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Medicare | Value-Based Care

Value-based Care Solutions: Medicare Wellness Visit to Identify Risk

November 28th, 2023 | 6 min. read



Content Team

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Medicare’s Annual Wellness Visit (AWV) can be instrumental in improving care quality for older adults. This yearly assessment captures information about a patient’s health and functioning to document disease and identify new or worsening risk factors.

AWVs ask about lifestyle, social history, mental health and home environment. Documenting these details can help providers risk-stratify patient populations and develop comprehensive, personalized care plans that can close gaps. 

This can help clinicians better coordinate services, streamline collaborative decision-making and support value-based care delivery. AWVs have been shown to build stronger provider-patient relationships, secure additional revenue and contribute to cost savings.

Annual Wellness Visits enhance care despite slow adoption

AWVs have improved disease diagnosis and patient health; however, completion rates continue to hover around 25%. One study found that 61% of patients had not heard of the service, despite it being fully covered by Medicare Part B.   Some patients weren’t clear on how AWVs differed from an annual physical or regular office visit. 

Physicians surveyed saw value in preventive discussions, but many believed they already had these conversations with their patients. Related to the AWV, physicians felt obliged to provide wellness and regular care during the annual visit, which was unsustainable.

Yet when practices had a clear strategy for offering AWVs and promoted their value, 90% of patients were open to receiving one.

Annual Wellness Visits effectively identify health risks

Studies have linked AWV participation to improved preventive care, cost savings and revenue generation. 

For example, a study published by Preventive Medicine found that AWVs are associated with higher use of mammography, Pap tests, prostate and colon cancer screenings, as well as flu shot vaccines. 

Another study found that more patients received all preventive health services appropriate for their age when they received an AWV.

Other studies have shown that patients receiving AWVs saw significant reductions in total healthcare spending within two years. Research conducted in 2021 found positive screening rates for fall risk (38%), cognitive decline (23%) and impairment with Activities of Daily Living (32%). AWVs also increased the odds that a patient would receive a high-risk prescription following these assessments. 

Most importantly, AWVs help uncover previously undiagnosed conditions and health risks. 

Research discovered that patients who participated in  AWVs were less likely to experience falls and fractures than those who did not. Patients experienced 3.9% and 4% reduced risks for future falls and fractures, respectively. An even more substantial fall reduction was found for patients living in rural areas. Patients who had received an AWV in three consecutive years had the lowest risk of future falls.

Health Risk Assessments are key to prioritizing which health issues to address 

There are three types of AWVs: the “Welcome To Medicare Visit” conducted within the first 12 months of Medicare enrollment, the initial AWV, and the subsequent AWVs each year afterward.

Various health assessments are used to establish a record of a person’s physical and mental well-being for preventive health planning. However, the Health Risk Assessment (HRA) is a vital component of an AWV.

It can uncover physical and behavioral health information not typically available in a patient’s chart. As a questionnaire and screening tool, the HRA drives this first visit, taking about 20 minutes for the patient to complete before or with assistance during the appointment.

The HRA focuses on the following:

  • Demographics – age, gender, etc.
  • Self-assessment of health/lifestyle – exercise, eating habits, alcohol, and tobacco use.
  • Activities of daily living (ADLs) – dressing, bathing, walking; including instrumental ADLs like shopping, housekeeping, medication management, etc.
  • Emotional health – mood, stress, life events.
  • Physical health – weight, blood pressure, cholesterol levels.
  • Medical history – current and previous health conditions.

Based on the results of the HRA, providers can stratify current and potential future risks to prioritize interventions. 

Create a plan to address health risks

Every patient should receive a Personalized Risk Prevention Plan based on the HRA and other assessments conducted during the AWV. 

This plan outlines: 

  • All relevant health risks
  • Recommendations for follow-up screenings
  • Appropriate tests or vaccinations 
  • A timeline of when these activities should be completed

Providers can also leverage AWVs to enroll patients in care management programs, such as Behavioral Health Integration or Chronic Care Management

Annual Wellness Visits enable person-centric value-based care

Practices that prioritize AWVs will be able to identify, mitigate and address more health risks. Using the HRA as the foundation, providers can deliver high-quality, value-based, and patient-centric care.

How ThoroughCare can help

ThoroughCare offers end-to-end workflow for Annual Wellness Visits.

We simplify the process and help providers engage patients to get their most relevant health information. Guided interviews help ask the right questions and ensure all service requirements are met. ThoroughCare includes digital solutions, such as:

  • An interactive health risk assessment
  • Screening tools, such as ADL, CAGE, DAST-10, GAD-7, MDQ, PAC, PHQ-2, and a mini cognitive exam
  • A care gaps summary with recommended interventions
  • A full report of Personalized Prevention Plan Services
  • Comprehensive care planning tools
  • Automated CPT code assignment for accurate billing

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