Hey, Medicare geezers, when was the last time your doctor saw you naked?

 The S.O. and I were chatting the other day, talking about doctor appointments and the annual "wellness" visit with one's primary care physician, and we started wondering just when was the last time either of us had an actual full-blown annual physical. In my case, it was probably in Atlanta. Might be the same for the S.O. In any case, it was before passage of the Affordable Care Act. 

One of the provisions of the ACA is that Medicare will pick up 100 percent of the tab for an annual wellness visit with your primary care physician. No co-pay like there always was (and still is) with an actual physical exam. And, yes, young folk, Medicare has co-pays just like every other insurance plan in the U.S. The stuff it covers (and there's a lot it simply doesn't cover, just like . . .) Medicare reimburses providers 80 percent of what they (Medicare) has decided is a reasonable rate. The patient is on the hook for the other 20 percent, although there are providers who are happy to just get the 80 percent -- they treat it like full payment and never bill the patient for the rest. Those providers are rare.

Anyway, the purpose of the wellness visit is supposedly to just chat with your PCP about your health, raise any concerns you may have, and decide if "further research is needed." This is actually the visit that had right wingers foaming at the mouth because it was originally framed as the moment when your doctor would ask you about care directives, the infamous living will. It got redefined as a time to talk with your doctor without getting naked. An office visit where the doctor and you would talk about your health in general and decisions could be made about what to do next. You know, do you need to actually take your clothes off for a thorough exam? Or maybe get a referral to a specialist? It was quite explicitly not meant to be an actual annual physical exam. 

Except, of course, it gets treated like one. You make an appointment for an 'annual' with your PCP and by default it becomes the wellness visit. Or, as I tend to refer to it, the "yes I'm still breathing" chat. You get your temperature and blood pressure checked, the nurse or technician reviews your record (any new medications? Been to any other doctors since the last time you were in?), and that's about it. Your doctor comes in, asks if you have any concerns, reminds you (if you're a woman) you're overdue for a mammogram, and life moves on. The guy I see will usually get out the stethoscope and listen to me breathe (confirming, I guess, that I'm not a revenant), he'll ask a few ADL-related questions* (e.g., can I still tie my own shoelaces), we'll make small talk about infectious disease (he went to Africa as part of a team responding to one of the Ebola outbreaks a number of years ago, I worked on the journal Emerging Infectious Diseases at the CDC), and we go our respective ways. No feet in the stirrups and an ice cold metal implement being inserted into a very personal space, no quick manual boob exam, no doing a quick scan of exposed skin for odd looking growths. None of the stuff that used to be a routine part of an "annual."

I see this as typical of the Law of Unintended Consequences. The intent of the wellness visit provision was to improve elderly person's health by giving them an opportunity to talk with their doctors. It was meant to be a complement to other routine care, like an actual annual physical. It was not supposed to replace it. But inevitably it did -- a wellness visit takes a lot less time than a full-blown physical, which means more patients can be scheduled in a physician's day, which in turn means more money and reduced expense for the provider. It may seem kind of minor, but when patients keep their clothes on you don't have to worry about providing gowns for them to change into, there's no time being wasted while waiting for patients to undress, there are no supplies like gloves or lube being used, cleaning the exam room between patients is a lot faster and easier. It adds up. 

It also makes perfect sense that in the profit driven model that is the American health care system that the wellness visit would morph into the primary visit. Next step, as we've already seen during the pandemic, is going totally to telemedicine. Health care delivered via telephone and Zoom meetings. We're all really close to being able to list WebMD as our PCP. 

Which, in an odd way, is rather comforting. Back when the annual was truly an annual, I swear every year found me with a new comorbidity. Since it became the 'are you still breathing' visit, no new pre-existing conditions have emerged. I am apparently a heck of a lot healthier now than I was ten years ago. Ignorance can be bliss.

 *ADL - activities of daily life. Questions about ADLs are meant to determine if you're still capable of living independently or do they need to start getting a bed ready for you at the local nursing home.