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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.
Limitations

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.

CONCLUSIONS

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.

Acknowledgments

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: abeckman@aledade.com.
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