Adult Physical Exam Coverage Wackiness

Most Americans understand our healthcare system is fragmented. It can also be rather irrational and today, we want to focus on a single issue, the adult physical exam, to underscore just how irrational coverage can be. In pediatrics there is a well-established approach to the frequency of wellness visits, vaccinations, tests associated with those visits, and how the visits are covered.

When it comes to adulthood, however, that’s another story.

To my recollection, the well care “movement” advanced significantly in the 1980s when large for-profit insurers began to offer managed care products like HMOs. It is sound practice to encourage contact with physicians or other providers for both prevention and early detection of disease. But there was also a gimmicky aspect to this “movement.” Historically coverage had been largely for “illness and injury” and promoting these fairly new organizations as supporting “well care” rather than “sick care” had a compelling marketing component.

The Affordable Care Act changes of 2014 took this “philosophy” to new heights. An annual exam for an adult is covered through the premium without meeting the deductible and no coinsurance or copayment. But there was a political component to this approach. Even in 2014 when ACA-compliant plans were first offered, it was common for Silver Plans to have a deductible as high as $3000. That would mean that for those for whom coverage wasn’t subsidized, many would pay premiums and have no covered services if they were relatively healthy and had few visits and services during the year. With the annual physical exam being covered through the premium, at least everyone would have some direct benefit from their coverage.

But the ACA changes of 2014 didn’t affect Medicare. Clients are shocked to learn that Medicare does not cover an annual preventive exam/physical. Medicare has a “welcome to Medicare preventive visit” and then an annual wellness visit but these are more risk assessments, not exams. In practice, more well care services are covered for those on Medicare due to how offices code claims. Those old enough to be on Medicare typically have pre-existing conditions so offices commonly add a diagnosis code to, for example, labwork, that for someone not on Medicare would be coded as well care. Nevertheless, the official stance (after almost sixty years of Medicare) remains that comprehensive annual exams are not covered.

In a rational world, evidence-based medical practice would determine the frequency of the annual adult physical, and other screening services, and coverage would follow. Instead, we have comprehensive coverage for the adults not on Medicare, and limited preventive coverage for the adults on Medicare while Longevity Centers and other providers promote services, often on a self-pay basis, in a manner which preys on the fears of older Americans about aging.

Medical evidence should determine what should be covered at a baseline level by both Medicare and sources of non-Medicare coverage. It simply does not make sense that we are told our entire lives to have an annual physical exam but then once we go on Medicare, that is not a paid benefit. But, rationality often has little to do with our healthcare system.

Thanks for reading.