I

n my work as a primary care physician, time is a precious commodity. I rarely have enough of it in office visits with my patients. That’s one reason I’m all in favor of Medicare’s free annual wellness visits, though I know that other physicians feel differently about them.

I began performing these exams with my older patients when Medicare began covering them in 2011. They afford me much-needed time to counsel my older patients about the potential benefits and risks of the ever-increasing number of preventive health measures available to them. I don’t simply check off whether a patient is up to date with his or her colonoscopy or other screening tests. (Screening means checking a seemingly healthy person for signs of hidden disease.) Instead, I use this time to talk with my patients about their overall health and goals so I can offer recommendations about their care that are in line with their values and preferences.

There is a delay — sometimes a long one — between having a screening test and possibly benefiting from it. Patients must decide if they want to undergo a test today that may have some immediate risks to detect a disease that could cause them harm in the future but may never do that. For example, an older woman who has a mammogram today may be diagnosed with a small breast cancer. For many of them, this cancer is unlikely to have caused any harm for a number of years and may, in fact, never harm them.

advertisement

Once breast cancer is detected, nearly all older women undergo treatment for it. Yet there are risks associated with treatment. For these reasons, the American Cancer Society and other organizations recommend that older women who expect to live fewer than 10 more years not have screening mammograms. The rationale is that these women are unlikely to live longer as a result of being screened and that screening puts them at risk for experiencing harms related to the diagnosis and treatment of their cancer.

Explaining the nuances of screening and the sometimes difficult-to-understand balance of benefits and risks isn’t easy to do in a minute or so. The Medicare annual wellness exam gives me time to discuss and individualize the benefits and risks of screening for breast, colon, prostate, and lung cancer based on the patient’s risk, life expectancy, and preferences. The visit also gives me time to provide individualized recommendations about the use of aspirin and statin medications for primary prevention of heart disease. Without the annual wellness visit, I would have limited opportunity to engage my older patients in these preference-based decisions.

The more relaxed nature of these visits helps some patients tell me things they might not have mentioned in a visit for an illness like an upper respiratory infection. During wellness visits, patients have told me about bothersome urinary incontinence and troublesome hearing loss. I have been surprised to learn that some patients do not have carbon monoxide detectors at home or have started smoking again. I have learned of patients who are experiencing problems with balance or mobility, leading me to refer them to physical therapy for exercises to prevent falls or possibly for evaluation for a device to help them walk more safely. I have recommended to some patients that they get medical alert devices, and encouraged others to think about with whom and where they would want to live if their health declined.

Many of these issues may not have come up without the time allotted by the annual wellness exam and the prescriptive nudges embedded in it that help me think about my patients’ physical function, social support, and quality of life.

My experience with Medicare’s annual wellness exam has been extremely favorable. I think my patients feel the same way. They often tell me at the end of the exam that they feel well cared for and that they are “very pleased” with the visit.

Newsletters

Sign up for our hospitals newsletter, On Call

Please enter a valid email address.

In a recent First Opinion article, Dr. Ishani Ganguli notes that Medicare annual wellness exams are driven more by doctors offering these visits than by patients asking for them. It’s true that none of my patients scheduled an appointment with me specifically for a “Medicare annual wellness exam,” though some of them came in saying that they were there for a physical. None complained about receiving an annual wellness exam, although a few felt burdened about completing the health risk assessment form that is required as part of these exams.

Unlike Dr. Ganguli, I’m not conflicted about the value of Medicare’s annual wellness visits. Instead, I believe they are a move in the right direction. They let me think about the care of my older patients in a comprehensive manner, rather than struggling to manage each of their health issues compartmentally.

To be sure, Medicare’s free annual wellness visits should be evaluated in order to learn which parts of them work and which don’t. That way we can improve these visits and design systems to support them. Equally important, we should find ways to increase awareness about them among patients and physicians so more older adults have a chance to experience these visits and receive the best care possible.

Mara A. Schonberg, M.D., is a primary care physician at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School.

Leave a Comment

Please enter your name.
Please enter a comment.

  • All I want and need to know is if I am in some way recquired to have an annual wellness exam or is this a free wil type of thing?

    • Norman Caraman

      If you are one of the 20% of us on traditional fee for service Medicare with an individually purchased private Medigap plan, the annual wellness visit is totally optional.

      If you are one of the 35% of us on a private group retiree plan of some type or one of the 35% of us on a public Part C Medicare health plan, the group or the health plan almost certainly covers and might require a true annual physical exam, not one of these useless visits, but I know of none that does.

      If you are one of the 10% of us dually on Medicaid and Medicare, the rules are all changing as we speak; stay tuned.

  • Very helpful in assessing the difference of an annual health exam & a wellness exam. I am 91 & Audrey is 86. We think of preventative medicine is the best way. In addition we prefer not to medicate in order to avoid side effects which could be worse than the affliction. Both of us have potential problems.

  • The problem with the Medicare “Wellness Visit” is that it is not a Physical Exam. People come thinking they are getting a real physical and they are not. Medicare does not cover a routine physical exam. You accurately describe what the wellness visit is. Nothing more than a conversation with the doctor. You cant even touch their belly, listen to their heart or talk to them about their newly diagnosed heart disease.

    • It is actually more than a conversation when done correctly. Sure, the only “physical” part of the visit are bp and weight, but there is a lot of vital information gathered about mental health, diet, sleep, depression, etc. Further, when used inside of a wellness platform this leads to many other assessments. (On average 4). In a good system, many of these assessments are self-assessments completed before the doctor-patient interaction thus making the visit very patient focused.

  • Dear Dr. Schonberg

    What about the problem that you never mention in your little epistle that the “talk” you are describing (which you purposely and inaccurately call an “exam” even though Medicare calls it “visit”) does not involve an exam. Are you just purposely lying to the reader, most of whom know nothing about Medicare?

    • What is the point you are trying to make? Why does she need to mention what you suggest? That is not the point of the visit. You are correct that many people do not understand what this visit is, but they’ve already covered the physical in the Wellcome To Medicare visit. Educating the patient at this time about the AWV would be a good suggestion.

      She rightly sees the AWV as a way to spend more time with the patient asking questions that often never get asked during time-squeezed exams. Better, more patient care. Increased revenue for the doctor while promoting wellness. I don’t see any problems with that.

    • Isn’t the point pretty clear? There is no exam. The author is lying to people. To call something an exam that is not an exam is a lie. I understand lying is the way the left advances its agenda but it is harming and scaring my fellow senior citizens and purposely misinforming people not of Medicare age. Lying to seniors is the most reprehensible activity of the left (out of a long list of possibilities).

      This particular lie is a long-time left-wing lie started by the Obama administration to deceive and confuse people on Medicare. And more important, the intention is to deceive people not on Medicare to think the Patient Protection and Affordable Care Act (PPACA) did something for seniors that it did not do.

      Another example is the Obama administration lie that PPACA gave “free” flu shots to people on Medicare. Flu shots have been part of Medicare and “free” since 1991.

      Another example is the Obama administration lie that PPACA eliminated the donut hole when all PPACA did was reduce the co-pay in the donut hole to 25%, the same as in the Initial Spend Phase. But previously many plans had an effective co-pay in the Initial Spend Phase of 5% or less so all reducing the donut hole co-pay did was increase the initial spend phase co-pay to balance the decrease in the coverage gap.

      Another example is the Obama administration lie that PPACA saved poor seniors on Medicare billions of dollars by closing the donut hole when poor people on Medicare were never (and still are not) subject to the co-pays in the donut hole.

      Lie after lie after lie. I guess nowadays they call it fake news.

      (And you are wrong. The Welcome to Medicare visit is also not an exam. It is basically exactly the same as an Annual Wellness Visit. See page 60 of “Medicare and You, 2017.”)

Sign up for our Morning Rounds newsletter

Your daily dose of news in health and medicine.