Currently Viewing:
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
Currently Reading
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.

Several factors should be considered in the interpretation of this study. First, the results should be interpreted in the context of the specific setting studied. AWVs were a key strategy of the ACOs, and rates of AWVs (54%) were substantially higher than national averages. It is possible that the results of this study would be replicable only in a setting willing to undergo workflow optimization to accommodate a high-value visit. In addition, the cohort studied did not include beneficiaries at the end of life and those who may be less able to receive an AWV due to being homebound, institutionalized, hospitalized, or enrolled in hospice. Thus, the findings cannot be generalized to all Medicare beneficiaries. Second, as with all nonrandomized study designs, a possibility exists for selection bias and residual confounding due to unmeasured differences. However, we used propensity score matching to account for observable differences and a DID design to account for unobservable time-dependent changes in spend, as was done recently in a CMS evaluation of chronic care management.42 A key matching variable for cases and controls was the number of baseline primary care visits, to account for the level of engagement with a PCP and the ability to come in for a visit. Furthermore, the association between receipt of AWV and healthcare cost reductions did not vary by whether or not patients received outreach, providing little evidence to suggest that the intervention effect was driven by differential outreach to patients who were predisposed to favorable cost trajectories. Finally, we were not able to ascertain whether patients had an AWV prior to 2014, although data suggest that fewer than 16% of Medicare patients were receiving them in 2013.13

These findings point to several priorities for payers and providers to consider. Because Medicare reimburses $175 for an AWV per member per year (PMPY), it is important to note that the true cost reduction may be smaller than the $456 PMPY effect estimate that we reported. However, given that the effect estimate is more than 2-fold the cost of the AWV itself, these data suggest that the additional expenditure on primary care can be worth the costs, particularly for a higher-risk population. It is also worth acknowledging that AWVs are one way to improve coding accuracy, and “upcoding” can be balanced by the legislatively afforded renormalization factor to account for risk inflation.43

Future Implications

Future research can help guide policy with respect to whether AWVs should be billable only by the patient’s PCP, who may be in the best position to comprehensively assess patient risk factors and preventive care needs. Our findings show that an AWV may achieve meaningful improvements in cost and quality, lending support that policy makers should further facilitate the adoption of high-quality AWVs by PCPs. Given that underserved populations are less likely to adopt AWVs,44,45 policies should be explored to expand access to AWVs for this important subgroup of patients.

Additional research is still needed to further understand answers to several key questions. Given the recent introduction of the AWV, it will be important to understand whether the impact of an AWV changes over a longer time horizon. Future research should also attempt to differentiate effects of specific AWV components on outcomes. Additional outcomes of interest beyond the scope of this initial study include effects on patient satisfaction, health behaviors, self-management of chronic conditions, and care continuity.


Among beneficiaries cared for by PCPs affiliated with 2 ACOs, the AWV was associated with delivery of greater preventive care and lower total healthcare costs, particularly for those among the highest quartile of HCC risk. The AWV may therefore be an important service for achieving the triple aim of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.”46 Future research should focus on replicating these results among other populations, given that the current study used data from 2 specific ACOs. It will be important for future studies to test the efficacy of AWVs in different geographical areas and in ACOs with different characteristics in order to provide robust evidence of AWV impact. Furthermore, identifying tactics to further facilitate adoption and optimize the effectiveness of the AWV in primary care practice will be important avenues for future research.


Adam L. Beckman, BS, and Adan Z. Becerra, PhD, contributed equally to this work and are listed as co–first authors.

The authors first acknowledge the 114 independent primary care providers from Delaware ACO and Primary Care ACO who led the ACO efforts through 2016. They also appreciate editorial inputs from Travis Broome, MPH, vice president of policy at Aledade.

Author Affiliations: Aledade, Inc (ALB, AZB, AM, CAD, KL, EM, FM, JK), Bethesda, MD; Harvard Medical School (ALB), Boston, MA; Social & Scientific Systems (AZB), Silver Spring, MD.

Source of Funding: None.

Author Disclosures: All authors were employed by Aledade when this study was conducted; as detailed in the manuscript, this is a peer-reviewed evaluation of our own program. Dr Becerra is now employed at Social & Scientific Systems, which was not involved in the study.

Authorship Information: Concept and design (ALB, AZB, KL, EM, FM, JK); acquisition of data (JK); analysis and interpretation of data (ALB, AZB, CAD, KL, EM, FM, JK); drafting of the manuscript (ALB, AZB, AM, CAD, EM, FM); critical revision of the manuscript for important intellectual content (ALB, AZB, CAD, KL, EM, FM, JK); statistical analysis (AZB, FM, JK); administrative, technical, or logistic support (AM, KL); supervision (EM, JK); and direct work with clinics (AM).

Address Correspondence to: Adam L. Beckman, BS, Aledade Inc, 4550 Montgomery Ave, Ste 950, Bethesda, MD 20814. Email:

1. Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med. 2007;146(4):289-300. doi: 10.7326/0003-4819-146-4-200702200-00008.

2. Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191. doi: 10.1136/bmj.e7191.

3. Emerson H. Periodic medical examinations of apparently healthy persons. JAMA. 1923;80(19):1376-1381. doi:10.1001/jama.1923.26430460003011.

4. Krogsbøll LT, Jørgensen KJ, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. JAMA. 2013;309(23):2489-2490. doi: 10.1001/jama.2013.5039.

5. Annual Wellness Visit. CMS website. Published August 2018. Accessed February 12, 2019.

6. Hughes C. What you need to know about the Medicare preventive services expansion. Fam Pract Manag. 2011;18(1):22-25.

7. Cuenca AE. Making Medicare Annual Wellness Visits work in practice [erratum in Fam Pract Manag. 2012;19(6):6]. Fam Pract Manag. 2012;19(5):11-16.

8. Hain DJ. The CMS Annual Wellness Visit: bridging the gap. Nurse Pract. 2014;39(7):18-26; quiz 26-27. doi: 10.1097/01.NPR.0000450741.00077.79.

9. Published recommendations. US Preventive Services Task Force website. Accessed February 12, 2019.

10. Chung S, Lesser LI, Lauderdale DS, Johns NE, Palaniappan LP, Luft HS. Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate [erratum in Health Aff (Millwood). 2015;34(2):359. doi: 10.1377/hlthaff.2014.1490]. Health Aff (Millwood). 2015;34(1):11-20. doi: 10.1377/hlthaff.2014.0483.

11. Hu J, Jensen GA, Nerenz D, Tarraf W. Medicare’s Annual Wellness Visit in a large health care organization: who is using it? Ann Intern Med. 2015;163(7):567-568. doi: 10.7326/L15-5145.

12. Jensen GA, Salloum RG, Hu J, Ferdows NB, Tarraf W. A slow start: use of preventive services among seniors following the Affordable Care Act’s enhancement of Medicare benefits in the US. Prev Med. 2015;76:37-42. doi: 10.1016/j.ypmed.2015.03.023.

13. Ganguli I, Souza J, McWilliams JM, Mehrotra A. Trends in use of the US Medicare Annual Wellness Visit, 2011-2014. JAMA. 2017;317(21):2233-2235. doi: 10.1001/jama.2017.4342.

14. Mehrotra A, Prochazka A. Improving value in health care—against the annual physical. N Engl J Med. 2015;373(16):1485-1487. doi: 10.1056/NEJMp1507485.

15. Bluestein D, Diduk-Smith R, Jordan L, Persaud K, Hughes T. Medicare Annual Wellness Visits: how to get patients and physicians on board. Fam Pract Manag. 2017;24(2):12-16.

16. Rothberg MB. The $50,000 physical. JAMA. 2014;311(21):2175-2176. doi: 10.1001/jama.2014.3415.

17. Mostashari F. The paradox of size: how small, independent practices can thrive in value-based care. Ann Fam Med. 2016;14(1):5-7. doi: 10.1370/afm.1899.

18. Powers BW, Mostashari F, Maxson E, Lynch K, Navathe AS. Engaging small independent practices in value-based payment: building Aledade’s Medicare ACOs. Healthc (Amst). 2018;6(1):79-87. doi: 10.1016/j.hjdsi.2017.06.003.

19. Emanuel EJ. Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations. New York, NY: PublicAffairs; 2017.

20. Mostashari F, Broome T. The opportunities and challenges of the MSSP ACO program: a report from the field. Am J Manag Care. 2016;22(9):564-568.

21. Mostashari F, Sanghavi D, McClellan M. Health reform and physician-led accountable care: the paradox of primary care physician leadership. JAMA. 2014;311(18):1855-1856. doi: 10.1001/jama.2014.4086.

22. Mostashari F, Brull J, Navarro J, Lilly J. Finding the bright spots in value-based care. Fam Pract Manag. 2017;24(5):21-27.

23. Claim and Claim Line Feed file data elements. CMS website. Published January 2019. Accessed February 12, 2019.

24. Medicare Shared Savings Program quality measure benchmarks for the 2015 reporting year. CMS website. Published February 2015. Accessed February 12, 2019.

25. Accountable Care Organization 2016 program quality measure narrative specifications. CMS website. Published January 13, 2016. Accessed February 12, 2019.

26. Hochberg Y. A sharper Bonferroni procedure for multiple tests of significance. Biometrika. 1988;75(4):800-802. doi: 10.2307/2336325.

27. Cao J, Zhang S. Multiple comparison procedures. JAMA. 2014;312(5):543-544. doi: 10.1001/jama.2014.9440.

28. Ho DE, Imai K, King G, Stuart EA. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw. 2011;42(8):1-28. doi: 10.18637/jss.v042.i08.

29. Bates D, Mächler M, Bolker B, Walker S. Fitting linear mixed-effects models using lme4. J Stat Softw. 2015;67(1):1-48. doi: 10.18637/jss.v067.i01.

30. Brooks ME, Kristensen K, van Benthem KJ, et al. Modeling zero-inflated count data with glmmTMB [published online May 1, 2017]. bioRxiv. doi: 10.1101/132753.

31. Wickham H. ggplot2: Elegant Graphics for Data Analysis. New York, NY: Springer-Verlag; 2009.

32. Jiang M, Hughes DR, Wang W. The effect of Medicare’s Annual Wellness Visit on preventive care for the elderly. Prev Med. 2018;116:126-133. doi: 10.1016/j.ypmed.2018.08.035.

33. Chung S, Romanelli RJ, Stults CD, Luft HS. Preventive visit among older adults with Medicare’s introduction of Annual Wellness Visit: closing gaps in underutilization. Prev Med. 2018;115:110-118. doi: 10.1016/j.ypmed.2018.08.018.

34. Shen AK, Warnock R, Kelman JA. Driving immunization through the Medicare Annual Wellness Visit: a growing opportunity. Vaccine. 2017;35(50):6938-6940. doi: 10.1016/j.vaccine.2017.10.055.

35. Pfoh E, Mojtabai R, Bailey J, Weiner JP, Dy SM. Impact of Medicare Annual Wellness Visits on uptake of depression screening. Psychiatr Serv. 2015;66(11):1207-1212. doi: 10.1176/

36. Tao G. Utilization pattern of other preventive services during the US Medicare Annual Wellness Visit. Prev Med Rep. 2018;10:210-211. doi: 10.1016/j.pmedr.2017.12.014.

37. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. doi: 10.1111/j.1468-0009.2005.00409.x.

38. Friedberg MW, Hussey PS, Schneider EC. Primary care: a critical review of the evidence on quality and costs of health care. Health Aff (Millwood). 2010;29(5):766-772. doi: 10.1377/hlthaff.2010.0025.

39. Bodenheimer T, Fernandez A. High and rising health care costs. part 4: can costs be controlled while preserving quality? Ann Intern Med. 2005;143(1):26-31. doi: 10.7326/0003-4819-143-1-200507050-00007.

40. Peikes D, Dale S, Ghosh A, et al. The Comprehensive Primary Care Initiative: effects on spending, quality, patients, and physicians. Health Aff (Millwood). 2018;37(6):890-899. doi: 10.1377/hlthaff.2017.1678.

41. Zulman DM, Pal Chee C, Ezeji-Okoye SC, et al. Effect of an intensive outpatient program to augment primary care for high-need Veterans Affairs patients: a randomized clinical trial. JAMA Intern Med. 2017;177(2):166-175. doi: 10.1001/jamainternmed.2016.8021.

42. Schurrer J, O’Malley A, Wilson C, McCall N, Jain N. Evaluation of the diffusion and impact of the Chronic Care Management (CCM) services: final report. Washington, DC: Mathematica Policy Research; 2017. Accessed February 12, 2019.

43. Shared savings and losses and assignment methodology. CMS website. Published April 2017. Accessed February 12, 2019.

44. Ganguli I, Souza J, McWilliams JM, Mehrotra A. Practices caring for the underserved are less likely to adopt Medicare’s Annual Wellness Visit. Health Aff (Millwood). 2018;37(2):283-291. doi: 10.1377/hlthaff.2017.1130.

45. Lind KE, Hildreth K, Lindrooth R, Crane LA, Morrato E, Perraillon MC. Ethnoracial disparities in Medicare Annual Wellness Visit utilization: evidence from a nationally representative database. Med Care. 2018;56(9):761-766. doi: 10.1097/MLR.0000000000000962.

46. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi: 10.1377/hlthaff.27.3.759.
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up