Outcomes of A Virtual Practice-Tailored Medicare Annual Wellness Visit Intervention

Discussion

A practice-tailored, virtually delivered intervention combining practice redesign and EHR tools and approaches increased AWV and preventive health service delivery in small community-based practices, with AWV use going from 7% at baseline to 54% 8 months postintervention implementation. The intervention improved AWV and preventive service use despite the impact of COVID-19 on practice demands during implementation. These increases may partially reflect improved documentation of AWV and preventive service completion. Better documentation often results in short-term improvements that wane over time, so it is encouraging to note that rates of AWV completion continued to increase throughout the measurement period. For the approximately 10% of patients in this study with Medicare Advantage insurance, providers may have replaced annual physical examinations with AWVs. Our intervention was likely effective because it met a demand – the practices and providers were already motivated to perform AWVs, but lacked tools to assess whether patients needed an AWV and to ensure fulfillment of all Medicare requirements for the AWVs.

Unexpected challenges arose during the study, largely resulting from the COVID-19 pandemic. The practices became COVID-19 vaccination sites, requiring attention to be diverted from performing AWVs. Surrounding communities were heavily affected by COVID-19, creating increased demand for acute care. The practices were further impacted when they began caring for COVID-19 patients without a regular primary care clinician. We addressed these issues by ensuring that all aspects of the intervention were tailored to the practices’ needs (eg, timing and duration of meetings with clinicians and staff), and developing workflows in which staff/scribes collected most of the information required for AWV documentation. An additional challenge uncovered by the study, but outside the scope of the intervention, was the mismatch between patients’ and clinicians’ expectations for comprehensive, integrated care, and the limited scope of the AWV.⁸

Before intervention implementation, these practices already received reminders regarding gaps in preventive service fulfillment at every patient visit. Yet after implementation, patient fulfillment of recommended preventive health services (of a maximum of 12) increased by a mean of 6.3%, or almost 1 additional preventive service per person. The greatest increases occurred for clinician-driven services (eg, advance care planning, depression screening, and alcohol misuse screening). These services incur no patient cost-sharing when performed in conjunction with an AWV, but clinicians rarely bill for them⁹ because they require specific documentation to satisfy billing requirements, as well as separate billing. These results suggest that the intervention’s focus on using the AWV as a means to deliver and bill for preventive health services can drive increased utilization of services. The COVID-19 pandemic may have attenuated the intervention’s effect, as patients may have been unwilling to make return visits for nonemergent screenings (eg, mammogram, colonoscopy). This is suggested by the decrease in preventive services received in patients not experiencing an AWV.

Patients who completed an AWV received more preventive health services than those without an AWV. Though our intervention did not specifically address the preventive service delivery process, patients in this study were more likely to complete each of the recommended services assessed. This is consistent with studies using Medicare claims data, which have demonstrated that AWVs increased the use of multiple different preventive services.¹⁰ Despite the USPSTF’s recommendation against PSA-based screening in men over the age of 70, prostate cancer screening in this population occurred more frequently when they had an AWV (Medicare covers annual PSA testing). This untoward effect warrants further study, and could be directly addressed during future efforts to promote AWVs.

Study limitations include possibly underestimating the intervention effect due to the short postintervention implementation follow-up, which may have limited our ability to capture patients who intended but had not yet completed preventive health services that required follow-up appointments or actions. The smallest site (practice 3), which had only 2 clinicians, experienced staffing issues during the assessment period that likely contributed to a smaller increase in AWV rates compared with the other sites. Generalizability is limited by implementation in 3 practices that belonged to the same organization. Most of the patients in the practices were white. We did not assess whether increased preventive service delivery was accompanied by increased billing for the services, but this warrants future exploration because practices’ ability to bill for screening and counseling services may drive increased utilization of these services. We also were unable to examine the quality or actual content of AWVs. Eight months postimplementation, the practices had several hundred fewer AWV-eligible patients than at baseline. Reasons for this could include patient attrition due to death or lack of patient visits in the past 12 months due to COVID-19.

The majority of the interventions described in the literature to promote AWVs focus on enlisting nonphysician health care providers (as opposed to primary care providers) to perform AWVs.^{11⇓⇓⇓⇓⇓⇓–18} These interventions may be difficult and costly for small and midsize practices with limited resources to implement. This study supports the use of an EHR-based intervention, coupled with virtually delivered practice-redesign approaches and tools, to enhance patient preventive health services utilization, and might serve as a model for virtual intervention implementation. Future studies are needed to rigorously evaluate the uptake and effectiveness of various intervention components.

This work is worthy of further evaluation in diverse practice settings. In the meantime, these findings support use of a practice-tailored remote redesign and electronic medical record support intervention to improve use of the Medicare Annual Wellness Visit and preventive service delivery and advance care planning.