When is a check-up not a check-up?

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Kaiser Health News told the story of a 69-year-old woman who went to a new doctor for her annual check-up, assuming it was covered by Medicare and was happy with the visit until she got a $400 bill.

Most Americans believe in “annual check-ups,” at which your doctor reviews your medical history, gives you a thorough physical and orders lab tests. The actual value of such visits has been questioned, but they are ingrained in our psyche. Such “well visits” are helpful for children, where preventive care, including counseling and immunizations, adds value. It is not of nearly as much value in adults, and the vaunted “executive physical” with its extensive battery of tests has been largely discarded. Yet, most of us still have gotten used to seeing our doctor once a year even if we are feeling fine.

When Medicare was first established, it was specifically geared to treating illness, and preventive care was excluded from coverage. Over the years a variety of preventive measures have been added as covered services, including screening tests and immunizations. The newest addition to this list is the “annual wellness visit,” which is fully covered under Part B. For those who are used to seeing their doctor for an annual check-up, this sure sounds like the same thing, and it does to many doctors as well. Unfortunately, if your doctor conducts this visit in the same way, with a review of your history, a physical and lab tests, you are likely to get an unexpected bill.

The Medicare Annual Wellness Visit is a very limited and specifically described set of services. At this visit, your height, weight and blood pressure are to be measured, but no other physical exam is to be performed. The doctor is supposed to assess your risk of falling, your ability to bathe and dress yourself and whether you are safe at home. You are to be screened for depression and dementia. Medications should be reviewed. A schedule of preventive services should be provided. If you have seen this doctor regularly, these may sound like a waste of time, and they may well be. I rarely did such visits. If at his last visit a patient had told me he had chopped too much wood and was willing to sell me a cord cheap, I would have felt like an idiot “assessing his fall risk.” What the doctor cannot do at such exams is check your blood pressure, tell you it is a bit higher than ideal and adjust your medication. If he or she does this, it is outside the parameters of the wellness visit and not covered. Because of the limited nature of the visit, over half of medical practices surveyed a few years ago did not offer these visits, and only 19 percent of Medicare beneficiaries received one.

What makes it even more confusing is that some — but not all! — Medicare Advantage plans will cover an old-school annual check-up.

So, bottom line: If you have standard Medicare, do not schedule an “annual physical” unless you are prepared to pay for it. Assuming you, like most of us over 65, have some chronic conditions being monitored, you should be able to get a longer visit at which all of these are addressed, and the doctor has enough time to throw in a little more preventive care.

Edward Hoffer is an internal medicine physician and author of Prescription for Bankruptcy: A doctor’s perspective on America’s failing health care system and how we can fix it. He blogs at What’s wrong with health care in America?

Image credit: Shutterstock.com

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