Is the Medicare Wellness Exam Mandatory?

Is a Medicare Wellness Exam Mandatory?

Medicare covers a “Welcome to Medicare” visit and annual “wellness” visits.

While both visit types are available to Medicare recipients, recipients aren’t required to participate in either visit type to maintain their Medicare Part B coverage.

Annual wellness visits: Not required, but worth it?

Medicare recipients are eligible for an annual wellness visit once they’ve had Medicare Part B for 12 months or more. According to Medicare.gov,  the goal of the visit is to develop or update a personalized prevention plan, “designed to help prevent disease and disability based on your current health and risk factors.”

Patients complete a health risk assessment, and providers typically complete a medical and family history review as well as take patients’ height, weight, blood pressure, and other routine measurements. Providers may also discuss recommended preventative services and screenings.

In an opinion piece for STAT, “Does Medicare’s free annual wellness visit do any good?”, Ishani Ganguili, MD, an instructor of medicine at Harvard Medicine School and primary care physician at Brigham and Women’s Hospital, questions the utility of the annual wellness visits.

Dr. Ganguili says that while the exam requires clinicians 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. . .Little is required in the way of a physical exam beyond checking vision, weight, and blood pressure.”

Patients who see the annual wellness exam as a substitute for an annual physical, therefore, may miss out on the opportunity to be thoroughly examined by a physician as they would be during the annual physical. Medicare does not pay for the comprehensive exam that most people think of when they think of “physical.”

Another potential problem with the annual wellness visits, Dr. Ganguili notes, is that many patients end up with unexpected medical bills from what they thought was a free checkup. While the basic wellness exam is free, if a provider discovers an issue during the visit, like knee pain or a cough, they are allowed to bill for the evaluation of that issue.

In looking at data from the year Medicare first began covering annual wellness visits, 2011, through 2014, Dr. Ganguili and her colleagues found that only 8 percent of those eligible had an annual wellness exam in 2011. Sixteen percent of those eligible had a wellness visit in 2014.  Out of the rather small percentage of eligible patients who are participating in annual wellness visits, they found that non-white patients with higher medical risk who were dually enrolled in Medicare and Medicaid were the least likely to receive an annual wellness exam.

While Dr. Ganguili says the exams represent a needed effort to direct more resources and attention towards primary care, she also says we must ask the same question of them as we should of all healthcare programs: “Does it have a measurable impact on the outcomes we care about, like keeping patients healthy and out of the hospital?”

More patient outcome data is needed to determine whether more resources should be invested in increasing access to and utilization of annual wellness visits.

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