In 2011, the Centers for Medicare and Medicaid Services created the annual wellness visit (AWV), a new visit type with no cost to Medicare patients, better reimbursement to primary care practices, and higher assigned credit for clinicians’ work. The visit takes about 30 minutes and includes a questionnaire covering home safety, falls risk, and ability to perform activities of daily living, along with a survey of recommended preventive services and depression and dementia screening. No physical assessment is required beyond vision screening and vital signs.
When the AWV was introduced, many of my colleagues and I were optimistic that it might inspire preventive care, and of course any improvement in reimbursement was welcomed.
Now, more than a decade later, the environment has changed: It is increasingly difficult for patients to schedule appointments, while technology offers new ways to address preventive care. That means this is a good moment for my fellow primary care clinician leaders and me to ask: Do incentives to perform wellness visits for Medicare patients still make sense?
The idea behind the AWV was laudable: encourage patients to address prevention and goals of care (which often rank lower in office visit priority than acute matters) as well as chronic disease. By marrying this with higher reimbursement to practices, the hope was for an all-around win. But the reality has been a bit more uneven.
There is some evidence that AWVs are associated with up to 5.7% reduced health care spending during the one-year period after the visit, especially in the highest hierarchical condition category risk groups. It is unclear, though, if it was the visits themselves that saved cost, or their components. In this same study, patients who had AWVs were more likely to receive guideline recommended preventive care.
Meanwhile, evidence that AWVs improve health outcomes is lacking.
One fundamental flaw in the AWV concept is that it inverts the usual primary care office visit process. When patients come in for a visit, it is their opportunity to voice concerns, while our primary clinician obligation is to receive and assess them. The AWV changes the visit into an entirely clinician-driven interview that sidelines patient concerns, a redirection that is inherently uncomfortable for both. If other problems do come up during the visit, the clinician may bill separately for the encounter, but that can be upsetting for patients who expected a free appointment.
Practices have been creative in finding ways to accomplish more AWVs without straining appointment access. One approach my group has piloted is to have nurses complete the visits, which a physician then reviews and signs. This is more efficient, but it still creates an additional trip to the office for patients, adds to the in-basket task load for physicians, and may be a resource drain, taking nurses away from other mission critical work in the practice, such as phone and portal message triage to address pressing concerns from patients.
Many clinicians try to weave the AWV into other scheduled office follow-up visits. Team-based workflows where medical assistants share elements of the interview and documentation that can improve efficiency. But this approach may often lead to add-on charges if problems are discussed, which removes the zero co-pay reward for patients.
It’s time to rethink the AWV. Primary care practice has evolved in ways that challenge the value of an actual visit as a sensible way to help patients achieve preventive care goals and establish clinician-patient relationships. Value-based care has inspired innovation in proactive outreach approaches to population management. Use of patient portals and text messaging are effective, low-cost options, which may include both reminders as well as assistance with scheduling evidence-based interventions like mammography, colorectal cancer screening, and vaccination. Patients can easily complete the questionnaire portion of the AWV asynchronously through portal or text-based platforms alone or with caregiver assistance. Artificial intelligence will undoubtedly soon add to improved methods for outreach.
Enhanced reimbursement from CMS for all non-procedural visits would serve primary care practices far better than incentivizing only visits of questionable value. Better yet would be further leveraging progressive payment models that reward achieving preventive and health maintenance goals rather than incentivizing more visit “widgets.”
Proponents often point to the relationship aspect of the AWV. It’s true that evidence supports that a strong connection to a primary care clinician leads to reduced mortality, improved diagnostic accuracy, and improved patient satisfaction, along with fewer emergency room visits and hospital admissions. These conversations can be valuable for both the patient and clinician to create a foundation for high value care.
It makes intuitive sense that a visit engineered to provide more time to discuss advanced care planning, care goals, and social determinants would improve the doctor-patient relationship. Maybe that’s true in ideal circumstances, with a robust primary care clinician workforce and minimal access constraints. But in the current appointment constrained state, where primary care clinicians either are caring for very large panels of patients or are in less overwhelmed practice models with a significant pay-to-join barrier? I think not. Any relational connection gained in an AWV is at risk of erosion if it negatively affects a clinician’s availability when a new concern arises.
It doesn’t make sense to fill up scarce primary care appointment slots with visits composed of elements we can easily address through technology-enhanced outreach. Imagine accountants insisting that all clients make appointments to complete their tax year planner packets in person, when now the client does the work independently in a manner that saves the accountant’s time for what only the accountant can do. We should encourage visits for our highest risk patients and make them constructive and patient-centered. Demanding efficiency in information acquisition and delegation of work not requiring physician time would create much needed space for patient-driven visits to address concerns, build trust, connection and continuity — the hallmarks of primary care.
Jeffrey Millstein, M.D., FACP, is an internist, clinical assistant professor at the Perelman School of Medicine of the University of Pennsylvania, and regional medical director for Penn Primary Care.