Improving Welcome to Medicare Visit Utilization Rates

Introduction

In an effort to increase the health and well-being of older adults, Congress authorized the Centers for Medicare and Medicaid Services (CMS) to provide an initial preventive physical examination (IPPE) to Medicare beneficiaries under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (DeWilde & Russell, 2004). New Medicare enrollees had six months to take advantage of the IPPE benefit, which has come to be known as the "Welcome to Medicare Visit" (WMV) benefit. The WMV includes a focused physical examination—rather than a head-to-toe physical—in addition to development of a health plan, advanced care counseling, and recommended screenings (Cuenca, 2012). Simply authorizing preventive care services for new Medicare enrollees, however, did nothing to increase preventive care utilization among older adults (HHS, 2012), so Congress authorized additional revisions to the benefit over the years to encourage its use, including extending the eligibility period to 12 months and eliminating co-pays under the Patient Protection and Affordable Care Act (ACA) of 2010 (Salloum, Jensen, & Biddle, 2013).

Recent research studies have revealed that utilization of the WMV benefit remains stubbornly low, somewhere between 3% (Salloum et al., 2013) and 13% (HHS, 2012). Some of the same studies have implicated widespread unawareness of the benefit among beneficiaries as the main reason for its underutilization (Salloum et al., 2013; Jensen, Salloum, Hu, Ferdows, & Tarraf, 2015), but participants in at least one study reported that physicians failed to recommend preventive screenings (Jensen et al., 2015). In addition, informal reports by primary care physicians suggest that many are reluctant to recommend the WMV benefit because reimbursement is too low given the amount of time required to meet all the requirements (Lesser, 2013). In light of this evidence, it appears that WMV underutilization is primarily the result of primary care provider reluctance. To better understand the barriers to preventive care utilization by Medicare beneficiaries, a review of recent research literature follows. This understanding will then be used to propose a health promotion project designed to increase WMV utilization.

This project is relevant to the advanced practice nurse role because it builds the skill set concerning the provision of care for older Americans and the promotion of optimal health among this demographic (O'Grady, 2008). Additionally, the project increases understanding of the importance of preventive care services for older adults and identifies the barriers to and promoters of preventive care that determine utilization rates among Medicare beneficiaries. Executing the health promotion project helps develop the skills needed to conduct community assessments, design interventions, and evaluate intervention efficacy, as part of health promotion responsibility and accountability within the communities served.

Literature Review

The literature review examined peer-reviewed research studies published within the last five years. The databases accessed to conduct this search were PubMed, ProQuest, and CINAHL, using various combinations of search terms that often included: barriers, preventive care, older adults, Welcome to Medicare, and/or Medicare. After sifting through the results, at least five peer-reviewed scientific studies were selected for evaluation and inclusion in the literature review. However, to provide a theoretical framework through which these findings can better be understood, Nancy Milio's (1976) framework for prevention model will be discussed first.

Milio's (1976) framework for prevention model proposes that individuals will make healthy choices based on ease and habit, but the number and nature of choices available to individuals is determined by organizations. In other words, if new Medicare enrollees are not aware that Medicare offers free wellness visits, then increasing utilization rates will depend on making changes to the organization—in this case, the primary care system. Substantial support for Milio's model in relation to preventive care utilization among older adults has been found in the research literature, which is discussed next.

One indicator of wellness benefit awareness is primary preventive care utilization among new Medicare enrollees during the eligibility period. When Salloum and colleagues (2013) examined mammogram and Pap smear utilization among new Medicare enrollees between 2001 and 2007, no increase was observed following implementation of the WMV benefit at the beginning of 2005. The main limitation of this study is its reliance on beneficiary self-reports. The sample size is so large (N = 10,581,445 to 10,685,374), however, that the absence of any effect is convincing enough to conclude that introduction of the WMV benefit had no effect on primary preventive service utilization among new Medicare enrollees. The most common reason given by participants for failing to utilize the WMV benefit was unawareness of its existence. When asked if they would have used the benefit had they known about it, 78% responded in the affirmative. This finding reveals that new Medicare enrollees are largely unaware of the WMV benefit—a finding consistent with Milio's (1976) framework for prevention model.

A follow-up study examined Medicare annual wellness visit (AWV) utilization before and after co-pays were eliminated in 2011, with a focus on traditional Medicare recipients who would benefit the most from this change (Jensen et al., 2015). The elimination of co-pays for AWVs had no effect on benefit utilization by any group of Medicare beneficiaries, based on self-reports for utilization of cholesterol tests, blood pressure checks, influenza vaccinations, endoscopy, fecal occult blood tests, and prostate and breast cancer screenings. The strength of the findings was weakened by the self-report nature of the data, but the sample was sufficient in size (N = 15,044) to detect even a small effect. Patients reported unawareness of the benefit as the most common barrier, in addition to physicians failing to adequately recommend screenings. These findings provide additional support for Milio's (1976) model because study participants claimed that the primary healthcare system failed to educate them about their wellness visit options or recommend screenings.

A similar conclusion was reached by researchers who examined the utilization of colorectal cancer screening among Medicare enrollees after expansion of Medicare coverage of preventive services in 2001 (Doubeni et al., 2010). Medicare participants without supplemental insurance, a usual place of care, or a high school education were significantly less likely to utilize preventive colonoscopy. Sample sizes ranged between 7,614 and 8,330, depending on the year survey data was collected, but most survey participants had supplemental insurance (76.2–81.1%) and a usual place of care (92.9–94.5%). Despite significant sample skewing, the data are convincing and suggest that Medicare recipients with access to a stronger primary care system tend to utilize preventive services more often. Again, this finding suggests that the primary care system determines the rates of preventive care use among older adults (Milio, 1976).

A recent study examined the incidence of primary care-treatable conditions presenting in emergency departments (EDs) between 1997 and 2009 and discovered that the number of Medicare recipients (N = 42,155) engaging in this activity increased an average of 0.52% per year (Purkurdpol, Wiler, Hsia, & Ginde, 2014). Although the definition of "primary care-treatable" can vary, the magnitude of the increase (6%) during this period, along with the large sample size, lends credibility to this finding. Accordingly, it seems reasonable to conclude that increasing Medicare beneficiary awareness would reverse this trend (Milio, 1976). Such efforts should probably target older adults years before they become eligible for Medicare coverage, since nearly 80% of adults under the age of 65 were also unaware of access to free or low-cost preventive care through their consumer-directed health plans (Reed, Graetz, Fung, Newhouse, & Hsu, 2012). Although this finding was limited to a relatively small sample (N = 456) of beneficiaries within a single health plan, the findings are consistent with those discussed above and are therefore credible and generalizable. This finding also provides support for Milio's (1976) proposition that individuals make choices based on ease and habit, which in turn suggests that an effective intervention for increasing preventive care utilization among Medicare beneficiaries should include encouraging regular use of preventive services among younger adults. If a wellness visit habit is established, new Medicare enrollees may expect continued access to preventive services and demand the provision of these services from their primary care provider.

All of these studies provided substantial support for Milio's framework for prevention model, because awareness levels predicted utilization rates. Evidence was also provided that laid the blame for this ignorance on the primary healthcare system; at least one study found fault with primary care providers (Jensen et al., 2015) and another discovered an absence of a preventive care utilization habit among younger adults (Reed et al., 2012). Together, these findings suggest an effective intervention would be to increase the willingness of primary care providers to offer preventive services to new Medicare enrollees.

Intervention

The best practice model developed by Cuenca (2012) and colleagues utilized a collaborative approach for the provision of Medicare wellness visits. Probably the most important innovation is the use of a same-day, 30-minute nursing previsit, which reduces the amount of time the physician or nurse practitioner (NP) must allocate to the wellness visit. A licensed vocational nurse (LVN) was tasked to collect vitals and perform procedures; if the LVN was unavailable, a medical assistant (MA) trained in WMV administration would take over these tasks. The day before the WMV appointment, the nurse and primary care provider would review the patient's records and decide what to focus on during the visit the following day. During the previsit, the nurse establishes an electronic health record (EHR) note for the WMV, obtains patient and family medical histories, reconciles medications, performs a PHQ-9 depression screening questionnaire and Mini Mental Status Exam, collects vitals, assesses functional abilities, screens for visual acuity and hearing problems, performs an ECG if recommended, and engages the patient in discussions about advance care planning.

The nurse then hands the patient off to the physician or NP to complete the WMV requirements (Cuenca, 2012). Within a 15- to 20-minute office visit, the provider reviews the notes made by the LVN or MA and addresses concerns with the patient, conducts a focused physical exam (not head-to-toe), provides diagnoses as appropriate, counsels the patient about advance care planning, creates a brief written care plan, educates the patient as needed, and provides referrals when indicated. A copy of the WMV summary is given to the patient for their records. The nurse previsit is billed as a no-charge nurse visit, and any services not covered under the WMV benefit are billed separately. Additional reimbursement is obtained for covered screenings, counseling, and procedures, which can increase reimbursement from the baseline of $155.89 to a maximum of $224.31. Any laboratory tests or diagnostic procedures are billed separately.

The other innovation implemented by Cuenca (2012) and colleagues was office staff training for interactions with Medicare patients requesting preventive care. Office staff were given cheat-sheets defining the WMV, annual wellness visit, and preventive physical exams, in addition to transcripts of suggested dialogues with patients.

The best practice recommendation of Cuenca (2012) is essentially a detailed plan for organizing the WMV to increase clinic workflow efficiency by minimizing the amount of time a physician or NP spends on the visit, clearing up patient misunderstandings during scheduling, and billing for all services provided. Condensing the 5-page document into a laminated cheat-sheet for distribution to primary care providers should increase its utility and possibly improve WMV utilization rates. A cheat-sheet has been adapted from the best-practice recommendations of Cuenca (2012) in an effort to reduce primary care provider reluctance to offer WMVs to new Medicare enrollees (Appendix A). This WMV Cheat-Sheet will be distributed to primary care providers and evaluated for its efficacy.

References

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Reed, M. E., Graetz, I., Fung, V., Newhouse, J. P., & Hsu, J. (2012). In consumer-directed health plans, a majority of patients were unaware of free or low-cost preventive care. Health Affairs (Project Hope), 31(12), 2641–2648.

Salloum, R. G., Jensen, G. A., & Biddle, A. K. (2013). The "Welcome to Medicare" visit: A missed opportunity for cancer screening among women? Journal of Women's Health, 22(1), 19–25.

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