Five ways to leverage the Medicare Annual Wellness Visit to promote value-based care


Value-based care (VBC) is a buzz phrase in healthcare. However, what does VBC actually mean? How do healthcare organizations provide it? And how do they know whether value-based care helps patients become and stay healthy? Providers, researchers, policymakers, and others continue to debate these important questions. However, VBC is ultimately about doing what’s right for patients—helping them access the services they need, make healthy choices, and prevent health problems from occurring or worsening.

An opportune time to do this? The Medicare Annual Wellness Visit (AWV). The AWV plays an important role in VBC because it’s when providers check in with patients, see how they’re doing, and make sure they’re on the right track. In essence, the Medicare Annual Wellness Visit embodies the spirit of value-based care.

The biggest challenge?

Getting patients in the door. Healthcare organizations need to know what patients are due for their Medicare Annual Wellness Visit and then outreach those individuals and encourage them to make the appointment. Technology can certainly streamline this process by providing an AWV-eligibility report. However, staff must also be adept at educating Medicare patients about the importance of the AWV and what it includes. It may be helpful to develop scripts for scheduling the AWV and identify other ways to streamline AWV workflows.

Once the appointment is made, healthcare organizations can leverage the Medicare Annual Wellness Visit in promoting value-based care. The following are five ways to do that:

1. Focus on chronic conditions. The Medicare Annual Wellness Visit is an ideal time to check in with patients about chronic conditions, document those conditions for proper risk adjustment under value-based payment models, and educate patients on how to avoid potential exacerbations. It’s also a great time to enroll eligible patients in a chronic care management (CCM) program and refer them to one or more specialists if needed. Technology can help provide a CCM-eligibility report that makes it easy to identify what patients qualify for CCM and why.

2. Screen for new and emerging health problems. When providers see patients once a year for their AWV, it becomes easier to identify changes in the patient’s health status. The goal is to address problems before they become out of control or even life-threatening. For example, providers can use the AWV to identify signs of cognitive impairment and risk factors for other health problems. The AWV is the perfect time to screen patients for opioid use disorder, falls, substance use disorder, and depression. By identifying these problems and treating patients as early in the disease progression as possible, providers improve outcomes and simultaneously lower costs.

In addition, many screenings and risk assessments may satisfy the requirements of the Merit-based Incentive Payment System and Advanced Alternative Payment Models pathways. Fortunately, technology can help providers easily identify opportunities for perform age- and gender-appropriate screenings, such as colorectal cancer screening, mammography, annual pap screening, bone density testing, ultrasound screening for abdominal aortic aneurysm, prostate cancer screening, hepatitis C and HIV testing, and more.

3. Ask patients to come prepared. It’s helpful to ask patients to complete their Health Risk Assessment (HRA) in advance through the patient portal. Providers can also send the HRA to the patient’s home before the scheduled Medicare Annual Wellness Visit or ask the patient to arrive early to fill out paperwork. It’s also a good idea to ask patients to bring a complete list of current medical providers, a complete list of all prescribed medications, over-the-counter medications, and supplements, and a complete medical, family, and social history. Having this information ready to go makes for a more productive and comprehensive AWV.

4. Proactively address social determinants of health (SDOH). The AWV is an optimal time to proactively address barriers to care. The goal? To help patients become and stay healthy for as long as possible. For example, providers can help patients find transportation to and from appointments, give strategies to lessen social isolation, and connect patients with community agencies and other resources.

5. Provide patient education. During the AWV, providers can educate patients on how to maintain optimal health and wellness. For example, they can provide information on nutrition and oral health, sexual health, alcohol consumption, tobacco use, motor vehicle safety, home safety, and more. They can also help educate patients about future care decisions and how they can let others know about their preferences. Having these plans in place can also help reduce long-term costs and simultaneously give patients peace of mind.


Clearly, the Medicare Annual Wellness Visit and value-based care go hand in hand. The AWV provides countless opportunities for services that ultimately improve patient outcomes and reduce costs. Healthcare organizations can leverage these opportunities to give patients the high-quality care they deserve.

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