Abstract
Introduction: The Centers for Medicare and Medicaid Services (CMS) has set requirements for the Medicare Annual Wellness Visit (AWV).
Methods: A cross-sectional online survey to explore the variability in assessments and tools used during the AWV was completed by 159 primary care providers from 145 practices in 36 states.
Results: The results confirmed wide variation in use of specific tools during AWV and provider interest in using several specific tools if available.
Conclusion: The results indicated a need for more comprehensive AWV content and a preference for more structured and objective ways to conduct AWV assessment.
- Annual Wellness Visit
- Chronic Disease
- Cross-Sectional Studies
- Counseling
- Medicare
- Preventive Health Services
- Primary Health Care
Introduction
The Centers for Medicare and Medicaid Services (CMS) introduced the Annual Wellness Visit (AWV) benefit in 2011 as part of the Affordable Care Act.1 The visit requires only those services listed in Table 2 to be completed and documented to qualify as an AWV.2
Characteristics of AWV Survey Physician Respondents (n = 159)
While specific about the required elements of the AWV, CMS does not specify which assessment tools should be used to comply with these requirements or elaborate on additional assessments beyond a minimum.3 Required and additional assessments vary substantially from provider to provider.4,5 To further understand the variability in assessments and tools used during the AWV, we conducted a survey of the American Academy of Family Physicians National Research Network (AAFP NRN) members. Specifically, the survey asked about various health status and risk assessments and tools primary care physicians currently use, would like to use if available, and would not use.
Methods
The AAFP NRN is the official practice-based research network of the AAFP. It comprises 2330 providers in 852 practices. Each year the AAFP NRN conducts or participates in over 20 research studies on topics of interest to practicing primary care physicians, advanced practice providers, and practice staff. All eligible practices are invited to participate in studies and most practices take part in 1 to 3 studies each year.
An invitation to participate in the 1 question survey was sent to the AAFP NRN membership for whom e-mails were available and who had consented to receive e-mails and surveys (n = 1463). A reminder e-mail was sent to AAFP NRN members who had not completed the survey 1 week after the initial invitation. The survey was distributed March 13, 2019 and closed March 25, 2019.
The survey included a comprehensive list of possible health risk and health status assessments and some specific standardized tools, such as validated questionnaires (eg, PHQ-9). Participants were asked to answer for each assessment and tool whether they (1) currently use, (2) would use this if available to them, or (3) would not use. The survey is provided in the Appendix. Limited provider demographics (decade of birth, gender, race, ethnicity, and specialty) were obtained from the AAFP NRN member database for those who responded to the survey.
Results
A web-based survey was completed by 159 providers from 145 practices across 36 states. One hundred (63%) were family physician members of the AAFP, and the rest were other primary care providers. Participant demographics are presented in Table 1.
Table 2 describes the use of various health risk and status assessments and tools. There is wide variation in use of specific assessments and tools; however, the majority of physicians (68%) reported using at least 1 assessment tool within each of the AWV required elements. Respondents reported they would be interested in using a number of specific tools if more readily available.
Survey Results (n = 159)
Discussion
Most older persons in the US are covered under Medicare as soon as they turn 65. Introduced in 2011, the Medicare AWV was designed to encourage preventive care to mitigate health risks through required age-appropriate and risk-modifying screenings and assessments. The intention was to have patients and providers engage in a conversation focused on health history, healthy behaviors, and disease prevention. The services provided during the AWV expand on a typical preventive care visit and include emotional and psychological wellbeing and end-of-life wishes, in addition to the patient's physical health. CMS does not specify how the assessments should be conducted, which assessment tools should be used, or elaborate on what specifically should be included in some general health risk assessment categories. Lack of specificity may lead to wide variation in preventive care services available to Medicare beneficiaries.6 Our study confirms this concern over what and how health risk assessments are obtained. First, the results indicated a need for more comprehensive AWV content than what is currently described by CMS. Respondents reported using a number of health assessments not explicitly included in CMS core requirements. For example, assessments of anxiety, driving safety and some other specific assessments are not required by the CMS. Second, as expected, the results highlighted a wide variation of services, for example, 55% use, 32% would like to use, and 14% would not use Activities of Daily Living Questionnaires during AWV. Some variation in assessment tools used is expected as physicians are likely to use tools they learned during their training, and tools may be more locally or culturally relevant. However, it is also unclear how some assessments and tools may align with CMS requirements leading to inaccurate reporting and potentially denial of payment for AWV services. In addition, it is possible that some required sections of the AWV may not be completed due to a need for tools or guidance for primary care physicians. Some respondents seem to not be doing during AWV or caring about some aspects of mental health, trauma, and quality of life. This points to the need for education around why and how these important health issues and associated risks can become important components of the AWV. Third, it appeared respondents preferred structured and more objective ways to conduct assessments via questionnaires and checklists. For example, many respondents indicated they already use structured tools such as checklists and questionnaires and a substantial proportion would like to use structured instruments if available including Quality of Life Questionnaire, physical ability functional tests, and AHRQ Preventive Services Calculator.
This study has some limitations that may affect the generalizability of results. The socio-demographic characteristics of the physician respondents are challenging to compare with the AAFP NRN membership due to high level of missing demographics data in the whole sample; therefore, respondents may not be representative of all primary care physicians in the US. This study is based on clinicians' self-reports and to that end, we do not know to what extent the self-reported practices correlate with the objective measures of clinicians' performance or quality of care around AWV.
The AWV is an opportunity for a patient and their primary care physician to have an extended conversation about their whole health, identify potential mental health risks, discuss end-of-life wishes, and assess their physical and mental well-being. While CMS has specific required elements for the AWV, there is wide variation in how these elements are measured. Further research on how current assessment tools align with CMS requirements may improve uptake, quality and efficiency of the AWV.
Appendix
Notes
This article was externally peer reviewed.
Funding: None.
Conflict of Interest: None.
To see this article online, please go to: http://jabfm.org/content/35/3/605.full.
- Received for publication August 11, 2021.
- Revision received November 29, 2021.
- Accepted for publication December 1, 2021.
