CMS incentivizes unnecessary Medicare wellness visits

In November, 2015,  I wrote an essay for Medical Economics detailing how the ethical bind resulting from the Centers for Medicare & Medicaid Services (CMS’s) pay-for-performance (PFP) programs drove me from practice¹. I described how CMS-by financially incentivizing certain clinical actions based on obsolete and/or methodologically-flawed guidelines-forces physicians to choose between doing what is best for the individual patient or doing what will enhance practice revenue.

The Hippocratic Oath directs physicians to act in a manner that advances patient well-being. Yet CMS, by offering financial reward for clinical behavior dictated by other considerations, has created a practice environment at odds with this directive.

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But CMS has not limited its interference in the doctor-patient relationship to its insidious PFP programs alone.  It has also utilized a generous reimbursement strategy to coerce physicians into incorporating the Annual Wellness Visit (AWV) into routine practice. The content of the MWV is almost entirely scripted by CMS, with the physician playing the role of a highly-paid scribe who provides no meaningful expert input regarding the needs of the individual patient. 

Born of the Affordable Care Act, the AWV made its debut in 2011, but for some practices, it wasn’t until several  years later that electronic health record (EHR) templates that captured CMS billing requirements for the AWV became available. Prior to 2011, preventive services such as colon and breast cancer screening, bone density studies, and cholesterol measurement were covered benefits under Medicare, but physician time spent coordinating such testing was not billable. Primary care doctors would, therefore, incorporate health maintenance items like these into periodic problem-focused visits.

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Now, however, not only does CMS cover annual visits with the putative goal of maintaining wellness, it reimburses for these visits at a relatively generous rate.  Medicare assigns 4.58, 4.89, and 3.26 Relative Value Units (RVUs) to “Welcome to Medicare,” “Initial Annual Wellness Visit,” and “Subsequent Annual Wellness Visit” respectively. 

Next: "Ethically problematic"

In comparison, it assigns 2.05 RVUs to a 99213 level follow-up visit and 3.01 RVUs to a 99214 level follow-up.  

CMS is very specific about what is and is not included in an AWV.  Notably, a physical exam is not included.  Since the visits are almost entirely scripted by CMS, documentation requirements are straightforward-satisfied by little more than the doctor clicking appropriate boxes in the electronic health record.

The easy documentation requirements, lack of physical exam, and high RVU reimbursement combine to create strong financial incentives for scheduling AWVs.  As a result, hospital administrators expect hospital-employed physicians to make the AWV a routine part of patient care.  This can be ethically problematic for the physician who already has systems in place to address wellness issues during the course of periodic problem-focused visits.

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The ethical dilemma is due only in part to the primary care physician being pressured to schedule Medicare patients for these unnecessary extra visits every year.  There is also the matter of a lack of evidence basis for the scripted AWV encounter content.  For example, assessment for fall risk is a key component of the AWV, yet there is little evidence that identifying individuals at high risk results in lower rates of hip fracture or head injury.

Some other features of the AWV involve gathering demographic data (asking about race and religion), screening for depression and dementia, and performing updated risk factor analysis for other conditions. Keep in mind that the same requirements apply to the MWV encounter involving a 66-year-old professor who runs marathons and a 96- year- old with dementia and advanced osteoarthritis in the hips and knees.

It is easy to understand why, for those of us already practicing evidence-based preventive medicine in our Medicare patient population, the introduction of the AWV was met with bewilderment.  There is no evidence that a yearly physical/health maintenance/wellness exam has any benefit above and beyond that realized by following an evidence-based health maintenance schedule².

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It is objectionable enough that CMS would financially incentivize these yearly “wellness visits”-and even more objectionable that it would have the institutional hubris to dictate the precise content of such visits, implying a level of expertise that does not exist.

Next: "It is time for us to reclaim our professionalism"

Beyond hubris, CMS has another motive for incentivizing the AWV: It views the AWV as a vehicle for data collection, one that advances federal population health research and policy-making.  Needless to say, usurping the well-established fiduciary.

nature of the individual doctor-patient relationship for the advancement of population health represents a radical departure from accepted ethical practice. 

Further reading: Physicians must harness their power to ensure independence

As stated in the Hippocratic Oath, physicians have a duty to act in the patient’s best interest.  As I have written previously, CMS’s PFP programs-specifically PQRS, Meaningful Use, and now MACRA-interfere with that duty.  The same applies to the AWV.  My colleague, David Norris MD,  suggested in a recent twitter post that physicians consider how they would treat a patient if he or she were self-pay - and then note how care is delivered to the same patient under Medicare. 

The question allows one to take measure of the ethical compromise physicians have had to make at the hands of CMS.  It is time for us to reclaim our professionalism.

1/ Cook, PC. How Perverse incentives are ruining healthcare. Medical Economics. Nov 30 2015.

2. Emanuel, EJ. 2015 Jan 8  Skip Your Annual Physical. New York Times. A23.