale School of
Medicine who has studied the issue for
nearly 20 years, says conventional wisdom
used to place the blame squarely on physi-
ciansandpatients:physiciansdidn’tplacea
high priority on preventive care, patients
didn’taskforitorweren’treceptivetoit,and
physicians’officesneglectedtoflagtherec-
ordsforpatientswhohadn’treceivedapar-
ticular vaccine or screening.
No question, all of those factors play a
role.Buttherootsoftheproblemextendbe-
yond the physician’s office to a US health
Medical News & Perspectives.....p1604
Filling the Gaps in Preventive Care Services
for Older Adults
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to Buy Cigarettes
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News & Analysis
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2. Copyright 2015 American Medical Association. All rights reserved.
care system that is designed to care for sick
patients, not help prevent them from get-
tingsickinthefirstplace,Shensonsaid,who
also serves as associate director of clinical
preventive services at the Yale-Griffin Pre-
vention Research Center.
Timeiscertainlyanissue,too.“Thedoc-
tor’s visit is so short,” Shenson said. “It’s not
surprising that we don’t do better. We’ve
sort of breathed down the neck of physi-
ciansandsaid,‘You’vegottodothis,you’ve
got to do that.’”
During his internal medicine residency,
Shensonsaid,“Ifounditverychallengingto
find enough time to explain to every one of
my patients over age 50 why screening for
colon cancer is so important and poten-
tially life-saving.”
The topic of colon cancer screening is
off-puttingtomanypeople,hesaid,so“this
is not a conversation you can rush through.
And that’s why I’m hoping the recent
changes in Medicare reimbursement and
preventiveservicevisitswillmakeanimpor-
tant difference.”
Checking Up on Checkups
UndertheAffordableCareAct(ACA),Medi-
care began fully covering annual preven-
tive care visits in 2011. And since 2005, the
program has offered new enrollees a 1-time
initial preventive “Welcome to Medicare”
visit,atwhichphysiciansareexpectedtodis-
cuss advanced directives, create a written
plan of needed preventive services, screen
for depression and safety, check vision and
bloodpressure,andcalculatebodymassin-
dex (http://1.usa.gov/1DaNQVm).
Butonly3%ofeligibleenrolleesin2006
and 2007 had such a visit, which must be
made in the first year after Medicare enroll-
ment, health care researcher Sukyung
Chung, PhD, of the Palo Alto Medical Foun-
dation, said in an interview. “Patients didn’t
know much about it, and the window was
really narrow.”
Althoughmorebeneficiariesaresched-
uling preventive care visits since Medicare
began covering them, many still do not,
Chung and her coauthors found in a recent
study (Chung S et al. Health Aff. 2015;34[1]:
11-20).
Chung’s team analyzed 2007 to 2013
datafromprimarycarepatients65yearsand
older at the Palo Alto Medical Foundation,
which serves people in 4 counties near San
Francisco. Before implementation of the
ACA, only 1.4% of Medicare fee-for-service
patients, who represent the majority of en-
rollees, had a preventive visit each year, the
authors found.
AfterACAimplementation,thatpropor-
tionjumpedto27.5%,butitwasstill10to20
percentagepointslowerthanthatforpeople
65 years and older who were insured
through their employer or those in a Medi-
care health maintenance organization
(HMO), which has traditionally encouraged
preventive visits as potentially cost-saving
as well as necessary to adhere to medical
guidelines.
Theannualrateofpreventivevisitswas
somewhatlowerinseniorsinsuredthrough
their employer than those in a Medicare
HMO, the authors wrote, possibly because
theydidn’tgivepreventivecareashighapri-
ority or they had a tough time fitting an ap-
pointment into their busy schedules.
Even seniors who get routine check-
upsdon’tnecessarilyreceivepreventiveser-
vices, Shenson, Anderson, and their coau-
thors found (Shenson D et al. J Fam Pract.
2011;60[1]:E1-E10). They assessed 2006
data from telephone surveys conducted by
the CDC’s Behavioral Risk Factor Surveil-
lance System (http://1.usa.gov/17AYMmF).
The data covered approximately 80 000
randomly selected individuals 65 years and
older from all 50 US states and the District
of Columbia. Most were fully insured, had a
personal physician, reported no cost bar-
rier to seeing that physician, and had re-
cently had a routine checkup.
Yet only 44.8% of men and 36.8% of
women who’d had a recent checkup were
up-to-date on the recommended preven-
tive services, the researchers found. “Our
study indicates that increasing the use of
routine medical checkups will have a negli-
gible impact on the delivery of preventive
services,” they wrote.
Even fewer Medicare beneficiaries ap-
pear to be taking advantage of another free
preventivehealthservicethatbecameavail-
able in 2011 under the ACA. Citing federal
data,KaiserHealthNewsreportedthatonly
50 000 of 13 million obese seniors sought
free weight loss counseling in 2013 (http:
//bit.ly/1DUWRY7).
WeightlossspecialiststoldKaiserHealth
News that low awareness of the service
amongbothbeneficiariesandphysicianswas
due to the fact that it is available only in pri-
marycareoffices.Medicarereimbursesnei-
therdietitiansnorendocrinologistsorother
specialists who care for obese patients for
weight loss counseling.
More recently, some experts have chal-
lengedtheoverallbenefitsofscreeningtests.
One review of meta-analyses and random-
izedtrialsrelatedto19differentdiseaseswith
USPreventiveServicesTaskForce(USPSTF)
statementsfoundthatseveralscreeningtests
didnotreduceall-causemortality,andreduc-
tions in disease-specific mortality estimates
were reported only for mammography for
breastcancerandfecaloccultbloodtestand
flexible sigmoidoscopy for colorectal cancer
(Saquib N et al. Int J Epidemiol. 2015;44[1]:
264-277). While the USPSTF recommends
screeningpeopleaged50to75yearsforco-
lorectal cancer (http://bit.ly/1GKsp46) and
women aged 50 to 74 years for breast can-
cer (http://bit.ly/1wC81yv), it does not ad-
visescreeningformostoftheotherdiseases
considered in the analysis.
The National Report Card on Healthy Aging:
How Healthy Are Older Adults in the United States?
Data Year
Healthy People
2020 Target, %
Score Target
Met or Not Meta
Flu vaccine in past year
Data for Adults
Aged 65 Years
or Older, %
Preventive Care and
Screening Indicator
Ever had pneumonia vaccine 68.1
66.9 90.0 Not Met
Not Met
Not Met
Met
Met
Not Met
90.0
70.0
70.5
50.9
52.7
2010
2010
2010
2010
2010
2010
Mammogram within past 2 years 82.9
Colorectal cancer screening 73.1
Up-to-date on select preventive servicesb
Women
Men
48.5
48.5
Data Source: Centers for Disease Control and Prevention, Behaviorial Risk Factor Surveillance System, 2009-2010.
Data for all indicators depict the mean for all 50 states and the District of Columbia.
a Score is based on attainment of Healthy People 2020 targets among the older adult population. Some targets are for
all adults 18 years or older, not just those 65 years or older. This table only reports data for older adults.
b For men, 3 services are included: flu vaccine in past year, ever had pneumonia vaccine, and colorectal cancer
screening. For women, these same 3 services are included, plus a mammogram within past 2 years.
Source: The State of Aging and Health in America 2013. Centers for Disease Control and Prevention.
http://www.cdc.gov/aging
News & Analysis
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3. Copyright 2015 American Medical Association. All rights reserved.
“It’s important to realize that, as with
checkups, mortality is not the only out-
come that matters,” Aaron Carroll, MD,
MS, vice chair for health policy and out-
comes research in the Indiana University
School of Medicine’s pediatrics depart-
ment, wrote recently in the JAMA Forum
about the screening review (http://bit.ly
/1Arjz33). “Trying to improve quality of life
or reduce morbidity are also important
outcomes.”
Out of the Clinic
and Into the Community
Although the physician-patient encounter
shouldbethecenterpieceforthedeliveryof
preventive services, Shenson said, “clini-
ciansarefocusedontheirpatientpanelsand
do not feel that their role is a public health
role. We need to bridge that gap.”
The best way to do that? “Getting out
to where people are in their daily life,” said
Kathryn Kietzman, PhD, MSW, a University
of California, Los Angeles, research scientist
who directs the ongoing Community
Health Innovations in Prevention for
Seniors (CHIPS) project, funded by the
CDC. “If somebody’s already thinking about
prevention by going into the pharmacy to
get a flu shot, that’s a great opportunity to
tap into the mindset of that individual.” For
example, besides administering a flu shot,
the pharmacist could ask whether the cus-
tomer has been screened for colorectal
cancer, Kietzman noted.
A program in San Francisco did just
that, according to a recent CHIPS report
(Policy Brief UCLA Cent Health Policy Res.
2014;[PB2014-6]:1-8). The program sought
to promote colorectal cancer screening
among people recruited at flu immuniza-
tion clinics in select pharmacies. It com-
pared providing home screening kits with
only providing education about colorectal
cancer screening and found that the former
was more effective in raising screening
rates (Potter MB et al. J Am Pharm Assoc.
2010;50[2]:181-187).
Another of the many programs de-
scribed in the CHIPS report is one that en-
listsblackwomenwho’vehadbreastandcer-
vicalcancertobearwitnessattheirchurches
about the importance of screening and re-
ferswomentolow-costmammographyand
cervical cancer screening (Erwin DO et al.
Cancer Control. 2003;10[5 suppl]:13-21).
Launched in rural Arkansas more than 20
years ago, the Witness Project is now a na-
tionalnonprofitwith18activesites,saidco-
founderDeborahErwin,PhD,directorofthe
office of cancer health disparities research
at the Roswell Park Cancer Institute.
AthirdprogrammentionedintheCHIPS
report is Vote and Vax, one of the biggest
projects of Sickness Prevention Achieved
Through Regional Collaboration (SPARC), a
Connecticut-based nonprofit agency work-
ingonexpandingthepopulation-wideuseof
preventive care (http://bit.ly/17yGdj1).
Vote and Vax, funded by the CDC, part-
neredwithlocalpharmaciesaroundthecoun-
try to administer flu vaccine, for a fee. Some
ofthevaccinationclinicswereadjacenttothe
polls,whileotherswereinnearbypharmacies.
Because it falls in November, Election
Day is the perfect time to immunize people
againsttheflu,Shensonnoted.Besides2012,
Vote and Vax also operated during elec-
tions in multiple states in 2004, 2006,
2008, and 2010, taking 2014 off to analyze
the data it had collected, Shenson said.
“Wearedefinitelyhopingtobeactivein
2016,” he said. “We’re now ramping up our
search for funding.”
Shenson sees no reason to stop at flu
shots.VoteandVaxalsocouldofferpneumo-
coccalvaccinationandtheopportunityforvot-
erstomakeappointmentsforscreeningtests.
“I’mnotdiminishingtheroleofthedoc-
tor-patient connection within the clini-
cian’soffice,”Shensonsaid.Buthesaid,“we
will not protect everyone as best we can if
we rely exclusively on that model.”
The JAMA Forum
Payment Reform Is About to Become a Reality
David M. Cutler, PhD
T
heUSDepartmentofHealthandHu-
man Services (HHS) continues to
take major steps toward transform-
ing the payment system for Medicare. Af-
terhintingaboutanewpaymentreformplan
in September (http://bit.ly/17cQ2mz), HHS
Secretary Sylvia Mathews Burwell put out
more specifics in late January.
Secretary Burwell’s proposal calls for
30% of Medicare payments to be based on
non–fee-for-service models by the end of
2016, and 50% to be so by the end of 2018
(http://bit.ly/15LuMEh).Bycomparison,such
payments did not exist in 2011 and account
for about 20% of Medicare payments to-
day. In addition, the Secretary intends to
have 85% of Medicare fee-for-service pay-
ments tied to quality or value in some fash-
ion by the end of 2016.
Make no mistake: this is major news.
Medicare is the largest health care pur-
chaserinthecountry,sothesechangesmat-
ter a lot. In addition, many private insurers
that have been hesitant about payment re-
formarelikelytofollowMedicare’slead.Pay-
ment reform is about to become a reality.
Cautious Reactions
Secretary Burwell did not announce specif-
ics about new payment models. This lack of
specificity may explain the cautious reac-
tion of professional societies to the news.
The president of the American Medical
Association, Robert M. Wah, MD, stated
David M. Cutler, PhD
AmericanMedicalAssociation
News & Analysis
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