Medicare Wellness Benefits. Veena Kulchaiyawat, DO UCI, Geriatric Fellow April 10, PDF Free Download

Medicare Wellness Benefits Veena Kulchaiyawat, DO UCI, Geriatric Fellow April 10, 2014

Objectives Understand the principles of preventative care. Describe the types of preventative care. Understand the concept of individualized goals of care and recommendations. Understand the 2 free medicare wellness visits and know what to expect. Discuss specific cancer screening and immunization recommendations. Steps to initiating your medicare preventative care services.

Being Healthy

Preventative Care Prevent new disease(s) and reduce risk factors Detect disease or cancer for early treatment and improved prognosis Prevent disease related complications

Counseling Smoking Cessation Lung Cancer Diet and Exercising Obesity, Diabetes, Heart disease, Hypertension, Hyperlipidemia Substance Use/Abuse Liver disease

Goal of Screening Identify asymptomatic persons with risk factors for earlier treatment options Do more good than harm

Ideal Screening Recommendation Reasonably priced Non-invasive Identify a disease that can be clinically significant but during the asymptomatic stage Disease must have acceptable treatment course

Challenges of Screening Recommendations Few clinical trials of people over 70 years Wide range of medical conditions, functional impairments Little survival benefit to cancer screening unless life expectancy exceeds 5 years

Numerous Recommendations U.S. Preventative Services Task Force (USPSTF) American College of Physicians (ACP) American Medical Association (AMA) U.S. Public Health Service American College of Obstetricians and Gynecologists (ACOG) American Geriatric Society (AGS) American Cancer Society (ACS) Centers for Disease Control and Prevention (CDC) American Diabetes Association (ADA)

Immunizations Prevent disease and suffering from a disease Have pre-made antibodies available for defense if exposed to microbe

Importance of Your Health Care

Clinical Encounter Limited time focused on a problem oriented visit Preventative care recommendations may be advised but with unanswered questions or without full understanding of the need

Medicare Benefits Welcome to Medicare Preventative Visit, Medicare Wellness Visit (Initial Preventive Physical Examination) - 2005 Annual Wellness Visit - 2011 **Medicare pays 100% if you have Medicare Part B = no co-pay and no deductible

Caveats to the Medicare Visits If additional tests/services that aren't covered under preventative benefits, you may have co-insurance with Part B deductible Further diagnostic tests may not be covered If polyp is found on colonoscopy, there may be copay for removal

Purpose of Medicare Wellness Visits Provide specific clinic visit to focus on a personalized preventative care plan with your primary care physician Encourage wellness and prevention Be proactive in your medical care Take control of your health care Living a healthy quality of life

Confusions of the Clinic Visit Excludes physical examination Does not address acute or chronic conditions during the visit

Medicare Wellness Visits Preventative care can lower costs, prevent illnesses and save lives Only about 16% of beneficiaries with original Medicare used this specific service

Welcome to Medicare Initial Preventative Physical Examination (IPPE) Once in a life time benefit Eligible within 12 months of entry into Medicare Purpose Promote health Prevent disease

Components to the Medicare Visit Complete a history risk assessment form PRIOR to the clinical visit Determine risk factors Screening questions NO routine physical examination Recommendations for your individualized preventative care plan with discussion and answers to questions that may arise

Medical Wellness Visit - History Past medical history, Past surgical history, Family History Current medication list List of providers and pharmacies Social history alcohol, tobacco, diet, work, physical activity, social activity Functional assessment activities of daily living, hearing, vision, cognition, fall risk, safety Depression screening

Medicare Wellness Visit - Exam Does NOT include routine physical examination Height, weight, body mass index, blood pressure Visual assessment Hearing assessment Optional EKG if indicated

Medicare Wellness Visit - Recommendations Education, counseling, referral for preventative services Individual health maintenance checklist Vaccinations DEXA screening Cancer screening Medical nutrition recommendations Abdominal aortic aneurysm screening as indicated Advance directives

Personalized Prevention Plan Services (PPPS) Checklist with your screening schedule based on your individual risk factors Personalized health advice Referrals for health education/counseling Referrals for preventative services Advance directives discussion

Annual Wellness Visit

Annual Wellness Visit Update personalized prevention schedule every year after your initial wellness visit

Annual Wellness Visit (AWV) No co-pay or deductible Must be more than 12 months from IPPE or from enrollment in Medicare **Medicare pays 100% if you have Medicare Part B = no co-pay and no deductible, however if additional tests/services that aren't covered under preventative benefits, you may have co-insurance with Part B deductible.

Annual Wellness Visit - History Review your medical history Review your family history Update list of medical providers Update list of pharmacies

Annual Wellness Visit - Exam Height, weight, body mass index Blood pressure No physical exam if not indicated Cognitive screening Depression screening Smoking and alcohol counseling if indicated

Annual Wellness Visit - Recommendations Update your checklist of your Personalized Prevention Plan Services (PPPS) based on your individual risk factors Personalized health advice Referrals for health education Referrals for preventative services Advance directives discussion

Preventative Services COUNSELING Diet, Exercise, Tobacco/alcohol, Depression CANCER SCREENING Mammogram, DEXA scan, colonoscopy, abdominal aortic aneurysm, CT chest IMMUNIZATIONS Influenza, pneumococcal, zoster,

Cancer Screening Facts Reduce cancer mortality with early stage disease if treated Benefit from screening may NOT be immediate Detect cancers that would result in death after more than 5 years

Harms of Screening Complications from further diagnostic testing Detect advanced cancer that is too aggressive to treat Psychological anxiety, stress, emotional pain of having cancer and tests needed False positive test results

Individualized Recommendations Past medical history Risk factors Family history Functional status Goals of care Values

Individual Goals of Care Treat to cure disease Live with disease with symptom control Think about your independency and functional abilities to help with decision making

Challenges to Recommendations Numerous organizational recommendations Dependent individual goals of care, values, personal medical/social history

Considerations Asymptomatic cancer vs complications for treatment of cancer Co-morbid conditions Functional impairment Disposition after treatment(s)

Decision-Making Process Understand potential need for further diagnostic work up Willingness to pursue treatment Early diagnosis of cancer for early treatment Possibility of functional decline and quality of life with treatment options Psychological impact on positive cancer screenings

Objectives Understand the principles of preventative care. Describe the types of preventative care. Understand the concept of individualized goals of care and recommendations. Understand the 2 free medicare wellness visits. Discuss specific cancer screening and immunization recommendations. Discuss importance of advance directives. Steps to initiating your medicare preventative care services.

Preventative Care Recommendations

Preventative Services COUNSELING Diet, Exercise, Tobacco/alcohol CANCER SCREENING Mammogram, colonoscopy, CT chest IMMUNIZATIONS MISC Influenza, pneumococcal, zoster, tetanus DEXA scan, abdominal aortic aneurysm

Counseling Alcohol misuse screening yearly 4 brief face to face counseling sessions per year Tobacco cessation counseling Up to 8 face to face visits within a 12 month period Www.nih.gov

Counseling Obesity Screening (BMI >30) Service Face to face visit each week for first month Face to face visit every other week for 2-6 months Face to face visit every month for 7-12 months, if you lose 6.6 lbs during 1-6 months

Nutritional Counseling Risk factors Diabetes, renal disease, kidney transplant Medical nutritional therapy counseling 3 hours of 1:1 counseling first year 2 hours year thereafter Diabetes self management training Teach management of condition to prevent complications (*20% payment) *www.medicare.gov/publications Medicare Coverage of Diabetes Supplies & Services) *1-800-MEDICARE

Advance Directives Legally valid document Preferences about medical care BEFORE faced with serious injury or illness Designates a medical power of attorney of health care proxy who is authorized to make medical decisions on your behalf.

Types of Advance Directives Directive to physicians Living will Do not resuscitate order POLST - 2009 Medical durable power of attorney Donor Registry

POLST Does not replace advance directive Provides medical orders in healthcare settings (home, nursing home, hospital) Advance directive and POLST should be reviewed for consistency and updated if any conflicts.

POLST Physician Order of Life Sustaining Treatment A: Cardiopulmonary Resuscitation (CPR) B: Medical Interventions C: Artificially Administered Nutrition D: Information and Signatures Completed by health care provider based on patient preference and medical indications

Benefits of Advance Directives Spare loved ones the stress/guilt of making decisions while you are sick regarding end of life decisions Limit conflicts amongst family members during emotional and situational stress Face end of life with dignity with treatment that reflects values

Cancer Screening Cancer Deaths in Females Lung Cancer Breast Cancer Colorectal Cancer Cancer Deaths in Males Lung Cancer Prostate Cancer Colorectal Cancer

Breast Cancer Most common cancer in women 2 nd most common cause of cancer death in women Risk Factors Family history of breast cancer (mom/sister, daughter) Never pregnant of first child after 30

Breast Cancer Screening Recommendations ORGANIZATION USPSTF 2009 RECOMMENDATION 50-74: Mammogram every 2 years >75 years: Insufficient evidence ACS 2013 > 40: mammogram and CBE every year 20-30: CBE every 3 years ACOG 2011 AGS 2004 AAFP 2014 > 40: mammogram and CBE every year <85: mammogram every 1-2 years with average or better health and life expectancy of > 5 years with periodic CBE Screening should continue if life expectancy > 4yrs <50: Individualize screening with counseling for potential risks/benefits of mammogram/cbe 50-74: Mammogram every 2 years >75: insufficient evidence to assess benefits and harms of screening AGAINST: self breast exam, INSUFFICIENT: CBE

Cervical Cancer Risk factors Multiple sexual partners (>5) HPV (human papilloma virus) Smoking Diethylstilbestrol (DES) exposure Abnormal PAP test History of HIV, sexually transmitted disease

Cervical Cancer Screening Recommendations ORGANIZATION USPSTF 2012 ACS 2013 ASCCP/ASCP 2012 AGS AAFP 2014 RECOMMENDATIONS 21-65: PAP smear at least every 3 years 30-65: PAP + HPV testing every 5 years AGAINST: routine PAP with TAH for benign disease AGAINST: routine PAP if >65 if with adequate prior screen/low risk 30-65: PAP every 3 years OR PAP +HPV test every 5 years High Risk: PAP every year >70: if normal x 3 AND no abnormal past 10 years May STOP. History of TAH with removal of cervix for benign disease May STOP 21-29: screen every 3 years 30-65:PAP + HPV every 5 years preferred OR PAP every 3 years >65: adequate negative prior screen, no history of CIN2+ within 20 years May STOP and due not resume for any reason STOP screening if with TAH for benign disease (never had CIN 2 or3) CIN 2 or 3: vaginal cytology every year until negative x 3 <70: PAP every 1-3 years (may need to individualize) >70: may stop if > 2 normal PAP since age 60, unable to tolerate tx *Two negative screens 1 year apart if never 21-65: PAP every 3 years 30-65: PAP + HPV testing every 5 years AGAINST: >65 with adequate prior screen AGAINST: TAH without cervix and without history of high grade pre-cancerous lesion (CIN grade 2 or 3 or cancer.

Ovarian Cancer Screening Recommends against routine screening with either trans-vaginal ultrasound or CA-125 (USPSTF, ACS, AGS) Physicians may discuss with patients concerning symptoms that will need further evaluation (ACOG) Increase abdominal size, abdominal bloating, fatigue, abdominal pain, indigestion, decreased oral intake, urinary frequency, pelvic pain, constipation, back pain, recent urinary incontinence, unexplained weight loss

Endometrial Cancer Screening No cancer screening guidelines issued (USPTF or AGS) or not recommended in asymptomatic women (ACOG) Recommends against routine screening but at the time of menopause, all women should report vaginal bleeding or spotting (ACS) *Hereditary non-polyposis colorectal cancer annual endometrial biopsy beginning at age 35 OR prophylactic hysterectomy after completion of childbearing (ACS)

Prostate Cancer Screening 2 nd cause of cancer death in men No published standards or guidelines for low risk patients Individualized weighing benefits and harms Beginning at age 50 years Debatable Digital rectal exam Serum prostate-specific antigen

Prostate Cancer Screening Willingness to go through further diagnostic testing and treatment Ability to tolerate symptoms related to prostate enlargement/cancer

Colorectal Cancer Screenings 3 rd most common cause of cancer death in U.S CRC increases with age but needs to be balanced against life expectancy given slow progression of adenomatous polyps to malignant lesions Risk Factors History of familial adenomatous polyposis Close family history of colon cancer or poylps History of inflammatory bowel disease (UC, Chron's)

Colorectal Cancer Screening Recommendations ORGANIZATION USPSTF 2008 ACS 2013 AGS AAFP 2014 RECOMMENDATIONS 50-75 years annual FOBT or flex sig every 5 years and FOBT every 3 years or colonoscopy every 10 years AGAINST: routine screen 76-85 years AGAINST: screening if >85 Insufficient evidence for CT colonography or fecal DNA > 50 years find polyps/cancer early flex sig every 5 years* or colonoscopy every 10 years or double contrast barium enema every 5 years or CT colongraphy every 5 years *if positive then perform colonoscopy **STOP if severe comorbidity preclude treatments No colorectal cancer screening guidelines issued 50-75: FOBT, sigmoidoscopy or colonoscopy AGAINST routine screen 76-85 AGAINST screening >85

Lung Cancer Screenings Risk factors Smoking history of > 20-30 pack year and still smoking or quit < 15 years

Lung Cancer Screening USPSTF 2013 ACS 2013 ORGANIZATION AMERICAN ASSOCIATION FOR THORACIC SURGERY AAFP 2014 RECOMMENDATIONS 55-80 years: annual low dose CT chest if with history of 30 pack years and currently smoking or quit in past 15 years *STOP screening if not smoked for 15 years or with limited life expectancy to undergo lung surgery 55-74 years: low dose CT chest in high risk patient in fairly good health history of 30 pack year smoking AND still smoking OR quit within last 15 years 55-79 years: annual low dose CT chest with 20 pack year smoking history with additional co-morbidities with cancer risk at least 5% over next 5 years INSUFFICIENT to recommend for or against screening with low dose CT chest

Osteoporosis Screening Risk Factors Long term steroid usage Vertebral abnormalities on x-ray (compression fracture) Hyperparathyroidism Fragility fractures

Osteoporosis Screening ORGANIZATION RECOMMENDATIONS USPTF 2011 All women > 65 Younger postmenopausal women with fracture risk equal to average 65 year old No recommendation for men AAFP 2014 > 65 women <65 women with fracture risk > 65 year old white women *women 65 and older with no other risks has 9.3% 10 year risk for any osteoporotic fracture 2011 INSUFFICIENT: evidence to assess benefits and harms in screening men NOF 2008 National Osteoporosis Foundation All women >65 All men >70 Younger postmenopausal women and men 50-69 with clinical risk factors

Immunizations Influenza Vaccine Pneumococcal Vaccine Zoster Vaccine Tetanus Vaccine

Vaccines Substance that stimulates the production of antibodies to provide immunity against one or several disease

Influenza Vaccine Types (IM, SQ) Live Attenuated (LAIV) Inactivated (IIV) High Dose Inactivated (IIV) Recombinant (RIV) No Egg protein Indications All person's annually Contraindications Severe anaphylaxis reaction after previous dose

Pneumococcal Vaccine Indication All persons > 65 years Adults < 65 years certain chronic diseases * Residents of nursing homes/long term care Indication for repeat vaccination after 5 years if < 65 Benefits Immunocompromised, Diabetes, Chronic kidney disease needing dialysis Protect against infections caused by bacteria called pneumococcus (pneumonia, septicemia, meningitis)

Chronic Diseases Chronic lung disease (COPD, emphysema, asthma) Chronic cardiovascular disease Diabetes mellitus Chronic renal failure (nephrotic syndrome) Chronic liver disease (cirrhosis, alcoholism) Cochlear implants Cerebrospinal fluid leaks Immuno-compromising conditions (cancer, HIV, CRF) Functional or anatomic asplenia (sickle cell, splenic dysfunction, splenectomy)

Pneumococcal Vaccine Protection against SERIOUS INFECTION in blood or brain that can be dangerous and lead to hospitalization or death

Zoster Vaccine Live vaccine Indication 1 single dose for adults aged > 60 regardless prior episode of herpes zoster Contraindication Known immunodeficiency (chemotherapy, HIV, cancer) Pregnant

Herpes Zoster (Shingles) Post-herpetic Neuralgia (>3months) Severe nerve pain from damage caused by the varicella zoster virus Unilateral dermatomic area

Tetanus Tetanus is caused by infection with Clostridium tetani bacteria which can enter through your wound/cut on your skin (soil, manure) that can be fatal Neurotoxin can disrupt normal nerve function causing muscle spasm, stiffness Risk factors Wounds or burns that need surgery Puncture type injuries (animal bites) Wound with foreign bodies Compound fractures (bone exposed)

Tetanus Types Tdap (Tetanus, diphtheria, pertussis) Td (Tetanus, diphtheria) Recommendation 1 dose of Tdap to pregnant women during each pregnancy (27-36 weeks) Unknown status, >11: get Tdap with Td booster every 10 years thereafter

Abdominal Aortic Aneurysm Indications Family history of abdominal aortic aneurysm Men 65-75 with history of smoking at least 100 cigarettes in your lifetime Screening abdominal ultrasound ONCE

Miscellaneous Cardiovascular disease screening Check blood pressure, promote healthy diet, ASA Fasting lipids every 5 years Diabetes screening year for high risk patients Fasting blood glucose Glaucoma screening high risk, yearly (*20% payment) HIV screening

Steps to Initiating Medicare Benefits Schedule your appointment Welcome to Medicare Preventative Visit Annual Medicare Wellness Exam

What to Bring to Wellness Visit Completed health risk assessment questionnaire List of medical and surgical history Immunization Record Bring all medications, supplements Bring list of all specialist Bring updated pharmacy names Bring Advance Directives (if you have one)

Ask your Doctor

Take Control of Your Health Exercise Eat well Keep healthy weight Stop smoking Get preventative screening tests Update yourself on immunizations

Key Points Preventative care is prevent risk factors/new disease/complications, detect early cancer and stay healthy. Welcome to Medicare and Annual Wellness Visit focused on health promotion and preventative services. Reviewed counseling, cancer screening, immunizations. Importance of advance directives. Steps to initiating your medicare preventative services.

Resources Www.medicare.gov Www.cancer.org Www.uspreventativeservicestaskforce.org

References Zoorob R, Anderson R, Cefalu C et al. Cancer screening guidelines. AAFP 2001;63:1101-12. Bernstein R, DeJoseph D, Buchanan EM. When to stop screening: a review of breast, gynecologic, and colorectal cancer screening in women over age 65. Care Management Journals 2010;11:48-57. Cuenca AE. Making medicare wellness visit work in practice. Family Practice Management 2012:11-6. Walter LC, Lewis C, Barton MB. Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence. The American Journal of Medicine 2005;118:1078-86. Bridges CB, Coyne-Beasley T. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older: Unites States, 2014. Annals of Internal Medicine 2014;160:190-7. U.S. Preventative Services Task Force. Screening for colorectal cancer: U.S. Preventative services task force recommendation statement. Ann Intern Med 2008;149:627-37. The American Congress of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists: Screening for Cervical Cancer. November, 2012.

References http://www.clevelandclinicmeded.com/medicalpubs/diseasemanag ement/preventive-medicine/principles-of-screening/ Bernstein R, DeJoseph D, Buchanan EM. When to stop screening: a review of breast, gynecologic, and colorectal cancer screening in women over age 65. Care Management Journals 2010:11(1):48-57. Cuenca AE. Making medicare wellness visit work in practice. Family Practice Management 2012:11-6.

Questions???

Medicare Wellness Benefits. Veena Kulchaiyawat, DO UCI, Geriatric Fellow April 10, 2014