Take on the “Welcome to Medicare” Exam Challenge and Create the Sequel

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• Barbara Resnick, PhD, CRNP, FAAN, FAANP

In July 2004, the Centers for Medicare and Medicaid Services announced plans to cover an initial comprehensive physical examination for new beneficiaries. Beginning in 2005, the proposed rule also covered screening tests for cardiovascular disease and diabetes for those beneficiaries identified as being at risk for these illnesses.

1.Review of comprehensive medical and social history

2.Review of risk factors for depression

3.Review of functional ability and level of safety

4.A focused physical exam that includes height, weight, blood pressure, and visual acuity

5.Performance and interpretation of an electrocardiogram

6.Brief education, counseling, and referral to address any pertinent health issues identified during the first 5 elements of the exam

7.Brief education, counseling, and referral, with maintenance of a written plan (such as a checklist), regarding separate preventive care services covered by Medicare Part B (11 services covered, with the 2 newest ones being cardiovascular disease screening and diabetes screening)

Older individuals turning 65 should be encouraged to give themselves the gift of a comprehensive review of their past medical history and their current health and health-related behaviors and evaluate whether changes can and should be made in health habits. These exams should pull together the individual’s past medical history (family history, prior illnesses, hospitalizations, surgeries, injuries, allergies) and list current medications, supplements, and vitamins. Specific health behaviors to address include alcohol, tobacco, and illicit drug use; diet; and physical activities.

The gift doesn’t end with the review of physical problems. Rather, the Welcome to Medicare Exam should include psychosocial issues, particularly any signs and symptoms indicative of depression. No specific screening tool for depression is required, and the provider “may select from various available standardized screening tests designed for this purpose.”¹ One quick assessment technique recommended by the U.S. Preventive Services Task Force⁴ involves asking 2 questions: “Over the past 2 weeks, have you felt down, depressed or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” An affirmative answer to either has been shown to identify effectively a patient who needs further evaluation for depression.²

A review of functional ability and safety concerns for older individuals (e.g., driving safety, functional falls) is an equally important component of the Welcome to Medicare Exam. Multiple tools are available to help with these assessments,³ and the can include self-report or direct observation of the individual.

The actual physical exam is rather simple, with the only required components being height, weight, blood pressure, and visual acuity (Snellen chart is sufficient). This is supplemented with a required electrocardiogram.

The most exciting part of the Welcome to Medicare Physical is that the provider must use the information obtained from all of these screenings and assessments to educate, counsel, or make referrals that address any pertinent health issues that are identified. A written plan is required for recommended interventions and may be a checklist for preventive care services (Table) authorized under Medicare Part B (11 services covered with the 2 newest ones being cardiovascular disease screening and diabetes screening). Additionally, the development of a patient-specific goal form or a patient contract⁵ are useful techniques to motivate older individuals to initiate and adhere to positive health behaviors over time.

Table. Preventive Services Covered by Medicare Part B

So, nurses, I encourage you to take on the Welcome to Medicare Exam challenge. This covered service is the core of good nursing care. Are you ready to jump in and help our physician colleagues in the completion of these important examinations? The Centers for Medicare and Medicaid Services considers the physician/nonphysician provider time component of the initial preventive physical exam to be equivalent to a 30-minute new patient level-three Evaluation and Management (code #99203). This is clearly a lot to cover in that time frame, and pulling together resources (e.g., preprinted materials about screenings, smoking cessation, etc.) is useful because are forms to guide the provider in completion of all Welcome to Medicare Physical Exam components.

Recognizing that many of us only provide care for older adults who have worn out their Welcome to Medicare (i.e., are much older than 65), we need to celebrate this as a first step in health promotion and disease prevention. We need to continue to work clinically and in our research endeavors to demonstrate that this is a useful allocation of resources. Moreover, we need to ask the important questions such as who follows up to be sure that the behaviors recommended are actually performed by patients? Who provides health promotion to individuals well over 65 years of age and to residents in long-term care facilities?

I encourage us all to take on the Welcome to Medicare Physical Exam Challenge and to get ready for the sequel—the Forever Medicare Physical Exam!⁴

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References 

1. CMS Manual System. Pub. 100-04. Medicare claims processing. December 22, 2004. Available at www.cms.hhs.gov/manuals/pm_trans/R417CP.pdf. Cited March 15, 2005.
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2. United States Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136:760–764
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3. Handbook of Geriatric Assessment. Boston: Jones and Bartlett; 2006;
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4. U.S. Preventive Services Task Force. Screening for hearing impairment. In: Guide to clinical preventive services: a report of the U.S. Preventive Services Task Force. 2nd ed.. Baltimore: Williams & Wilkins; 1996;p. 393–405
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5. Haber D. Health Promotion and Aging. (3rd Ed). New York: Springer; 2004;
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