May 3, 2018

Medicare Annual Wellness Visits: A Unique Opportunity for Holistic Senior Care

Preventive care at its best

Cleveland Clinic is poised to launch an initiative to encourage Medicare-eligible geriatric patients to utilize their 60-minute, fully covered Annual Wellness Visit benefit.

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“This effort will involve offering geriatric patients and their families an opportunity to connect with the Center for Geriatrics as an easy access point for holistic assessments and screenings.” explains Ardeshir Hashmi, MD, Director of Cleveland Clinic’s Center for Geriatric Medicine.

An underutilized opportunity

Medicare introduced the annual wellness visit benefit in 2011, yet by 2015, 51 percent of practices nationwide were still not providing this benefit to their eligible. This runs counter to evidence showing that adopters tend to see increases in their primary care revenues, enjoy a more stable patient assignment and have a slightly healthier patient mix.

With the complexities of the Medicare incentive structure, adding healthy Medicare patients can financially benefit practices by lowering their costs per patient. At the same time, adding unhealthy patients with undiagnosed illnesses presents opportunities to identify these (co-billing occurs in roughly 40 percent of these visits); the practice gets “credit” for taking on those sicker patients, thereby increasing the Medicare spend.

But basing your practices on these labyrinthine incentives can be complex. What is clearer are the benefits that accrue to the patient from a full 60 minutes exploring a patient’s health holistically. Dr. Hashmi advocates focusing on this value. “It is an opportunity for patients to come in and talk about items we normally don’t have time for, but which are crucially important to touch base on at least once a year — most notably, we can make sure their medical record is updated and they are receiving important clinical screenings.” The template has several geriatric screening and discussion features, including:

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  • Cognitive function/memory impairment
  • Mood disorders
  • Medication/polypharmacy review
  • General healthcare screenings (such as colonoscopy, mammography, prostate, PAP, glaucoma, aortic aneurysm, diabetes, bone mass)
  • Goals of Care /advance directives
  • Activities of daily living (ADLs) and instrument activities of daily living (IADLs),
  • Screening for and reducing fall risk, improving balance

Building the geriatric medical home

“At the core is ‘one-stop shopping’ with development of care plans and close communication among a multidisciplinary team to give a geriatric medical home to our senior patients,” Dr. Hashmi explains. Along with the physician, this team may incorporate physician assistants, nurse practitioners, registered nurses, care managers, social workers, geriatric pharmacists, physical and occupational therapists, and others who are tasked with the all-important role of following up, assuring durable medical equipment (DME) and other resources are supplied and plans carried out.

“Integral to all of this is working effectively with the internists,” he adds. “Complete physical-only visits don’t screen for memory problems, depression, falls and frailty and there is often no discussion around goals of care, or enough time to go over all recommended healthcare screenings for each age.” Of course there is even scarcer time for all this in the 20 minutes allotted for an office visit regarding an acute injury or illness.

Partnering with community physicians

Dr. Hashmi offers that “Cleveland Clinic can be a partner to internists in assessing the broader picture and helping on the preventive end.” For example, he has his patients bring every bottle of medicine they use to the wellness visit. More the rule than the exception is finding patients taking medications no longer indicated, or contraindicated. Dr. Hashmi sees this as a top-tier concern. “Polypharmacy is a huge issue. Because the current state of our system is fragmented and in silos, these patients may have several medications started by their specialists which feature on the PCP’s med list, but no one knows when it started or why, or whether they were to be long-term or for a specified duration.”

The big benefit to the primary care provider? “If I am an internist with a patient over 65, I know once a year all these areas will be touched on. I have greater peace of mind from knowing that despite the hectic nature of my schedule, if I open the medical record, I may find more information that can help explain my patient’s condition or obstacles to following the treatment plan,” Dr. Hashmi says.

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To raise awareness of the value of Annual Wellness Visits, Dr. Hashmi and his team will be communicating the many benefits to Cleveland Clinic ACO patients. While the initiative will start with a focus on the county where Cleveland Clinic main campus is located, Dr. Hashmi expects that they will expand beyond the borders to other counties. He and his team what to spread the good news of these fully covered visits, which have stayed too long under the radar.

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