Medicare Wellness Visit Adoption Boosts Primary Care Revenue

February 13, 2018 - Practices that performed Medicare wellness visits on at least a quarter of their patients earned greater primary care revenue, experienced more patient assignment stability, and treated patients who were slightly healthier, a new Health Affairs study uncovered.

Researchers from Harvard Medical School reported the following key differences among wellness visit adopters and non-adopters based on Medicare claims data:

• Average annual primary care revenue for practices that adopted the wellness visit had consistently greater revenue than practices that did not conduct the visit

• Wellness visit adopters increased their primary care revenue by 2015, while non-adopters saw their primary care revenue slightly decline

• Practices that conducted the wellness visits had greater patient assignment stability at baseline, with 68.6 percent versus 62.4 percent for non-adopters

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• Adopters experienced slower decreases in patient assignment stability during the period, with declines of just 1 percent compared to 4.8 percent among non-adopters

Adopting practices also saw a slower increase in average risk, with an increase of 0.02 in risk scores versus 0.04 among non-adopters. Higher risk patients cost more to treat compared to lower risk patients.

Despite the financial benefits of conducting the annual wellness visit, just 23 percent of the 50,591 practices analyzed realized the benefits from high-adoption of wellness visits.

The majority of practices studied (51.2 percent) were considered non-adopters, or practices that provided no annual wellness visits.

“While it is unclear whether these changes were driven by the adoption itself or by other changes implemented by adopters during the same period, it does point to some benefits for practices that adopt the visit,” researchers stated.

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Under the Affordable Care Act, Medicare introduced the annual wellness visit to boost preventative care. Medicare incentivizes providers to adopt wellness visits by increasing the reimbursement rate over that of the problem-based visit rate. Providers can also co-bill for wellness visits if a patient discusses an acute problem during the appointment.

Medicare also induces patients to attend wellness visits by offering the appointment at no cost for fee-for-service beneficiaries.

Despite the financial incentives, only 15.6 percent of eligible beneficiaries received annual wellness visits by 2014, a recent JAMA analysis found.

Low wellness visit rates may be explained by the visit’s complex and confusing requirements. A cited 2015 survey of physicians found that providers were “well-informed about Medicare’s criteria for the visits but seemed to struggle with whether to include chronic disease management or address acute concerns”

The interviewed providers also went beyond the scope of the Medicare wellness visit, addressing new patient concerns, reviewing chronic issues, completing the annual wellness visit questionnaire, and performing a full physical exam. For this reason, providers stated that they avoided recommending the visit to eligible patients.

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Researchers in the Health Affairs study also pointed to the additional resources needed to perform wellness visits as a barrier to adoption. Practices have stated that they need new workflows, EHR templates, and non-physician providers to facilitate wellness visits.

Practices that lack these resources did not meaningfully adopt the wellness visit despite the potential financial benefit, the study showed.

For example, rural practices had lower rates of wellness visits than practices in other settings. The annual wellness visit rate at rural practices was 8.1 percent compared to 24.4 percent at metropolitan practices.

Practices that had patients with high medical risk and higher rates of Medicaid enrollment also experienced lower annual wellness visit rates, the study showed.

“Rural practices that disproportionately care for minority and low-income patients lag in EHR adoption and are more likely to have difficulty filling clinical positions, in addition to facing other resource challenges,” researchers wrote. “Clinicians serving underserved populations have greater workloads, which may make the adoption of a new visit challenging.”

EHR capability was a sign of wellness visit adoption. Practices with EHR capability were more likely to provide wellness visits than other practices, with 26 percent of practices with at least 50 percent participation in the Medicare EHR Incentive program versus 15 percent of practices with lower participation.

“As Medicare and other payers introduce an array of innovation programs and alternative payment models, practices previously engaged in such efforts may be more likely to take on innovations in general,” researchers explained. “This finding raises the possibility of widening gaps between practices that engage in innovation programs and those that do not.”

While the analysis indicated that resource availability contributed to wellness visit adoption, researchers found that independent practices may actually have an advantage over larger, more equipped hospital-based practices.

Almost 25 percent of independent practices provided wellness visits compared to just 9.8 percent of hospital-based organizations.

Smaller, independent practices may have fewer resources available than larger hospital-based practices with more staff and infrastructure. But they make up for it in agility, researchers stated. And the statistic shows how just one clinician can transform his practice.

Low wellness rate adoption among hospital-based practices may also indicate that hospitals are more focused on growing inpatient or specialty care to boost revenue rather than wellness visits.

While resources may be scarce for some practices, the organizations could benefit from conducting higher rates of Medicare annual wellness visits. Researchers suggested that policymakers and HHS officials reduce wellness visit requirements to boost adoption among providers.

“While annual wellness visit requirements serve to remind clinicians of evidence-based screenings and discussions, the complex requirements may be a greater challenge when treating underserved populations,” they wrote.

Policymakers should also consider health policy that encourages nurses or pharmacists to perform annual wellness visits within the context of a team-based care model, researchers recommended.

Incentives paid directly to patients, such as the $25 patient engagement incentive offered under the Next Generation ACO model, could also encourage beneficiaries to seek out an annual wellness visit.

In addition, CMS could develop a “less prescriptive form of the visit or even a new annual wellness visit to be used with medically and socially complex patients.”

“For these gains to be shared more equitably, policymakers might encourage the use of annual wellness visits through mechanisms adapted to underserved populations and the practices that serve them,” researchers concluded.