Each dot represents 1 hospital referral region. Annual wellness visit rates were rounded to whole percentages to facilitate presentation.
Ganguli I, Souza J, McWilliams JM, Mehrotra A. Trends in Use of the US Medicare Annual Wellness Visit, 2011-2014. JAMA. Published online April 19, 2017. doi:10.1001/jama.2017.4342
In 2011, Medicare introduced the annual wellness visit (AWV)—a form of the periodic health examination that remains a ubiquitous yet controversial feature of primary care1—through the Affordable Care Act. The AWV has been promoted as a way for physicians and other clinicians to encourage evidence-based preventive care and mitigate health risks in aging patients through required screens for cognitive function and fall risk, for example.2 The visit is free for beneficiaries, although patients have reported unexpected out-of-pocket costs when AWVs are concurrently billed with problem-based visits.3 Although single-institution studies have suggested pockets of adoption,4,5 national patterns and predictors of AWV use have not been described.
The Harvard institutional review board waived study review. For each year from 2011 through 2014, we analyzed Medicare claims for a random 20% sample of beneficiaries who were continuously enrolled in fee-for-service (FFS) Medicare in both the previous year and concurrent year (while alive in the case of decedents). We compared the proportion of beneficiaries receiving an AWV (Current Procedural Terminology [CPT] codes G0438 and G0439) by sociodemographic and prior utilization characteristics as well as by attribution to an accountable care organization (ACO). We built a multivariable logistic regression model of 2014 AWV receipt using sex, age, race, family income, residence, Medicaid eligibility, number of comorbidities, and per-beneficiary Medicare spending as covariates. We examined AWV rates across hospital referral regions and the association of AWV rates with total per capita risk-adjusted Medicare spending. We also analyzed use of AWVs and problem-based visits (CPT codes 99201-99215; Healthcare Common Procedure Coding System code G0463) among primary care physicians (PCPs; internal medicine, family medicine, general practice, or geriatrics). Reported P values were 2-sided and considered significant at less than .05; analyses were performed using SAS (SAS Institute), version 7.12.
The percentage of beneficiaries receiving an AWV increased from 7.5% (95% CI, 7.5%-7.5%) in 2011 to 15.6% (95% CI, 15.6%-15.6%) in 2014. In our 20% sample of Medicare beneficiaries, 5 983 154 beneficiaries were eligible for an AWV in 2014 (mean age, 72.4 years; women, 55.6%). White individuals, urban residents, and those from higher-income areas and with 1 or 2 comorbidities were more likely to receive an AWV (Table), as were beneficiaries who received an AWV in the previous year (53.4% receiving an AWV in the previous year vs 10.4% not receiving an AWV in the previous year; P < .001) or belonged to an ACO (25.9% belonged to an ACO vs 17.6% did not belong to an ACO; P < .001). Among all AWVs, 44.4% (95% CI, 44.3%-44.5%) had a concurrent problem-based visit.
Regional AWV rates in 2014 varied from 3.0% (95% CI, 2.5%-3.5%) in San Angelo, Texas, to 34.3% (95% CI, 33.0%-35.8%) in Appleton, Wisconsin (Figure). Rates were not correlated with Medicare spending (Pearson coefficient, 0.01; P = .85).
Most AWVs (90.7% [95% CI, 90.7%-90.8%]) were performed by PCPs. Of the 157 750 PCPs who billed Medicare for any office visit in 2014, 40.8% (95% CI, 40.6%-41.1%) performed at least 1 AWV. Among PCPs who provided an AWV, the top decile by AWV volume performed 41.6% (95% CI, 41.5%-41.7%) of AWVs, but only 11.2% (95% CI, 11.2%-11.3%) of all office visits.
AWV use increased from 7.5% in 2011 to 15.6% in 2014 but remained modest on average. Adoption was concentrated in ACOs and among certain PCPs and regions of the country, suggesting that the decision to perform an AWV was primarily driven by practice factors. This finding aligns with reports that some physicians and health systems are incorporating strategies such as templates, workflows, or dedicated nonphysician health professionals to complete, document, and bill for AWVs.2 PCPs or regions using more AWVs did not deliver more health care overall, suggesting that AWV adoption and other types of utilization were driven by separate mechanisms.
Annual wellness visits were frequently co-billed with problem-based visits, corroborating patient concerns about unexpected costs and emphasizing the need for conversations about potential cost-sharing. There were also notable socioeconomic disparities in AWV use.
This study has several limitations. Claims data could not show how often AWVs were performed by nonphysicians under physician supervision, and the extent to which AWVs represent delivery of additional visits vs substitution for other visits remains unclear. More research is needed on whether AWVs increase use of preventive care or mitigate health risks.1,4,6
Corresponding Author: Ishani Ganguli, MD, MPH, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Third Floor, Boston, MA 02120 (email@example.com).
Published Online: April 19, 2017. doi:10.1001/jama.2017.4342
Author Contributions: Dr Ganguli and Mr Souza had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Ganguli, McWilliams, Mehrotra.
Acquisition, analysis, or interpretation of data: Ganguli, Souza, McWilliams.
Drafting of the manuscript: Ganguli.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Ganguli, Souza, McWilliams.
Administrative, technical, or material support: Mehrotra.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: This article was supported by grant P01 AG032952 from the National Institute on Aging of the National Institutes of Health.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Previous Presentation: Presented at the Society of General Internal Medicine Annual Meeting; April 19, 2017; Washington, DC.