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Use Annual Wellness Visits to Amplify Overall Quality

 |  By Debra Shute  
   September 29, 2017

Whether you are delivering primary care through a multi-state integrated system or a rural independent practice, benefits abound in optimizing this fully reimbursed Medicare service.

Despite primary care providers' celebration when the Centers for Medicare & Medicaid Services began paying for the preventive service now known as the Annual Wellness Visit (AWV) in 2011, the majority of PCPs continue to forgo those dollars.

But according to organizations that have made a concerted effort to promote and perfect the service, revenue is far from the only benefit of a strong AWV strategy.

Success key No. 1: Educate providers

Nationally, in 2016, 19.8% of eligible Medicare Part B beneficiaries utilized the AWV, according to a CMS report, despite the fact that CPT codes G0438 for the initial visit and G0439 for a subsequent AWV are paid 100% by Medicare and can be combined with another visit with the addition of a modifier.

The barriers to higher uptake are mostly cultural.

In particular, there is a common perception among physicians that the service is unnecessary.

"A lot of folks seem to feel that they're already meeting the need that's intended by the AWV without needing to do a distinct service," says Dan Hager, MHA, program manager for physician and ambulatory services for Bon Secours Health System.

Doctors often argue, for example, that the questions raised in the AWV about recommended cancer screening and immunization are already raised during the course of regular primary care, says Hager.

Oftentimes, providers also experience or fear seniors being dissatisfied with coming to the office for a visit that involves no physical exam.

"An important first step was just getting physicians acquainted with what it was," Hager says. "After that it was really about removing as many impediments as possible to getting it done." 

For Bon Secours, this meant developing a complete toolkit that explained what should be included in an AWV, how to bill for it, and when and why a copay might be required.

"The toolkit started as an internally developed communication outlining the reason for prioritizing the AWV as well as a summary of the documentation requirements and tips for coding the visit. It also included some tools available from the CMS Learning Network and others including potential workflows, scripts, explanatory articles, and other tips," Hager says.

As the toolkit developed, Hager says Bon Secours relied more on its internally developed documents based on its experience and identified best practices. 

"This included education on coding, the EHR workflows we developed, a scheduling/registration workflow, and scripting to encourage our patients in the office and over the telephone to get an AWV," he says. 

Thus, consistent, systemwide communication was important in Bon Secours boosting its own 26% AWV rate to approximately 65% within three years. "Critical to this success was talking about it, communicating, and explaining our strategic initiative in terms of driving population health outcomes," Hager says.

Today, Bon Secours AWV progress continues, with about 61% of eligible patients getting the visit and high hopes for reaching 65% by fall of 2017.

Success key No. 2: Engage patients

For South Arkansas Medical Associates, a six-physician primary care practice in rural El Dorado, persuading its doctors and advanced practice clinicians to perform AWVs wasn't nearly as challenging as selling patients on the idea, says Pete Atkinson, MHA, the group's administrator.

"When Medicare first started to allow AWVs, we kind of dabbled in it. From a flow standpoint we struggled, and a lot of that was getting patients to come in specifically for that wellness visit," he says. "For that generation, it's a new thing. To them, you go to the doctor when you're sick. It doesn't make sense to them to come to the doctor when they feel fine."

SAMA has found much better success in scheduling AWVs in conjunction with other follow-up and acute visits, he says. Patients who come in for a diabetes follow-up visit, for example, can undergo their AWV the same day.

"Fall of 2015 is when it started ramping up," Atkinson says. And having joined an ACO last year as well as participating in CMS' Comprehensive Primary Care Plus (CPC+) program, the practice is now conducting the visits with nearly 60% of its Medicare patients.

For many seniors, especially those with transportation problems, the twofer visit has a social appeal as well.

"It's their chance to get dressed and get out of the house. And if they're coming on one of the senior buses they get to visit with peers," says Gary Bevill, MD, a founding member of the practice. "They seem to appreciate the fact that they're not just in and out for a so-called eight-minute visit."

And now that many patients have participated in one or two recurrent AWVs, their engagement in their overall health seems to be on an upswing, says Bevill.

For example, Bevill describes a patient who recently visited the office with her husband, and apologized for not bringing with her the printout of recommended screenings from her own recent AWV, on which she'd diligently filled in all of the test dates and results. 

"She didn't know that I'd gotten the results, but she was going to bring the form back so we could update our system," he says. "Again, she didn't realize that we're already updating it, but this is a senior with a lightbulb going off—see? That to me felt like maybe we're making some inroads," Bevill says.

Success key No. 3: Take a team approach

On the flipside of these successes can be the challenge of maintaining the capacity to provide increasing initial and recurrent AWVs, notes Hager. 

"Now that we're in our fourth year of focus on this … and the number starts to climb higher and higher, it highlights for us some of the areas where we have challenges when it comes to patient access," he says.

The system's next areas of focus, therefore, are "expansion of the infrastructure, coming to grips with our overall access, and exploring how we use the AWV as part of an overall strategy for engaging patients and earning their loyalty."

SAMA has had to work out its share of flow and capacity challenges as well, Atkinson says, but many have been solved by implementing staff ideas.

"We turned a lot of it over to the nurses and care coordinators. In particular, our population health nurse and IT nurse came up with a lot of the flow," says Bevill. "I think if you talk to some of our employees they're pretty happy campers because they feel like they have input. And if something is not working, they can suggest an alternative."

For example, care coordinators will often call patients before their AWV and ask several screening questions then, Atkinson says. "So when they come in, it's a shorter time in the clinic. That's been a huge help."

But even a full AWV takes an average of 30 minutes total, he says, only about 5 minutes of which involves the physician. "Most of it is done by the nurse."

Another key to efficiency is that care teams review a patient's EMR prior to any visit and know of any issues, such as an elevated A1C level, before walking into the room, notes Bevill.

The nurse is fully prepared by the time she gets the patient out of the waiting room, and reviews the recommendations with them while walking back out.

"It doesn't take a ton of my time," says Bevill, "but I reinforce the fact that as your doctor I want you to have these tests, and they usually go along with it."

Success key No. 4: Connect to quality

With an average reimbursement of $172 for an initial AWV and $111 for subsequent AWVs, the revenue can add up for primary care practices of all sizes.

But the value is best measured in terms of benefit to the patient, says Hager.

"It was incredibly important that it not be about the money so much as it was about the value that we were driving for our patients, for our community, and even for our payer. CMS is asking us to be good stewards by making this available, and we want to make sure we're delivering the aims they intended when they created the opportunity to do an AWV."

Indeed, Bon Secours' own data has revealed that patients who get AWVs are also dramatically more likely to follow through on other preventive services.

For example, while the causal relationship is unclear, Bon Secours' Medicare beneficiaries who had an AWV in 2015 were significantly more likely to receive breast cancer screening, colorectal cancer screening, pneumonia vaccination, and influenza vaccination.

While just 53.6% of patients older than 66 without an AWV got a pneumonia shot, for example, 84.5% of those who attended an AWV were immunized, Hager says.

"A lot of folks seem to feel that they're already meeting the need that's intended by the AWV without needing to do a distinct service."

And although SAMA has not run such comparisons, Bevill notes that the practice is on track to conduct foot exams for 85%–90% of the group's diabetic patients whether they've had a wellness visit or not. "We're seeing a huge jump in our quality metrics on all of our patients," he says. 

Perhaps that's because the practice has reinvested most of the revenue collected from AWVs into its overall quality initiatives.

"Having been in solo practice for 15 years and here for 19 years, [I know] PCPs are always looking for ways to increase revenue," says Bevill. "But we're also a CPC Classic and now a CPC+ clinic."

Participating in those initiatives has involved significant growth. In 2012, for example, the practice had four physicians, two advanced practice nurses, and less than 30 employees. Today, SAMA has 14 providers and 74 employees. 

"And that has a cost," Bevill says. "While the Medicare wellness visit does generate an increased revenue stream, we have turned around and invested that revenue into the additional staff it takes to do population health."

Success key No. 5: Celebrate success

With the wrinkles ironed out, AWVs can also have a positive impact on providers and employees.

At Bon Secours, for example, the systemwide AWV initiative helped strengthen its network relationships.

"It was actually very well timed because we'd been in the midst of a primary care growth strategy to rapidly increase the amount of PCPs we had in our communities," Hager says. "The AWV came around the mid-point of that growth effort and provided a great opportunity for us to establish an identity across all of our diverse providers in the practices and give us something we could all work on to get there."

Meanwhile at SAMA, job satisfaction is on the rise in an era when clinician burnout has become epidemic.

"The doctors and APNs—we love coming to work," says Bevill. "It is so much easier to take care of these chronic, complicated patients with the system that we have put in place. That's made it worth every penny." 

Debra Shute is the Senior Physicians Editor for HealthLeaders Media.


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