Medicare Annual Wellness Visits

Written By: J. Andrew Culp, MD, Chief Medical Officer – Pivotal Health

What is the point of a Medicare Annual Wellness Visit?

Here’s a brief history lesson:

Healthcare keeps getting more expensive – especially for older adults. In the U.S., adults age 55+ make up only 30% of the population but account for 56% of health spending! Before 2005, most efforts to curb these costs were focused on “managed care” – where private insurers and healthcare systems (i.e. HMOs and PPOs) controlled healthcare costs by managing which patients got which services, therefore managing financial risks. Central to this model is the idea of “fee-for-service”, where the healthcare systems get paid for each service rendered.

Between 2005 and 2010 when the Affordable Care Act was passed, “value-based care” was introduced as an alternative to “managed care” – especially for the Medicare population. With “value-based care”, healthcare providers are rewarded with incentive payments for the quality of care they give to people with Medicare. So currently, health plans are paid by Medicare on a per member per month basis according to the quality of care each Medicare member receives.

The Medicare Annual Wellness Visit (AWV) is one of the main tools by which Medicare decides how much to pay Medicare Advantage plans for each of its Medicare members. Medicare’s governing body (Centers for Medicare and Medicaid Services, or CMS) states that the purpose of this visit is “to develop or update your personalized plan to help prevent disease and disability, based on your current health and risk factors”.

Medicare has two main goals for these visits. First, identify all your current health problems and risk factors for future problems. Second, use this updated list of problems/risk factors to plan ahead and make sure you have all the recommended health screening and treatments in place. Ultimately, the AWV helps determine how much your local health plan gets paid to care for you.

Is this visit mandatory?

No. Medicare cannot force you to complete this annual visit. But because your Medicare Advantage plan is paid based on the results of these visits, the plan is motivated to help you get your AWV done. And your participation in the AWV directly supports the quality of care at your local hospitals and clinics.

What should I expect during the visit?

Since the AWV is focused on identifying your active health problems/risk factors and helping you prevent more serious problems in the future, this is quite different from your typical clinic visit. You’ll spend most of the time simply talking with your provider. They’ll review your active health problems, immunizations and your screening tests for diabetes, cancer and bone health. They’ll ask questions about your mental health, your ability to take care of yourself at home and what you’ll do if you cannot care for yourself (Advanced Directive). There won’t be much of a physical exam, besides an updated height, weight and blood pressure.

How does this visit benefit my personal health?

Many people bristle at the idea of the AWV. Why do I need to go all the way into the clinic just to talk to my doctor about my health history? I just saw my provider last month? What’s in it for me? This is a very reasonable reaction.

On the face of it, one purpose of the AWV is to ensure that your doctor and your health plan get paid to care for you. But the AWV ideally serves to make sure that everyone involved in your healthcare – Medicare, supplemental health insurance, your local health plan and your primary provider – are all on the same page. Sadly, there are many cases where our current complex healthcare system misses opportunities for prevention, diagnosis and treatment of serious health problems – simply because of poor communication.

Beyond improved communication, the AWV provides a chance to make your overall healthcare more efficient. During the AWV, you can often spend more time with a provider who attends to the “big picture” of your health. What problems do you have, and what problems might be missing from your record? What screening and prevention measures do you need in the coming year to make sure you stay as healthy as possible?

How can I optimize this visit?

Answer: A good, old-fashioned house call.

These days, primary care providers (PCPs) are in high demand. It can often take weeks, even months, to get in to see your doctor for a clinic visit. Nationally, many healthcare systems look for help outside of the primary care clinic to complete these AWVs. This reduces the burden on the PCPs and clinics. It also provides a very convenient alternative for Medicare members like you: an AWV house call, when and where you need it.

Pivotal Health can arrange for a skilled provider to come right to you for your AWV. Our providers have much more time to spend with you compared to a clinic visit – around 45 minutes face-to-face for an AWV. And unlike other services that provide AWVs at home, Pivotal Health providers can actually do some of the screening/preventive services you need right during the visit. As needed, your provider can give you your annual Flu vaccine shot or your COVID booster. You can also get updated screening tests for diabetes. Beyond the AWV, Pivotal Health can attend to any urgent care or convenience needs you might have at the time.

Thanks for taking the time to learn a little healthcare history and economics lesson! Be well, and remember that you can make the Medicare AWV work for you.

 

Pivotal Health is transforming urgent care and primary care with its innovative clinician house call service. Consumers can schedule a clinician house call by calling directly (888-688-4746) or by using the Pivotal Health mobile app for their urgent and primary care needs and an Advanced Practice Provider will come to them to provide care in the comfort of their home, office, or other location of need. Founded in Madison in 2020, Pivotal Health now serves the greater Milwaukee metro area – Milwaukee, Waukesha, Ozaukee and Washington counties. Explore the Pivotal Health website or download the mobile app to learn more.