In this country, healthcare costs are now $2.5 trillion a year. It is believed that 30 percent or greater of these costs are related to over-utilization of unnecessary services or duplication of services. There are two ways to decrease over-utilization. One is to keep patients healthy with evidence-based preventive services and the other is to prospectively identify high- risk over-utilizers and provide care coordination. The Medicare Annual Wellness Visit (AWV) achieves both these goals.
The AWV is not a yearly physical exam. The purpose of the visit is to deliver evidence-based preventive services by an appropriate clinical provider in the appropriate clinical setting. It is also mandatory to provide a Health Risk Assessment (HRA) as part of the visit. The HRA identifies the high-risk over-utilizer; CMS uses the CMS-HCC risk methodology. The use of HCC scoring may be of benefit in designing care plans, particularly in planning for post-discharge care. Given that patients with higher HCC scores and therefore a greater number of medical complications have significantly higher post-discharge costs, it may be useful for the clinical care team to carefully review all of the diagnoses for all patients to identify those patients having medical conditions that may create significant post-discharge costs. The AWV HRA is an opportune time to collect the ICD-9 codes necessary for CMS-HCC risk adjusting methodology. There are software applications that automate this process in a prospective fashion.
There are many advantages for a physician to provide an efficient and cost-effective AWVHRA and CMS-HCC risk adjustment. There is significant reimbursement to deliver the AWV, provide the indicated preventive services, and identify and provide diagnostic tests to identify early chronic disease. In addition, the ICD-9/HCC codes are of considerable value to the Medicare Advantage Plans. The codes determine the plan's reimbursement from CMS. Providers can receive incentive payment by providing the ICD-9/HCC codes to the plans. Higher risk scores can also be leveraged for increased reimbursement to care for sicker patients. While risk adjustment has been used in setting payment rates in public programs for quite some time, risk adjustment for provider payment has been relatively recent, especially in accountable care organizations (ACOs) and Patient-Centered Medical Home programs among private payers.
The Advantage Plans will receive increased revenue providing they can demonstrate HEDIS quality measures. Delivering the AWV and indicated preventive services will improve 23 HEDIS quality measures.
Chronically ill patients require care coordination over a continuum. CMS has created two new G codes for care coordination. Reimbursement for care coordination G codes will begin in 2015. To qualify for the reimbursement each patient receiving care coordination must first have an AWV.
A recent study of Medicare retirees from General Motors suggested those who completed HRAs and engaged in one or more health promotion programs had lower Medicare costs per year, ranging from $95 to $577 per person per year, depending on the analysis, according to CMS
It is obvious that the future of healthcare will start with an AWV and a HRA. Physicians must make a paradigm shift to wellness, prevention, and care coordination. If they don’t make this paradigm shift, more and more primary-care providers will be non-physician caregivers.