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What You Need to Know About the New, Free Medicare Checkup

The new benefit isn't what you might think

En español | When is a physical not a physical? That's what William Schmitz wanted to know after he went to his doctor for what he thought would be a free Medicare exam and was later charged $70 for it. Other patients who had the same experience say they've been charged up to $400

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Drawing of a doctor giving a reflex exam to patient. What is covered under a Medicare wellness exam?

Be careful what you ask for. A Medicare "wellness exam" differs from a "physical exam." — llustration by: Jon Krause

Schmitz, a retired engineer from Portland, Maine, was pleased when he read that, under the new health care law, Medicare had begun covering annual physicals free of charge. But after he had one, Medicare denied his claim.

"When I asked the doctor's office what had happened, they clued me in that I was mistaken about the difference between [Medicare's] wellness exam and a physical," he says. "I was upset that the way it's set up is misleading."

The official handbook, "Medicare & You 2011," says that "Medicare covers two types of physical exams — one when you're new to Medicare and one each year after that." It describes these as the initial "Welcome to Medicare" physical exam and the yearly "wellness" exam.

Both have value, but neither are what patients and physicians usually regard as a physical. "The annual wellness visit can be performed without the patient ever having to undress, and that sums up the problem," says Yul D. Ejnes, M.D., a practicing internist in Rhode Island and chair of the board of regents of the American College of Physicians.

The federal Centers for Medicare & Medicaid Services (CMS) now acknowledges that using the term "physical exam" in the 2011 handbook is misleading. "This description of the wellness visit has been clarified in the latest Medicare handbook, which is currently being printed for mailing in September," CMS spokesperson Ellen Griffith tells the AARP Bulletin.

Until Jan. 1 this year, Medicare did not cover any routine exams except for the "Welcome to Medicare" exam for new beneficiaries. The Affordable Care Act created the once-a-year wellness visit as a new benefit, paying doctors to perform it and making it free to patients. By the end of June, Medicare had paid for nearly 1 million such visits, according to CMS.

Next: How do you get a free checkup? >>

During a wellness visit, the doctor measures the patient's height, weight, body mass and blood pressure — and perhaps listens to his heart through his clothes. The rest is a discussion of the patient's medical and family history, any physical or mental impairments, and risk factors for potential diseases such as diabetes and depression. The doctor also establishes a schedule for future care, and may refer the patient for other tests and screenings, many of which are now free under Medicare. (See a full list of services covered by the wellness visit.)

In other words, it provides a snapshot of the patient's current health, as a baseline for future yearly visits, and is intended as a preventive service, a way of catching potentially serious health issues early.

"The fact that Medicare is now recognizing the importance of these types of services and is willing to pay for them is a big step forward. That cannot be overstated," says Ejnes. "A lot of times, the counseling that occurs is more important than the poking and prodding. You're talking about weight, smoking, exercise, screening for depression. But it's not what we would normally consider a physical. Hence the resistance we're seeing from physicians offering this service and perhaps a sense of dissatisfaction when the patient leaves and realizes that what they got wasn't what they thought they'd be getting."

Among doctors in general, there is no agreement of what should be done in an annual physical — and some regard it as unnecessary, with no good evidence to show that otherwise healthy patients derive any benefit from it, but even they concede that most patients like it.

Physicians also have varying opinions on Medicare's wellness visit. Some welcome it as a long overdue opportunity to spend 45 minutes talking with healthy patients to help them stay healthy — or perhaps detect, during the conversation, some sign of an issue that merits investigation.

Research has shown that most doctors don't talk to their patients about weight loss or diet, but when they do take time to discuss it, people often act on it. In one study, patients who were obese and advised by their doctors to lose weight were three times more likely to try to lose weight than obese people who didn't receive such advice.

Next: Reduce your risk of illness. >>

Doctors often find it difficult to work a 45-minute wellness visit into an already overstretched schedule. Many say that they've been covering its elements for years in other ways, by working a discussion of preventive measures into a regular visit when examining a patient with, say, diabetes or heart problems. "A lot of this happens on the fly in a primary care practice," Ejnes says.

Patients should also be aware that some physicians do not offer the Medicare wellness visit at all.

Medicare pays doctors according to numerical billing codes they submit for each service. In 2011, doctors are paid about $170 for the first time a patient has a wellness visit (coded G0438) and about $111 for subsequent annual visits (coded G0439), according to the American College of Physicians.

Patients should also be aware that some physicians do not offer the Medicare wellness visit at all. The law does not require them to. "Just as Medicare does not have the authority to tell physicians who they will treat, it does not have the authority tell a physician what services to perform," says Griffith of CMS. "As with any service, if a beneficiary's physician declines to perform the annual wellness visit for any reason, the beneficiary is free to seek care from another physician."

The Obama administration recently launched a nationwide campaign to raise awareness of the new Medicare benefits now available under the law. "Even in your 70s, 80s or beyond, you can reduce your risk of disability and chronic illness if you take care of yourself," CMS Administrator Donald Berwick, M.D., said. "With the new free annual wellness visits and free preventive care, people with Medicare have the tools to take commonsense steps to control their health."

You may also like: How to talk to your doctor. >>

Patricia Barry is a senior editor with the AARP Bulletin.

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