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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.
Association of AWV With Healthcare Costs and Utilization

In the pre-AWV period, average trends in healthcare cost were similar for the intervention and control groups (eAppendix Figure 2). In 2015, a first-time AWV was associated with a 5.7% (95% CI, 0.3%-11.4%) reduction in total healthcare costs in the post-AWV period (excluding the cost of the AWV itself). This association translated to a $38 (95% CI, $9-$67) per-member-per-month (PMPM) reduction over 11 months of follow-up, or approximately $418 per beneficiary (Figure 123). The association between a first-time AWV and reduced costs was stronger among beneficiaries in the top hierarchical condition category (HCC) risk quartile. In this population, the adjusted differential change in total healthcare cost between the intervention and control groups was 6.3%, a PMPM decrease of $81 (95% CI, $12-$150) over 11 months of follow-up (Figure 123).

Analysis of category-specific costs suggested that the primary drivers of this impact were reductions in hospital acute care costs (incidence rate ratio [IRR], 0.88; 95% CI, 0.80-0.97) and hospital outpatient non-ED costs (IRR, 0.93; 95% CI, 0.89-0.97). Table 323 reports the differential change in each category-specific cost between the intervention and control groups. With respect to healthcare utilization, first-time AWVs were not associated with a statistically significant change in the total number of ED visits (IRR, 0.97; 95% CI, 0.83-1.15) or hospitalizations (IRR, 0.95; 95% CI, 0.78-1.11).

Results of the sensitivity analyses were consistent with the main findings. Of note, the AWV association from the main analysis was not systematically different among beneficiaries who were invited by phone or email to schedule an AWV by the PCP practice (defined as receiving outreach) and beneficiaries who were not invited. In addition, using an alternative matching method to identify the comparison group and limiting the sample to those who were continuously attributed were consistent with a robust association between receipt of an AWV and reduced healthcare costs. Additionally, results were consistent with the main analysis when intervention patients who matched to controls who had an AWV in the post-AWV period were excluded. Finally, the effect of the AWV was not different between AWVs conducted in the early versus late part of the calendar year (See eAppendix for additional details.)

Association of AWV With Clinical Quality

Of 16 quality measures evaluated (Figure 224), a first-time AWV in 2015 was significantly associated with greater performance on 7 measures in adjusted analyses (all P <.01): fall risk screening (94% vs 15%), pneumococcal vaccination (86% vs 69%), tobacco screening and cessation (91% vs 77%), depression screening and follow-up planning (87% vs 18%), colorectal cancer screening (69% vs 60%), breast cancer screening (81% vs 66%), and controlled glycated hemoglobin (A1C) (77% vs 65%). AWVs were not statistically significantly associated with diabetes eye exams, use of aspirin, controlled hypertension, BMI screening, medication documentation, blood pressure control, influenza vaccination, diabetes therapy, or heart failure therapy. We speculate that AWVs had a lesser impact on these quality measures because they may already be prioritized in general primary care settings.

DISCUSSION

In this cohort of Medicare beneficiaries, first-time AWVs were associated with a significant improvement in use of preventive care and a reduction in total healthcare costs compared with matched controls. Rates of screening for fall risk and for clinical depression with follow-up plan, which are not typical components of a traditional evaluation and management visit but are components of an AWV and included in visit templates, were more than 70 percentage points higher among beneficiaries who received an AWV. These beneficiaries were also more likely to experience improved A1C control and to receive other key preventive services, including breast and colorectal cancer screening and tobacco use screening with cessation intervention. Changes in total healthcare costs were greatest among beneficiaries in the highest quartile of HCC and were driven by reductions in hospital acute care and hospital outpatient non-ED spending. Although there was a trend toward reduced hospital utilization, it was not as pronounced as that for hospital costs and did not achieve statistical significance. This would imply that the hospitalizations that did occur tended to have lower severity. These findings suggest that an AWV can be a helpful tool for improving care quality and containing costs within a primary care setting that prioritizes patient engagement, utilization management, and care coordination.

To our knowledge, this study is the first in the peer-reviewed literature to estimate the association of an AWV with measures of healthcare quality, costs, and utilization within the same study. Use of the AWV has been rising slowly since its introduction as a Medicare-reimbursable service in 2011, but there has been a paucity of evidence to guide AWV implementation into routine clinical practice in the primary care setting and to establish the potential value of this type of visit for ACOs and the Medicare program. Our findings add to a growing body of literature suggesting that the AWV can substantially improve rates of preventive services32-36 (which may be directly related to the administration of screening tools) while providing new evidence of substantial near-term effects on total cost of care. By further delineating that the association of the AWV with healthcare costs may be most pronounced among highest-risk patients, our findings lend support to a strategy of population risk segmentation for prioritization of AWV outreach efforts to maximize savings benefits. Furthermore, although there is general consensus that strong primary care is essential to containing healthcare costs,37-39 recent payment and delivery system innovations that intend to enhance primary care services beyond usual care have shown mixed results.40,41 Our study results suggest that a primary care service under a system that provides the right incentives for all may contribute to cost reductions.

The mechanisms explaining the cost reductions of AWVs are not well known, but we speculate that numerous aspects of the AWV might explain its benefits. A successful AWV means that practices are not merely “checking the box.” These screenings can be used to provide updates on medical history and self-reported data as an opportunity to step back from typical acute complaints and meaningfully engage in personalized conversations about risk factors, preventive needs, and a patient’s long-term health goals. This attention on wellness may improve clinical quality, including the delivery of general clinical preventive services and secondary prevention among patients with chronic conditions. An optimal AWV can include medication review and regimen optimization, identification of uncoordinated use of specialty care, and discussion of social or environmental barriers to self-care that may benefit from enhanced care coordination. This up-front investment in preventive care and care coordination may avert subsequent spending. By devoting time to explore the patient’s overall health status, risks, and values, the AWV may enrich the patient–provider relationship, improve patient engagement, and reinforce the core primary care tenets.


 
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