Medicare AWVs and Preventive Care

Policy Recommendation Paper for ABC Medical Group Regarding AWV
Introduction
The purpose of this policy recommendation paper is to provide education for the managers of ABC Medical Group regarding the Medicare annual wellness visit (AWV). The AWV is a yearly doctor’s visit covered by Medicare in which Personalized Prevention Plan Services (PPPS) are received. The AWV is a health risk assessment, which is beneficial for the patient (CMS, 2017). The AWV is not the same as a yearly physical, nor are clinical laboratory tests included in it. There is no deductible or copay involved as both are waived by Medicare. Offering the AWV is also beneficial for professional health care providers in that it allows their practice to provide preventive care with a value-based model “to keep patients as healthy as possible” (AAFP, 2016). By establishing a process that encourages patients to take advantage of their AWV, practice managers will be able to collect information to gain better understanding of their needs of their patient population and more effective ways to serve them, leading to the development of new business models and services provided by the medical practice as well as the expansion of existing service lines to capture market shares.
Medicare ACO
An Accountable Care Organizations (ACO) is a group of physicians, hospitals, and other health care providers who voluntarily work together to provide quality care to Medicare patients. They coordinate with one another in order to ensure that these patients received the care they require when they require it. Through coordinating their efforts, they also ensure that there is no unnecessary repetition of services and the medical errors are not made with regard to the patient’s health and handling while receiving care from the various outlets available to him or her. The purpose of the ACO is to assist in the streamlining of Medicare delivery to patients so that there is less waste of energy and resources and more efficiency in terms of high-quality care being given to the patient. For its services, the ACO is rewarded with a share of the savings that it is able to obtain for the Medicare program (CMS, 2016).
Medicare Annual Wellness Visit Program Overview
The AWV is similar to the Welcome to Medicare Visit, which is a one-time visit within the first year of a person’s enrollment in Medicare Part B. The AWV, however, is offered once every year and gives the patient a chance to receive an updated personalized prevention plan that can help him or her mitigate risks and “prevent disease and disability” (NCOA, 2016).
At the AWV, the patient will provide the care giver with personal and family medical history information. The personal history will include such information as immunizations, illnesses, hospitalizations, surgeries, symptoms and/or treatments since the patient’s last visit. The patient will also provide a list of medication that he or she is taking or has taken in the past. The names of providers and suppliers of medical equipment is also given to the care giver.
The professional care giver in turn conducts a routine body measurement/assessment, including height, weight, BMI, and vital signs. A depression screening is performed. A cognitive impairment assessment is conducted. The patient’s functionality and safety levels are assessed. And a health risk assessment is provided. Added to this, the health care provider also gives a 5-10 year schedule of screening and preventive services to the patient along with personalized health advice and referrals regarding health education, falls prevention, smoking cessation, nutrition, weight loss and other health-related issues.
Health care professionals who are certified to deliver the AWV include medical doctors, nurse practitioners, physician assistants, and any other medical professional (such as a registered dietician, nutritionist or other licensed professional) so long as it is under the supervision of a physician.
Reimbursement for Annul Wellness Visits
So long as the health care provider accepts Medicare patients, the beneficiary of the AWV pays nothing. This may change if the AWV is conducted along with other tests and/or services that are not part of the AWV—such as labs or screenings. In such cases (if the extra services are subject to Medicare Part B cost-sharing), the patient may have to pay a deductible plus 20% co-insurance (NCOA, 20160. Providers are “well-reimbursed” for the care they provide, and as a potential revenue opportunity, CMS shows that there is between an $111 and $172 average annual reimbursement for every qualifying patient (Levinthal, Teske, Kontor, 2015). Likewise, Kontor (2015) notes that “even for health systems that aren’t setting out to become population health managers, getting more AWVs is a win. It’s one of few strategies that help transition to value-based payment while also reaping benefits under fee-for-service.” Kontor (2015) also adds that in terms of financial benefits, providers stand to gain substantially: “Right now, only 14% of Medicare beneficiaries receive an AWV. I’ve seen medical groups increase that to over 70%. And the financial impact of that increase is impressive. For a 100-provider practice, the additional revenue can total as much as $3 million annually.” With such a significant return, offering the AWV is easily one of the most business-friendly services a provider can give.
Challenges and Barriers offering Annual Wellness Visits
Currently there are few challenges to offering the AWV. The reason that so few Medicare beneficiaries take advantage of it is that they are either unaware of it as a service that is free for them to obtain, or their health care providers do not offer it as part of their in-house services.
Other barriers that have been known to exist from the provider’s point of view are nothing out of the ordinary: they consist of language barriers and late arrivals (Cuenca, 2012)—but these can be challenges no matter what the service is that is being provided.
The most basic challenges associated with the AWV are, however, the following:
1) a lack of knowledge on the part of the provider as to what the AWV is and who it is for;
2) a sense on the part of the physician that the AWV is time-consuming and complicated (because of the paperwork and personalized plan that must be constructed for the patient—as well as the documentation required for billing);
3) The idea that wellness visits take physicians away from sick patients and thus waste the doctors’ time;
4) The number of services similar to AWV is already significant and distinguishing among them all—whether it is the Initial Preventive Physical Exam, the Initial Annual Wellness Visit or the Subsequent Annual Wellness Visit—can be complicated, which is a problem for some administrators who have difficulty assigning the right CPT code for billing purposes (MGMA, 2016).
These challenges can easily be overcome with a little education, training and preparation. Physicians can see that preventive health care is just as important as providing care to sick patients, and administrators can quickly learn to distinguish between the types of visits to ensure that proper billing is achieved.
Developing a Process Improvement for AWV in ABC Medical Group
A process improvement plan for implementing AWV services at ABC Medical Group should include providing time for all practitioners to obtain education on why the AWV is helpful and how it can effectively and efficiently be provided to Medicare beneficiaries, using a streamlined process that will make the offering cost-effective and beneficial for providers as well.
Staff and patients should be educated about the AWV as well, so that all stakeholders are aware that it is a service that is being offered and what the benefits of having it performed are for the patient.
Non-physician care givers (such as physician assistants or NPs) should be encouraged to oversee the AWV as well, as they are both permitted to conduct the visit according to governmental regulations.
An accounting program will need to be developed or purchased and implemented in order to assist with documenting AWVs in the EMR and ensuring that all protocols are followed and adhered to so that billing is correctly applied.
Focus should be placed not on the financial benefits of offering AWV services (those these certainly do exist) but rather on the need for transitioning to a value-based model of quality care for patients (Holm, Zucker, 2016).
By emphasizing the transition to value-based care, the workplace culture can promote the patient’s needs and the concept that health care providers are there to supply the patient with every opportunity possible to have a happy and healthy life. For this reason, preventive care posters and educational material should be readily available for viewing in the lobby and staff should be thoroughly informed on how to address patients regarding the AWV and its benefits to them.
Successful Process Improvement for AWV in ABC Medical Group
Since February 2017, ABC Medical Group’s Population Management Team has found that 5,773 of its 6,772 patients, who are over the age of 65, are overdue for their AWV. That equates to approximately 85% patients who are eligible for the visit not taking advantage of the free risk assessment. In other words, only 15% of patients eligible for the AWV at ABC Medical Group are actually receiving this service. This statistic alone shows how much improvement stands to be made by implementation of the plan described above. Since so many Medicare beneficiaries are unaware that AWVs are fully covered by Medicare, it is no surprise that they do not seek to schedule a yearly visit with their provider. What is more worrisome, however, is that providers take so little time to actually promote the AWV to beneficiaries.
A successful process improvement, therefore, required the following:
1) The initiation of a quality improvement process that utilizes gap analysis to assess the causes of gaps in scheduling AWVs so that these gaps may be closed;
2) Once the gap analysis was conducted, a PDSA cycle was implemented to measure and make changes when necessary. The model allowed for a continuous formative process as well as for any mid-course corrections to be made to facilitate the erection of a more efficient structure and process so as to ensure that the practice was optimized to reach workflow potential and to redefine staff functions.
3) ABC Me Medical Group Population Management Team searched the Electronic Medical Records (EMR) to determine which patients were overdue for their AWV, starting from 2014. A patient was considered overdue if he/she had not had an assessment within one year since his or her last wellness visit. Based on that search, a list of overdue patients was developed and sent to each of the ABC Medical Group Internal Medicine Office Managers.
4) Relevant literature review materials and implementation toolkits conducive to action plan implementation were also on hand to facilitate the process.
5) Finally, interviews and meetings with ABC executives, directors, officers and managers were conducted to ensure that all variables impacting the process were appropriately understood.
Conclusion
Medical practice administrators should be aware of the ways in which the healthcare environment is changing and must be ready to take advantage of opportunities like the AWV to ensure that preventive services are being provided so that their facilities can transition to value-based models of care. Doing so will allow added value to be brought to the organization and increased revenue streams to result. The benefits for providers are that providing the AWV gives high quality care at a low cost with solid reimbursement. The AWV is an important way to ensure that the necessary restructuring of the Group’s medical practice to the value-based model of care is successful. It will also effectively contribute to the survival of the Group amid the fast-changing atmosphere of the healthcare industry.

References
AAFP. (2016). FAQ on the Medicare annual wellness visit (AWV). Retrieved from
http://www.aafp.org/practice-management/payment/medicare-payment/awv/faq.html#whyawv
CMS. (2016). Accountable care organizations (ACO). Retrieved from
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/
CMS. (2017). The ABCs of the annual wellness visit (AWV). Retrieved from
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf
Cuenca, A. (2012). Making Medicare wellness visits work in practice. Retrieved from
http://www.aafp.org/fpm/2012/0900/p11.pdf
Holm, A. & Zucker, H. (2016). Top 10 ways to improve your physician quality reporting
system/group practice reporting option. American Journal of Managed Care, 4(1), 57-50.
Konger, J. (2015). Why the annual wellness visit is actually a big EHR opportunity.
Retrieved from https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2015/05/sw-annual-wellness-visit
Levinthal, N., Teske, K., Kontor, J. (2015). How to make the most of 4 Medicare
reimbursement opportunities. Retrieved from https://www.advisory.com/research/medical-group-strategy-council/practice-notes/2015/june/are-you-maximizing-all-medicare-reimbursement-opportunities
MGMA. (2016). An incremental process to prepare for value-based contracting:
Implementing Medicare annual wellness visits to improve quality and practice income. Retrieved from http://www.mgma.com/practice-resources/articles/fellow-papers/2015/final-acmpe-9-15-2016?ext=.pdf
NCOA. (2016). A closer look: Medicare’s annual wellness visit. Retrieved from
https://www.ncoa.org/wp-content/uploads/medicare-annual-wellness-visit.pdf