Sorry for this. The original post was done in Word, but I can't cut and paste.
This is going to be long. I'd appreciate the views n how other PCP's practice. I am approaching this issue totally ignoring pay for performance, quality measurements or factors other than trying to practice good medicine and getting reimbursed without artificial incentives.
Our practice is all adult medicine, pretty much 100% with more than one chronic medical issue. For years I have been struggling with the concept of the "Wellness Exam." It has not been a big issue previously since most of the insurances we deal with did not pay for an exam done for no specific problem., and the annual comprehensive exam to review all medical issues served as an adequate opportunity to review vaccinations, refill prescriptions and address preventive health issues. We were told by managers of the few companies that did cover "wellness" that we specifically could not offer any treatment, diagnostic testing, or write prescriptions at a wellness visit (although I did stretch this often.)
Now, of course, with Obamacare things are changing as to coverage, and I foresee a lot more people wanting to get everything done under their "free annual exam." Also, we recently did a review of the USPSTF recommendations, and clearly they are mushrooming at a logarithmic rate. Certainly, they have gone beyond what I can hope to cover in a one hour time slot while addressing several chronic medical conditions. So, maybe the time has come to rethink what to do with this wellness exam and how to use it in our practice as a separate visit from an annual reevaluation. But this brings up a lot of potential problems.
1. I can foresee a LOT of pushback if someone comes in for an annual wellness exam , spends the entire session going over preventive health issues, then is told they will need to make to return for another comprehensive exam to actually deal with their medical issues. However, all the actual medical decision making would be taking place outside of this "wellness" setting and of course is where most of the medically useful energy belongs.
2) What about the physical exam? It is not that useful in the first place, and It seems ridiculous to do two complete physical exams in a brief period of time, yet this seems necessary for reimbursement.
3) It seems most efficient to do a wellness exam first to arrange for screening labs, etc. and then have the patient return to discuss actual medical issues and get refills. If done in the other order, there is no incentive for the patient to return for the preventive health portion, in which case I would not have addressed these factors. However, I can imagine the howls of outrage from a patient who has taken time off work for an annual appointment who is told he or she has to make another appointment to get refills, etc. as we did not address any of their actual medical issues.
4) It is tempting to have a medical assistant do the preventive services checklist ahead of time, but I think there is too much medical decision making necessary. Example: is low dose CT chest screening at age 50 or 55 for a smoker who quit 8 years ago with a 20 pack year history? Recommendations are in conflict. Who must NOT get a live virus vaccine?
So, in summary, how are you all dealing with this?
