Internists may finally have the luxury of spending a little more time with older patients on preventive health care.

Effective Jan. 1, Medicare beneficiaries will be eligible for an annual wellness visit that includes an assessment of their health risks and creation of a personalized prevention plan.

Medicare will pay for the visit when it is provided by a physician, a physician assistant, a nurse practitioner or a clinical nurse specialist, or by a medical professional or team of medical professionals under a physician's supervision.

The new benefit is one of many health-care changes enacted in March as part of the Patient Protection and Affordable Care Act. The Centers for Medicare and Medicaid Services (CMS) is in the process of defining the elements of the wellness visit and how much Medicare will pay for it, with a decision expected by about Nov. 1. How it will be integrated into medical practices across the United States remains to be seen.

"The ultimate goal is to build much of what is included in a wellness exam into the patient-centered medical home, where resources and payment are more appropriate for effective primary care," said Dr. J. Fred Ralston Jr., president of the American College of Physicians.

CMS has proposed including certain elements in the beneficiary's first visit. These include:

• Establishing a medical history and family history.
• Establishing a list of current providers and suppliers who are regularly involved in providing medical care to the individual.
• Measuring the person's height, weight, body mass index (or waist circumference, if appropriate), blood pressure and taking other routine measurements.
• Detecting any cognitive impairment that the person might have.
• Reviewing any potential risk factors for depression.
• Reviewing the person's functional ability and level of safety.
• Establishing a written screening schedule for the next 5 to 10 years, based on recommendations of the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices and on the person's health status, screening history and age-appropriate preventive services covered by Medicare.
• Establishing a list of risk factors and conditions for which interventions are recommended or underway for the individual and a list of treatment options and their associated risks and benefits.
• Providing personalized health advice and a referral to health education or counseling programs to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention and nutrition.

CMS has proposed creating two new "G-codes" for reporting the first and subsequent wellness visits. The values assigned to the codes are equivalent to a "level four" patient office visit -- Current Procedural Terminology (CPT) 99204 and CPT 99214. In comments submitted to CMS, ACP has said that it believes the payment values are reasonable but suggests revisiting the issue once there is sufficient experience with the benefit. Low use of the benefit, for example, could indicate that the payment level is inadequate, ACP said.

In the proposed regulation, CMS said it would pay for acute or chronic care services provided as part of the wellness visit but noted that such scenarios would probably be "uncommon." ACP, however, urged CMS to rethink its interpretation. It is more likely that physicians and patients would combine the wellness visit with other patient-care services, ACP noted.

Whether a regular patient visit is purposely combined with the wellness visit or it occurs organically, "it kind of argues for flexibility to allow for the physician and the patient to schedule this and work this in a way that makes the most sense for both of them," said Brett Baker, director of ACP's regulatory and insurer affairs department.

Baker added that ACP has also urged CMS to clarify whether physicians will still be allowed to give the wellness exam, paid for by Medicare, and also administer a more comprehensive examination, which most patients think of as a physical, and bill patients directly for that exam.

A more precise description from CMS of the new wellness visit benefit, including how it relates to the more hands-on physical exam, Baker said, would reduce the need for individual physicians to have to interpret and explain everything to their patients.

Once CMS has issued its rulings, ACP will offer informational material to its members, Baker said.

More information

For more on the new health-reform law, check out the ACP/AARP guide, The New Health Care Law: How It Might Affect You and the ACP publication, An Internist's Practical Guide to Understanding Health System Reform.