Alex Tse, MD

Medicare Annual Wellness Visits (AWVs) offer practices a way to improve the health of their patients, increase revenues, and improve quality scores in value-based reimbursement programs.
	
	Yet, according to a 2017 SmartLink survey, only 10 percent of clinicians have done AWVs with more than 80 percent of their eligible Medicare patients. Half of the surveyed providers brought in less than 40 percent of eligible patients for AWVs.
	
	This data is consistent with a recent analysis of Medicare claims data showing that nearly half of AWVs were performed by just 10 percent of the doctors who provide them. A national study by the American Medical Group Association found that under 20 percent of eligible Medicare patients received AWVs in 2016.
	
	What accounts for this shortfall? Wide  geographical variations in the prevalence of AWVs suggest that physicians are much more likely to promote them to patients in some areas than in others. Accountable care organizations (ACOs) are also more likely than practices outside of ACOs to offer AWVs because they benefit financially from assessing health risks and filling care gaps, according to a 2017 report in JAMA.
	
	Another reason is a lack of understanding among patients and providers as to what services the AWV includes. On the clinician side, this confusion results in operational challenges. Clinics often lack the appropriate process, staffing, and technology necessary to provide all the required services to a large percentage of patients.
	
	While orchestrating an AWV program requires time and money, the practices able to deliver AWVs effectively to most of their eligible patients could see a substantial return on investment. Moreover, these visits would generate follow-up visits for preventive services that patients might not otherwise seek from their physicians.
	
	AWVs offer additional benefits. The screening tests and other preventive services arising from those visits can help physicians raise their quality scores in the Merit-based Incentive Payment System (MIPS), CMS’s pay-for-performance program. If they belong to an ACO that participates in the Medicare Shared Savings Program (MSSP), AWVs can help ACOs improve their scores on 13 MSSP quality metrics. AWVs also can support the attribution of patients to ACO providers.
	
	


	
	In order to provide AWVs at scale, it’s important to think through all the steps that it entails: who does what, how, and when. Patient identification, eligibility checking, education and outreach, office workflow, data capture, ability to retrieve the data  for future quality metrics reporting, and completion of the scope of service all have to be taken into consideration.
	
	One of the most important aspects of the AWV process is patient education and scheduling. Patients need to have a clear understanding of what to expect, as an AWV visit will be different from that of a “sick” E/M visit.
	
	AWV is not an office visit that requires a physical exam by the provider. The patient is screened with multiple questions related to their wellness, usually by a nurse.  If the patient has questions related to an acute or chronic illness, or medication refills, they will be asked to schedule a future E/M visit.
	
	According to CMS, an AWV (G0438/G0439) and an E/M service (99212-99215) can all be billed on the same date, as long as separate documentation supports each of these services. However, frequent billing of both AWV and E/M services on the same day may have higher risk of triggering an audit, according to coding experts.
	
	


	
	As a preventative care visit, the AWV does not usually require a provider to spend face-to-face time with the patient (except in an FQHC/RHC setting). However, in order to conduct the AWV visit using clinical support staff such as an MA or LPN and without provider involvement, the visit needs to be highly structured.
	
	Clinical pathways and algorithm logic are necessary to ensure interventions for health risk factors and that the appropriate preventative screening schedule is created for the patient. It’s possible to capture the required patient information either on paper or via an EHR template; in general, however, both paper and EHRs fall short when it comes to the beneficiary counseling component and creating a personalized prevention schedule.
	For example, establishing a list of risk factors and conditions for which interventions are recommended along with treatment options, as well as furnishing personalized health advice and referrals as appropriate, cannot be provided by the EHR or determined by an MA without appropriate guidance.
	
	EHRs also can’t provide eligibility checking for any recommended preventative services, causing the AWV to take  longer than it should. As a result, both paper and EHR templates for AWV information gathering would require manual eligibility checking for preventative services and the development of clinical pathways and protocols. Otherwise, the AWV should be conducted by more highly skilled staff, such as an RN, non-physician provider, or physician.
	
	The other option is to use interoperable software on the EHR that is specifically designed to process the AWV smoothly and ensure compliance with all of the CMS requirements, including the automatic creation of an eligibility-based personal prevention plan. Then support staff can  be used to quickly complete the AWV.
	
	


	
	Once the process and technology are defined, a staffing plan can be created. The decision to use either contract or permanent employees, and the number of employees to hire, will be influenced by patient volume and seasonality factors.
	
	For example, the winter season is usually accompanied by more acute sick visits, so the practice might decide to focus on performing more AWVs during the summer months. Depending on the volume of AWVs to be done per day, the practice may need additional staff.
	
	Practices also need to make sure they have the appropriate staffing level for patient outreach, education, and scheduling. This assumes, of course, exam room availability to see the desired volume of patients within a defined timeframe.
	
	


	
	Clinics that approach launching an AWV program with the right people, process, and technology can be successful, regardless of whether they outsource all or part of the program.
	
	However, many that insource their AWV program struggle to scale the program effectively. While on the surface it may seem more cost effective to insource, clinics tend to underestimate the full cost of doing AWVs on their own, especially during the ramp-up phase when processes are inefficient and/or insufficient.
	
	One Federally Qualified Health Center, for example, was able to garner only 112 AWVs in the first six months using four staff members across six locations. They decided to test outsourcing at one location with one contracted medical assistant onsite. Over the next three months, their own staff of four completed 172 AWVs across six locations.
	
	In contrast, the outsourced location completed more than 200 with only one MA. From both a revenue and profitability perspective, the outsourcing approach proved to be more productive as well as more lucrative.
	
	When you do the math, it’s easy to see why an outsourced program, when deployed efficiently and at greater scale, will be more economically viable than an insourced program. According to the latest Physician Fee Schedule, Medicare pays $161-$227 for initial AWVs and $108-$152 for subsequent AWVs, depending on practice location.
	
	For practices that lack the know-how and staff, but prefer an insourcing model, a hybrid approach may make sense. An outside vendor can supply just the technology, patient outreach, and scheduling, while the clinic provides the staff to conduct the AWV. Another possibility would be to initially outsource the program entirely so as to leverage an outsourcing firm’s expertise in AWV processes and best practices.
	
	After the program is up and running and there is time for knowledge transfer to take place, the clinic can transition to a partially or fully insourced model.
	
	


	
	In the Medicare patient population, prevention is often overshadowed by chronic  and acute issues. The AWV is an opportunity for both physicians and patients to make preventive care a priority. But it is significantly underutilized.
	
	Practices that wish to increase the percentage of Medicare patients receiving AWVs will need to overcome some operational challenges. However, a combination of the right staffing, technology, and process, whether insourced or outsourced, can help them provide this important service to the majority of eligible patients, while earning additional income.

Alex Tse, MD, is a primary care provider and chief medical information officer of SmartlinkHealth.

Articles

The annual exam is significantly underutilized, but provides opportunity for both physicians and patients to make preventive care a priority.

Leverage the Annual Wellness Visit

Medicare Annual Wellness Visits (AWVs) offer practices a way to improve the health of their patients, increase revenues, and improve quality scores in value-based reimbursement programs. 

, only 10 percent of clinicians have done AWVs with more than 80 percent of their eligible Medicare patients. Half of the surveyed providers brought in less than 40 percent of eligible patients for AWVs. This data is consistent with a recent 

, which showed nearly half of AWVs were performed by just 10 percent of the doctors who provide them. Overall, 

a national study by the American Medical Group Association

 found that under 20 percent of eligible Medicare patients received AWVs in 2016.

What accounts for this shortfall? The wide geographical variations in the prevalence of AWVs suggest that physicians are much more likely to promote them to patients in some areas than in others. Accountable care organizations (ACOs) are also more likely than practices outside of ACOs to offer AWVs because they benefit financially from assessing health risks and filling care gaps, according to 

. Another reason is a lack of understanding by both patients and providers as to what services the AWV provides. On the clinician side, this confusion over the scope of service results in operational challenges. Clinics often lack the appropriate process, staffing, and technology necessary to provide all the required services to a large percentage of patients. 

While orchestrating an AWV program requires time and money, the practices able to deliver AWVs in an effective manner to most of their eligible patients could see a substantial return on investment. Moreover, these visits would generate follow-up visits for preventive services that patients might not otherwise seek from their physicians.

AWVs offer additional benefits. The screening tests and other preventive services arising from those visits can help physicians raise their quality scores in the Merit-based Incentive Payment System (MIPS), CMS’s pay-for-performance program. If they belong to an ACO that participates in the Medicare Shared Savings Program (MSSP), AWVs can help ACOs improve their scores on 13 MSSP quality metrics. AWVs also can support the attribution of patients to ACO providers.

In order to provide AWVs at scale, it’s important to think through all of the work that it entails: who does what, how, and when. Patient identification, eligibility checking, education and outreach, office workflow, data capture, ability for the data to be retrieved for future quality metrics reporting, and completion of the scope of service all have to be taken into consideration. One of the most important aspects of the AWV process is patient education and scheduling. Patients need to have a clear understanding of what to expect, as an AWV visit will be different from that of a “sick” E/M visit.

AWV is not an office visit that requires a physical exam by the provider. The patient is screened with multiple questions related to their wellness by a nurse.  If the patient has questions related to an acute illness or chronic illness, or medication refills, they will be asked to schedule a future E/M visit.

According to CMS, an AWV (G0438/G0439) and an E/M service (99212-99215) can all be billed on the same date, as long as there is separate documentation supporting each of these services.  However, frequent billing of both AWV and E/M services on the same day may have higher risk of triggering an audit, 

As a preventative care visit, the AWV does not usually require a provider to spend face-to-face time with the patient (except in an FQHC/RHC setting). However, in order to carry out the AWV visit using clinical support staff, such as an MA or LPN and without provider involvement, the visit needs to be highly structured. 

Clinical pathways and algorithm logic are necessary to ensure interventions for health risk factors and the appropriate preventive screening schedule is created for the patient. It’s possible to capture the required patient information either on paper or via an EHR template; however, in general, both paper and EHRs fall short when it comes to the beneficiary counseling component and creation of the personalized prevention schedule.

For example, establishing a list of risk factors and conditions for which interventions are recommended along with treatment options, as well as furnishing personalized health advice and referrals as appropriate, are not things that can be provided by the EHR or determined by an MA without appropriate guidance. Eligibility checking for the recommended preventative services is also not provided by EHRs, causing the AWV to take a lot more time than it should. As a result, both paper and EHR templates for AWV information gathering would require manual eligibility checking for preventative services and the development of clinical pathways and protocols. Otherwise, the AWV should be conducted by more highly skilled staff, such as an RN, non-physician provider, or physician.

The other option is to utilize EHR-interoperable software that is specifically designed to process the AWV smoothly and ensure compliance with all of the CMS requirements, including the automatic creation of an eligibility-based personal prevention plan. Support staff can then be used to quickly complete the AWV. 

Once the process and technology are defined, a staffing plan can be created. The decision to use either contract or permanent employees and the amount of employees to hire will be influenced by patient volume and seasonality factors. For example, the winter season is usually accompanied by more acute sick visits, so the practice might decide to focus on performing more AWVs during the summer months. Depending on the volume of AWVs to be done per day, the practice may need additional staff. 

Practices also need to make sure they have the appropriate staffing level for patient outreach, education, and scheduling. This of course assumes that there is exam room availability to see the desired volume of patients within a defined timeframe. 

Clinics that approach launching an AWV program with the right people, process, and technology can be successful, regardless of whether they insource or outsource all or part of the program. 

However, many that insource the AWV program struggle to scale the program effectively. While on the surface it may seem more cost effective to insource, clinics tend to underestimate the fully loaded cost of doing AWVs on their own, especially during the ramp up phase when processes are inefficient and/or insufficient. One federally qualified health center, for example, was able to garner only 112 AWVs in the first six months using four staff members across six locations. They then decided to test outsourcing at one location with one contracted medical assistant onsite. Over the next three months, their own staff of four completed 172 AWVs across six locations. In contrast, the outsourced location completed over 200 with only one MA. From both a top line revenue and bottom line profitability perspective, the outsourced approach proved to be more productive as well as more financially lucrative. 

When you do the math, it’s easy to see why an outsourced program, when deployed efficiently and at higher scale, will be more economically viable than an insourced program. According to 

, Medicare currently pays $161-$227 for initial AWVs and $108-$152 for subsequent AWVs, depending on practice location.

For practices that lack the knowhow and staff, yet prefer an insourcing model, a hybrid approach may make sense. An outside vendor can supply just the technology, patient outreach, and scheduling, while the clinic provides the staff to conduct the AWV. Another approach would be to initially outsource the program completely in order to leverage an outsourcing firm’s expertise in AWV process and best practices. 

After the program is built up successfully and there is time for knowledge transfer to take place, the clinic can then transition to a partial or full insource model.

In the Medicare population, prevention is often overshadowed by chronic issues and acute concerns. The AWV is an opportunity for both physicians and patients to make preventive care a priority. But it is significantly underutilized. 

Practices that wish to increase the percentage of Medicare patients will need to overcome some operational challenges. However, a combination of the right staffing, technology, and process, whether insourced or outsourced, can help them provide this important service to the majority of eligible patients, while earning additional income.

Alex Tse, MD, is a primary care provider with over 40 years of primary care practice. He is the chief medical information officer of 

The annual exam is significantly underutilized but provides opportunity for both physicians and patients to make preventive care a priority.

Author | Alex Tse, MD

Articles

Leverage the Annual Wellness Visit

Leverage Annual Wellness Visits to improve value-based performance