A priority goal of the MaineHealth ACO in 2018 is increasing the number of Medicare Annual Wellness Visits (AWVs) ten percentage points over 2016 rates. In 2017, between 30 and 40 percent of patients covered by the MaineHealth ACO’s Medicare Shared Savings Program contract received an annual wellness visit.
Why increase AWV rates? The ACO is motivated by the opportunities AWVs provide for increasing preventive care and improving clinical documentation. Studies have shown that patients who’ve completed an AWV are more likely to participate in preventive screenings and vaccinations.  Our own research supports that conclusion. And AWVs present a good opportunity to increase the specificity and accuracy of clinical documentation, since a thorough review of conditions is built into the visit. Both of these benefits, increased access to preventive care and improved clinical documentation, can contribute to better patient outcomes and better ACO performance overall.
Like many worthwhile endeavors, starting and maintaining an AWV initiative can be difficult. EMRs need to be customized to support a new workflow, pre-visit planning time becomes more important and patients must acclimate to a new kind of visit. Despite these challenges, a number of primary care teams participating in the MaineHealth ACO have figured out ways to make AWVs work. We recently interviewed three of them. Some key takeaways follow.
1. Combine AWVs with physical exams
When Dr. Stephen Goss and his MA McKenzie Searles first started doing AWVs at Franklin Health Internal Medicine, they booked AWVs as nurse visits. “It was an extra trip into the office for the patient and there were very few people participating,” says Dr. Goss. Soon, they switched to adding AWVs to acute visits. “I’ll bill the wellness visit code and put in an E&M code for their acute issue.”
“Patients walk out happy. They get to see their provider, they get education and they get a list of their previous visits and health maintenance,” says McKenzie.
At Pen Bay Internal Medicine, Dr. Cornelius Yetman wouldn’t dream of doing an AWV without a physical, even though Medicare doesn’t reimburse for annual exams. “It doesn’t feel right to just take a history,” he says. “I’m trained to do an exam and I don’t want to bring them back in for a separate physical. It doesn’t make sense. So, the exam ends up being a freebie for Part B patients, but for Martin’s Points Generations Advantage patients, they get two codes. One for the annual wellness visit and one for the exam.” Martin’s Point Generations Advantage encourages and reimburses for combined wellness visits and annual exams.
For both providers, the reimbursement component was a consideration but the decision to combine visits primarily came down to patient preference and acceptance. “There’s a lot of overlap anyway,” says Dr. Yetman. “It’s been a smoother transition (to AWVs) for the patient. I think it’s been received fairly well.”
2. Allow for pre-visit planning and preparation
The three teams we spoke to all emphasized that pre-visit planning was crucial to efficient AWVs. Strategies include using admin time once per week or prepping the night before.
“I’m using the admin time I have every Tuesday morning for an hour,” says Heather Champion, LPN, at Maine Medical Partners Westbrook Family Medicine. “I’ll go through all of our patients individually and identify health maintenance items that are due up front. I’m also incorporating their last physicals, AWV, labs, other major things like mammos, paps, colonoscopies into the record. We did a time study on this and it take an average of between 1.5 and three minutes per patient. It really helps with providers’ time in the room, so they can use it with patients to direct what they need.”
Other practices spend longer on pre-visit planning. McKenzie Searles, at Franklin, says “ideally, the day before, I go in and I look up every preventative screening they may need. I date them and I put it into the preventative medicine section (of eClinical Works) with the dates. If it’s an initial AWV, that can take 15 minutes or so, sometimes even more when you have to research insurance.”
3. A visit that incorporates an AWV requires 30 to 45 minutes
The time required for an AWV varies depending on several factors, including how healthy the patient is, how extensive the pre-planning has been, the level of team involvement, and whether it’s the initial AWV or a subsequent one. Experience counts for something as well. Dr. Goss and McKenzie Searles, who’ve been doing AWVs together for two years, currently average about 30 minutes per AWV.
Dr. Brett Loffredo, practicing at Maine Medical Partners Westbrook Family Practice with Heather Champion, typically books AWVs for 45 minutes. “The dual visit (both physical and AWV) is 45 minutes so it allows for incorporating acute issues that crop up,” he says. Typically, Heather spend 5 to 15 minutes with the patient, followed by Dr. Loffredo.
At Pen Bay Internal Medicine, “the MA is in the room for quite a long time, fifteen minutes or more,” says Dr. Yetman. “Doing med rec (medication reconciliation), going through questions, doing the PHQ2/9, memory questions. That’s all preloaded so I can either review it in my office or in the exam room with the patient.”
Discussions about patients’ end-of-life care wishes and advance directives are another component of AWVs that take time. Dr. Goss says “they get a folder with an advance directive in it . . . I go over that with them . . . I’ll tell them to find someone they can trust to make healthcare decisions.”
4. AWVs are effective in filling gaps in preventive care and hold other benefits for provider and patient.
AWVs require planning, time and resources, three things that can be in short supply at a busy practice. The three teams we spoke to have persevered through the challenges because they found AWVs to be effective in closing gaps in preventive care and made other visits more efficient and effective.
The benefit “is the thoroughness and the high likelihood that we’re going to catch patients’ screenings and vaccines,” says Dr. Goss. “It’s tough in this day and age to keep up with all the acute stuff going on and make sure that all this preventive work is happening too. It can get lost in the craziness of the day, but not so much since we’ve been doing these.”
“It’s nearly impossible to miss health maintenance,” adds McKenzie Searles.
“It helps me a lot in terms of managing a panel of patients,” says Dr. Yetman. “It gives you a little bit of freedom at other appointments to know that you did the discussion about colon cancer screening or prostate cancer once a year. The AWV is an extension of the basic philosophy to include those things. It’s an opportunity to do a very thorough review of everything, not just what’s on the problem list.
Dr. Goss agrees that the AWV improves the focus and efficiency of other visits. “We notate when they’ve had an annual wellness visit in the record so, going through my day, if I see that I know that I don’t have to worry about vaccines or any of that. I can just move.”
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Annual Wellness Visit resources:
ACO Insider Webinar: Annual Wellness Visits and Clinical Documentation (recording)
MaineHealth’s Medicare Wellness Visit Web Page – Resources for Practices and Providers
 Camacho, F., Yao, N. and Anderson, R. (2017). The Effectiveness of Medicare Wellness Visits in Accessing Preventive Screening. Journal of Primary Care & Community Health, 8(4), pp.247-255.
 Tao, G. (2018). Utilization pattern of other preventive services during the US Medicare annual wellness visit. Preventive Medicine Reports, 10, pp.210-211.