Medicare Annual Wellness Visit- A Critical Analysis

January 1, 2014

This is written on the first day that ACA, also known as Obamacare, takes effect, an issue so controversial that readers of this essay will have to accept that this is neither an attack or defense of the underlying law.  I will argue that this analysis is important, yet has only been addressed in academic and professional circles.  This essay is about the elderly, those on Medicare, which now begins with the patient being offered this Welcome to Medicare" preventive visit (WTM ref. 1) with an annual followup that is described below.


There is an immediate semantic challenge that must be addressed.  The followup, the Medicare Annual Wellness Visit-or AWV is an interaction between patients, also called "beneficiaries" because they are recipients of a Medicare insurance benefit, and a physician controlled office, yet it is not what usually occur in this setting.   This memo from Empire Blue Cross announcing that they are discontinuing annual examinations explains what AWV is not:  "These services are preventive focused and should not be mistaken for a routine physical."  The term used under this law which is "visit" is used even though the word itself implies a casual non-official interaction.  I will use the word Visit to describe AWV with quotations understood, as it is a misuse of the deeper meaning of the word.


I will be presenting the case against AWV, and will only briefly define the consensus of government and medical interests that support it, as to the best of my knowledge there has been no openly published dialogue on the perspective I am presenting.  I am taking the position that this Visit, far from being a casual get together, has profound implications for our society on many levels. There has been no previous examination of the adverse effects expressed in this essay, therefore the refutation, the opposing argument is not conveyed as such. Unlike a legal arguments with briefs from both sides, this is one side of the issue, that while written to make a point, is also an invitation for a substantive rebuttal, that will lead to a further public discussion.  For these reasons this essay is a polemic that will focus on the unfounded assumptions inherent in the official expanation, the obfuscation of them to the beneficiary-patient, and the long term effect this augers for societal and individual perception of aging.

AWV is representative of a larger movement of expansion of public health interests over that of the individual.  Ironically, this larger issue has only captured the public's attention over one element of the initial visit, "Welcome to Medicare" which is now described as: "An offer to talk with you about creating advance directives."  Because this issue became politicized during the legislation, characterized as part of a death panel,  of all the evaluations, tests, and discussions that are mandated in WTM-AWV series, only this one must be first described to the patient, and permission obtained before proceeding.  I happen to agree that this information for every patient is important to have on record, and it certainly is not a conspiracy defined by the words, "Death Panel."  Yet, the treatment of the  question of advanced directives illustrates how easily it would be to have considered the autonomy by the patient, the need for them to be ready to discuss a given issue with a given professional.

At this point it is important to understand this essay is about societal norms that transcend health care policy.  These two interactions, initial and subsequent, will be between a patient and a medical professional.  If every such interaction were with a familiar, knowledgeable, unhurried, idealized physician, this would hardly be an issue.  Such a Doctor internalizes the sensitivity and concern for his/her patient that negates many of the issues I raise.  Yet the reality is often quite different, and will be more so given the changes of systems, group practice and other mandates of ACA.  The epitome of the impersonal nature of the questioning is that companies are offering to do a part of these session on line, to relieve the physician of spending time with patients and increasing profits (their sales pitch, not my evaluation)  How closely will the physician "directly supervise" the registered dietitian or nutrition professional" who may do the mandated assessments such as for depression or cognitive decline?  These are complex subjective experiences for the patient, and a challenge even for neurologists and clinical psychologists who have years of specific training.  


My argument is buttressed by an exacting analysis of a document on AWV now on line by CMS, Center for Medicaid and Medicare Services, which is the major operating agency under Health and Human Services:   Providing the ANW.   (ICN 907786 July 2012).  ANW is described in another CMS document, the 32 page manual (CMS 10110) available on line, Your Guide to Medicare Preventive Services. 

My criticism of ANW is that by its structure, incentives to providers along with the unarticulated assumptions in the presentation to users, it has the effect of exacerbating one of the most debilitating effects of aging.  This is psychological dependency, a relinquishing of autonomy to others-- in the case of AWV,  to an amorphous collection of medical providers selected as much by their political clout, than by evidence of professional efficacy.  This service, under the rubric of "preventive care," is so favored that the usual co-payment is waived, so providing a greater incentive to the patient.   It is an all or nothing offer (except for the one item described above) , with the patient not being given the option in advance of evaluating what elements to be reviewed, who will be making what could be life altering assessments. Beyond this major societal adverse effect, at least one of these assessments with dire emotional life changing consequences may be performed by individuals with no appropriate academic background.  Here is a description from CMS (linked above pg 5) of who can provide this visit:

The AWV must be furnished by a health professional, meaning:A physician; A physician assistant, nurse practitioner, or clinical nurse specialist; (I interpret this to mean that the two para-professional groups may operate without direct supervision by a physician, unlike below)
or

A medical professional (including a health educator, a registered dietitian or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician.

Here is the list of the elements of AWV

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Addendum and Notes:

Note 1  My text reads "It (AWV) is an all or nothing offer, with the patient not being given the option in advance of evaluating what elements to be reviewed"  There is one exception to this which illustrates the political nature of this AWV, for better and for worse.  One element of the initial Welcome to Medicare visit was to be a discussion of end of life care, whether the individual wanted all efforts to be made to prolong life if he/she were unresponsive in a terminal condition or to be allowed to expired.  This is the single element that became controversial, as it was depicted as part of the accusation of the legislation having "death panels."  A solution was that this discussion must be prefaced by approval by the beneficiary, who could decline to engage in this discussion-this compromise is documented but is not in the current instructions linked above.  Evaluation of depression, something that is inherently part of the deepest levels of an individuals values, relationships, experiences and beliefs, is not optional, and is mandated to be part of the AWV. 

Note 2  There is a large literature of explanation of how the cognitive assessment is to be performed, including on-line testing services.  Some are described in this article that I wrote.  All of the formal assessments are based on standardized memory tests- the assumption being that these correlate with the ability of the individual to function, which is formalized in Activities of Daily Living (ADL) which is a legal concept for long term care insurance.  This N.Y. Times article,Vitamin E Slows Decline of Some Alzheimer’s Patients in Study on the possible therapeutic effects of multidoses of vitamin E, showed no correlation between cognitive tests and ability to function without assistance, ADLs. 

Note 3  This link is an addendum with connection my article in The Humanist focusing on the adverse consequences of cognitive assessment requirement of AWV.  There are two reports, one from the International Journal of Alzhiemer's Disease that supports my contention that the default option should not be disclosure of decline of cognition.  What is fine with approval by patient based on his/her evaluation of the relationship between medical provider, should not be general rule under all circumstances.