Medicare, the government insurance program for those aged 65 and older and others with certain disabilities, started covering an annual "wellness visit" without charge or co-pay for the first time on Jan. 1. While most of its provisions for patient care are clear, there is still some confusion surrounding the inclusion of a discussion of end-of-life care.
In the initial bill authorizing the wellness visit, the requirement that doctors ask patients if they want to discuss end-of-life care spawned the charge of "death panels" from opponents. When the bill took effect on Jan. 1, liberalized wording prompted physicians to ask individuals if they wanted information on the subject of "advance care planning." Then, just a few days later, the regulatory provision was pulled and the subject no longer has to be mentioned — but that information has not been routinely conveyed to doctors serving Medicare patients.
Another snag in the implementation of the wellness visit is that despite its authorization on Jan. 1, there is no money to pay claims until April 1, according to Glenn Ross, an internal medicine physician with the Sentara Medical Group in Port Warwick, half of whose patient visits are Medicare.
Ross embraced the advance-planning requirement and said that patients had taken to it very well. He still has not received notification of a change from either the Center for Medicare Services or the American College of Physicians. He reports that more than 50 percent of his patients say they already have living wills and advance directives for their care. Others say they haven't thought about it, but most of those want to take the relevant literature home with them. Sentara has a 12-page handout that includes forms for a living will and the appointment of a medical agent.
"It's a good thing to bring it up, it initiates a discussion," says Ross. He notes that patients will often cite a family member as the person who'll take care of their medical decisions, so this helps them to formalize the arrangement.
O.T. Adcock Jr., a family medicine physician with Riverside Medical Group and service line chief for primary care, emphasizes that the "end-of-life" discussion was always discretionary or voluntary, though he hopes that everyone would have a living will. He adds, "It's a way to make sure a patient's wishes are carried out when they're no longer able to express them. It's a way to protect their assets." He broaches the topic selectively with patients, according to their outlook. "You get to know them, if they'd be interested," he says.
Aside from the lack of clarity on "advanced care planning," the annual wellness visit offers several defined services for Medicare patients, including setting up a personalized health plan. When a patient leaves, says Adcock, he or she should receive a preventive checklist — when the last vaccine was, when the next is due, and so forth. It's also an opportunity to schedule necessary shots, etc.
Medicare now covers a slew of preventive screenings (with some restrictions) — cholesterol, diabetes, bone density, mammograms, pap smears, colonoscopy, prostate, HIV — as well as annual flu vaccinations and a pneumonia vaccine for lifetime protection without a co-pay or deductible. Prior to January 1, all Medicare services carried a 20 percent co-pay. "One would hope that it will bring more people to doctors; that they'll realize they can now go to a doctor even if they're not sick — for wellness, vaccinations and prevention," says Ross.
The wellness visit involves taking the patient's vital signs, a vision and hearing check, family history, inventory of medications and compiling a list of attending doctors. It also includes a cognitive function screening, a basic screening for depression, and inquiries about home safety and any unmet needs for living independently, such as transportation, meals, etc.
"Patients don't understand it initially. They think 'oh great Medicare is paying for physicals. It never has….Essentially, they've taken the Welcome to Medicare visit, made it free, and allowed it every 12 months," says Adcock.
Just as it sounds, a "wellness" visit does not include tending to any medical problems. "It's at the discretion of the doctor. If someone comes in with a runny nose or a rash, it's possible it could be taken care of. If it's a bladder infection, then it would involve a charge and a co-pay. If it's something major, we'd take care of it immediately and reschedule the wellness visit," says Adcock. Ross believes that out-of-pocket costs could shrink dramatically thanks to the preventive care now covered through annual wellness visits. "It will allow physicians to devote time and energy to preventive care and actually be compensated for their time, which is a win-win situation for patients and their health."
And it's also an opportunity for patients to bring up their wishes about advance-care planning, whether or not the doctor initiates the discussion.
For complete information on the changes, go to http://www.mymedicare.gov or call 1-800-633-4227.
New 'wellness visit' and many preventive services now free with Medicare
Status of end-of-life discussions in 'wellness visit' unclear
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