Pay A Little, Get A Little: Medicare’s Annual Wellness Visit Misses The Mark

When most of us think of an annual doctor visit, we typically think of the annual physical, the kind we’ve generally received that might have been paid out of pocket but that is more recently covered by private insurance plans. But that’s not what seniors under Medicare Plan B are getting with their “free” annual wellness visit. This consultation lacks the key checklist people have come to expect as part of a routine physical. While a wellness visit may help some on the margins, what many seniors receive will be of little benefit. All this “free” visit just contributes to is the complexity that props up and sustains a perpetually broken healthcare delivery model.

In a wellness visit, you keep your clothes on and have a friendly discussion about ailments, symptoms, diet, exercise habits, mental health, stress levels, one’s enjoyment in life, etc. The quantitative health data collected is just the basics—weight, height, blood pressure, listening to heart and lungs. The exercise is finally crowned by tailored advice to ‘stay healthy.’ Most of this could, and should, easily be handled on a phone call or via remote monitoring or reporting.

Any other testing is not covered here unless you have a defined diagnosis. Then the visit does allow for a more comprehensive ‘physical’ at an expanded reimbursement for the physician and defined co-pays for the patient/consumer. Some physician offices make their healthy patients even come back a second time for the ‘diagnostic’ workup, separating what used to be integrated into one visit into two different visits—‘wellness’ and ‘physical’.

The physical is the real deal, a true diagnostic and health evaluation. It Includes blood work and other tests measuring cholesterol levels, sugar, etc. and yes, the wellness discussion also happens, but the real healthcare work occurs here.

The rub: patients are conditioned to getting it all at once as private insurance picked up much of what was included in what we think of as an annual physical. But at age 65 when Medicare kicks in, what was fully covered the year before, is now split in two, doubling the inconvenience as well as the cost. Half of your old exam, the easy part, is now deceptively advertised as some new commitment to prevention while your real physical is often pushed to another date.

Proponents of Medicare for All describe this kind of initiative as a money saver for Americans. But it adds to the cost by introducing another ‘care’ visit on top of what Americans were accustomed to receiving. The Centers for Medicare and Medicaid Services (CMS) rails against excessive and unnecessary medical billing, accusing practitioners of nickel and diming them, while at the same time adding another layer of codes under the wellness check umbrella. This encourages more fees for service, not less. Doctors should be compensated, but CMS is adding its own smoke and mirrors when they lead people to believe the “wellness visit” is a new and material benefit from Medicare.

The complexity of the game is mind-numbing. To patients, and even most medical professionals, the process is opaque at best. For others it is impossible to navigate. For provider and delivery offices to process and bill CMS correctly for these exams and procedures they need specialized staff who typically do this work exclusively. It is absolutely critical that staff are steeped in an ever-changing array of five-digit Current Procedural Codes - they are a key component of the complexity.

Current Procedural Codes (CPT) number over 10,000, with many revisions which offices are required to incorporate routinely to stay compliant. To get a job in the field an associate's or a bachelor's degree is typically required. Job candidates then have to complete medical coding training which takes several months to accomplish followed by certification exams.

You would think that with all this attention on credentialing the system would be efficient and airtight. Unfortunately, this is not the case. The latest reports reveal that improper payment due to error or fraud, i.e., coding incorrectly or inappropriately, costs CMS over $25 billion a year.

Further, the complexity of this system not only invites fraud and abuse but does nothing to foster trust and transparency between providers and their patients. Patients are not in a position to even verify what is being charged, making disputes impossible or even making informed judgments about the quality of their care.

Meanwhile, the pharmaceutical sector gets hammered for being greedy because of its high prices. Yet pharma accounts for about 15 cents of every healthcare dollar spent. Some of the industry’s greatest inefficiencies rest within the delivery segment where the bulk of the spend resides. Ironically, the current delivery financing mechanism represented by Medicare is pushed as ‘the’ solution to our nation’s problems with healthcare cost and quality. With a wellness visit, providers get two bites at the apple. Payers get billed for two separate visits—only one of which is likely to deliver hard information on which healthcare improvements might be made, and patients have the quality of their visits diluted while being inconvenienced.

Expanding wellness checks to everyone is a band-aid solution to improving overall health. Fee for service, lack of transparency, and the inability of patients to easily shop around make securing accountability across the continuum of care out of reach. Instead, we have a system that drives patients to the highest-priced items on the menu. Expanding this broken system to everyone, as proponents of “Medicare for All” like to trumpet, would be an enormous mistake. Before we expand coverage, we need to fix the fundamentals of a deeply broken system.