Medicare Coverage of Routine Screening for Thyroid Dysfunction (2003) / Chapter Skim
Currently Skimming:
5. The Cost of Coverage
5. The Cost of Coverage
Pages 44-68
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 44... ...
This cost is dependent on the number of people screened and changes in the use of resources that result from screening. This chapter begins with an examination of the effect that Medicare coverage has had on the use of other preventive services and identifies factors from that experience that may be relevant to screening with TSH for thyroid dysfunction.
|
From page 45... ...
b 1993 27.8% 50.9% 1995 38.4% 60.0% 1997 45.7% 65.9% 1999 54.9% 67.4% 2001 61.3% 66.2% aFirst year of Medicare coverage -1981 bFirst year of Medicare coverage -1993 SOURCE: Centers for Disease Control and Prevention, 2001 TABLE 5-1B Use of Preventive Services Covered by Medicare: Mammography and Breast Examination Mammogram & Breast Exam Ever Within 2 Years Year Age 50-64 Age 65+ Age 50-64 Age 65+ 1990 l99l 1992 1993 1994 1995 1996 1997 1 998 1999 2000 70.4% 74.2% 75.0% 78.8% 79.5% 82.6% 83.9% 85.0% 85.2% 86.1% 87.8% 58.9% 64.8% 66.2% 71.0% 71.3% 72.6% 75.3% 76.8% 75.6% 78.6% 79.3% 63.8% 67.0% 67.7% 70.6% 71.9% 74.5% 76.1% 76.9% 77.6% 79.1% 81.2% 54.3% 58.0% 60.7% 64.5% 65.4% 65.8% 67.2% 70.0% 72.4% 73.3% 77.1% aFirst year of Medicare coverage bAnnual mammography covered SOURCE: Centers for Disease Control and Prevention, 2001 Coverage for preventive services has been accompanied by only gradual increases in the use of those services. In the case of pneumococcal vaccine, for example, by 1993 only 27.8 percent of the population age 65 and older reported that they had ever been immunized even though Medicare has covered the service since 1981.
|
From page 46... ...
This appears to have been the case for pneumococcal vaccine significant educational and outreach programs were used to increase immunization rates (GAO, 2002~. The close correlation between the usage of services in the population over age 65 and in younger age ranges suggests that demand for preventive services by Medicare beneficiaries parallels more general trends in society.
|
From page 47... ...
Creation of a preventive services benefit for TSH screening should only affect directly those Medicare beneficiaries who do not already have an indication for testing. To estimate the size of the potential screening population, it is necessary to count only those beneficiaries who would not already be covered for serum TSH testing under current Medicare coverage policy.
|
From page 48... ...
Although many of these diagnoses are obscure, a large number describe conditions that are common in the Medicare population, including diabetes, hypertension, hyperlipidemia, anemia, dementia, cardiac arrhythmias, palpitations, insomnia, fatigue, weight change, and constipation. This would indicate that many Medicare beneficiaries already have an indication for TSH testing and, therefore, should be unaffected by coverage of TSH screening as a preventive services benefit.
|
From page 49... ...
separately from the 414 Hispanic subjects. We estimated the number of subjects who did not have an indication for TSH testing under current Medicare coverage policy by removing from the sample those who appeared to have an indication for testing: · Known thyroid disease: A history of thyroid disease or current thyroid medication use · Hypertension: Systolic blood pressure above 160 mmHg, self-reported hypertension, or current antihypertension medication Current fatigue Weight gain or loss of more than 10 pounds in the past 6 months Hyperlipidemia: Serum cholesterol greater than 240mg/dl Insomnia Current hoarseness Arrhythmia on electrocardiogram or physical examination History of depression Anemia: Men with a hematocrit below 40,women with a hematocrit below 35 Diabetes: Current diabetes medication or history of diabetes Current neurological problem · Current chronic constipation · Current tranquilizer use as evidence of anxiety or insomnia
|
From page 50... ...
. Medicare Claims Analyzing Medicare claims data was the second method the Committee used to estimate the number of Medicare beneficiaries who would become eligible for TSH testing with the establishment of a preventive services benefit.
|
From page 51... ...
To perform this analysis, we created a cohort consisting of 5 percent of Medicare beneficiaries enrolled on January 1, 1997. Using physician and outpatient claims files for 1997, we then examined their submitted claims for diagnoses that are approved for TSH testing under current policy.
|
From page 52... ...
Fewer than 10 percent of these candidates for screening received testing for diabetes or cholesterol; if the remainder of this group were screened for these other conditions instead of being screened for thyroid disease, those who tested positive would have an indication for testing and no longer be considered candidates for screening. For the purposes of our estimates, we have taken the middle figure from Table 5-2, 2.7 percent, as the proportion of Medicare beneficiaries who will be available and newly eligible for serum TSH testing because of the implementation of a screening benefit.
|
From page 53... ...
Under the screening program (Part A) , all people screened would initially receive a serum TSH test, and those with positive test results would receive an office visit, a repeat serum TSH test, and a serum free T4 test to confirm the abnormal results and rule out false positives.
|
From page 54... ...
TABLE 5-3C Components of a Cost Analysis of Screening for TSH: Evaluation and Treatment of Subclinical and Overt Hyperthyroidism Potential Costs Evaluation for treatment of hyperthyroidism Treatment for hyperthyroidism detected by screening detected by screening Potential Savings Amelioration of hyperthyroidism detected by screening Serum triiodothyronine tests Serum antithyroid antibody tests Radioiodine tests Endocrine consultations Office visits for follow-up Serum free T4 tests Serum TSH tests Antithyroid drug or radioactive iodine treatment Blood counts, liver function tests Thyroid hormone therapy for hypothyroidism caused by radioactive iodine treatment Reduction in consultations and tests for unrecognized symptoms of hyperthyroidism (e.g. anxiety, weight loss, cardiac arrhythmia)
|
From page 55... ...
In the absence of sufficient evidence to estimate these health benefits and their associated medical costs, we have estimated the components of a cost analysis that do not incorporate an assessment of the effectiveness of screening: the costs of the screening program and the costs of treating cases detected by screening. For a cohort of 1 million Medicare beneficiaries 65 years or older who were screened, Tables 5-4A and 5-4B provide estimates of the prevalence of thyroid dysfunction that would be detected and the services that would be used to further evaluate and treat those people found to have thyroid dysfunction.
|
From page 56... ...
Endocrine consultation 1,425 1,200 1,500 T4 treatment 2,850 2,400 3,000 Follow-up after treatment (people with either subclinical or overt hypothyroidism) 29,850 13,200 Year 1, after treatment started Follow-up office visits, 2 29,850 13,200 51,600 Follow-up serum TSH tests, 2 29,850 13,200 51,600 Years 2 and beyond Lifelong T4 treatment 29,850 13,200 51,600 Follow-up office visits, 2/year 29,850 13,200 51,600 Follow-up serum TSH tests, 2/year 29,850 13,200 51,600 aPrevalence data for high and low serum TSH concentrations extrapolated from Hollowell et al.
|
From page 57... ...
Follow-up office visits, 3 3,000 1,200 6,450 Serum free T4 tests, 3 3,000 1,200 6,450 Serum TSH tests, 3 3,000 1,200 6,450 Hypothyroidism after radioactive iodine 750 300 1,612 treatment (all treated with T4) Years 2 and beyond Follow-up of group with hypothyroidism after radioactive iodine treatment Lifelong T4 treatment 750 300 1,612 Follow-up office visits, 2/year 750 300 1,612 aPrevalence data for high and low serum TSH concentrations extrapolated from Hollowell et al.
|
From page 58... ...
· There are no recent data (<10 years old) indicating how physicians would evaluate people with overt thyroid disease and no data at all indicating how they would evaluate people with subclinical thyroid disease; nor are there data indicating what proportion of people with either subclinical hypothyroidism or subclinical hyperthyroidism would be treated.
|
From page 59... ...
The price chosen for levothyroxine was the lowest quoted price for 100 tablets of the leading brand name. Tables 5-6A through 5-6C show our cost estimates for each 1 million Medicare beneficiaries screened.
|
From page 60... ...
. cInitial office visits after a screening test is found to be positive in all groups is estimated as requiring more than minimum time Measurement of serum antithyroid peroxidase (microsomal)
|
From page 61... ...
Year 1 Follow-up office visits,C 3 99212 $33.57 Serum free T4 tests, 3 84439 $12.60 Serum TSH tests, 3 84443 $23.47 Hypothyroidism after radioactive iodine treatment (all treated with T4) Years 2 and beyond Follow-up of group with hypothyroidism after radioactive iodine treatment in year 1 Lifelong levothyroxine treatment $0.315/day Follow-up office visits,C 2/year 99212 $33.57 Follow-up serum TSH tests, 2/year 84443 $23.47 Follow-up of all other groups (euthyroid after radioactive iodine and antithyroid drug treatment)
|
From page 62... ...
Follow-up office visits, 2/year $25,174,069 $20,139,255 $5,034,814 $55,430,7 Follow-up serum TSH tests, 2/year $17,600,101 $17,600,101 $38,753,6 Total Cost - Hypothyroidism $98,766,732 $46,567,161 $52,199,571 $206,381, NOTE: Costs after the first year are discounted at 3% per year in the base and lowest cost estimates. No discounting is used in the highest cost estimate
|
From page 63... ...
THE COST OF COVERAGE dicare 63 Highest Cost Lowest Cost ther Payer Total Medicare Other Payer Total Medicare Other Payer $23,470,000 $23,470,000 $23,470,000 $23,470,000 dicare Highest Cost Lowest Cost ther Payer Total Medicare Other Payer Total Medicare Other Payer 566,160 $2,830,800 $2,264,640 $566,160 $2,830,800 $2,264,640 $566,160 $1,408,200 $1,408,200 $1,408,200 $1,408,200 $756,000 $756,000 $756,000 $756,000 $1,016,500 $1,016,500 $203,300 $203,300 $328,580 $328,580 $87,240 $87,240 18,341 ,071,935 $1,065,069 $852,055 $213,014 $236,682 $189,346 $47,336 $5,529,483 $5,529,483 $1,228,774 $1,228,774 73,285 $122,550 $98,040 $24,510 $98,040 $78,432 $19,608 324,260 $341,326 $341,326 $273,061 $273,061 100,826 $3,464,424 $2,771,539 $692,885 $886,248 $708,998 $177,250 $1,401,159 $1,401,159 $1,401,159 $1,401,159 12,659,951 $93,932,950 $93,932,950 $18,864,702 $18,864,702 ,034,814 $55,430,784 $44,344,627 $11,086,157 $11,132,252 $8,905,801 $2,226,450 $38,753,664 $38,753,664 $7,782,959 $7,782,959 '2,199,571 $206,381,489 $93,995,005 $112,386,484 $47,189,417 $23,786,076 $23,403,341 ,t estimates.
|
From page 64... ...
No discounting is used in the highest cost estimate
|
From page 65... ...
THE COST OF COVERAGE dic are 65 Highest Cost Lowest Cost ) ther Payer Total Medicare Other Payer Total Medicare Other Payer )
|
From page 66... ...
In the case of serum TSH testing, more than 90 percent of Medicare beneficiaries have indications for testing that are already covered by the Medicare program. Aside from beneficiaries with known thyroid disease, fewer than 25 percent of beneficiaries with these indications are tested annually.
|
From page 67... ...
THE COST OF COVERAGE TABLE 5-7A Cost Estimates Based on Size of Screening Population: Initial Screening Tests - Cost to Medicare 67 Number Screened Base Lowest Highest 250,000 40,000 2,500,000 $5,867,500 $938,800 $58,675,000 $5,867,500 $938,800 $58,675,000 $5,867,500 $938,800 $58,675,000 NOTE: No payment by other sources TABLE 5-7B Cost Estimates Based on Size of Screening Population: Follow-up and Treatment for Suspected Hypothyroidism Number Screened Base Lowest Highest Medicare 250,000 40,000 2,500,000 Other Payers 250,000 40,000 2,500,000 Total Cost 250,000 40,000 2,500,000 $11,641,790 $1,862,686 $116,417,903 $13,049,893 $2,087,983 $130,498,928 $24,691,683 $3,950,669 $246,916,831 $5,946,519 $951,443 $59,465,190 $5,850,835 $936,134 $58,508,353 $11,797,354 $1,887,577 $117,973,543 $23,498,751 $3,759,800 $234,987,512 $28,096,621 $4,495,459 $280,966,211 $51,595,372 $8,255,260 $515,953,722 TABLE 5-7C Cost Estimates Based on Size of Screening Population: Follow-up and Treatment for Suspected Hyperthyroidism Number Screened Base Lowest Highest Medicare 250,000 40,000 2,500,000 Other Payers 250,000 40,000 2,500,000 Total Cost 250,000 40,000 2,500,000 $2,132,865 $341,258 $21,328,646 $638,067 $102,091 $6,380,671 $2,770,932 $443,349 $27,709,316 $958,602 $153,376 $9,586,019 $269,582 $43,133 $2,695,818 $1,228,184 $196,509 $12,281,837 $5,224,210 $835,874 $52,242,102 $1,592,459 $254,793 $15,924,593 $6,816,670 $1,090,667 $68,166,696
|
From page 68... ...
What can we learn from prior experience of Medicare reimbursement for screening and clinical preventive services. Presentation at Institute of Medicine Workshop on Screening for Thyroid Dysfunction.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.