Medicare's missed checkups: Few seniors get wellness exam

The vast majority of Medicare patients will be eligible for free wellness exams in 2011. But unless there is a remarkable turnaround, tens of millions of patients won't get one.

The initial wellness visit for new program beneficiaries, known as the "Welcome to Medicare" exam, has been available since 2005. Even though more than 2 million seniors become eligible for Medicare every year, only about 100,000 of these exams are billed to the federal government each year.

The annual wellness visit, which started in 2011, is designed to serve as a regular checkup for established Medicare patients. The Centers for Medicare & Medicaid Services reported that 298,000 beneficiaries received that service between Jan. 1 and March 23. Unless the uptake rate increases significantly this year, that puts Medicare on track to cover the visits for only about 1.3 million people -- well shy of the more than 46 million who are eligible to receive one.

A lack of physician awareness might be one reason the exams are not more popular. Still, many doctors who know about the services don't offer them. Some point to the time and resources they must expend to offer exams they consider to be of limited value.

The concept of the new wellness exam feels counterintuitive to some doctors who already are providing annual checkups that involve more diagnosis and less recordkeeping. Some look at Medicare's initial welcome visit and note that they can meet practically all the requirements without laying hands on the patient.

"It doesn't fit with what we do," said Joseph Rothstein, MD, an internist in Dallas.

The lack of interest in the exams doesn't necessarily mean that patients aren't getting needed care. The components of the initial wellness visit, including a review of medical history, medication checks and height, weight and blood pressure readings, are incorporated into other services Dr. Rothstein provides. He said the wellness visit isn't set up for the physician to make medical decisions that address a patient's problems -- that's what traditional evaluation and management visits are for.

"If you're my patient and you already come in for regular visits, you're not going to make an extra trip to go through that extra drill," he said.

The new services definitely are a shift from the more traditional injury and illness care coverage provided to Medicare patients, said Ann O'Malley, MD, MPH, a senior health researcher with the Center for Studying Health System Change in Washington, D.C. However, the continued evolution of the services and health system reform might lead to more use of the exams over time, she said.

"I think what Medicare is trying to do is encourage providers to think not just about the complaint a patient may have but also provide forward-looking care," Dr. O'Malley said.

Some physicians are willing to give the new preventive services a chance. Wellness exams allow a patient to take ownership of his or her health, said Douglas Curran, MD, a family physician at Lakeland Medical Associates in Athens, Texas. He said he had yet to provide an annual wellness exam to an established Medicare patient because nobody has asked for one, but he provides about one Welcome to Medicare exam a month to new beneficiaries. The visits allow him to have important discussions with patients about quitting smoking, losing weight and preventing bad outcomes.

"I enjoy and will participate in any opportunity to talk about health care with a patient," Dr. Curran said. "I often only see the ones that don't want to take my advice."

A problematic beginning

Architects of the national health system reform law envisioned how Medicare patients and their physicians would get into a yearly routine for preventive care. The initial annual exam involves creating a screening schedule of preventive services for the patient to follow over five to 10 years. The exam's other components are similar to the Welcome to Medicare visit, both of which carry no extra costs for patients.

Despite this inducement, not everyone sees the value of the exams as laid out by CMS in a November 2010 final rule.

Eric Einstein, MD, an internist at Arbor Medical Group, a three-office practice in southern Connecticut, recalled telling one of his elderly patients about the significant amount of documentation that goes on during the exams.

"She told me, 'Why would I go to the doctor for that?' " Dr. Einstein said.

The group put together a letter encouraging its Medicare patients to opt for a traditional physical instead. The wellness visits can best be described as a counseling service, not a comprehensive history and physical exam, it states. The wellness visit requires height, weight and blood pressure measurements, but it does not cover assessments of the function of the heart, lungs, abdomen and carotid arteries.

The physical, on the other hand, includes reviews of major systems, such as cardiovascular and respiratory checks and an appropriate exam of the body, the letter notes. Medicare does not cover these exams, and patients are advised that they would need to pay for the care themselves. However, patients requiring monitoring for chronic conditions or treatment for illnesses can have the physical exam partially offset when a doctor bills for a covered office visit.

Some physicians who have taken up Medicare on its new offer have been tripped up by statutory limits on the services. Patients must wait at least one year after receiving the Welcome to Medicare exam before receiving the first annual wellness visit, and at least one year between follow-up wellness visits.

Physician assistants, nurse practitioners or clinical nurse specialists can provide the wellness visits in place of a physician or as part of a team, CMS says. A health educator, registered dietitian, nutrition professional or other licensed practitioner working under the direct supervision of a physician also can provide the service.

But the fact that any health professional can offer the service creates problems for physician practices, Dr. Einstein said. The Welcome to Medicare exam and the initial annual wellness visit are once-in-a-lifetime services. A physician who provides one of the exams to a patient who already received the service from a clinic, for instance, won't be paid, he said.

Without notification from the patient, "we have no idea of knowing if a previous exam has been billed," Dr. Einstein said.

The exam's requirements can change over time. Glen Stream, MD, a family physician in Spokane, Wash., provided a Medicare wellness exam to a patient with complex health problems this year, which took him about 30 minutes to complete. But his billing office flagged the service as unbillable, because he neglected to document whether he discussed advance directives with the patient.

Voluntary advance-care counseling was listed as a component to the service in the November 2010 CMS rule, but the Obama administration removed it on Jan. 5 when it proved controversial. Voluntary end-of-life planning remains a part of the Welcome to Medicare visit, as it has since 2009. The confusion about the coverage eventually prompted Dr. Stream's office to forgo filing a claim.

Despite not being paid for that service, Dr. Stream, president-elect of the American Academy of Family Physicians, believes that wellness exams will be a great asset to the Medicare program over the long haul. Regular screenings, such as those monitoring cognitive ability, allows the physician to keep discussing care as the patient ages. For instance, such patients could begin planning for living assistance years before their health deteriorates too much.

"My hope is that physician offices are getting comfortable with the requirements," Dr. Stream said. "Once the bugs are worked out, we'll see more practices promote the service for patients."

A sea change in delivery?

Supporters of health system reform -- and the legislation establishing the Welcome to Medicare exams -- said paying upfront for preventive care is far better than budgeting for health problems later. In the context of a reform effort that largely has been focused on raising the number of insured -- and thus increasing overall service volume -- they cited the exams as one major way in which reform can improve health delivery, not just boost coverage rates.

Seniors advocates, such as AARP and the Medicare Rights Center, backed the new preventive services in part because they are free to the patient.

"The reality is patients call us and say, 'We can't go to the doctor for preventive care,' " said Joe Baker, president of the Medicare Rights Center. "They have to save money for when they actually need medical care."

For physicians, the national payment rate for an initial wellness visit is $161.05, while the Welcome to Medicare service pays $147.80. In 2012, physicians who provide follow-up wellness visits will receive $107.37 if 2011 pay rates are carried over.

Although physicians complain about the adequacy of overall Medicare rates, Leslie Witkin, a physician practice consultant in Orlando, Fla., said the pay for the preventive exam is fairly competitive in relation to what private insurers pay. One practice she works with in northern Florida, for instance, receives an average of $139 for preventive visits from private payers covering Medicare-age patients.

The money Medicare pays "doesn't seem bad at all, especially since there is wiggle room where a physician can approach the annual wellness visit from a team concept," she said.

But the wellness exams might not be able to produce a sea change in health delivery if patients and their physicians don't respond to the inducements.

CMS Administrator Donald M. Berwick, MD, acknowledged that Medicare still has a ways to go in getting people on board. "I think doctors want to engage in prevention activities. As more become aware of the benefit, I think we will see an increase," he said.

Providing more coverage for preventive services is a big step forward for Medicare, he said. Wellness visits can help physicians keep patients healthy by using the time to discuss lifestyle changes, such as quitting smoking or discussing nutrition. Increased utilization of these services should pay dividends in the future, with doctors detecting and managing chronic conditions earlier, he said.

The Medicare agency does not plan to revise what it requires for the wellness visits, but that doesn't mean it's not flexible for physicians, Dr. Berwick said. There is no provision that restricts a physician from going beyond the basic elements of the service, so doctors are free to conduct a physical or full exam when they believe it is necessary.

"We are not [getting] in the middle of the encounter," Dr. Berwick said. "That's important for the patient and the physician to understand."