Preventive care, such as routine general health checks, has long had correlations with better health outcomes. Immunizations greatly reduce the risk of infection and often prevent diseases; screenings have caught cancer in early and curable stages; and counseling on proper diet and exercise have enabled patients to better manage weight, blood pressure, and cholesterol. Evidence-based preventive services, as recommended by the U.S. Preventive Services Task Force, can be pivotal in helping people avoid future health problems and related costs.
When tracking alignment with the quadruple aim of health care (increase quality, lower cost, improve patient experience, and improve provider experience), metrics that can be telling include per member per month (PMPM) cost, emergency department (ED) visits, and readmissions. When these metrics are high, a population is typically less healthy and there is less alignment with the quadruple aim. Proper preventive care through a primary care physician (PCP) has the potential to improve those metrics, as shown by our recent work around the Annual Wellness Visit for people covered by Medicare.
Medicare is a federal program to provide health insurance to people age 65 and above and to people with disabilities. Some people also choose to get Medicare Advantage Plans offered by Medicare-approved private companies. In 2019, the Medicare population accounted for more than 20% of all U.S. health care expenditures, totaling nearly $800 billion.
For people with Medicare coverage, one preventive service that can help improve health outcomes is the Annual Wellness Visit. Conducted by a PCP, this visit entails a series of questions to understand the patient’s health, history, and what future care will be needed. The output of the visit is a care plan that documents what the patient will need for the remainder of the year based on their current heath and underlying risk factors. For example, the patient might be due for a mammogram or a colonoscopy that year. The care plan spells out the health care services required, and then the PCP can work with the patient to get these services scheduled. For qualified individuals, the cost of the Annual Wellness Visit is 100% covered, once every 12 months, as are many specific preventive services.
In terms of improving overall quality of health, the Annual Wellness Visit not only has value in itself, it also frequently serves as a gateway to additional preventive services. A population health team at Highmark Health therefore hypothesized that when participation in the Annual Wellness Visit is higher in a population, there should be lower PMPM cost, lower emergency department visits, and lower rates of readmission.
To test this hypothesis, the team conducted analysis using historical medical claims data for more than 150,000 Medicare Advantage members from January 1, 2019 to December 31, 2019. As expected, the results showed correlations between higher Annual Wellness Visit compliance and better health metrics. Comparing Medicare Advantage members who had an Annual Wellness Visit in 2019 with those who did not, on average the members who had an Annual Wellness Visit had:
This analysis suggests a strong positive correlation between Annual Wellness Visit compliance and better health outcomes with lower costs. To be clear, correlation does not mean causation. It is possible that the data may overestimate the value of the visit. For example, “reverse causation” could be a factor: Members who schedule Annual Wellness Visits are probably more likely to already take better care of their health in general, including on-time adherence to prescriptions and following through with recommendations by their physicians. However, the analysis provides convincing evidence that the Annual Wellness Visit carries real preventive power and that members who do not schedule an Annual Wellness Visit could be more likely to need more care, and more costly care, in the future.
Per the analysis results, the population health team felt that promoting Annual Wellness Visit participation could be an effective way to help improve health metrics. In looking at the obstacles to greater participation, the team looked not only at patients, but also at providers. One factor that stood out was that it is not always easy for PCPs to know how they are performing with Annual Wellness Visit compliance, or how Annual Wellness Visits might be impacting their practice. Medicare Advantage medical claims data can help PCPs fill in those information gaps. This led the population health team to collaborate with internal partners to develop an actionable report on Annual Wellness Visit performance and opportunities that would help PCPs prioritize and improve Annual Wellness Visit participation by their patients.
The report is created with data at the level of an individual practice and at an entity level that practices may be under. Based on all attributed Medicare Advantage members over the last 18 months, it shows the number and percent of members who have and have not had an Annual Wellness Visit over the last 12 months. It also tracks and compares PMPM cost, ED visits, and readmissions between members with and without an Annual Wellness Visit over the last 12 months.
In addition to these metrics, the report offers a list of members attributed to the practice or entity who may need a visit soon. This list is ranked by risk level, with higher risk members at the top, giving PCPs a valuable tool to help decide how to prioritize Annual Wellness Visits and conduct outreach for their patients.
The goal of this report is to increase Annual Wellness Visit compliance, thus also increasing follow-through on necessary preventive care services, and improving the overall health of the Medicare Advantage member population. This also empowers providers with an actionable means of increasing their performance in value-based reimbursement arrangements.
Armed with this data, PCPs are better able to prioritize Annual Wellness Visit participation, and thus bring necessary preventive needs to the forefront for each patient. This is a simple but powerful example of how data-driven collaboration can help everyone progress toward achieving closer alignment with the quadruple aim of health care: increase quality, lower cost, improve patient experience, and improve provider experience. As the health care industry evolves, this kind of trust, transparency and collaboration between payers and providers central to Highmark Health’s blended health approach will continue to be the catalyst for positive systemic change.