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A Medicare 'benefit' provides wellness exams instead of physicals

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@patriciaborns  While people under 65 will be eyeing the health plans on the marketplace opening Oct. 1, people with Medicare will be getting a 100-plus-page annual benefits handbook from the federal Centers for Medicare & Medicaid Services (CMS) explaining their options. The term wellness exam, or visit, that increasingly fills the healthcare airwaves was coined to clarify a "benefit" of the Affordable Care Act that, according to the AARP and many seniors, may be of less benefit than hoped for.

While the ACA requires insurers to provide wellness benefits, including a physical exam, free of charge in health plans for people under 65, in 2010 it introduced a different kind of exam for seniors. Called a "physical exam" in the original CMS handbook, the once-a-year visit pays doctors, nurses or other staff to perform an introductory exam, and an annual exam thereafter.

The exams according to CMS take the patient's medical history, inventory any medications they're taking, and discuss end of life planning, They can also recommend a very limited set of followups, such as a prostate cancer screening. Both exams can be performed without blood screenings, a doctor, or even without a patient undressing. 

After the free benefit was introduced CMS substituted the term "wellness" for "physical" when seniors complained they weren't getting the benefit they thought they should be. 

Semantics aside, are wellness exams shorting seniors on getting the care they need? A physical exam "includes reviews of major systems, such as the cardiovascular and respiratory checks and an appropriate exam of the body," one doctors' practice advised its Medicare patients, according to the American Medical Association.

Medicare doesn't cover these physical exams -- the patient does. If a patient has an illness or needs monitoring for a chronic condition, the cost of the physical exam can be partially offset through a billing code. 

Wellness visits were rationalized as a preventive tool to save healthcare costs down the road, by managing a patient's care in the context of a healthcare team that includes a doctor, according to CMS. In the future, seniors whose care is provided by Federally Qualified Health Centers (FQHCs) appear likely to have extremely limited access to a doctor's care as the agency proposes to loosen the requirements for doctors' involvement in these health centers. 

The CMS proposal allows a chiropractor or other non-primary care doctor as a substitute for doctor supervision of a FQHC, and does not require the FQHC to have a doctor supervise the health centers' activities on the premises, as is required in other settings today. At the same time, the proposal appears to compensate FQHCs to perform wellness exams at a higher rate -- $201.50 -- than doctors receive.   

The following Medicare compensation figures for a doctor's visit come from the AMA:  

2005	$97.40	 
2006 $92.61
2007 $92.47
2008 $91.41
2009 $92.69
2010 $136.80* n/a n/a
2011 $147.80 n/a n/a

* Physician pay for the exams increased from $133.85 in mid-2010 after enactment of the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.
Source: Centers for Medicare & Medicaid Services

The CMS proposal is open for comments until Nov. 18, 2013.

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