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Three unrecommended preventive services cost Medicare $325 million annually

by Robin Lasky, Contributing Reporter | May 13, 2021
Business Affairs Insurance
Payments for seven medically unsupported services account for up to $478 million in Medicare spending a year, and of those services, the bulk of it could be attributed to just three.

The new findings come from a study conducted by researchers at UCLA and published this month in the Journal of General Internal Medicine. Their objective was to shed some light on the degree to which Medicare waste results from payments for unrecommended low-value or otherwise harmful services.

To do this, they looked at seven patient-specific services that could be sufficiently identified using the information compiled by National Ambulatory Medical Care Survey (NAMCS) in which the U.S. Preventive Services Task Force (USPSTF) has assigned a D rating.

“The Grade D designation for a particular service requires sound evidence that the service either offers net harm or offers no net benefit to asymptomatic patients," the authors wrote. "Grade D services, therefore, are among the most rigorously developed lists of low-value services to target for reduction."

Of the $478 million the researchers concluded could be saved by excluding coverage for these seven services, just three of them accounted for $325 million in annual Medicare payments. The three services that had the greatest impact on spending included: Screening for asymptomatic bacteriuria in non-pregnant women, Vitamin D supplementation for fracture prevention in postmenopausal women, and screening via colonoscopy or sigmoidoscopy for colon cancer in adults 85 years and older.

Information on cms.gov indicates that two out of these three procedures, asymptomatic bacteriuria screening and Vitamin D supplementation, may already fall under explicit coverage exclusions or otherwise be subject to strict coverage limitations.

“We did not examine whether these services were explicitly excluded from Medicare coverage," study author, Dr. Carlos Oronce, told HCB News. "Therefore one of the limitations is that we were unable to determine if spending on these services fell onto patients as a full out-of-pocket expense or was covered by Medicare."

This may raise questions as to what extent the authors of the study have identified services that ought to be excluded from coverage as a cost-saving measure, rather than having identified improper payments by Medicare for uncovered services, or out-of-pocket payments by individuals or private commercial carriers.

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