BMJ  2005;330:E337-E338 (12 February), doi:10.1136/bmj.330.7487.E337

BMJ USA: Editorial

The "Welcome to Medicare" visit: a chance to raise the profile of prevention among older adults

Americans receive only half of recommended clinical preventive services—screening tests, counseling about health behaviors, immunizations—due to deficiencies in the delivery system that extend to therapeutic services as well.¹ Gaps in preventive care are a special concern, however, because of their importance in maintaining the health of the population and in stemming the rising incidence and costs of chronic diseases.

The failure of older adults to receive preventive services is exacerbated by special issues. Many seniors live with the misconception that it is too late to benefit from stopping smoking or physical activity, although science suggests otherwise.^2,3 A longstanding impediment has been lack of coverage of preventive services under the Medicare program. The legislation that created Medicare in 1964 authorized coverage only of diagnostic and treatment services, making it necessary for Congress to pass individual laws to provide coverage for Pap smears and other preventive services.⁴

A string of such bills, enacted between 1980 and 2003, has now expanded Medicare coverage to include screening for breast cancer, colorectal cancer, cervical cancer, prostate cancer, osteoporosis, hyperlipidemia, diabetes, and glaucoma, as well as pneumococcal, influenza, and hepatitis B immunizations. But problems persist. For example, some preventive services that are recommended for older adults are not covered under Medicare, and the services that are covered are not always received by beneficiaries.⁵

One strategy to address this problem, which has been advocated for two decades, is for new Medicare enrollees to have a "Welcome to Medicare" visit (WMV), an appointment with their primary care provider devoted to organizing a preventive care plan. The value of the WMV is that it establishes a source of primary care for beneficiaries who lack access, and it provides a dedicated opportunity to emphasize the importance of prevention as patients enter a new phase of their lives. They can be reminded about the benefits of exercise, healthy diet, smoking cessation, and injury prevention, even after years of inattention. Clinicians can underscore the importance of recommended screening tests and immunizations and can either provide these services at the WMV or arrange referrals or future appointments.

The WMV was transformed from an idea to a reality in December 2003, when Congress passed the Medicare Modernization Act.⁶ That law drew public visibility because of its prescription drug benefit, but it also introduced coverage for the WMV, which took effect on January 1, 2005. Under the provisions of the law, new beneficiaries are now eligible for one WMV if it occurs within the first 6 months of the beneficiary's Part B coverage (if their coverage began on or after January 1, 2005).

What the WMV should entail was specified by Congress and clarified in regulations issued in November 2004 by the Centers for Medicare and Medicaid Services (CMS), which administers the Medicare program. The WMV is expected to include a history with special attention to modifiable risk factors for disease; screening for depression, functional ability, and level of safety; selected physical examination procedures; and education, counseling, and referral (see table). Beneficiaries are to be made aware of the preventive services that Medicare covers and provided a written checklist for obtaining them. A notable feature mandated by Congress is that the physician must obtain an electrocardiogram to bill for the WMV. Both the visit and electrocardiogram must be performed for either component to be paid. Further details about the administration of the WMV, including the appropriate billing codes, can be found at the CMS web site.⁷ Resources that detail which preventive services older adults should receive are available, for both clinicians⁸ and patients,⁹ at the web site of the Agency for Healthcare Research and Quality.

View this table: [in this window] [in a new window]   What the "Welcome to Medicare" visit should include

 

The WMV has its limitations. For example, although many of the services mandated by Congress (eg, hearing screening) are evidence-based, the required electrocardiogram and other requirements conform less to current guidelines.¹⁰ It may be difficult in one visit for clinicians to administer the screening questions and provide necessary follow-up counseling, especially in today's pressured primary care environment, and clinicians may consider the reimbursement inadequate. Congress chose not to waive the deductible for the visit. For new beneficiaries who have not met their deductible, the out-of-pocket costs ($110 for 2005, plus coinsurance fees) may dampen patient interest in the WMV, especially among the poor. Finally, one visit is insufficient for preventive care, which requires an ongoing relationship. Not all of the services that can be undertaken at the WMV are covered by Medicare when performed at subsequent visits. Perhaps most importantly, the 46 million existing Medicare beneficiaries are not eligible for the WMV.

Despite these limitations, the WMV represents important progress in the preventive care of seniors. This issue of BMJ USA arrives as new enrollees begin making appointments for their visits, providing an opportunity for a new generation of Medicare beneficiaries (swelled by the baby boom) to work with their primary care providers to apply the principles of prevention to live healthier lives and forestall chronic diseases. Clinicians should use the opportunity provided by the WMV to assess the risk status of patients and encourage the adoption of healthy behaviors. By using the visit to arrange with patients a written plan for recommended screening tests and immunizations, the one-time WMV can bring about a longitudinal improvement in preventive care over time and thereby have a disproportionately large impact on the health care of older adults. Making this exercise systematic for all seniors, by using reminder systems and other evidence-based practice solutions,¹¹ may not be fully covered by Medicare (for established beneficiaries) but would enable all older adults to enjoy the same enhancement in the quality of their preventive care.

Virginia Commonwealth University Fairfax, Virginia swoolf{at}vcu.edu

Partnership for Prevention Washington, DC

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Competing interests: At the time this article was written, SHW was executive vice president of Partnership for Prevention. ABC none.

Acknowledgments: The authors thank J. Michael McGinnis and the staff of the Centers for Medicare and Medicaid Services for their helpful comments on a previous draft of this manuscript.

References

1. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348: 2635-45.[Abstract/Free Full Text]
2. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 2004;328: 1519.[Abstract/Free Full Text]
3. Gregg EW, Cauley JA, Stone K, Thompson TJ, Bauer DC, Cummings SR, Ensrud KE. Relationship of changes in physical activity and mortality among older women. JAMA 2003;289: 2379-2386.[Abstract/Free Full Text]
4. Institute of Medicine. Extending Medicare coverage for preventive and other services. Washington, DC: National Academy Press, 2000.
5. Partnership for Prevention. A better Medicare for healthier seniors: recommendations to modernize Medicare's prevention policies. Washington, DC: Partnership for Prevention, 2003.
6. Coffield AB, Omenn GS, Fielding JE, Long PV, Kamerow DB. The camel's nose is under the tent: opportunities for prevention associated with the 2003 Medicare Act. Am J Prev Med 2004;6: 375-6.[CrossRef]
7. http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3638.pdf.
8. Recommendations of the US Preventive Services Task Force, http://www.ahrq.gov/clinic/uspstfix.htm.
9. Pocket guide to staying healthy at 50+. http://www.ahrq.gov/ppip/50plus.
10. US Preventive Services Task Force. Screening for coronary heart disease: recommendation statement. Ann Intern Med 2004;140: 569-72 http://www.ahrq.gov/clinic/uspstf/uspsacad.htm.
11. Southern California Evidence-Based Practice Center. Interventions that increase utilization of Medicare-funded preventive services for persons age 65 and older. Baltimore: Health Care Financing Administration, 1999.

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