Nine diseases you can get from kissing

It's Time To Rethink The Medicare Annual Wellness Visit

In 2011, the Centers for Medicare and Medicaid Services created the annual wellness visit (AWV), a new visit type with no cost to Medicare patients, better reimbursement to primary care practices, and higher assigned credit for clinicians' work. The visit takes about 30 minutes and includes a questionnaire covering home safety, falls risk, and ability to perform activities of daily living, along with a survey of recommended preventive services and depression and dementia screening. No physical assessment is required beyond vision screening and vital signs.

When the AWV was introduced, many of my colleagues and I were optimistic that it might inspire preventive care, and of course any improvement in reimbursement was welcomed.

Now, more than a decade later, the environment has changed: It is increasingly difficult for patients to schedule appointments, while technology offers new ways to address preventive care. That means this is a good moment for my fellow primary care clinician leaders and me to ask: Do incentives to perform wellness visits for Medicare patients still make sense?

The idea behind the AWV was laudable: encourage patients to address prevention and goals of care (which often rank lower in office visit priority than acute matters) as well as chronic disease. By marrying this with higher reimbursement to practices, the hope was for an all-around win. But the reality has been a bit more uneven.

There is some evidence that AWVs are associated with up to 5.7% reduced health care spending during the one-year period after the visit, especially in the highest hierarchical condition category risk groups. It is unclear, though, if it was the visits themselves that saved cost, or their components. In this same study, patients who had AWVs were more likely to receive guideline recommended preventive care.

Meanwhile, evidence that AWVs improve health outcomes is lacking.

One fundamental flaw in the AWV concept is that it inverts the usual primary care office visit process. When patients come in for a visit, it is their opportunity to voice concerns, while our primary clinician obligation is to receive and assess them. The AWV changes the visit into an entirely clinician-driven interview that sidelines patient concerns, a redirection that is inherently uncomfortable for both. If other problems do come up during the visit, the clinician may bill separately for the encounter, but that can be upsetting for patients who expected a free appointment.

Practices have been creative in finding ways to accomplish more AWVs without straining appointment access. One approach my group has piloted is to have nurses complete the visits, which a physician then reviews and signs. This is more efficient, but it still creates an additional trip to the office for patients, adds to the in-basket task load for physicians, and may be a resource drain, taking nurses away from other mission critical work in the practice, such as phone and portal message triage to address pressing concerns from patients.

Many clinicians try to weave the AWV into other scheduled office follow-up visits. Team-based workflows where medical assistants share elements of the interview and documentation that can improve efficiency. But this approach may often lead to add-on charges if problems are discussed, which removes the zero co-pay reward for patients.

It's time to rethink the AWV. Primary care practice has evolved in ways that challenge the value of an actual visit as a sensible way to help patients achieve preventive care goals and establish clinician-patient relationships. Value-based care has inspired innovation in proactive outreach approaches to population management. Use of patient portals and text messaging are effective, low-cost options, which may include both reminders as well as assistance with scheduling evidence-based interventions like mammography, colorectal cancer screening, and vaccination. Patients can easily complete the questionnaire portion of the AWV asynchronously through portal or text-based platforms alone or with caregiver assistance. Artificial intelligence will undoubtedly soon add to improved methods for outreach.

Enhanced reimbursement from CMS for all non-procedural visits would serve primary care practices far better than incentivizing only visits of questionable value. Better yet would be further leveraging progressive payment models that reward achieving preventive and health maintenance goals rather than incentivizing more visit "widgets."

Proponents often point to the relationship aspect of the AWV. It's true that evidence supports that a strong connection to a primary care clinician leads to reduced mortality, improved diagnostic accuracy, and improved patient satisfaction, along with fewer emergency room visits and hospital admissions. These conversations can be valuable for both the patient and clinician to create a foundation for high value care.

It makes intuitive sense that a visit engineered to provide more time to discuss advanced care planning, care goals, and social determinants would improve the doctor-patient relationship. Maybe that's true in ideal circumstances, with a robust primary care clinician workforce and minimal access constraints. But in the current appointment constrained state, where primary care clinicians either are caring for very large panels of patients or are in less overwhelmed practice models with a significant pay-to-join barrier? I think not. Any relational connection gained in an AWV is at risk of erosion if it negatively affects a clinician's availability when a new concern arises.

It doesn't make sense to fill up scarce primary care appointment slots with visits composed of elements we can easily address through technology-enhanced outreach. Imagine accountants insisting that all clients make appointments to complete their tax year planner packets in person, when now the client does the work independently in a manner that saves the accountant's time for what only the accountant can do. We should encourage visits for our highest risk patients and make them constructive and patient-centered. Demanding efficiency in information acquisition and delegation of work not requiring physician time would create much needed space for patient-driven visits to address concerns, build trust, connection and continuity — the hallmarks of primary care.

Jeffrey Millstein, M.D., FACP, is an internist, clinical assistant professor at the Perelman School of Medicine of the University of Pennsylvania, and regional medical director for Penn Primary Care.

Medicare's 2024 Physician Fee Schedule Is Out: More Cuts? Yup

On Thursday, July 13, Medicare released its Proposed Rule delineating changes in a variety of Medicare programs including, but not limited to, quality programs, MIPS, rural work, telehealth, etc. The 2,033 page annual epistle of joy delineates programmatic changes proposed for CY 2024. Between the Draft Rule and the Final Rule's release in the fall, interested parties were invited to comment on the proposals. The Final Rule (FR) was released in early November of 2023.

While varying professional medical associations and others have lamented, and rightfully so, the CY 2024 conversion factor (CF) reduction from $33.89 to $32.74 (a $1.15 or 3.4% reduction), many folks in the healthcare space writ large presume that the 3.4% reduction means their reimbursements, net/net, will decline 3.4% during 2024. This simply isn't true.

Conversion Factor

For those unfamiliar with Medicare reimbursement math, it basically entails a series of calculations taking into account relative value units (RVUs) including work (wRVU), malpractice (mRVU), and practice expense (peRVU). While these values can change annually, once set the RVU values are static throughout the entire US. In Figure 1 below I delineate how you arrive at the Medicare "allowable" for a given CPT code. The RVU component pieces are multiplied by geographic practice cost indices (GPCIs) and the sum of those products is then multiplied by the CF to arrive at a geographically adjusted reimbursement rate for a CPT code. GPCIs are deployed to allow for cost differences in the delivery of care between different areas of the country.

Figure 1

Medicare allowable math

Gorke

To see the math "in action," in Figure 2 below we examine reimbursement for a 99203, a Level 3 New Patient Visit, in both Atlanta, Georgia, and Richmond, Virginia, respectively. I compare CY 2023 to CY 2024 and make allowances for the 2024 change in CF as announced in the FR.

Figure 2

ATL v Richmond

Gorke

As you can see, the "work value" of the 99203 has not changed between 2023 and 2024. That implies that the "work" involved in delivering a 99203 has remained static. However, wGPCI has changed for Richmond. Note, too, that practice expenses in Richmond (peGPCI) for a 99203 have, in theory, decreased. Also, the theoretical malpractice cost exposure (mGPCI) has decreased in Richmond between 2023 and 2024 but has increased in Atlanta. The bottom line to this exercise is that after geographic disparities and the new CF are taken into account, the payment for 99203 in Atlanta has dropped almost $2 while a 99203 in Richmond has decreased more than $3.50.

The Sky Is Falling

Maybe, maybe not. It all depends on your patient mix, specialty, etc. Let's look at Atlanta and the reimbursement changes in established patient (EP) visits and new patient (NP) visits between 2023 and 2024. E&M codes, especially EP and NP visits, account for much of the billing that is submitted annually in the US.

In Figure 3 you can see the delta between 2024 and 2023 Medicare allowables. For EP visits, the allowable is reduced between .96% and 1.90%. Likewise, for NP visits the per CPT reduction ranges between 1.32% and 2.32%. So, while the CF has been reduced by 3.4%, you can see that, with these select codes, the reimbursement reduction is nowhere near 3.4%.

Figure 3

EP/NP Delta

Gorke

That said, your overall reduction is really predicated on your CPTs billed, your patient mix, and geography/demographics. In Figure 4 we examine a practice in Atlanta.

Figure 4

Comparison

Gorke

In our fictional outpatient clinic Dr. X billed 100 99202s and 100 99205 office visits in 2023. The FR was released and he ran his data, based purely on what he billed last year. As Figure 4 delineates, Dr. X would, all things being equal, lose $154 on 99202s and $305 on 99205s for a total loss, performing the exact same work, $459 or about 1.5%. A couple of takeaways: first, this is obviously a fictional example but makes a pretty clear point; to wit, your practice may not experience a 3.4% reduction in reimbursement. Next, percentages are fairly irrelevant; the cost to the practice are the "real dollars" that disappear. Lastly, given inflation and the ever-increasing cost to run health systems and clinics, the 1.56% cut in Figure 4 is decidedly no victory.

Am I suggesting that clinicians should bill the same exact services and/or change billing habits to optimize revenue (or decrease your losses)? Absolutely not! Coding/billing is predicated on what is presented to the clinician. This exercise simply offers you a facile idea, all things equal, about what the Medicare changes for CY '24 could mean to your clinic finances.

As a side note, and equally as important: outpatient clinics must understand, with clarity, their payer contracts. Many contracts are tied in to the Medicare allowables which means if Medicare cuts allowables, you may receive a cut in your commercial allowables, too.

The moral of the story as we head into 2024? Is the sky falling? No. But it may be raining really hard!

What To Do For Medicare Open Enrollment Before It's Too Late

The Medicare annual enrollment period ends on Dec. 7 — and even if you plan to make no changes, reviewing your coverage could save you money. 

Retirement Tip of the Week: It may be the last minute to make changes to your Medicare health plan, but take advantage of the enrollment period before it's too late. 

Many enrollees may not feel it's necessary to check coverage options if they're content with their existing plans, but that could cost them. More than seven in 10 Medicare beneficiaries didn't compare their coverage during the annual enrollment period in 2018, according to the nonpartisan think tank KFF, partially because the process can be so complicated. In some cases, they may pay $1,000 or more for ignoring the deadline because the right plan isn't the one they currently have. 

Many factors determine the "right" Medicare plan, including location, in-network doctors and facilities, prescription drugs and other medical necessities. Plans are also subject to change from year to year, which enrollees would be notified of before the upcoming year. 

Just because a plan worked one year doesn't mean it will be the best choice next year, said Terri Swanson, president of Aetna Medicare. "These things change." 

Here are a few last-minute tasks to consider before the open enrollment window closes on Dec. 7. 

Compare prices

Comparing plans could take a lot of time, but reviewing the costs for medicine and health expenses under a current plan and one or two others could save hundreds, if not thousands, of dollars. The National Council on Aging's BenefitsCheckUp tool can quickly offer eligible enrollees programs to parse through. 

Medicare.Gov also has a tool to find and compare coverage. Users with an account on the site will get a summary of their current coverage, along with drugs or pharmacies they use, to help compare costs. 

Look at Star ratings

Medicare beneficiaries can use Star ratings to understand the quality of a health plan. Star ratings are based on up to 40 quality and performance measures, depending on the type of coverage, according to the Centers for Medicare & Medicaid Services. "It is a way to measure the performance and quality of the Medicare Advantage plan," Swanson said. 

For example, around 42% of Medicare Advantage plans with Part D for 2024 have earned four or more stars, according to the Centers for Medicare & Medicaid Services. Almost three-quarters of enrollees in Medicare Advantage with Part D plans are in contracts for coverage that earned four or more stars. 

Talk to someone — including yourself 

Still need help? There are resources, such as the state health insurance assistance program (known as SHIPs). Every state has its own program, offering counseling services to beneficiaries who have trouble making sense of their options. 

In these last few days, go through a checklist of questions to ask yourself, including what your copay at the doctor's office is, and if there are any additional medications you'll be taking in the new year. Check that your doctors and medical facilities will still be in-network in 2024, or what other changes may occur with your current plan in the new year. 

Look to the next deadline

Medicare Advantage has its own open-enrollment period, which is between Jan. 1 and March 31. This period allows anyone who is already in a Medicare Advantage plan to switch to another Medicare Advantage plan with or without drug coverage, to add drug coverage or drop that plan to go back to Original Medicare. This is separate from the current open enrollment period, since those who have Original Medicare can't join a Medicare Advantage plan during the period beginning in January.

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