Medicare free visit: I’d rather see a veterinarian

Opinion: A friend went in for his Medicare free “wellness visit,” compliments of the Affordable Care Act (ACA). He assumed it was like a doctor’s annual check-up. After all, when he took his dog to the vet for a wellness visit, little Sparky was examined and tested for worms. So my friend made the mistake of asking the doctor to listen to his heart and lungs – just because that is what we expect physicians will do. Then he got a bill. Neither my friend nor his physician realized that if the patient was actually touched during the free wellness visit, it ceased to be free.

Medicare’s annual free wellness visit includes a review of medical and family history; making a list of current “providers” and prescriptions; measuring height, weight, body mass index, and blood pressure; and giving the patient a schedule and/or referrals for appropriate preventive services. The visit is “free”— the doctor must take “assignment” (be paid by Medicare, not by the patient) and waive the usual 20 percent “co-payment.” The Medicare Part B deductible does not apply.

Physicians and a host of others, including “health educators,” can furnish the visit. Indeed, the California legislature is considering authorizing pharmacists and optometrists to serve as primary care providers. It is likely, since we are struggling with a shortage of physicians, that most offices have nursing assistants furnish the free wellness visit. Or if a physician in a smaller office with fewer personnel chooses to conduct the interview, he is relegated to the role of a scribe.

What patients need is an annual visit to be examined by a physician. They need a visit in which the physician can detect that new asymptomatic heart murmur or discover cancerous or pre-cancerous skin lesions. The Medicare Handbook makes it clear: Medicare does not cover routine physical examinations (average cost, $80 to $200).

Yet Medicare is willing to pay $155.89 for the free wellness visit. Perhaps a better investment would be a physical examination that would allow the patient and the doctor—not an office worker—to connect with one another. We all know the value of human contact for engendering trust in a relationship. Twenty minutes with the physician behind the computer doing data entry is not how most patients expect to spend their precious time during a medical visit.

The wellness visit is neither new nor an improvement over existing Medicare laws. Through the Medicare Prescription Drug Improvement and Modernization Act of 2003 and the Medicare Improvements for Patients and Providers Act of 2008, a physician can actually perform an exam during the once-in-a-lifetime free Initial Preventive Physical Exam (IPPE). The IPPE is a beneficiary’s introduction to Medicare and must be done within the first 12 months of Medicare Part B (physicians’ services) enrollment. This visit focuses on health promotion and disease prevention. It is not a “head to toe” physical examination. Medicare’s payment for this service is also $155.89.

Caveat emptor (buyer beware). The free IPPE does not include any baseline clinical laboratory tests. And if the doctor orders a screening EKG at this visit, the beneficiary is responsible for the co-payment and $147 annual Part B deductible. (Since this is an initial visit, the deductible likely will not have been met). It is important to note that this screening EKG is a once-in-a-lifetime event. Presumably, the bureaucrats don’t care that some 25 per cent of heart attacks are silent, i.e., the patient has no symptoms.

Considering what it actually involves, the free wellness visit looks like a marketing ploy to demonstrate how the ACA would improve our lives. Advocates for ACA make it sound as though the Act would give Medicare beneficiaries a free annual trip to the doctor! In fact, the free wellness visit is mainly a lost opportunity to discover conditions unknown to the patient and for patients and doctors to enhance their special relationship. It is, however, an opportunity for the government to collect data about the patient.

Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and Association of American Physicians and Surgeons (AAPS) member. Despite being told, “they don’t take Negroes at Stanford”, she graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. She was an instructor, then Assistant Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins Hospital in Baltimore, Maryland before returning to California for private practice.

While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers. Dr. Singleton recently returned from El Salvador where she conducted make-shift medical clinics in two rural villages. Her latest presentation to physicians was at the AAPS annual meeting about challenging the political elite.