T

he 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.

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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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  • My family doctor retired and I found a new doctor to take his place. I went a couple of times and wasn’t that impressed. Nevertheless, after a couple of visits I scheduled a “Wellness exam”. In the meantime, my wife tried to make an appt. with her doctor and because she hadn’t seen him in 7 years they either expunged her records or lost them and wouldn’t allow her back in. I suggested she go to my doctor and she did. After my “wellness exam” I got a bill for my visits, and I immediately complained since I had told at least 3 people there that the reason for my visit was a “wellness exam”. After threatening the billing dept. with a call to Medicare, they relented and gave me a “courtesy discount”. This whole medical thing just seems like it’s all about the money, and not the well being of the patient. What happened to the Hippocratic oath? I now see the medical profession as no different than other businesses and it’s fueled by greed.

    • it is my understanding the wellness visit is free. It is a benefit from Medicare. if you need help, email me.

    • It sounds like your doctor didn’t know what the Medicare Annual Wellness Visit is. Which is not surprising..less than 30% of all primary care providers offer the AWV, and most of those don’t follow the Medicare requirements. I wish they had come up with a different name for the AWV, as everyone (patients and providers) confuses it with an annual physical or annual exam which it definitely is not. If your doctor did not follow the guidelines of the free Medicare AWV, then he can not bill Medicare for it or he will be committing medicare fraud. So it then becomes a decision for the practice on whether they want to charge you for copays, etc. for a visit that is not what you specifically asked for.

    • Patricia–my doctor gave up–my stupid Advantage Medicare network decided to ask if a person is planning on traveling overseas– The first time I told them it was none of their business. I called up and asked if this was a required question– They said– NO–so I told them it wasn’t required–When they got snippity about me not sharing my planning, I told them since they were concerned so much- let’s go over my travel immunizations—They leave me alone now

  • For the thousands of Medicare beneficiaries at Bon Secours Health System who received their AWV and were eligible for vaccinations and preventative screening, 40% more beneficiaries received a pneumonia vaccine and 30% more received colon and breast cancer screening than those who did not ge their AWV. Bon Secours’s mission is to serve the poor and the vulnerable.

  • Dr. Ganguli, response to your question depends on who the stakeholders are, their knowledge, and perspectives.

    Statistically, USA and world population is increasingly reaching Medicare program enrollment age. Young and Midle age adults might not take advantage of an annual visits, or might not visit a Medical practice for year or even decades.

    Medical perspective and patient perspective differ. In addition federal & state policies, payment reimbursement models(….code allocation…), insurance providers, are perpetually at adds, or in disagreement.

    It has been my own family’s and possibly million other families experience to encountered unexpected health related issues, with in months of a perfectly clean, yearly, medical exam visit or HWV.
    We can not control destiny’s inflicted and unexpected changes in health but we can certainly prevent the expected.
    So in regard to that limited time with patient – if ongoing communication was enabled via a knowledgeable team, providing follow up, enhancing patient knowledge and supporting the afflicted, that alone would be of tremendous impact. Such communication could reduce anxieties due to disease, treatment, conditions and prevention unknowns. Such medical team to patient interactions could possibly reducing overall health care cost, enhance treatment quality and extend life.

    Following on Anne Llewelyn question, “should it be a must?” Yes, only if it demonstrates to provide added value and benefits.

    I recently, enjoyed listening to at least one patient celebrating her 99th Birthday. Her Daughter and her were checking in for her annual check up. While several younger patients and I awaited our turn, we questioned her about the 99th birthday and smiling she said “I follow Dr. M. Leibo…..’a advise – He knows best”
    We shall all be so sound and healthy to similarly walk right-in, check ourselves before our 99th+ Birthday visits.

    In a perfect (disease and virus reduced) world – healthcare cost should decrease health improve, and life expectancy increase proportionally.

  • I belong to an HMO type of Advantage Medicare Plan. It runs a very tight ship. We go to the large family practice clinics, where the doctor or PA does the Wellness assesment. The NW gleans money by trying to make life-style changes according to Medicare and CDC population prevention/control of obesity, diabetes, Lipids-plaque, etc. To meet these goals, and get extra money for supporting oncology patients-it built a HealthPlex, with a gym, pool, physical, speech, and occupational therapy, counseling, diet-nutrition counseling, weight room (weight lifting specialists didn’t know why women got carpal Tunnel from gripping a vege can. I explained it to them), yoga, exercise groups- etc. A frustrated counselor told me that I needed to walk past my weight bench and be driven to the healthplex and exercise under their supervision-this would cause the network to get more money and it would help other seniors and onocology patients. I drive 5-on-the-floor vehicles with a real clutch-I told them about the vege cans and carpal tunnel syndrome-hands too small to grip the can- They seem to be leaving me alone now. I’m a survivor- and doing well-in spite of Congress and medicare edicts. This is just more than bone density scans-it’s also certified diet counseling, supervised exercise, therapy programs.

  • It does a lot of good for the insurers, especially the Medicare Advantage ones. They get paid for all the Annual Wellness visits they do plus the 360 physicals, home assessments, etc. No wonder I have so many of these exams so close together.

    • What’s a “Medicare Advantage insurer?”

      With the possible exception of the Kaiser Integrated Health System (the third largest public Part C health plan sponsor), almost all public Part C Medicare Advantage health plan sponsor also sell private Medigap insurance, and Part D standalone drug plans, and participate in all other parts of the health insurance market — both as actual insurance companies but more so administering self-insured plans. Five of them also run Original Medicare Parts A and B as MACs. There is no such thing as a “Medicare Advantage insurer.”

    • The MA plans (Medicare Part C) do not get paid for doing the Medicare AWV themselves, although they are still required to reimburse providers for any AWV’s performed by a patient’s own provider.

      Most MA plans have begun sending Nurse Practitioners out to do their own version of the AWV, but the reason is that if they can find more medical conditions on a patient, they can increase the amount they get paid by Medicare. Insurers do not have any set guidelines or Medicare regulations to follow regarding these visits.

      It is very confusing for the patients when the insurer does it’s own visits; plus, none of the information gathered is given back to the patients own provider. It is strictly for the use of the insurance company.

      Medicare has been looking at this practice as potentially creating a fraud situation, but so far have not done anything to keep the insurers from doing their own visits for the purpose of increasing their Medicare payments.

    • Chuck Smith —

      Please stop misinforming people about the public Part C health plan program.
      1. “The MA plans (Medicare Part C) do not get paid for doing the Medicare AWV themselves…” They don’t get “paid” for any particular service; it is capitated fee arrangmene
      2. How the public Part C health plan sponsor deals with the provider is up to the contract with the two. It is true that “they are still required to reimburse providers for any AWV’s performed by a patient’s own provider” if that’s what the contract says. Plus many sponsors are often integrated health delivery systems (Kaiser is the third largest Part C sponsor) so any payment is just some kind of internal bookkeeping.
      3. It is simply not true that “Most MA plans have begun sending Nurse Practitioners out to do their own version of the AWV…” Maybe some are but certainly most are not…
      4. Unlike Original Medicare, most public Part C health plans provide a true annual physical exam and they tend to incorporate the AWV protocol into that (I believe simply to feed some government bureaucracy need for data since an annual physical always included those things anyways)
      4. Sponsors are not doing home visits because “if they can find more medical conditions on a patient, they can increase the amount they get paid by Medicare.” This is a different issue; you don’t need an AWV for this. You just need some coders going over medical records no where near a patient. There is nothing wrong with doing either — home visit or records exam — for this purpose. In fact, many of we seniors like the home visit. The fraud is if you lie about what you find, as United Healthcare allegedly has done (but it denies it vehemently)
      5. “Insurers do not have any set guidelines or Medicare regulations to follow regarding these visits.” Again A. not all public Part C Medicare health plan sponsors are insurers and B. the sponsor is compensated per capita and must provide at a minimum all the services in Original Medicare so it has no specific regulations for these visits because these visits are not covered by Original Medicare (nor does Original Medicare cover hearing services, vision services, dental services, an annual out of pocket spending cap, the physical exam mentioned above, self administered prescription drug coverage, and many other things included in most public Part C Medicare health plans)
      6. “It is very confusing for the patients when the insurer does it’s own visits…” Says who. Seniors I talk to appreciate the convenience.
      7. It is not true that “none of the information gathered is given back to the patients own provider. It is strictly for the use of the insurance company.” A. Again not all sponsors are insurance companies and B. Of course it is (it is absurd to write that)
      8. It is not true that “Medicare has been looking at this practice as potentially creating a fraud situation…” In fact, they are looking at more home services even in Original Medicare. What Medicare is looking at — finally now that the ideologues are out of CMS — is fraud, whereever it occurs (usually not in home visits).

  • I find the comments coming in really disturbing. When people are on Medicare they are usually elder (65 or over) or they have a disability or they have Chronic Kidney disease. What in those three areas, do you not see the need for an annual physical if we want to have a healthier nation?

    • We aren’t complaining about an annual physical–Many of us are talking about the annual wellness check, where we are lectured about diabetes, even if we go into the ER with low glucose-other events like trauma is what caused us to go to the ER-and low glucose seemed to go with the trauma– Actually my low blood sugar was diagnosed by a 17 year old student, who said, “Miss, you seem to have low blood sugar. Ask your doctor about it. You really need a small candy bar about 1:30, you get pale, tired, cranky.” It took me a few years before doctors said– Yes- you are correct– all ER labs show low blood sugar. Only then did they quit trying to lecture me about diabetes.

      I need a healtheir ME. Cannot you understand they are talking about lectures and not providing medical care for real problems like lung cancer?

  • One of the biggest problems with Medicare’s Annual Wellness Visit is that it is misunderstood. Medicare finally figured out that prevention is cheaper than intervention and this is their first step toward that model. Most patients only see their doctor when they are ill. Medicare specifically states that this visit is to be done when a patient is well. It does not include a physical exam, but let’s just admit it…a physical exam is really worthless unless you are checking for a specific condition or problem. Medicare does not pay for an annual physical exam. Physicians don’t understand the AWV, and I would venture to say that if Medicare audited their AWV records, over 90% would fail the audit because they were not actually meeting the AWV requirements.

    I have personally performed over 1500 AWV’s in the last 18 months for patients ranging from 20yrs to 98 years. I can unequivocally say that almost every one of them walked (or rolled) away with a better understanding of their own health and improved ability to care for themselves. When done correctly, the visit can take a full hour but it is well worth it. Based on the preventive screenings ordered as a result of the AWV, we detected 8 early stage lung cancers, 7 colon cancers, 3 prostate cancers, and 6 breast cancers that would have otherwise gone undetected. All but one of these was very early stage and had successful treatment. Every one of our patients also walks away with a complete Emergency Health Record to be used whenever they go to the ER, see a new doctor, or travel…because health information is just not easily accessible in electronic format yet between health systems.

    Now lets talk Medicare Savings: the 1500 AWV’s cost Medicare $240,000. Assuming 2 year survival, lung cancer will cost at least $180,000, colon cancer $150,000, prostate cancer $90,000, breast cancer $93,000. Based on the cancers we discovered, the cost for late stage detection would have been $3,318,000. From just our one clinic we saved Medicare over $3million.

    Overall, I think the biggest problems have been a lack of promotion by Medicare, a lack of understanding by providers, and confusion for patients. However, the potential for improved care is tremendous if the AWV is actually performed as designed.

    • Then you must be one of the very few that does this correctly, which makes it a bigger waste of money and time. My network values speed, but my doctors usually give me more than 15 minutes.

      Below, I told how my husband had heavy asbestoes exposure-non-smoker- he spent years begging for X-Rays. He moved to a different state after the divorce-different medical systems and doctors. He tripped down some steps- broke his shoulder-X-Rays for his shoulder showed a lung filled with cancer- scan showed both lungs completly filled with mesothelioma. He passed 8 months later— Your wonderful system didn’t work for him—They talked to him about his weight, his diet, lipids, exercise, glucose, good that he didn’t smoke. There’s time that talk needs to end, and something needs to be done. That didn’t happen for him. I’ll start on myself—low glucose is a chronic problem- and doctors don’t want to hear that.

    • Your experience seems totally at odds with the “exam” I experienced as a 73 year old healthy Medicare patient. So the quality of the exam and therefore the value of the exam is totally variable and dependent on the provider. Not useful. I would argue that bloodwork, UA (older people don’t like to discuss frequency and painful urination), etc. would find a lot of disease and disability not caught by the “hands off” exam.

    • Well said. I think the problem is that there’s just a lot of confusion around what’s covered in the visit and the intention behind them — to promote wellness and be an occasion to see the doctor, rather than a pure
      diagnostic exam. There really does need to be more informational material from the CMS or other healthcare providers about the purpose of wellness visits so patients understand what they’re getting. Here a few that are worthwhile.
      https://www.medicaresupplement.com/content/medicare-wellness-exam
      http://www.hcma-nb.com/File%20Library/pdfs/Medicare-Wellness-Visit-Forms.pdf

  • Just had my second Medicare Wellness Visit. Last year’s visit was performed by my family doctor, who is quite aware of my multiple health problems.
    This year’s visit was performed by a physician assistant, who did an adequate job and even ordered a bone density test.
    Overall, however, I feel that these “free” visits are a waste time and money.
    Put that MWV back into Medicare to help seniors with their medical problems!

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