Standardized Patient Assessments at the Medicare Annual Wellness Visit: Results from the AAFP National Research Network

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.