Obamacare changed the Medicare payment system, by going from a pay for service system to a system based on patient outcomes.

  • In 1980 the largest change came to the Medicare payment system,  since the 1960’s. Medicare would now give a set amount of funds for specific populations. If the person’s cost of care turned out to be higher than that number, the health care provider lost money. But if the person’s care turned out to cost less the health care provider made money.
  • In the 1990’s diagnosis related groups were introduced. Certain diagnosis groups were paid a set fee for care service, at a binding price. If the service provided cost less there was a profit, if the service provided cost more there was a loss on that patient.
  • In 2010 the Affordable Care Act passed, this would change the Medicare payment system to one of patient outcomes, and would be rolled out in stages.
  • In 2012 the largest change was enacted, value- based purchasing. Valued based purchasing is a method that pays based on patient outcomes rather than services. Before this, it was standard practice to order more tests, and because payment was based on services, patient care would then cost more. Now the focus was squarely on the patient’s outcome to be eligible for payment. (see blog on how Obamacare affects Doctors)
  • 2013 – Medicare begins to enact penalties for hospital re-admissions, resulting in loss of reimbursement.
  • 2015 – Big change for health care institutions, when Medicare eliminated reimbursement for treatment of hospital acquired conditions. Now if you entered a hospital infection free, and as a result of being in that hospital you acquired an infection.  The hospital would not be reimbursed by Medicare for the treatment of that infection.
  • Going forward – Nursing Homes would begin a Medicare payment system of reimbursement on patient outcomes, as well as the patients perception of their care, rather than the fee for service system.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing


There are consequences to living a risky lifestyle. The wellness check list tells you what a healthy lifestyle is and isn’t. Taking a close look at the areas that the wellness check targets, tells you what behaviors are ultimately going to cause disease.

Many of the tests check for cancer. Cancer is caused by external factors such as tobacco, infectious organisms, eating an unhealthy diet as well as internal factors such as inherited genetics, mutations, hormones and immune conditions. These factors may act together or in sequence.

What this tells us is that a substantial proportion of the cancers diagnosed could be prevented. All cancers caused by tobacco use and heavy alcohol consumption could be prevented.

Of the over 589 thousand deaths predicted in 2015 from cancer in the United States, 178 thousand will be directly caused by smoking alone. A third of the cancer cases will be directly related to obesity, physical inactivity and poor nutrition.

Seventy-eight percent of all cancers diagnosed are in people age 55 and older. The cost of cancer in 2011 in the United States alone was 88.7 billion.

So what about the wellness check? Will it make a difference? Only, if people are able to make the changes recommended. The best place and most obvious place to start are with smoking and diet.

Increase fiber, vegetables, fruit, (only if you do not have a sugar problem) reduce the use of red meats and eliminate processed foods and meats. And with winter behind us, time to increase that physical activity they talk about.

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing


Part II

Preventative care under the ACA is offered by the insurance provider – but when is it free? When isn’t it free?

There is a list of 15 preventative services that are recommended by the Affordable Care Act. These are things like blood pressure screenings, testing for cholesterol levels, mammograms, colonoscopies, vaccines and so on.

These recommended preventative services require no; co-pay, out of pocket payment or meeting any deductible. The goal here is to offer these screenings/services to catch a disease process before you have any symptoms.

So what isn’t considered preventative and so isn’t free?

Any change in your health that is found through the preventative screening, requiring follow up testing and treatment, is not free. This could include lab work or other testing to manage or treat a condition. Medical treatment for a specific health condition and any on-going care is not included in “preventative” care. Any future diagnostic care or treatment is not part of preventative care.

Once a condition is identified, that will require any on-going or future treatment, it now is covered under your health care policy with the deductibles you selected.

Wellness checks serve an even greater purpose through organizing your healthcare. Instead of the burden being placed on the patient, to always know what is significant to report to the doctor. The wellness check will now ferret out those facts. If you are uncomfortable bringing up unusual bowel movements with your doctor, the wellness check will bring it up for you.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing


Part I

Several seniors have asked me lately about the “wellness check form” they have received from their health insurance provider. This wellness check is a direct result of the Affordable Care Act (ACA/Obama care) under “preventative care”.

Why is this coming from the insurance company instead of the doctor?

You would think that a health insurance company would want to catch a disease process early when it is not only easier to treat but cheaper to treat. But this hasn’t been the case. Standard medical practice has put a large burden of medical care in the hands of the consumer. A person would need to know that they have a problem and then seek out the physician.

Once at the doctors the individual would have to be a good communicator as well as historian to recount their symptoms. Now with ACA the first move to identify a disease could come from the insurance company, through a screening process. The screening might be a questionnaire as well as some routine lab tests. The burden of identifying illness then rests with the check list and starts with your insurance provider.

The thinking behind creating the wellness check, assumed that people are slow to contact their doctor for financial reasons. This is why the screening for many disease processes are considered preventative and are free. This could be true, based on the many seniors who once on Medicare, spend a considerable amount of their time visiting a round of doctors.

But for the people who are in denial about their health, it has been easier to avoid thinking about the consequences of a risky life style, by just not going to the doctor. For these people the check list might also make a trip to the doctor easier. After all, you received this form from your insurance company and “they” want you to see your doctor.

Part II – Preventative care is free? When does it stop being free?

Part III – How does the check list tell you what is a healthy life style?

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing