Whereas, Medicare law requires that in order for expenses incurred for items or services to be covered, they must be “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”; and

Whereas, the Centers for Medicare and Medicaid Services, as a result of this legislative language, will allow Medicare coverage of preventive services only when 1) the benefit is required by specific legislation (e.g., influenza and Pneumococcal vaccination) or 2) the preventive service can be considered “treatment” because of the presence of related comorbid disease, condition, or symptom (e.g., tobacco cessation counseling for smokers with a smoking-related disease or symptom); and

Whereas, Medicare’s fragmented coverage of evidence-based clinical preventive services reduces or delays Medicare beneficiaries’ access to preventive services, impairs their collective health status, and increases health care costs;  and

Whereas, Many other insurers pattern their benefits after those of Medicare; and

Whereas, AMA policy states that:

“The AMA advocates revision of current Medicare guidelines to include coverage of appropriate preventive medical services” (H-425.992)

“Our AMA will: (1) advocate with the United States Congress for Medicare reimbursement of preventive services; and (2) investigate how Medicare coverage can be extended to evidence-based clinical preventive services without having to change federal law for each preventive service to be covered” (D-390.993)

“Our AMA shall … urge Congress and the Administration to provide coverage for these clinical preventive services by the Medicare program … (and) pursue the provision of preventive services with the intent of also pursuing additional funding added to the Medicare program without any reduction in reimbursement for other physician services or Medicare updates” (D-330.967); and

Whereas, The U.S. Preventive Services Task Force (USPSTF), which is administered by the Agency for Healthcare Research and Quality in the U.S. Department of Health and Human Services, issues recommendations for clinical preventive services based on a rigorous evidence-based review process (http://www.ahrq.gov/clinic/uspstfix.htm); and

Whereas, If Medicare law were to be amended to allow coverage for items or services that are “reasonable and necessary for the prevention, diagnosis, or treatment of illness or injury,” the USPSTF recommendations could serve as the basis for determining which preventive services would be considered “reasonable and necessary”; therefore be it

RESOLVED, That our American Medical Association endorse an amendment to Medicare law that would allow coverage for items or services that are “reasonable and necessary for the prevention, diagnosis, or treatment of illness or injury” (New HOD Policy); and be it further

RESOLVED, That our AMA advocate for this change in federal law, in partnership with other appropriate organizations (Directive to Take Action).

Fiscal Note:

Received: