The annual checkup is an almost distinctly American ritual. It’s the single most common reason we see our doctors, despite persistent controversy about it (these pro and con articles sum this up well) and thin evidence about whether it does any good.

Prompted by the Affordable Care Act, Medicare followed the lead of private insurers in 2011 and began paying in full for a yearly checkup. This so-called annual wellness visit was designed specifically to address health risks and encourage evidence-based preventive care in aging adults.

The visit is quite prescriptive, requiring a doctor or other clinician to run through a lengthy list of tasks like screening for dementia and depression, discussing care preferences at the end of life, and asking patients if they can cook and clean independently and are otherwise safe at home. Little is required in the way of a physical exam beyond checking vision, weight, and blood pressure.

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Medicare made a hefty investment in this new benefit — by my calculation, the visit fees alone would have come to $5 billion in 2014 if all eligible patients had gotten the visit. Starting this year, Medicare will even throw in a $25 reward to certain patients for making this visit. The American Health Care Act, despite its many catastrophic features, doesn’t touch the ACA’s enhanced Medicare benefits, so the annual wellness visit is likely here to stay.

Yet early research showed that it had a rocky start. At first, many people didn’t know they were eligible, and local adoption has had mixed results. My colleagues and I wondered how these visits were playing out across the country. Using national Medicare billing data, we looked at the adoption of the annual wellness visit from its start in 2011 through 2014, the last year for which data were available. Our results appear in the June 6 edition of the Journal of the American Medical Association.

We discovered that only 8 percent of Americans eligible for the annual wellness visit had one in its first year of operation; that rose to 16 percent by 2014. We saw signs that these rates were driven more by doctors or medical practices offering the visits than by patients asking for them. For example, the chance of getting a wellness visit varied tremendously based on geography — from 3 percent in San Angelo, Texas, to 34 percent in Appleton, Wis. Patients who belonged to an accountable care organization — a group of clinicians who work together to provide coordinated care for Medicare patients — were more likely to get the visits. Nearly half of all annual wellness visits were performed by just 10 percent of the doctors who provided them. We think, and are now trying to confirm, that the doctors and practices that do more of these elaborate visits have had to hire a dedicated nurse or invest in special work processes to make them happen.

Women were a bit more likely to get their visit — 17 percent of eligible women in 2014 compared to 15 percent of men — as were white urban-dwellers who lived in more educated and affluent areas. The single biggest predictor of getting an annual wellness visit in 2014 was having gotten one the year before — 53 percent of patients who had gotten the visit in 2013 followed suit the next year, compared to 10 percent of those who hadn’t.

We also found that many patients may be getting surprise medical bills for these seemingly free checkups. If other problems come up during the wellness visit, like knee pain or a cough, clinicians are allowed to bill for evaluating this problem as well. It turns out this happened in 44 percent of the visits in 2014, validating patient concerns about what should have been free visits, and suggesting that practices need to do a better job telling patients what to expect, ideally well before the visit has started.

I became interested in the annual wellness visit in part because, as a primary care physician, I perform them; about two dozen so far. And I must say that I am conflicted on the subject. I’ve found that the visit can provide a useful space and time to talk with patients about difficult yet important topics that are otherwise crowded out by more urgent issues, such as planning for end of life, and to ensure they are up to date on their colonoscopies, shingles vaccines, and the like. More broadly, these visits represent a well-meaning and needed effort to shunt resources toward primary care; to make an investment, as countries like the United Kingdom have done, in the foundation of health care.

But the reality of the visit can fall short of its intentions — like the woman who sheepishly answered that she wasn’t independent at home because she had hired a cleaning service. The results in our JAMA paper tell us that the individuals getting the visits are more often those who are already well-connected to the health care system rather than the historically underserved, including certain minorities and Medicaid-eligible patients, who may be more likely to benefit from them. As we come up with more sophisticated ways to track aspects of patients’ preventive care needs, an in-person visit dedicated to this purpose starts to feel obsolete.

Is the annual wellness visit the best use of my limited time with my patients? While elements of it are based on solid evidence, the visit itself must answer to the same question that continues to swirl around the ubiquitous original annual checkup: Does it have any measurable impact on the outcomes we care about, like keeping patients healthy and out of the hospital? That is the question we’re hoping to answer next.

Ishani Ganguli, MD, is an instructor of medicine at Harvard Medical School and a primary care physician at Brigham and Women’s Hospital.

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  • If the purpose of the “wellness exam” is to turn people away from wanting t see their doctors, congrats, it’s working.

    What a total waste of resources. Demeaning and annoying. I feel like I’m held hostage by my need for a couple of prescriptions. Gah. Now that I’ve been weighed and measured, and patted on the head, I feel so much better now. Gee, thanks!

  • I just had my first Wellness Visit with my family doctor. I was appalled about it. I didn’t know that it was not really a physical exam and I thought the questions were highly intrusive. The doctor really has no power to help me with most of my problems (like the money questions – is the doctor going to reach into her pocket and pay my bills?). It was totally meaningless. I am age 66, still working full time, and I really didn’t have time for a 19 year old practical nurse to be asking me to draw a clock and remember 3 words. I would much prefer that the government gave me a check for the money they wasted on this program.

  • I am a nurse who performs annual wellness visits. The purpose of an annual wellness visit isn’t to be a physical exam. It is to inform patients of free screening that is available to them based on certain criteria. It helps catch missed opportunities by medical providers and helps close gaps in care. Most providers do not know what screening services are available and what those guidelines are. If a patient views it as a physical exam, then whoever spoke with them from the physician’s office and scheduled them did not know what they were doing. An annual wellness visit is a preventive planning visit for the patient. It covers topics that ARE NOT addressed during a routine physical. A counting backwards test or drawing a clock should not be seen as demeaning. Its a simple method to help rule out cognitive deficiencies. Home safety is assessed because not everyone is able to live independently and an annual wellness visit can help identify needs that can allow that person to continue to live independently. Early detection is crucial with anything. We have caught triple A’s, early breast cancers, assisted patients with obtaining DME’s and a lot of other interventions that can help keep them healthy. Preventative care works.

  • I had ONE wellness check and I found it a complete waste of time. It was demeaning and condescending, in my opinion. I get an annual physical each year and don’t need to be asked if can live independently or count backwards by 7. The questions are redundant and can be quickly accessed during my annual physical. They can ask me if I’m depressed, anxious or whatever during this visit. I will not do another. I have good doctors to take care of all medical needs and give me sound advice for all my ailments. Aging is hard enough without being treated like I’m ready for ‘the home’ before my time!!! This is a huge waste of Medicare money.

    • I agree 100%.l just had physical,all blood work,mamogram,all just fine,l felt Demeaned,l had t remember 3words,write 8.30,on clock face,l could cry,as very intimidating t me.

  • The problem I see over and over is that patients are expecting a physical exam with annual screening labs. They are disappointed to find out that they are not a part of the wellness exam. I have for years just done a quick exam to avoid their disappointment but the lab fees are out of my hands. How do other providers handle that?

    • Whoever is scheduling the AWV’s in your office is not doing it correctly if a patient believes it is a PE. It should be presented to the patient as a preventative planning opportunity or visit. It is not when screening labs should be done or any screening should be done. The patient is supposed to get a personalized plan that informs them of what screening measures they need and qualify for. A patient should have a whole separate visit for screening labs as they are not pertinent to an annual wellness visit.We, the nurse do the visit at my office and the patient is given the recommendations on paper and it’s also scanned to chart and in a simple note.That way the patient can see the guidelines and know what they need. The patient is encouraged to make an appt w the provide to discuss any screenings they feel they would like to have.

    • When the annual Wellness visits first started my doctors told me that it was mandatory. I felt that it wasn’t mandatory and that the doctors were just trying to squeeze more money out of Medicare. I took one the first year and I saw it as a waste f my time and a waste of the doctors time. In fact the doctor didn’t even participate in the actual Wellness Visit, he had a nurse take care of it and I saw the doctor for 5 minutes at the end. I felt that the visit was very condescending toward me as a patient. Having me count backward by the number minus 7, having me draw the time on a clock, asking me questions to see if I was senile.

      I refused to take the Annual Wellness Visit the following year. I called Medicare and asked them if it was “Mandatory” and I was told no, but they suggested that I should take it. When my physicians office phoned me to schedule my next Annual Wellness Visit, I told them I was refusing to participate and I told them I had checked with Medicare and I was told that it was not mandatory. The employee at the doctors office told me it was mandatory but I still refused to schedule a visit. Three days later I received a letter from my doctors office telling me that if I did not schedule a Annual Wellness Visit that I would be “fired by the doctor as a patient”. I called Medicare and I reported this. They told me again that the Wellness Visit is not mandatory. I wrote a letter to the my primary care doctor and told him that I was firing him. I also told him that I had talked to Medicare and reported how he had threatened to fire me as a patient unless I took the Annual Wellness Visit. I found aew doctor and I told them UPFRONT that I would not be participating in any Annual Wellness Visits as I had talked to Medicare and they assured me that the Annual Wellness Visit is not mandatory.

      I just did a search… Is the annual Medicare Wellness Visit mandatory? Here is what I got back at this link that explains why it is not mandatory. https://www.carecloud.com/continuum/medicare-wellness-exam-mandatory/

  • All younger doctors I talk to feel the wellness visit fall far short of practicing good medicine. Now I must pay an additional $250 for a full physical yearly. I guess the medicare program now considers just an expense? Too bad our medical practices have fallen so low for older people.

    • An annual wellness visit is 100% free to you. You pay nothing. Please see my other posts re: what an annual wellness visit should be. It should be specific to you and your needs and is actually a wonderful preventive tool for a patient if the physician office is doing them properly.

  • Just had my first “Wellness Exam”. Tremendous waste of time and money for the Dr., medical staff and myself. Will not take another, I’ll just go when I have a problem. The exam would likely discover very little to nothing. This should be a time to discuss any issues, not just a boilerplate list.

  • Carbon1 first, the Medicare visit is voluntary. if you don’t want it, you don’t need to take it. The exam is preventative. Many people are in need and these test can help those in need. Medicare is a benefit. You should be glad you have it.

    • Well said. The visit is free and informs patients of FREE screening services they should be able to take advantage of to stay as healthy as possible or to help them get healthier.

  • And this my friends is why people hate the ACA. I don’t want to see a doctor for a so called wellness visit, when the end game is to get into my personal business. I resent being asked all kinds of intrusive and ridiculous questions about my home life. I just became eligible for Medicare. I still work because I choose to. I’m the same person I was at 64 years 11 months and 29 days. Pardon me, if I don’t want to answer questions such as “Do you have to hold on to furniture when you walk around your house?” That may be the case some day, and if it happens, I’ll ask for help at that time. Until then, stay out of my business! If I could get out of Medicare, I would.

    • We recently were informed it was time for our yearly ACO (wellness exam). We declined since we have never had one before and are really not interested. One week later my husband and I received letters in the mail discharging us from our Physicians practice because we had declined. We have been with this Physician 3 years and the subject never came up before – so at the moment we are searching for another Doctor – most here in Spartanburg/Moore sc. refuse Medicare patients so us 2 elders are under undue stress and shock that this has occurred.

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