Across the nation, Medicare Annual Wellness Visits (AWV) — a yearly appointment that helps Medicare beneficiaries maintain their health and promote preventive care — are heavily underutilized.
Recognizing the importance of the AWV, Froedtert & the Medical College of Wisconsin — under the leadership of Dr. Mark Lodes, vice president and chief medical officer, population health and medical education, and Annie Penlesky Gelder, program manager — deployed a customer-first digital bulk outreach strategy to help maximize the visits.
“The Medicare AWV is an important opportunity for providers to review their patients’ health status, create a personalized care plan and ensure preventive care needs are discussed,” Dr. Lodes said. “From a managed care perspective, the AWV also is an opportunity to document and code conditions that comprise the Risk Adjustment Factor, which impacts the care funding health systems receive from the Centers for Medicare & Medicaid Services.”
Medicare first began covering these visits in 2011 without copays and deductibles as part of the Patient Protection and Affordable Care Act, but it’s been a struggle to get patients and some healthcare providers to understand the value of the visits.
“We know that the Medicare recipients who attend these visits have lower healthcare costs, lower utilization, better healthcare outcomes and they're more up to date with their gaps in care,” he said. “Part of the challenge is creating the cyclical muscle memory — for patients and providers — around getting these done yearly.”
Digital scheduling and routine outreach timeframes
The team addressed the problem head-on by using the foundational elements of outreach to drive consumer loyalty, starting with digital scheduling.
Through digital bulk outreach in the electronic medical record, they contacted patients who were due or overdue for their AWV and allowed them to self-schedule directly from the message, an approach that is less resource-intensive than phone calls. Gelder noted that 80% of their patients are active on MyChart, making it a successful way to engage with them.
Secondly, they established routine outreach timeframes that patients anticipate each year.
They used a “birthday model” for Medicare Fee-for-Service patients and a triannual outreach cadence to Medicare Advantage patients. Fee-for-service patients receive outreach during the week of their birthday and Medicare Advantage patients receive outreach during the months of March, April or May. Maintaining these parameters have primed patients to anticipate when to schedule their annual visit, leading to increased compliance.
Gelder said using a compelling message in their content is key, and it’s the part of their strategy that has shifted the most over time.
“Fee-for-service ‘birthday model’ messages emphasize prioritizing health as the patient celebrates another year of life, while Medicare Advantage patient messages emphasize the components of the AWV,” she said. “In addition to all of our messages including a signature by the primary care provider to instill trust, we’ve been able to tweak our messages over time to keep them fresh and appeal to the top concerns of patients, such as reminding them that the visit is a covered benefit.”
While Gelder and the operations team led the charge, they’ve collaborated with several teams: IT to implement the initiative, legal to ensure the messages are compliant, clinical to approve messages and understand staff scheduling implications, and leadership to help advocate and cascade information down to the clinical level.
“We leaned into our interdisciplinary committees and were able to stand up the project quickly to fill an operational need as well as create rigorous measures to evaluate its success,” Gelder said.
Because the schedulers and frontline care teams are now more in lockstep with the visits, the nearly 75,000 outreach messages for AWVS that were sent from 2021 to 2023 contributed to a 15% increase in patient retention for scheduling.
The impact also is financial in meeting the quality metric requirements of their value-based contracts. Since 2021, Froedtert & the Medical College of Wisconsin Clinically Integrated Network has received more than $2 million in quality bonus payments for AWV completion.
“We’ve made huge improvements,” Gelder said, noting that front desk staff have patients fill out questionnaires specific to the AWV, which creates better understanding and intentionality for the patient and provider.
Dr. Lodes said one of the great challenges over the last few years has been creating access that allows providers to see all their Medicare patients for these visits. But making it a priority to look at how they schedule the visits has been extremely important in helping to provide additional resources and identify areas to create efficiencies, such as conducting a chronic disease screening during the annual visit.
“For example, when a provider also is able to evaluate a patient’s diabetes or hypertension, provide advanced care planning counseling or administer a new immunization that comes out like RSV in the wellness visit, they can be more effective in closing chronic disease gaps,” he said.
Continuous improvement
Keeping patients engaged and compliant is a fundamental challenge of value-based care and population health strategy. But the Froedtert & Medical College of Wisconsin work highlights the impact of maintaining consistency with outreach to achieve trust, retention and loyalty among patients and their commitment to quality care.
Also, because the project efforts are digital, and the team has successfully created templates, Gelder says the work has proven sustainable. They’ve also expanded their outreach efforts to target other important care gaps in adult and pediatric populations.
“We’ve applied this very specific framework to other care gaps this past year with outreach in mammography, diabetic eye exams and colorectal cancer screenings,” Gelder said. “We continue to improve our outreach to these patients to ensure they become compliant for these visits because it’s the right thing to do. Their health is our primary concern. The work never ends.”
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