Many insurances will not cover “well” visits anymore if “problems” such as BP, cholesterol are addressed . They can, and do, link payments to practices based on standards of care such as these problems need every 3 month visits or these need every 6month, and it can depend on labs(such as poorly controlled vs well controlled diabetics). Doctors can actually lose out on portions of pay if they see a high % of patients who have uncontrolled diabetes based on lab values (insurance payment goes to cover paying staff, overhead, etc, not into the docs pockets). As if it is the doctor’s fault that the diabetic patients are not controlled. They can refuse to pay the practice if you prescribe antibiotics too much, order too many labs or not frequent enough labs. They can refuse to count a visit as a well-visit if there are any other issues addressed, etc. Most people have no idea how hard it is to deal with the huge amount of HMO, medicare, name-your-insurance rules and still be able to afford good-quality staff and equipment. The standards of care by the way are based on studies that show more frequent med checks or lab checks are associated with catching issues early, especially as you age past 40. Of course, some patients stay very balanced and likely do not warrant the standard frequency, but if your doc allows you to come less frequently than the standard, they are likely taking a cut or seeing you for “free” for some of those visits(when insurance denies the claim).
Many insurers started covering telemedicine visits during covid. I love telemedicine. My doctor will order labs that I can have done at a clinic in the network that is close to my house (just have to stop in and it usually takes 15 minutes or so) and then the doc will either call to discuss (by appt) or just send me a message on MyChart.
I have to have an in-person appt once per year. Either way, in person or telemed, it’s 20 minutes and boy, they really stay on track. I have my questions ready, she answers them. I think I’ve sent questions by MyChart 4 or 5 times during the year, usually about medications.
I also have specialist appts as needed, like eye doctor, dermatologiest, heart check (the doctor wanted that one) and my PCP gets the reports and follows up if any questions.
I think MyChart is the most wonderful thing in the world. My mother has cancer and thus 9 million doctors, and none of them seem to know what the others are doing. She was trying to get a prescription renewed and the pharmacy was sending the renewal to one of the specialists, but he never responded. Her PCP got it done right away. My PCP knew when my dentist prescribed something for me as it was in MyChart.
A friend mentioned the above and that is precisely why DH is taking a low dose statin, because there is some research saying it’s smart, not because of his numbers.
Someone above mentioned “standard of care” and I think that is what I am trying to determine. Did the standard of care recently change, is this an office/company standard or a state requirement.
At the risk of being politically incorrect, the three older MDs have been fine with year long renewals, it’s the mid-levels who are asked, in between MDs coming and going in the practice, and usually it’s an NP who has never met my DH who says 6 months is standard of care. Does that mean MDs are less restricted or does that mean that older MDs (ages 50-70) are comfortable with an older standard, or is it that they have seen him and examined him so are therefore comfortable with his apparent good health. I can certainly understand being conservative when you’ve never met the patient, except there should be a decade of good notes attesting to the examining physician’s assessments.
As @2Devils said, there is a fine line to qualifying for a well check, and now that we are dealing with Medicare, an entirely new set of rules to learn.
Our insurer has never denied any of our visits, even when we see our MDs multiple times/year. Maybe it depends on your insurance? Our neighbors (both in 70s) were told by their hmo only need to get physical every 5 years and then each was diagnosed with cancer and had prolonged and expensive treatments.
We’re thankfully have very good insurance through my husband. His insurance covers us overseas even. Right now my husband pays nothing when he visits his doctors. I have to pay for copays but not for well-check visit. But when I get Medicare I will pay nothing except for premium part B.
I go once a year. Am on two prescriptions.
While I’m not doubting that your neighbors told you that their HMO told them to only get a physical once every 5 years in their 70’s, I would love to know the name of the HMO that said that.
So I could avoid them
Standard of care can vary from place to place a little, but I think in this case it probably comes down to claiming “standard of care” because they are uncomfortable and also uncompensated for filling a prescription for a patient they have never seen. If someone is my regular patient, I know their bp and cholesterol are well controlled, so I can press the yes button for refills on the computer without even having to look in their chart. Takes me not much time. But if I had never even met the patient?! Then I would have to read the previous doc’s notes, pulling up the last labs, pulling up the documentation on when last refills were, all taking a million clicks with the clunky computer chart, wasting precious time I don’t have because I am stressed to the max as a new doc in this practice full of patients I am just meeting and learning. And I would be getting zero money for this but taking on all the liability(because my name is now on the bottle.) No thanks!
My MD wants to see me only once a year, unless something is going on. For DH, who has a potpourri of health concerns, with the same MD it’s every six months. So that might factor into it.
Regarding annual (or otherwise) physicals, it seems like the current term is “wellness visit”, which may be somewhat different from what “physical” used to be.
The HMO was Kaiser Hawaii the cancer treatments they had cost over $1mm, and I think maybe it may have been caught earlier and been less expensive to treat if it was caught earlier for both of them. They both survived the treatments.
@ucbalumnus That’s a great link & summary of the differences. A true wellness exam does not cover much, which is infuriating imho. We discovered this when we changed from employer coverage to Medicare.
One purpose of going to the MD regularly is to catch issues before they become bigger problems. A “hands-on” physical is far better for this than the typical “Wellness” questionaire, which can be done virtually.
I’ve asked others how their MD’s handle it, and have found a wide variety of differences. Some shared their annual exams cover nothing but the Wellness questionnaire. Some say it still includes a light physical. One person I know, goes to a regional clinic for a full and extensive physical exam every year, including labwork and their visit IS fully covered by Medicare.
This is very confusing! Is it all dependent on how it is coded? Do some Advantage plans cover full physicals, while Traditional Medicare does not?
I get one very full physical annually covered by my Medicare PPO Advantage plan. It’s a very robust advantage plan. This includes full coverage for all blood and lab work.
My co-pay for all other visits is $10, so when I go for my six month PCP check in…it’s $10.
Blood tests are fully covered.
The eye doc visits are all $10 co pay as are the specialist visits…doesn’t matter how many times a year I go.
I get a lot more than on the list for my wellness visit. Bloodwork is always done ahead before I see him, otherwise what’s the point. I told him I don’t mind telemedicine but the PA insisted that I came in, so I did. They always took$25 in cash ahead and when I’m done they gave me back $25.
The eye doctor here is 40 per visit, so I see him once a year, but he recommended that I see the specialist more often, last time is to keep a base in case of cataract surgery, this time my eyes have been stabilized for 5-6 years, so I was just silent, not agreeing, not disagreeing either. But the specialist charged me $150 copay and that was 4-5 years ago. I’m not going to see him often, not when my eyes are getting better. My overall health is 100% better. I might have slight cataract but not glaucoma, nothing serious.
@fiftyfifty1 I can absolutely see that point of view, though in this case, it’s all at the same office location for 20 years. The fact that the staff keeps changing since the longtime MD retired is neither the patient nor the mid-level’s fault, but an inconvenience to all. Whether DH has ever seen this current person, perhaps, not sure, but not in the last 2-3 years at least.
Absolutely. An inconvenience for all, as well as a potential danger, because when there is a lot of turnover, nobody really knows you as a patient. When a location seems to be in perpetual turnover you have to ask yourself if it is worth staying.
The reason my neighbors switched from BCBS PPO to Kaiser HMO was because their primary care MDs would retire or leave and not transfer their care and they got tired of hunting for new primary care MDs.
It has been a bit of a challenge but so far I and my extended family have always managed to obtain good to great MDs, even when our original MDs retire. We like our BCBS PPO. With Medicare A+B and insurance we rarely have any copays.
Frequent turnover is very frustrating and not a good way to get consistently good care.
I just want to add. My liver function is important to me so I have NO issue with my doctor ordering blood work twice annually because I take a statin. I can do a virtual visit for this second visit a year.
My physical is a very thorough one. That’s once a year.
Just as an FYI for other readers, the standard of care on monitoring liver function tests while on statins changed about 10 years ago. The recommendation used to be every 12 months while on statins, but this was found to be unnecessary. Now most doctors test liver function once before starting the statin and just once afterwards and then not again unless there is some other reason to do so. YMMV if you have chronic liver problems for some other reason.