What doctors wish patients knew about Medicare annual wellness visits

There has been a shift toward focusing on more preventive measures in health care. This can be seen with Medicare annual wellness visits, which have emerged as an element in promoting overall health and well-being among patients enrolled in the government program.

But there is some confusion about what distinguishes a traditional physical exam from the Medicare annual wellness visit. As these terms get used interchangeably, it is essential to clarify their distinct purposes and components to help patients make informed decisions about their health care needs.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two AMA member physicians took time to discuss what patients need to know about annual wellness visits. They are:

• Sarah G. Candler, MD, MPH, an internist in Houston, and a delegate for the American College of Physicians. 
• Kevin Hopkins, MD, a family physician and primary care institute vice chief for Cleveland Clinic. He is also a senior physician advisor for practice transformation at the AMA.

More than a decade ago, “Medicare created this benefit because prior to it, Medicare had never covered a routine annual physical. They only paid for problem-based visits,” Dr. Hopkins said. “So, they created this as a way to give some parity to people who used to be on commercial health insurance and were used to getting an annual physical.

“But what they created was really a visit that only addresses health maintenance and preventive care,” he added. “In fact, included in the Medicare annual wellness visit there is no requirement for an actual hands-on physical exam such as listening to your heart and lungs.”

“It is really just to check on stuff that is not actively going on that you might not have symptoms of—and that’s what makes it different from other types of visits where you usually go in because either you’re sick, you’re not feeling well, there’s something wrong or you already have a disease that you’re managing and want to make sure that it hasn’t gotten worse or ... what to do next for it,” Dr. Candler said.

The annual wellness visit “is really to go looking for stuff that we don’t know is there that we might be able to do something about if we find it.”

“There are a lot of people who use multiple different terms interchangeably—annual wellness exam, annual physical, a checkup, a routine exam and, for pediatric patients, a well-child check,” Dr. Hopkins said, emphasizing that “they really are not the same.”

“When it comes to an annual wellness visit or an annual wellness exam, you come to see your primary care physician, they ask a lot of questions, they address health maintenance—the preventive care that is recommended for your age group,” he explained. “A Medicare annual wellness visit is something that is totally different than what we think of as a regular annual physical.”

Such carelessness with terminology “creates a lot of confusion and sets patients up for frustration, because they come with an expectation and what we deliver is not always aligned with their expectations,” Dr. Hopkins said.

“In order for Medicare to pay for annual wellness visits, at least 11 full months must have elapsed,” Dr. Candler said.

“What the annual wellness visit does is it combines all the recommendations that doctors and other scientists have for how to stay healthy. We like it as that bookmark or placeholder to do some of those reminder things,” she said. “But the reason that one year is a good frequency for it is because a lot of screening tools work best at specific frequencies.”

“There are guidelines that we use to decide what makes a good screening test and those types of things include how frequently,” Dr. Candler said. For example, “these days we know a lot about a colonoscopy and colon cancer. So, for most people, if you have a normal colonoscopy, you don’t need another one for five to 10 years.

“In those cases, we know enough about the disease and enough about the screening tool to know that the right frequency is about five to 10 years for most people,” she added. “Then there are other things that we think we probably need to screen more frequently like breast cancer, depression or anxiety and other conversations that are more important to have more frequently because they can crop up more quickly.”

Annual wellness visits are used “to address preventive care and health maintenance,” Dr. Hopkins said. “If you’ve got a nagging injury, you’ve got a sore knee, you think your blood pressure might be too high—don’t save that up and wait for your annual wellness visit.

“Go see your doctor now so that we can use that annual wellness visit for health maintenance and preventive care,” he added. “The other thing an annual wellness visit is not intended for is to follow up on all your chronic health conditions.”

“When I see a patient with diabetes, high blood pressure, high cholesterol, chronic kidney disease, and congestive heart failure come into their annual wellness visit expecting that we’re going to address all of those things plus all of the health maintenance and preventative care, it creates a conflict of expectations and purpose. There’s not adequate time in the appointment to be able to do all of that,” Dr. Hopkins said.

Annual wellness visits go through screenings recommended by the U.S. Preventive Services Task Force (USPSTF) and vaccines recommended by the Advisory Committee on Immunization Practices and do not include an exam.

“The big things are cancer screenings, screenings for high blood pressure, diabetes and high cholesterol and immunizations,” Dr. Hopkins said. “People tend to think about immunizations with children specifically, but there are lots of routine immunizations that are recommended for adults, especially those with chronic health conditions or over the age of 65.”

“So, it’s probably those three things specifically: cancer screenings, immunizations and chronic-condition screening,” he emphasized.

“Those things get a little bit trickier as you get older,” Dr. Candler said. “If you’re wondering what is due for you, USPSTF actually has a really cool app where you can look up what you might be due for and it asks you things like your age, your sex and gender and those kinds of things to know what your risk factors might be.

“It’ll let you know just what is absolutely recommended. They grade everything and it’ll tell you what they for sure should screen,” she added. “And then a couple things that maybe you and your doctor should talk about for screening that maybe isn’t 100% for you, but could be.”

“Most electronic health records have what’s called a health maintenance tool. These are really useful to show us what the patient is due for based on their age, sex and gender,” Dr. Hopkins said. “So, most EHR systems have a patient portal where the patient can see their health maintenance and what they’re due for or overdue for.” 

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Such electronic flags may spur patients to call “and that triggers a conversation to take place between the primary care physician and the patient,” he said. “And we do what’s called shared medical decision-making.

“We talk about the risks and benefits, the pros and cons, and come to a shared decision between patient and trusted primary care physician about whether to do this test or that test or neither,” Dr. Hopkins added. 

“For patients who are getting ready for this visit, I really like to know if you have medical history sitting around somewhere. It’s great to have an idea of when your last vaccines were—your shingles, pneumonia, flu, COVID-19 and tetanus shots,” Dr. Candler said. “And a list of your last dates of any other screenings that you’ve had such as colonoscopies or mammograms.”

“And then also a family history—things that have gone on in your family so that we know whether you’re due for something ahead of schedule based on your family history and your other risk factors,” she said, noting “this is also the time to think about an advance directive—which is something that says what you would want to do if you were so sick you couldn’t make your own medical decisions—and to have one on file.”

“Many people only come to the doctor when they’re sick or when they’re hurt. And while that may be the time that you feel that you need us most, if we only ever see you when you’re sick or when you’re in pain, we never get a chance to talk about being and staying well,” Dr. Hopkins said. “To most physicians, especially in primary care, that’s something we’re really passionate about—helping our patients get and stay well.”

“Addressing that preventive care, health maintenance, can really save time, money, frustration and hassle down the road by detecting conditions that are brewing early and treating them early to reduce the risk of complications and bad outcomes down the road,” he said. “And it can improve overall health and well-being and quality of life.”

“Annually feels really good for most of us as physicians because it really helps build those relationships so that if and when you do get sick, we’ve at least done the preventive stuff and we can see you for the sick visits and know better how to help you,” Dr. Candler said.