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.
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.
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.