Host Dr Jill Jin speaks with Dr Philip Bain, a general internal medicine specialist at Bozeman Health Belgrade Clinic in Montana and the Physician Assistant Director for Primary Care at Bozeman Health, regarding strategies on streamlining workflow to ensure a thorough and efficient annual wellness visit.
To learn more on this subject, access the online AWV toolkit.
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Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Jill Jin, MD, MPH: Hi everyone, my name is Dr Jill Jin, and today I'm talking with Dr Philip Bain, who is the general internist at Bozeman Health Belgrade clinic in Montana, as well as the assistant director for primary care at Bozeman Health. Dr Bain, welcome, and thank you so much for being with us today. So, our topic today will be the Medicare annual wellness visit, which is also called the AWV, which is a very important, but somewhat nebulous visit for Medicare patients. And of course, somewhat daunting for primary care clinicians. Dr Bain, you were one of the authors for the AMA STEPS Forward® toolkit that was published about the Medicare AWV, which aimed to help practices streamline AWV workflow and improve the AWV experience. So, would you like to tell the listeners a little bit about yourself and your background?
Philip Bain, MD: I'm a born and bred Midwesterner, having lived in Wisconsin all my life up until about three years ago, when I relocated to Bozeman, Montana. Throughout my career, Jill, I've been very interested in practice efficiency and streamlining processes in the office. For a while, I worked with people in the department of industrial and systems engineering at the University of Wisconsin in Madison to identify opportunities for streamlining workflow and processes in primary care. You know, when you asked me a few years ago to help with the STEPS Forward® module on the annual wellness visit, I thought this was particularly suited to workflow analysis and redesign.
Dr Jin: So, let's start with the basics. What exactly is a Medicare annual wellness visit?
Dr Bain: Well, Jill, the AWV was a concerted effort by CMS to incorporate preventive care and wellness into the traditional chronic disease model that primary care physicians and APCs are very familiar with. This was formally introduced around the time that the affordable care act was passed, and it recognized that in addition to the more traditional chronic disease management approach, we really need to focus on helping people stay well. So, the AWV is a visit type that involves preventive care measures, advanced care planning, as well as depression, and dementia, and fall risk screening. CMS recognized that this additional focus takes time, and they created reimbursement codes specifically for this. I should say that in the past, all of these elements or many of these elements of the AWV were kind of stuffed into a already full annual visit, and were either often overlooked or given short shrift during the visit.
Dr Jin: Yeah. So, you're, I guess, what it's saying is that it's an important visit that has lots of important components, yet, I, you know, the uptake of AWVs is quite low. So, why do you think the uptakes of AWVs is low?
Dr Bain: The uptake, as you said, has been extremely slow. I think that across the US, it's something like less than 20% of the eligible seniors actually get an annual wellness visit. And I think that the reason for this are many, first of all, PCPs, we're trained to kind of fix what's broken, alluding to that chronic disease management approach. The wellness and preventive movements have not been embraced to the extent that it deserves over time. And then also, PCPs are overwhelmed with so many issues to attend to at each visit, that they rightly feel that they just can't get it all done. And then there's this idea that docs have to answer all the questions and address all of the issues by themselves. And Jill, historically docs have not been as good at leveraging all members of the care team, including the patients.
Dr Jin: Right, that is a good point. And I think that, I guess that if there's one thing we want to impart upon our audience today, it is that this needs to be a team-based approach, that it is not something that physicians can do alone. And the misconception that it is, that's what's so daunting and intimidating. Just to step back a little bit. So how do you, how do you convey the difference between an AWV as opposed to a quote, unquote routine physical?
Dr Bain: Well, Jill, that's a good question. It's actually one that people—there's a lot of misunderstanding between the two. I think of the AWV and chronic disease visit as a true enhancement of the antiquated old annual exam, annual physical. I combine the two visits and tell the patient that the annual exam now consists of chronic disease management like you are used to, in addition to the prevention and wellness part that emphasizes how they can stay healthy and safe.
Dr Jin: And so, the annual wellness visit itself actually does not cover a physical exam, correct?
Dr Bain: Correct. I mean, in the sense, in the broad sense, I, again, I think of the exam as kind of the old annual exam on steroids, in a sense. So, that's an important distinction though, because as you said, Jill, care teams can do it kind of one of two ways. They can separate out the visit into two visits, you know, one visit for wellness and one visit for chronic disease management on different days. While that's easier for the care team, at least on the surface, it is more inconvenient for the patient as they have to come to the office twice. Access, though, is an issue because, you know, in many practices, docs kind of shutter at the idea that they have to have two instead of one visit, so that in and of itself scares PCPs away from this two separate visits.
Now, I think the more common practice is that care teams will have both visits on the same day. This is more convenient for the patient, but on the other hand, the care team and PCPs may get nervous about the length of the visit, and also giving too much information for the patient, resulting in information overload. But regardless of what option is chosen, you mentioned before that it is critical that the PCPs realize that they don't have to, and actually should not do the majority of the AWV.
Engaging the patient by having them fill out, for example, the health risk assessment questionnaire before the visit is a huge time saver. Engaging the care team, especially the rooming staff, saves a lot of time as well. For example, having the roomer confirm answers on the health risk assessment and record them in a smart list before the PCP even enters the room will allow the PCP really just to focus on the pertinent positives. Also, having the roomer briefly inform the PCP what items were positive on the health risk assessment will save a lot of time as well. Finally, it's very time efficient to create, or, in a sense, beg, borrow, or steal from colleagues, smart phrases that include resources and recommendations that can be blown into the after-visit summary to address those pertinent positives, such as fall prevention, advanced care planning, medication reconciliation, tobacco use, alcohol use, and others.
Dr Jin: Okay, Phil. So, if I were a Medicare patient, can you take me through the workflow of your practice, starting from a few weeks before my appointment, to the day of the appointment, to afterwards?
Dr Bain: Yeah, that's a good question, Jill. Let me go over my workflow or our care team's workflow. So, first of all, we remind all Medicare patients that they're eligible for a once-yearly annual wellness visit that covers both prevention and chronic disease management. We encourage them to schedule it, and we're starting to actually review our panel registry on a regular basis to see which eligible patients are due for their annual wellness visit. So, when they call to schedule the appointment, the front desk staff lets the patient know that they will be receiving a health risk assessment questionnaire in the mail in advance of their visit and that they should fill it out before they come in. Our clinic staff contacts the patient either by phone or preferably by MyChart about a week before the visit, and asks them to come in for pre-visit labs, and reminds them to complete that health risk assessment before they arrive. The patient is asked to arrive about 15 minutes early for their annual wellness visit.
The clerical staff asks the patient at the time of check-in if they've completed the health risk assessment. If they haven't, the clerical staff gives them a new health risk assessment questionnaire and asks them to fill it out. Now, if the patient has arrived too late to fill out the health risk assessment, they're asked to reschedule the annual wellness visit portion and that today's visit will only be the chronic disease management visit. One important issue is that while all insurance companies cover the annual wellness visit at no cost of the patient, no copay, some don't cover the chronic disease management portion completely, and the patient may be responsible for a copay. If the practice is decided to do both visit types on the same day, the patient should have this explained very transparently and explicitly. In fact, we have them sign a waiver before the visit asking them to check off whether they'd like today's visit to be an AWV only, a chronic disease management visit only, which likely would involve a copay, or a combination in which a copay may be involved. So, by making this discussion routine and transparent, you can prevent a lot of frustration down the line on the part of the patient who may call later explaining — hey, I thought this was supposed to be free.
Dr Jin: Phil, do you have any final pearls of wisdom for practices who are struggling with implementing an efficient AWV process?
Dr Bain: Sure, Jill. I want to make sure that, probably, the first thing a care team should do is to decide if you're going to do two separate visits on two separate days, or do both on the same day at the same visit. If you're going to do this combined visit, make it very explicit that a copay may be involved and preferably use a waiver that they can sign before the visit. But probably the most important take home message from today: the physician or APC does not and should not do most of the work of an AWV. You need to engage the patient to fill out the health risk assessment before the visit, you need to leverage the care team to confirm and record the answers to the health risk assessment using a negatively defaulted smart list, again, creating or beg, borrowing, and stealing from colleagues, smart phrases for each of the items on the health risk assessment that turn up positive with local resources and specific recommendations.
And Jill, before I go, I want to tell you about a pilot that we're starting soon. We're going to have a newly hired nurse practitioner in our practice to do my AWVs. She'll review my registry and see which patients are eligible and overdue for the AWV. She'll then invite them in for the AWV about two to four weeks before their chronic disease management visit. Now, some practices have had RNs do this for years — so, Jill, it's not like I thought this up in our practice. We call these nurse practitioners annualists, and we make sure that patients know that we work very closely with them and that they'll have the time and expertise to help them stay well. This nurse practitioner will carefully screen the patients — colon cancer screening, breast cancer screening, and cervical cancer screening, as well as bone density, diabetes, and lipid screening. So, he or she will discuss the importance of not only focusing on chronic disease management but also how important it is to talk about prevention and wellness to stay healthy. I think that this approach represents an exciting paradigm shift in primary care, and given CMS's reimbursement for this type of visit, there should be no problem having a program like this pay for itself.
Dr Jin: Thank you so much, Dr Bain.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
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