The Ghosts in the Exam Room – Part 1

The Medicare Annual Wellness Visit

One of the ghosts in every exam room is the institution that pays many private doctors over ten million dollars, the authority that determines that you can order a BNP (brain natriuretic peptide) to look for heart failure in patients with shortness of breath but not when they have leg edema – you know who I’m talking about – Medicare.

Medicare is not only deciding what services to pay for; they are also scripting entire doctor-patient visits.

As Medicare goes, so goes the nation’s healthcare. Except when it comes to annual checkups. For decades, just about all insurers except Medicare covered annual exams, and even paid pretty well for them. Now that the US Public Health Service Task Force on Prevention has stopped recommending annual exams, Medicare – read Obamacare – has started demanding them. However, they are not paying for the kind of exams patients have come to expect, but a watered-down, scripted event in the spirit of the “Welcome to Medicare” exam that at least yours truly refused to provide from Day One.

I have been brushing off the Annual Wellness Visit (AWV) until now, but it has become a quality indicator that our clinic has to report statistics on, so I need to change my ways.

For the past few days, I have been studying the scripts for the AWV. I have printed up the forms I will need in order to follow the script, since our EMR only has a template for the “Welcome to Medicare” visit, but not for the Annual Wellness Visit.

I have scratched my head about the covered baseline EKG when the USPHS recommends against it, the PSA screening when the evidence doesn’t support it, and several other items on the checklist.

I have duly noted that some clinics, after being audited, have had to call patients back in at no charge to complete missing items on the checklists. I have also noted, although I’m not sure I can comply with, the requirement that any actual physical exam performed during one of these visits requires the patient to sign an ABN (Advance Beneficiary Notice) that they might get a bill that isn’t covered by Medicare. I think I’ll just listen to some hearts and lungs without telling Uncle Sam about it.

Actually, I am a bit surprised that the roll-out of this scripted non-physical didn’t cause more of a stir when it happened. I was only vaguely aware of it. It is quite remarkable that a payer is now micromanaging what happens in the exam room to such an extreme degree.

I am figuratively holding my breath to see what my patients will think of this regimented encounter; they are used to me letting them speak, and me only gently steering the conversation in the exam room. I expect many will feel uncomfortable about the obvious presence of the ghost of the Government in what used to be our private space.

1 Response to “The Ghosts in the Exam Room – Part 1”


  1. 1 Julia June 8, 2014 at 2:06 am

    I am a home health nurse. We do the same depression/home safety eval but my patients are a fall risk with over 12sec TUGO. No matter how high a fall risk they are, getting people to remove the throw rugs is almost impossible. Apparently, the government wants them to SELF-REPORT!! I do not see this happening. Grab bars also do not usually happen as they don’t want to ruin the tile.
    I am a bit younger than you & have seen the same changes in health care. Apparently, we can do a MRI/CT scan with no pre- auth now but heaven forbid either the ER doc or hospitalist actually physically lay hands on a patient with abdominal pain who does feel better in a few days. I could feel the thrill from the AAA just attempting to check a BP.
    My physician who is my age, has given up attempting to manage 2500+ patients & has transferred to a concierge group & will only have about 600 patients. Can’t say I blame her.


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s




Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Bookmark and Share

Mailbox

contact @ acountrydoctorwrites.com

RSS A Country Doctor Reads:

  • Three Little Words
    Newly minted physician Pranay Sinha, opening up about early professional doubts, writes about the comfort a senior colleague’s three words gave: “Dude, me too!” “We need to be able to voice these doubts and fears. We need to be able to talk about the sadness of that first death certificate we signed, the mortification at […]
  • Babies Have Privacy Rights, Too
    Baby picture collages on the walls of doctors who deliver or care for babies must go, according to HIPAA privacy regulations. I must admit, this hadn’t occurred to me until I read this morning’s The New York Times. Baby pictures are as protected as medical records under the law… “I think we have to have […]
  • Hypoliquidemia, a Worrisome New Syndrome
    Margalit Gur-Arie, a frequent contributor over at KevinMD.com, has written about an important syndrome to consider when planning elective, expensive procedures: “Hypoliquidemia is a disease of the financial system. It is characterized by low levels of liquid cash in your bank account, low credit scores and low socioeconomic status (SES). Other signs and symp […]
  • Medico-Legal Integration in Primary Care?
    We have Behavioral Health Specialists embedded in our medical clinics. Now I hear that some clinics are doing the same with lawyers for the benefit of their patients. The New York Times has an interesting article about this: “In the early 1990s, Barry Zuckerman, the chief of pediatrics at Boston City Hospital (now Boston Medical […]
© A Country Doctor Writes 2008-2014. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.