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The American Journal of Managed Care March 2019
Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Incorrect and Missing Author Initials in Affiliations and Authorship Information
From the Editorial Board: Austin Frakt, PhD
Austin Frakt, PhD
Implications of Eligibility Category Churn for Pediatric Payment in Medicaid
Deena J. Chisolm, PhD; Sean P. Gleeson, MD, MBA; Kelly J. Kelleher, MD, MPH; Marisa E. Domino, PhD; Emily Alexy, MPH; Wendy Yi Xu, PhD; and Paula H. Song, PhD
Factors Influencing Primary Care Providers’ Decisions to Accept New Medicaid Patients Under Michigan’s Medicaid Expansion
Renuka Tipirneni, MD, MSc; Edith C. Kieffer, PhD, MPH; John Z. Ayanian, MD, MPP; Eric G. Campbell, PhD; Cengiz Salman, MA; Sarah J. Clark, MPH; Tammy Chang, MD, MPH, MS; Adrianne N. Haggins, MD, MSc; Erica Solway, PhD, MPH, MSW; Matthias A. Kirch, MS; and Susan D. Goold, MD, MHSA, MA
Did Medicaid Expansion Matter in States With Generous Medicaid?
Alina Denham, MS; and Peter J. Veazie, PhD
Access to Primary and Dental Care Among Adults Newly Enrolled in Medicaid
Krisda H. Chaiyachati, MD, MPH, MSHP; Jeffrey K. Hom, MD, MSHP; Charlene Wong, MD, MSHP; Kamyar Nasseh, PhD; Xinwei Chen, MS; Ashley Beggin, BS; Elisa Zygmunt, MSW; Marko Vujicic, PhD; and David Grande, MD, MPA
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Medicare Annual Wellness Visit Association With Healthcare Quality and Costs
Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
Specialty Care Access for Medicaid Enrollees in Expansion States
Justin W. Timbie, PhD; Ashley M. Kranz, PhD; Ammarah Mahmud, MPH; and Cheryl L. Damberg, PhD
Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration
Guneet K. Jasuja, PhD; Joel I. Reisman, AB; Renda Soylemez Wiener, MD, MPH; Melissa L. Christopher, PharmD; and Adam J. Rose, MD, MSc
Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics
Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD
Health Insurance Literacy: Disparities by Race, Ethnicity, and Language Preference
Victor G. Villagra, MD; Bhumika Bhuva, MA; Emil Coman, PhD; Denise O. Smith, MBA; and Judith Fifield, PhD

Medicare Annual Wellness Visit Association With Healthcare Quality and Costs

Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
In the context of 2 primary care physician–led accountable care organizations, Medicare Annual Wellness Visits were associated with lower healthcare costs and improved clinical care quality for beneficiaries.

Objectives: Although use of the Medicare Annual Wellness Visit (AWV) is increasing nationally, it remains unclear whether it can help contain healthcare costs and improve quality. In the context of 2 primary care physician–led accountable care organizations (ACOs), we tested the hypothesis that AWVs can improve healthcare costs and clinical quality.

Study Design: A retrospective cohort study using propensity score matching and quasi-experimental difference-in-differences regression models comparing the differential changes in cost, emergency department (ED) visits, and hospitalizations for those who received an AWV versus those who did not from before until after the AWV. Logistic regressions were used for quality measures.

Methods: Between 2014 and 2016, we examined the association of an AWV with healthcare costs, ED visits, hospitalizations, and clinical quality measures. The sample included Medicare beneficiaries attributed to providers across 44 primary care clinics participating in 2 ACOs.

Results: Among 8917 Medicare beneficiaries, an AWV was associated with significantly reduced spending on hospital acute care and outpatient services. Patients who received an AWV in the index month experienced a 5.7% reduction in adjusted total healthcare costs over the ensuing 11 months, with the greatest effect seen for patients in the highest hierarchical condition category risk quartile. AWVs were not associated with ED visits or hospitalizations. Beneficiaries who had an AWV were also more likely to receive recommended preventive clinical services.

Conclusions: In a setting that prioritizes care coordination and utilization management, AWVs have the potential to improve healthcare quality and reduce cost.

Am J Manag Care. 2019;25(3):e76-e82

View an infographic of this abstract here.
Takeaway Points

In the context of 2 primary care physician (PCP)–led accountable care organizations, Medicare Annual Wellness Visits (AWVs) were associated with lower healthcare costs and improved clinical care quality for beneficiaries.
  • Our findings suggest that an AWV can achieve meaningful improvements in cost and quality, lending support that policy makers and payers should further facilitate the adoption of high-quality AWVs by PCPs.
  • Because Medicare reimburses $175 for an AWV per member per year and the AWV was associated with a $38 per member per month ($456 per member per year) decrease in costs, these data suggest that the additional expenditure on primary care can be worth the costs, particularly for a higher-risk population.
  • Future research can help guide policy with respect to whether AWVs should be billable only by the patient’s PCP and whether payment should be higher for higher-risk patients.
The Annual Wellness Visit (AWV) was introduced in 2011 by Medicare and made available to all eligible beneficiaries without deductibles or co-payments. Unlike a traditional periodic health examination or annual physical, which may be performed without a specified protocol,1-4 the AWV includes a list of required components5 that prioritize preventive care and investing in the relationship with the patient rather than addressing acute complaints or chronic disease (Table 1). It includes assessing risk factors, inquiring about care support, creating a personalized care plan, and educating beneficiaries on how to maintain their health outside of an acute illness episode.6-8 Notably, the only physical examinations required of the visit are blood pressure measurement and height/weight measurement for body mass index (BMI), reflecting the US Preventive Services Task Force’s recommendation against routine physical examinations for asymptomatic adults 65 years or older.9

Previous work has demonstrated growing adoption of AWVs since their introduction, but modest use overall,10-12 with 7% of Medicare beneficiaries receiving an AWV in 2011, increasing to 16% in 2014.13 More than 90% of AWVs nationally in 2014 were performed by a primary care physician (PCP).13 Although utilization of the service is increasing, the benefits of an AWV for improving patient outcomes and controlling healthcare costs continue to be debated.14-16 This lack of evidence regarding the possible impact of AWVs on important outcomes restrains providers and policy makers from optimally using the service.

In order to address these gaps, we examined the association of an AWV with healthcare costs, utilization, and measures of clinical quality among beneficiaries cared for by 2 PCP-led accountable care organizations (ACOs). We focused on beneficiaries cared for by PCPs in the ACOs formed in 2015 by Aledade, a national network of independent practices.17-21 Aledade has prioritized AWVs to improve quality and focus a primary care relationship on preventing adverse health events. It has supported its partners in performing AWVs by identifying high-risk beneficiaries, building user-friendly technology to schedule AWVs with these beneficiaries, providing face-to-face practice transformation support to optimize workflows, implementing templates in the electronic health record (EHR), providing data tools to support performance monitoring, and facilitating best practice sharing across a network of doctors.22 Evaluating the AWV in the context of a highly motivated and supported physician network leads to greater understanding of how AWVs can contribute to improving healthcare quality and reducing costs under optimal conditions.


Study Design and Sample

Primary data source. We used insurance claims from the CMS Claim and Claim Line Feed23 as our primary data source to assess the association of an AWV with cost and utilization. These data include services provided under Medicare parts A and B for patients assigned to 2 PCP-led ACOs. Data from these specific ACOs were used because they were the first ACOs that Aledade partnered with that had complete follow-up data. The observation period was from January 1, 2014, to December 31, 2016. Permission to use data for the study was granted through the Medicare Shared Savings Program data use agreement, and institutional review board (IRB) approval was granted by Hummingbird IRB (IRB #2017-278).

Intervention and control groups in primary data source. Among patients attributed to ACOs 1 and 2 at the start of 2015, we identified intervention beneficiaries who had an AWV in 2015 (Current Procedural Terminology codes G0402, G0438, or G0439). We excluded beneficiaries who had missing data, died during the study period, or had received an AWV in 2014 (we wanted to focus on the effects from a first-time AWV, assuming that patients who did not receive an AWV in 2014 did not receive one in 2011-2013). To identify a control group, we matched the intervention beneficiaries to beneficiaries who did not have an AWV in 2015 and who met the same inclusion and exclusion criteria as the intervention group (for additional information about the matching process, see the eAppendix [available at]). Control patients were assigned the AWV month of the intervention patient to whom they matched. We removed the month that the AWV was done (and thus the cost of the AWV itself, because we wanted to focus on the subsequent AWV impact), which allowed us to define the 11 calendar months before the AWV as the pre-AWV period and the 11 calendar months after the AWV as the post-AWV period. Because Medicare only bills AWVs once every 12 months per patient, the intervention group by definition did not have any AWVs in the post-AWV period. After matching, we excluded all control patients who had an AWV in the post-AWV period, as well as all patients with outlier spend (to reduce skewness). For a visual definition of this cohort, see eAppendix Figure 1.

Secondary data source for quality of care. To assess impact of an AWV on clinical quality, we used data on clinical quality measures reported to CMS as part of the ACO program.24 These data are reported to CMS for a different randomly selected sample of beneficiaries for each measure. Beneficiaries met exclusion/inclusion criteria as defined by each measure definition in accordance with Medicare specifications.25 Each sample was then divided into 2 groups: The control group included beneficiaries who did not receive a first-time AWV in 2015 (but could have received one in 2014 or 2016) and the intervention group included beneficiaries who did receive a first-time AWV in 2015 (including the “Welcome to Medicare” visit). We included all beneficiaries who were reported on by CMS regardless of whether they were in our final primary analytic sample.

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