by Lou Antosh

It may be America’s most unpopular freebie. It is available each and every year to 55 million citizens, worth more than $100, and almost guaranteed to have a positive impact on the gift recipient.

So why do 80 percent of American Medicare beneficiaries miss their AWV, or Annual Wellness Visit? It could be that they’ve heard nothing about it, or, it could be that what they have heard about it sounds a little weird. Like being asked by your medical provider to draw a clock. Or to do some math problems.

When this Medicare member was called by his family doctor’s office recently to schedule a visit, I assumed it was for an annual physical. Seemed right that I was asked to step on the scale for a weight and height check, then asked to sit for a blood pressure reading. Physical exam, right?

Not even close. Soon, the nurse practitioner (doctors need not be involved) told me three words – Apple, Watch, Penny – I would need to remember. After she began asking me about my lifestyle (was I depressed, physically active, using tobacco?), I recalled my friends describing their own odd Medicare visits, during which they needed to draw a clock and were asked about gun ownership. I then realized I was in the middle of what I later learned was called the Annual Wellness Visit.

It included a math pop quiz, starting with something like 65 minus 7, then four more subtraction questions in rapid fire that had me reeling like a tv quiz show contestant. Did I remember the three words? (Yes). She handed me a sheet of paper, saying: “With your non-dominant hand, fold this in half and put in on the floor?”) Geez, could I use two hands to fold it? Yes. On the sunny side, it was easier than doing a push up.

When it ended, I got a sheet with a couple recommendations checked off (lose weight, yeah, I know) and walked out somewhat underwhelmed. But I’m sure my visit brought love to the Medicare officials who have been promoting AWVs since they began in January of 2011. The Centers for Medicare and Medicaid Services (CMS) reports that for everyone like me, there still are four Medicare recipients – just about 80 percent — who do NOT get their AWV.

The AWV premise? It was prompted by some pretty lousy statistics. Almost 100 percent of Medicare benefits go to people with at least one chronic condition. Costs are skyrocketing for hypertension, diabetes and high cholesterol, conditions with causes such as obesity that can be modified if managed well, but are poorly managed. Preventive services can promote better management, but among those 65 or over, the majority does not seek such preventive and management help.

CMS said it decided to provide the free AWV to “encourage individuals to take an active role in accurately assessing and managing their health, and consequently improve their well-being and quality of life.”

But a 2016 study in the Marshall Journal of Medicine (Marshall University) found that Medicare patients were less than lukewarm to the AWV idea. “We contacted 1,537 eligible Marshall Health patients by telephone, and 211 (14%) of those agreed to schedule their AWV,” said the study. Those who declined and gave reasons said they refused because they saw no reason for the visit, they had too many providers to see, or they disliked the Affordable Care Act.

Annual Wellness Visits carry no mandate and are not required of either patients or physicians, who may assign another medical professional (physician assistant, nurse practitioner, registered dietitian, etc.) to perform the patient assessment. In 2017, Medicare pays the provider $173.70 for the first AWV and $117.71 for each subsequent visit. Those payments have not exactly triggered a AWV boom. This Medicare recipient has been eligible for the annual visit for more than a couple years and only this year got the first AWV invitation.

The AWV aspect that prompts the most conversation among seniors is cognitive assessment, those little memory tests, math quizzes and other such tools designed to spot cognitive impairment. A 2011 article in the Journal of Family Practice said that while AWVs offer “an unparalleled opportunity for early detection and treatment of dementia,” relying on physician observation and patient reporting was not an efficient approach.

“Physicians often fail to identify cognitive impairment until it becomes quite severe,” said the study. “Reliance on patient self-report is also likely to be a flawed approach.” It said one community sample found dementia patients denied they had memory problems. These patients often made such statements as “I remember everything I need to remember.”

The use of standardized assessment tools (drawing clocks, word memorization, for example) provides for more objective data collection, according to the study.