Forget Medicare’s “Free” Annual Wellness Exam, We Need Medicare to Cover Annual Physicals
To be our nation’s largest healthcare program, Medicare doesn’t always operate in a way that makes sense. True fact: Medicare doesn’t cover an annual check-up with your doctor.
Federal law actually prohibits Medicare from paying for annual physicals, and patients can be responsible for the entire cost if they get one. This could mean hundreds of dollars in unexpected costs. Because of this, many patients go without regular annual checkups, and serious health conditions can get worse between doctor visits. If you take prescription medications on a regular basis, doctors do need to see you at least once a year, if for no other reason than to review the medications you are taking and update prescriptions.
Although annual physicals aren’t covered, Medicare does provide an Annual Wellness Exam with a nurse that is fully covered with no co-pay or co-insurance. The exam is ostensibly designed to help prevent disease and disability by helping your provider develop a “personalized prevention plan” based on your medical history and current needs. The visit does NOT include any face-to-face time with the doctor though, or much more than a height, weight, and blood pressure check from a nurse. If an Annual Wellness Exam veers away from the specific questions or discusses treatment, whether at the urging of the nurse or patient, Medicare beneficiaries can wind up with co-pays or out-of-pocket costs for the exam.
What it does include are questions — 11 pages (!!) of surprisingly invasive questions that Medicare is collecting about you. After filling out all 11 pages on behalf of my 70-year old brother who has cognitive issues, I have questions about the questions. Why is Medicare collecting this specific type of information, when Medicare doesn’t cover many of the conditions that the questions flag? Will the patient be referred to services in the community that may help?
In the case of my brother, we did not need the wall chart vision test to learn that his eyesight is diminished. Because my brother’s income is so very limited and because he can’t read or manage belongings without high risk of loss and breakage, he’s never opted to get a pair of glasses. But since having the annual exam, so far there has been no effort to refer my brother to any local programs that could help fit him for a free or low-cost pair of glasses.
The following list gives you an idea of the type of questions that you can expect from Medicare’s Annual Wellness Exam:
- Ability to perform tasks of daily living. These are similar to, if not the same criteria used to determine the need for long-term care services and supports. Routine long-term care services are not covered by Medicare. 2 pages.
- Physical and aerobic activity level. 2 pages.
- Nutrition. 1 page.
- Hearing. 1 page. (Hearing services are not covered by Medicare).
- Fall risks. 1 page
- Sleep habits. 1 page
- Behavioral health, tobacco use. 1 page
- Alcohol use. 1 page
- List for you to fill in of your medical providers and suppliers. 1 page
I question how most of the information collected from these exams would be used. The questions do not directly address actual health conditions or medical history. The information collected, however, appears to be of potential interest to private insurers like Medicare Advantage plans, because the information could be used to determine the patients’ “risk scores” which are used to adjust the level of reimbursement from Medicare. The sicker the patient, the higher the reimbursement from Medicare.
In fact, before my brother’s exam was even over, the nurse fished out a packet of information and a free pill organizer from my brother’s Medicare Advantage plan — Humana. His plan is offering gift cards of $25 to $50 for making “healthy choices” such as walking regularly or getting an Annual Medicare Wellness Exam.
According to a recent study published by the journal Health Affairs, in 2015, less than 19 percent of eligible beneficiaries received an Annual Wellness visit. That, in my opinion, is plenty. Congress needs to rethink the Medicare Annual Wellness Exam. These exams are not “free” to Medicare, and the increased cost to Medicare drives up Medicare Part B premiums for all of us. Meanwhile, without linking patients to services and programs in the community, the benefits from these exams, if any, are extremely hard to identify and quantify. On the other hand, the benefits to insurance companies for adjusting rates upward is great.
Instead, I’m far more interested in Medicare coverage for an annual check-up with our primary care doctor. Annual exams help catch changes in our health earlier, when they are easier to treat and can perhaps reduce spending for bigger health problems later on. Even if we still pay our typical co-pay or co-insurance for the visit, that would be a much more valuable new benefit, one with a known track record for helping patients stay healthier, longer.
To learn more about the Annual Medicare Wellness Exam, talk to your primary care doctor, before making an appointment with a nurse. Ask your doctor if the exam would help uncover any new information that he or she doesn’t already know.