Medicare to improve access to prevention, mental health services: Congress passes bill over president's veto.

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Thanks to recent changes to the Medicare program, access to preventive and mental health services will soon be getting easier for millions of older Americans.

In early July, Congress overrode President Bush's veto of the Medicare Improvements for Patients and Providers Act of 2008, securing new procedures for prevention services, creating parity for mental health co-payments, blocking cuts in physician payments and strengthening protections for low-income beneficiaries. The new measures garnered praise from a number of public health advocacy organizations, including APHA, which had strongly advocated for an improvement in how preventive services are added as well as equal access to mental health services for Medicare's 44 million beneficiaries.

"This bill is a victory for our nation's seniors and individuals with disabilities," said APHA Executive Director Georges Benjamin, MD, FACP, FACEP (E). "It provides those enrolled in the Medicare program with improved and affordable preventive and mental health benefits and also ensures they have access to the providers they need."

According to the new law, the U.S. health and human services secretary now has the authority to add preventive and early detection services to Medicare that receive grades of an "A" or "B" from the U.S. Preventive Services Task Force. Previously, such measures had to go before Congress before they could be incorporated into the national health care program. In addition, the eligibility period for beneficiaries to take advantage of a "Welcome to Medicare" visit--a preventive physical examination--was extended from six months to one year, and the deductible for the visit was eliminated. Mental health also received a boost, with the new law bringing Medicare co-payments for outpatient mental health services into agreement with other medical services. Over the next six years, the current 50 percent coinsurance rate for mental health services under Medicare will phase out to 20 percent--the same rate for other medical outpatient services. The law also blocked a more than 10 percent cut in Medicare physician payments as well as pending payment cuts through Dec. 31, 2009. Limits on cost-sharing for low-income Medicare beneficiaries also made it into the final bill.

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John Clymer, president of Partnership for Prevention, called Medicare's new preventive services procedure a "huge milestone," adding that it is a "major step toward putting prevention on a level playing field with diagnostic and therapeutic procedures under Medicare." While the Centers for Medicare and Medicaid Services has an orderly process for making Medicare coverage decisions, adding preventive services to the program previously required an act of Congress--a step that is often time-consuming and results in Medicare's preventive services lagging far behind other health sectors, Clymer said. For example, he told The Nation's Health, Medicare did not cover routine mammography until 20 years after the American Cancer Society began recommending it. Similarly, Medicare only began covering cholesterol screenings in 2004, with the congressional passage of the Medicare prescription drug benefit, Clymer said.

"This comes at a good time, because there's an increasing realization among lawmakers, the public and with the health policy community that we need to push our health care investment upstream," Clymer said. "In addition to maintaining our leadership in treating disease, we need to become leaders in keeping people healthy and this is a significant milestone toward realizing that vision."

For more than a decade, Partnership for Prevention has been advocating that lawmakers change the way preventive services are added to Medicare, first testifying before Congress on the subject in 1997. For a long time, Clymer said, "we were a lone voice in the wilderness...it wasn't long ago that no one in Congress would sponsor this, but the tide began to turn in the middle of this decade." With the help of a growing number of advocates, such as APHA and AARP, the balance was tipped in favor of "common sense policy," he noted. Clymer said Partnership for Prevention will continue its Medicare prevention advocacy and will quickly begin pushing to expand tobacco prevention and cessation services. Three years ago, Medicare coverage expanded to include smoking cessation counseling for people with a smoking-related disease, but now Medicare will be able to add smoking cessation as a preventive service, Clymer said.

"This is about value, this is about getting more bang for the buck," he said. "Prevention is a great value ... and helping people stay healthy is the best health care investment we can make."

Clymer noted that Medicare can be a "bellwether" program, as coverage decisions made elsewhere in the health system often follow Medicare's lead. The same Medicare trickle-down effect will, with hope, lend support to ending discrimination in mental health coverage, said Ralph Ibsen, vice president for government affairs at the advocacy group Mental Health America. Bringing outpatient mental health co-payments on par with medical services breaks down a significant barrier for those seeking help with mental illness, Ibsen said. Ideally, he said, the new Medicare law would have simply repealed the higher co-payment--instead of phasing it out over six years--but "given the fiscal environment we're in, the pressure at play in terms of finding offsets and the competing provisions, we understood the dynamics and nonetheless celebrate this achievement," Ibsen told The Nation's Health. He noted that "there is every expectation" that Congress will pass additional legislation this year requiring such mental health parity in employer-provided coverage.

"Given the fact that Medicare law has stigmatized mental illness since its founding ... and the 50 percent co-payment requirement has been a formidable barrier to care for many decades, it's a tremendous step and one that our organization and many others have been working to change for many years," he said. Among older Americans, data suggest that about 20 percent have or will experience a mental disorder, Ibsen noted, and among the population that receives Medicare benefits due to a disability, there are estimates that more than half suffer from a mental illness. Stigmatizing such illnesses and blocking access to treatment not only results in greater suffering, but can complicate and slow down treatment of other health conditions as well, he said.

"The science supports that mental health is fundamental to overall health," he said. "When federal policies allow for meeting mental health needs, we have every reason to believe that we will get better health outcomes and less costly care."

Blocking payment cuts for physicians serving Medicare patients was another provision celebrated in the recently passed law. According to American Medical Association President Nancy Nielsen, MD, a scheduled 10.6 percent cut would have been "devastating to seniors and the disabled who rely on Medicare for the health care they need." The new law gives Medicare physicians a 1.1 percent payment raise, which keeps Medicare physician payments at about the same rate as they were in 2001. During the forthcoming 18-month moratorium on Medicare physician payment cuts, Vicki Gottlich, senior policy attorney at the Center for Medicare Advocacy, said she is looking forward to a bipartisan discussion on how to revise and sustain Medicare's payment system. Advocates need to make sure that doctors are paid "adequately and fairly for their services," Gottlich told The Nation's Health, and that payment structures do not discriminate against providers who serve rural communities, under-served populations and people living on low incomes.

In related Medicare news, the U.S. House of Representatives in late July passed a resolution, known as H. Res. 1368, that would delay action on a White House proposal to cut Medicare spending. The proposal was submitted earlier this year after Medicare trustees pulled what is known as a "trigger," under which Congress could expedite legislation to cut Medicare services or shift more costs to beneficiaries. Created in 2003, the trigger is sounded when more than 45 percent of Medicare expenditures are financed via general fund revenue. However, many advocates define the 45 percent cap as arbitrary, including APHA, which passed policy in 2007 opposing the trigger. As of early August, the resolution had not passed the Senate.

For more information on Medicare's new prevention and mental health measures, visit www. prevent.org or www. mentalhealthamerica.com. For more on the new law, visit www.thomas.gov and search for public law No. 110-275.