Welcome to Medicare

[FinallyRetired]

So this year I hit the magic age at which I qualify for Medicare. By the way, for younger guys, t's not as much fun being retired after you hit an age at which you should be retired Enjoy it while you can.

Anyway, as I have for most of my adult life, I went in for my annual physical and when I got my statement I noticed that Medicare did not cover it. I called them and was told they only cover the first physical, they call it a "Welcome to Medicare" physical, but my doctor didn't code it as such. I called the office and they changed the code.

But now I'm scratching my head. A yearly physical is designed to catch diseases before they are too hard and expensive to treat, right? So Medicare gives you the first one, then no more. I suppose the beancounters figure the less we know the less we will go back for treatment until we have symptoms that are so bad that we won't last long.

 

[BigNick]

But now I'm scratching my head. A yearly physical is designed to catch diseases before they are too hard and expensive to treat, right? So Medicare gives you the first one, then no more. I suppose the beancounters figure the less we know the less we will go back for treatment until we have symptoms that are so bad that we won't last long.

I'd be interested to see if there is any real evidence about the actual outcomes of annual physicals. An annual physical checkup sounds great, but given the false positive rate of many diagnostic tests, the actual health benefits may be small or less. The benefit to the company billing it is indisputable.

See for example here and here.

We already know, for example, that for certain categories of women, regular breast cancer screening can be worse than useless, because the health costs of the complications associated with false positive tests outweigh the benefits of the correct tests.

The bottom line is that there's a lot of counterintuitive stuff once the Reverend Bayes gets involved.

 

[audreyh1]

But now I'm scratching my head. A yearly physical is designed to catch diseases before they are too hard and expensive to treat, right? So Medicare gives you the first one, then no more. I suppose the beancounters figure the less we know the less we will go back for treatment until we have symptoms that are so bad that we won't last long.

I think this kind of thing has been changed by the new bill. At least all new plans are required to cover preventative checkups such as this, the idea being catching things when they are less costly to treat. I don't see why Medicare would be different - but what do I know?

Audrey

 

[FinallyRetired]

An annual physical checkup sounds great, but given the false positive rate of many diagnostic tests, the actual health benefits may be small or less.

As I was saying, the bean counters got invoved

I'm not personally receptive to this argument, since my own life was saved through early screening for prostate cancer. But, no doubt, a statistical argument could be made that annual physicals are not cost effective.

OTOH, while some diagnostics may be questionable, screenings such as blood pressure, blood sugar, weight control, etc, undoubtedly help the individual to control factors that can reduce serious disease.

 

[ERD50]

I'm not personally receptive to this argument, since my own life was saved through early screening for prostate cancer. But, no doubt, a statistical argument could be made that annual physicals are not cost effective.

I'm certainly glad you caught your issue in time, and had a good outcome. But I think it is more than just a case of being 'cost effective'. Rich-In-Tampa has talked about this, and if I have it right, there are risks with many of these tests - so to run the test often enough to catch the majority early enough, might actually have more (overall/average) downside than upside.

That might not apply in your situation, but I think it does for many conditions.

-ERD50

 

[Rich_by_the_Bay]

I'd be interested to see if there is any real evidence about the actual outcomes of annual physicals.

The bottom line is that there's a lot of counterintuitive stuff once the Reverend Bayes gets involved.

You're correct: very few aspects of a "complete physical" have been shown to save lives or even to improve lives. Items accepted by "gospel" which are not proven to improve outcomes include prostate exam, breast exam, multiple "panel" blood tests, fecal occult blood, stress tests and more. Much of this is contaminated by the nasty frequency of false positives which in turn lead to a whole new round of fruitless additional testing, etc. (the Bayes problem as you note).

In the gray zone are mammograms, blood sugar/glucose and even colonoscopy - benefits presumed but not proven. Blood pressure, most vaccines, Pap smears and cholesterol every 5 years are probably helpful.

Though absence of evidence is not the same as evidence of ineffectiveness, the bottom line is that the routine physical -- unless done with great selectiveness -- is an exercise in futility in terms of mortality. In support of a periodic visit is the opportunity to do lifestyle counseling and to psychosocial issues affecting quality of life, as well as the chance to provide reassurance about numerous trivial symptoms we all accumulate along the way.

Medicare reimbursement decisions, OTOH, are like playing roulette.

 

[BigNick]

But, no doubt, a statistical argument could be made that annual physicals are not cost effective.

This is not just about cost-effectiveness. The point is that even if you have the best medical care plan in the world, there is little evidence that annual physicals make any difference to health care outcomes. As Rich_in_Tampa points out, a reassuring chat with the doc about that mole on your arm while he checks your BP is all good psychologically, but that's about it.

OTOH, while some diagnostics may be questionable, screenings such as blood pressure, blood sugar, weight control, etc, undoubtedly help the individual to control factors that can reduce serious disease.

Blood pressure: probably. But that doesn't have to be part of an annual physical - my doctor checks that every time I go to see him. Weight control: doesn't need an MD. You can check your BMI on a WiiFit. Now, blood sugar: I'm not at all sure that routinely checking the blood sugar level of people with no symptoms or history of diabetes, has any measurable effect on health outcomes. (I wonder if there are any studies on that?) That's exactly the kind of thing that "is obvious" but often turns out not to be.

Here's an article worth reading. (The original article starts after the 4 initial paragraphs in brackets, which are the comments by the person posting it. The article appears in the current edition of Skeptic magazine and probably shouldn't have been posted online, seeing as you can also pay $9.95 for it at Amazon. ) Check out what it has to say about coronary artery bypass surgery and other surgical cardiac interventions, versus simple exercise.

Extract:

the final insult, perhaps, was a July 2000 article in JAMA. The article, "Is U.S. Health Really the Best in the World?", posed that healthcare itself is the third-leading cause of death in the U.S., directly responsible for between 230,000 and 284,000 fatalities per year. Shockingly, these so-called
"iatrogenic" deaths--caused by doctors or treatment--place medicine behind
only heart disease and cancer in mortality tables.

The JAMA article mentioned can be found here. Some may find some of its conclusions to be rather political in nature, and there are no comparisons of iatrogenic death rates with other countries - hospitals kill people in large numbers pretty much everywhere. But given the non-zero risks associated with almost every medical procedure, it seems reasonable to suggest that too much treatment is not only not cost-effective, it can also be positively harmful.

 

[FinallyRetired]

Items accepted by "gospel" which are not proven to improve outcomes include prostate exam, breast exam, multiple "panel" blood tests, fecal occult blood, stress tests and more. Much of this is contaminated by the nasty frequency of false positives which in turn lead to a whole new round of fruitless additional testing, etc. (the Bayes problem as you note).

Rich, with all due respect, and you know I respect your posts on this health board, I think this particular statement is misleading and potentially dangerous to some. Let me tell you why, and feel free to counter.

You might place me in the category of a rare save for prostate cancer from screening. Fine, I'm not going to argue my particular case. But I will use PC since (thankfully) that is the only condition I'm personally familiar with.

There are two misleading portions to your (well-meaning) statement. First about prostate exam not proven to improve outcomes. How about the long term research at the University of Gothenburg who conducted a long term trial of 20,000 men between 50 and 65 years old, randomized to either get PSA screening every two years or not. After 14 years of looking at these men, the study found that the PSA screened group had HALF the PC-specific mortality rate of the non-screened group. Why was that? Because those that were screened and found to be suspicious for PC had options for treatment (or not, depending on individuals). Now, you may argue that there were many false positives, that there are other studies, etc, but I think studies like these argue against the type of statement you made. Even if such a study does not absolutely prove with 100% certainty (what does) that screening is effective, tell the average guy that here is a painless blood test that has been shown to reduce PC deaths by 50% in studies of 20,000 men over 14 years. How many will say, thanks Doc but that's not enough proof for me, I don't want the blood test?

The second misleading portion of your statement is the (unintended I'm sure) implication that a PSA test leads to rounds of "fruitless" testing, with "nasty consequences" which in many minds reads as "costly," "painful," etc. Nothing could be further from the truth.

As you know, PSA testing is just another number from a blood test, and is not PC-specific. But what it allows us to do is to establish our personal baseline from which we can monitor future progress. Some increase is expected as we age, and some of us have higher numbers than others for unknown reasons. But a single suspicious PSA means very little other than, let's check it again in 6 months, in a year, whatever. Does that cause mental anguish? Yes. Is the mental anguish part of life, and something completely meaningless for someone whose life might be saved? You bet.

So the PSA is high and gets rechecked. Still, so what? Most of the time the uro will just say that we may have benign prostate enlargement, and should take some antibiotics to bring it down. I know you are the expert on this stuff, I'm just spelling it out for the average guy like myself who doesn't know. So we take pills for a month or two, the PSA comes back down, and we get on with our lives. That is the most common outcome, no big deal, no pain, not that costly, and it does help the urinary function.

Now about the man whose PSA doesn't come down with pills but keeps going up over months or years. A biopsy will probably be done. Again, no big deal, for me it was less painful than filling a dental cavity, though not pleasant from the mental perspective. In many (most?) cases the biopsy will either be negative or be PC that is so early that nothing needs to be done at that point or, possibly, ever.

It's only in the case in which PC is found at a sufficiently advanced stage that there is a high likelihood for PC specific mortality that active treatment comes into play. And there are so many treatments that the main problem at this point is deciding what to do. It's no longer a question of only open surgery as you well know. There is radiation, there are new ultrasound methods, etc. And even for surgery there is robotic pinhole surgery, which I had, with minimal side effects.

Now, you may consider that all of the above is "fruitless," and based on sheer numbers a case might be made that not that many cancers will be found. But that would not be a medical argument, it would be a statistical argument.

In summary, I believe your statement, as well-intended and as informed as it is, is also misleading and potentially dangerous because it steers men away from testing that recent studies suggest leads to cures, and does not explain the way testing is conducted.

I only addressed PC but I suspect similar stories are there for breast cancer and other types of screening.

As far as Medicare paying, that's a separate issue and even if they didn't I would gladly pay out of pocket for some of these tests.

Here is a metalink to the study I referenced:

http://prostatecancerinfolink.net/2...-suggest-that-screening-does-lower-mortality/

 

[Rich_by_the_Bay]

Rich, with all due respect, and you know I respect your posts on this health board, I think this particular statement is misleading and potentially dangerous to some. Let me tell you why, and feel free to counter.

FR, I said prostate exam (digital rectal exam), not PSA.

- Rich

PS: I would probably include PSA in the gray zone. Some studies show benefit, some do not. The false positive problem is not trivial. It implies a healthy man having a needle stuck numerous times through the anal wall into the prostate, and can (rarely) cause sepsis (I have seen patients die of this), bleeding, etc. And even then it can miss an existing cancer.

I am glad it worked out well for you. There are many for whom no screening works out best, and others who might have cancer and would live to age 100 without ever knowing they had it. Funny things happen with large number of patients, low likelihood of disease, and invasive tests. It's about which odds to play, and the jury is still out. Everyone deserves a balanced, objective review of the facts with their physician before deciding whether to screen with PSA, and if so, how often.

Let's hope for a better screening test in the near future.

 

[FinallyRetired]

FR, I said prostate exam (digital rectal exam), not PSA.

- Rich

Fair enough, Rich, though to me, as a layman, "prostate exam" could mean a DRE, PSA, or any other way you have to check a prostate.

But, back to my OP, we would not be able to get a DRE, PSA, or any of these routine tests without a physical exam. Without a routine physical, I would only have had my prostate checked (by whatever means) because of symptoms. And for PC, as with many (most?) other cancers, they don't give symptoms until they are pretty advanced -- so advanced that in many cases a cure is difficult, and only the symptoms are treated.

Furthermore, a physical gives you, as the doctor, the opportunity to discuss with me, as the patient, my particular situation, prognosis, and need for testing -- including the risks for false positives, etc. It's just difficult for me to accept a "no physical" policy on the grounds that it's frivolous, or may do more harm than good. I know you are not arguing that, but the Medicare policy is tantamount to that.

 

[BigNick]

It's just difficult for me to accept a "no physical" policy on the grounds that it's frivolous, or may do more harm than good.

And yet, in many cases, it's true.

It's hard for a lot of people to accept a lot of counterintuitive things. For the first 75 years of the 20th Century, medicine was a one-way bet: new drugs were coming out every year that did amazing things, and in most cases the fact that the benefits outweighed the downside was visible to any lay person from a couple of miles away. Now, it seems that we're approaching the limits of what medicine can do(*), while at the same time, we all have a natural human tendency to discount the advances - not least because we don't see the bodies of all those who didn't fall by the wayside.

That you survived your brush with prostate cancer is great. But somewhere there's a guy who had an unnecessary test, a dubious result, invasive treatment, and complications under anaesthetic. He isn't writing here, either because he died, or because he never made the connection.

Another thought: beware of the line of argument which runs:
- I think X sounds cool
- I think M should pay for X. I heard that M always used to pay for X.
- I find that M won't pay for X.
- M saves money by not paying for X.
- Therefore, it's an economic decision.

This is fallacious logic for a couple of reasons:
- Nothing prevents (not doing X) from being both economically cheaper *and* clinically better.
- Every dollar not spent on X is potentially availably to pay for Y, which might have better outcomes. There's a finite pool of money in M.

t's also the same logic used by people like the individual who was in here a few days ago hawking his or her salve which cures cancer:
- My salve cures cancer
- Doctors and pharma companies say it doesn't
- Doctors and pharma companies sell expensive chemo/radio/surgery (and lots of people still die from cancer)
- Therefore, the main interest of doctors and pharma companies is in selling expensive chemo/radio/surgery
- Therefore, there's a conspiracy to keep my salve from the public, because doctors and pharma companies don't want cancer to be cured

By the way, the correct response in those cases where the seller of the quack remedy claims that doctors are happy for people to die of cancer because they make money off of them, is to ask the quack seller to check what treatment doctors themselves use when they get cancer. If the doctors themselves use conventional treatments, does that mean that they are prepared to die rather than reveal the secret?

This is not to defend pharma companies, by the way. Because they don't have many miracle answers for the remaining major medical issues of our time, they have in some cases been reduced to inventing conditions to treat.





(*) As a back pain sufferer, I should qualify this. Medicine has, as far as I'm concerned, no freaking clue about back pain!

 

[friar1610]

So this year I hit the magic age at which I qualify for Medicare. By the way, for younger guys, t's not as much fun being retired after you hit an age at which you should be retired Enjoy it while you can.

Anyway, as I have for most of my adult life, I went in for my annual physical and when I got my statement I noticed that Medicare did not cover it. I called them and was told they only cover the first physical, they call it a "Welcome to Medicare" physical, but my doctor didn't code it as such. I called the office and they changed the code.

But now I'm scratching my head. A yearly physical is designed to catch diseases before they are too hard and expensive to treat, right? So Medicare gives you the first one, then no more. I suppose the beancounters figure the less we know the less we will go back for treatment until we have symptoms that are so bad that we won't last long.

I also recently went on Medicare. But I have been on Tricare for years. (Tricare is the program for retired military folks, families of active duty personnel, etc.) Tricare's rules are essentially the same as Medicare's. I have simply asked my doc to code my annual physical as a series of individual procedures (such as follow up on hypertension, blood work, etc.) He seems to be able to figure out how to do that so that it goes through every time. Admittedly, I have not tried that under Medicare and will not for a while since I will use the "Welcome to Medicare" visit as my physical for this year.

 

[travelover]

Ironically, if I don't get an annual physical exam, I have to pay a higher rate for my health insurance. My company started this two tier system last year. I'll be interested to see if they continue it.

 

[FinallyRetired]

I also recently went on Medicare. But I have been on Tricare for years. (Tricare is the program for retired military folks, families of active duty personnel, etc.) Tricare's rules are essentially the same as Medicare's. I have simply asked my doc to code my annual physical as a series of individual procedures (such as follow up on hypertension, blood work, etc.) He seems to be able to figure out how to do that so that it goes through every time. Admittedly, I have not tried that under Medicare and will not for a while since I will use the "Welcome to Medicare" visit as my physical for this year.

I didn't mention it, but I'm in your same category. Tricare for years, then went Medicare this year. Never had to worry while under Tricare, they always covered yearly physicals. As you know, with Medicare, that becomes primary and Tricare secondary, so Tricare only pays, or not, whatever Medicare covers.

Good tip, next year I will ask my doctor if he would code my physical as a series of individual procedures. Seems that will just add to the overall cost, but that's the system we live under. For example, I need a yearly PSA test as a PC survivor, and that would normally be covered in my physical. Now I have to ask the doctor to code that as a PSA test only. Then I need a yearly test for a couple of other conditions, but no longer can they be done as a physical, they have to be coded as individual tests with more paperwork, more processing, more cost.

 

[mickeyd]

Just turned 65 in November and specifically ordered up a Welcome to Medicare physical. Medicare only paid $22.20 of a $250 amount billed, but Tricare picked up the rest of the "allowed amount" so I had no out of pocket payment to make.

Seems like most of the expense was for lab work and I received a lengthy report for a lab that was quite instructive and complete.

 

[FinallyRetired]

Just turned 65 in November and specifically ordered up a Welcome to Medicare physical. Medicare only paid $22.20 of a $250 amount billed, but Tricare picked up the rest of the "allowed amount" so I had no out of pocket payment to make.

Seems like most of the expense was for lab work and I received a lengthy report for a lab that was quite instructive and complete.

I don't understand why Medicare covered so little. In my case, my physical cost $225 and Medicare paid $148.16, with the remainder going to Tricare. If they were both Welcome to Medicare physicals, they should have covered about the same percentage. You don't think the gummint would mess up, do you?

 

[mickeyd]

I don't understand why Medicare covered so little. In my case, my physical cost $225 and Medicare paid $148.16, with the remainder going to Tricare. If they were both Welcome to Medicare physicals, they should have covered about the same percentage. You don't think the gummint would mess up, do you?

Check your "Medicare Summary Notice" that they should have sent you. Mine indicates that "$155 of this amount ("amount you will be billed") has been applied toward your deductable." You have to meet the deductables in order to qualify for full paymant, evidently. You are using the word "covered", they use the words "Medicare approved."

Don't worry, Obamacare will clear all of this up soon.

 

[FinallyRetired]

Check your "Medicare Summary Notice" that they should have sent you. Mine indicates that "$155 of this amount ("amount you will be billed") has been applied toward your deductable." You have to meet the deductables in order to qualify for full paymant, evidently. You are using the word "covered", they use the words "Medicare approved."

Don't worry, Obamacare will clear all of this up soon.

Yep, you're quite right. Of the $148.16 that Medicare Approved, the Summary Notice says I may be billed $148.16, and the footnote says it goes to deductible. So I assume TFL will pick that up.

I think next year I will go either to a military facility or to a VA hospital for my physical. No questions, no paperwork, no billing.

 

[Emeritus]

Yep, you're quite right. Of the $148.16 that Medicare Approved, the Summary Notice says I may be billed $148.16, and the footnote says it goes to deductible. So I assume TFL will pick that up.

I think next year I will go either to a military facility or to a VA hospital for my physical. No questions, no paperwork, no billing.

OMG you would be getting SOCIALIZED medicine delivered by salaried civil service government employees. Some people would run screaming in sheer mindless terror at the thought

 

[oilspill]

Waiting until retirement age to worry about your health is like waiting until your funeral to buy a nice shirt.

Might as well sit back and eat junk food and enjoy what's left of life.

 

[FinallyRetired]

Waiting until retirement age to worry about your health is like waiting until your funeral to buy a nice shirt.

Might as well sit back and eat junk food and enjoy what's left of life.

Actually, health care is the least of my worries, as I have several alternatives to good health care. My sympathies reside with those who have planned their retirement based on programs that are built on quicksand. Unless one is self-insured or qualifies for the "socialized" military health care system, the only guarantee is that there will be surprises in store.

 

[dex]

By the way, for younger guys, t's not as much fun being retired after you hit an age at which you should be retired Enjoy it while you can.

Can you elaborate.

 

[TromboneAl]

Can you elaborate.

I think it's like this phenomenon: having a lazy day on Monday is more fun than having a lazy day on Sunday.

Welcome to Medicare Physical

I picture balloons, confetti, and champagne sipping while you get your digital rectal prostate exam.

 

[FinallyRetired]

Can you elaborate.

I think TromboneAl pretty much summed it up. It's the guilty pleasure of playing golf, going for a walk, taking a nap, or doing anything you feel like it while colleagues your age are slaving at the office. Once you are 65, most of your colleagues are there with you doing nothing.

 

[dex]

I think TromboneAl pretty much summed it up. It's the guilty pleasure of playing golf, going for a walk, taking a nap, or doing anything you feel like it while colleagues your age are slaving at the office. Once you are 65, most of your colleagues are there with you doing nothing.

Thanks, I thought I was in for a surprise.