As most of you know, there were several giant changes to health care for older Americans in 2010, such as the rollout of the $500,000,000 community care transitions program and the "stand-up" of the Center for Medicare and Medicaid Innovation (CMMI).  There are also many smaller ones.  A new one that started this week, which got attention only for its pseudo-controversial end of life components, is the addition to Medicare of an Annual Wellness Visit--a regular check-up! According to the documents posted on the CMS website, the new visit seems to require several key assessments that are core to quality geriatric care:

b. Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.

d. Detection of any cognitive impairment that the individual may have as defined in this section.

e. Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression

f. Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire

g. Establishment of the following:

  • (1) A written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
  • (2) A list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.

h. Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.

This new benefit is an expansion of the "welcome to Medicare" special visit authorized by the Medicare Modernization Act of 2003, which created for the first time a prevention-oriented, well-person visit within Medicare.  Unfortunately, uptake of that benefit has been slow—apparently only 10% of eligible beneficiaries have used their "welcome to Medicare" visit in their first year of coverage.

This expanded benefit will now be available annually, with no Medicare deductible or co-pay requirement for beneficiaries.  Even better, although the payments for the official visit codes (G0438 & G0439) are not yet available on the CMS website, according to the American College of Physicians website, physicians will be paid on average $172.00 for the first visit and $111.00 for follow-ups.  Given that the history and physical exams required are extensive, as is the documentation, this payment rate should make possible a visit three to four times as long as the usual evaluation and management visit that pays proportionally less.  Even better, this comes on top of the 10% payment "bump" for primary care practitioners (including geriatricians) billing for primary care services. It seems that Medicare is taking giant strides towards becoming a more primary-care-oriented, health promoting, and patient-centered system.

Of course, I hope non-geriatrician primary care physicians and other primary care providers will take this opportunity seriously, get training on the selection and use of appropriate screening tools, learning counseling techniques, build linkages to community resources, and develop systematic approaches to this new work.  Our experience to date is that even such obviously important issues as documenting care plans, recording provider contact information, and fully reviewing prescription drugs and over-the-counter medications and supplements is neither easy nor something that providers do on a routine basis.  I would hate to see this effort fail due to half-hearted implementation.

And of course, for those drawn to controversy, the visits also may include:

Voluntary advance care planning (as defined in this section) upon agreement with the individual.

Note: Voluntary Advanced Care Planning refers to verbal or written information regarding an individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions and whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive.

I, for one, don't see the controversy.  I was under the impression that I was entitled to this stuff already.