At 40 Years, Medicare a Leader in Ensuring Access to Health Care

New Chartbook Shows Where Medicare Has Made Great Strides,
Where It Can Do More to Improve Quality of Care for Seniors and All Americans New York, NY, May 6, 2005—Forty years after its creation, the federal Medicare program has succeeded in ensuring access to needed care and improving the provision of preventive services to millions of elderly and disabled beneficiaries, and Medicare patients are more satisfied with their care than privately insured adults. But despite progress, Medicare can do more to ensure patients are screened for colorectal cancer, treated for depression, immunized against pneumonia, and protected against falls and fractures, says a new report released today. Quality of Health Care for Medicare Beneficiaries: A Chartbook Focusing on the Elderly Living in the Community is the third in a series of such publications that analyze data published since 2002 to shed light on quality of care. Funded by The Commonwealth Fund and authored by quality experts Sheila Leatherman, a professor at the University of North Carolina and Douglas McCarthy, president of Issues Research, Inc., the report illustrates in a set of sixty charts both Medicare's progress and deficiencies in the quality of American health care, as well as disparities and unjustified variations in care. The report, to be discussed today at an Alliance for Health Reform briefing in Washington DC, also showcases eight promising quality improvement activities from around the country. "Medicare is a national program that should guarantee high standards of care throughout the country but right now the quality of American health care is too variable and uneven," says Leatherman, Research Professor, University of North Carolina's School of Public Health. "Although the federal government's current Medicare quality efforts represent a promising start, they need to be intensified and accelerated to improve care not only for Medicare beneficiaries but for all Americans." "This chartbook makes the case for a concerted effort towards a national agenda for quality that sets out explicit targets to achieve and by when," says Commonwealth Fund President Karen Davis. "Medicare has done a remarkable job of ensuring secure and stable coverage for elderly and disabled beneficiaries. Now it needs to be an innovative leader in improving the quality of American health care by making information on quality and efficiency more widely available and rewarding health care providers for high performance." Highlights of some of the positive findings on quality of care:

• Medicare has achieved its major purpose of providing the elderly and disabled with access to needed care. Once previously uninsured adults become eligible for Medicare, their use of recommended preventive services increases substantially. (Chart 5:5)
• Only 2.5 percent of elderly adults report not getting needed care, in contrast to 6.1 percent of adults ages 45-64. (Chart 3:1)
• More seniors have a usual source of care, important to assuring the provision of preventive care. (Chart 3:4)
• The proportion of women at least 65 years of age who get mammograms has tripled over the past decade. (Chart 1:2)
• Between 1996 and 2000, the proportion of seniors receiving inappropriate medications declined 37 percent. (Chart 2:5)
• Fewer Medicare patients are dying in the hospital after being treated for certain conditions such as heart attack, heart failure, and stroke. (Chart 1:10)

Despite Medicare's successes, the report outlines large gaps in screening for colorectal cancer, treatment for depression, and control of high blood pressure and high cholesterol. In addition, potentially preventable hospitalizations have increased for certain conditions, as have reported rates of adverse events or complications of care in the hospital. The report shows that:

• Less than half of older adults have been appropriately screened for colon cancer. (Chart 1:3)
• Only 30 percent of patients treated for pneumonia in the hospital got all recommended care. (Chart 1:7)
• There has been little recent progress in boosting immunization rates for flu and pneumonia; one-third of elderly still do not receive annual flu shots and nearly one-half never received the pneumococcal vaccine. (Chart 1:1)
• Although osteoporosis screening has been a covered benefit since 1998, only one-third of women are being screened and one-half have never talked to their doctor about it. (Chart 1:4)
• About half of Medicare patients undergoing selected surgeries did not receive prophylactic antibiotics in a timely manner to prevent post-operative infections. (Chart 2:4)

The quality of care Medicare beneficiaries receive is not related to higher spending:

• States with higher spending per Medicare beneficiary tended to rank lower on 22 quality of care indicators. This inverse relationship might reflect medical practice patterns that favor intensive, costly care rather than the effective care measured by these indicators. (Chart 5:9)
• Several innovative practices show promise for improving quality and reducing costs. In one study, elderly patients hospitalized for heart failure were less likely to be readmitted to the hospital or to die and had lower health care costs overall when they received transitional care from an advanced practice nurse who provided needs assessment, care planning, patient education, and therapeutic support through discharge planning and home follow-up visits. (Chart 6:3)

Provision of care for chronic illness also is a mixed picture. The report shows that less than one-third of depressed elderly patients are receiving potentially effective treatment and only 40 percent of Medicare managed care plan members hospitalized for mental illness in 2003 received recommended follow up care. Diabetes treatment also could be better. Although diabetic beneficiaries are getting their blood sugar and blood lipids monitored, one-quarter are not receiving eye or foot exams as recommended, the report says. The chartbook also highlights areas where there are deficiencies in quality for certain populations. Vulnerable elderly at risk of health problems are not getting screened or treated for falls or urinary incontinence. In addition, minority elderly patients were more likely than white elderly patients to suffer certain potentially preventable adverse events or complications of care, or to receive substandard care. For example:

• Black patients were 2.3 times more likely than white patients to suffer a pressure sore during a hospital stay of at least five days. (Chart 5:1)
• Black patients were less likely than white patients to receive recommended chronic care services, such as blood tests to check on control of diabetes. (Chart 5:6)
• Minorities were less likely than whites to receive some preventive services, such as flu shots and colorectal cancer screening. (Chart 5:2)

Leatherman and McCarthy note that end-of-life care can be improved. Half of patients did not get any or enough emotional support, and one-quarter did not have adequate pain management, according to family members. In addition, the Medicare program can do a much better job of informing beneficiaries about the benefits and services it offers.