Family Practice Management (FPM) published several articles and an encounter form last year related to Medicare’s new annual wellness visit (AWV) benefit. Some physicians decided not to offer the AWV due to the complexity of the requirements, but many adapted to Medicare’s version of preventive care and provided these visits in 2011. Unfortunately, the requirements for 2012 have changed.
MEDICARE WELLNESS CHECKUP: HEALTH RISK ASSESSMENT FORM
The Affordable Care Act directed the Centers for Medicare & Medicaid Services (CMS) to require that a health risk assessment (HRA) be completed as part of the Medicare AWV. Efforts by the American Academy of Family Physicians and others to persuade CMS to delay the HRA requirement and allow time for physicians and practices to prepare for this change were unsuccessful, and late last year CMS published the final rule making the HRA requirement effective Jan. 1, 2012. The purpose of the HRA, according to CMS, is to help systematize the identification of health behaviors and risk factors such as tobacco use and nutrition that the physician can discuss with the patient in an effort to reduce risk factors and related diseases. The idea is that physicians will use the information from the HRA in developing a personalized prevention plan for the patient.
CMS has not required a specific HRA form. The Centers for Disease Control and Prevention published a “framework” for the HRA in a 52-page report in December. The report provides a 6-page example of an HRA, but the example does not contain all of the 34 elements required by CMS in the final rule definition.1 The HRA must be written at a sixth-grade literacy level and be designed so that most patients can complete it in 20 minutes or less. It does not have to be scored.
Compliant HRA tools are presumably being developed by a variety of organizations. One source, HowsYourHealth.org, provides free online assessments that meet the CMS requirements and has developed the paper-based questionnaire published with this article (see HowsYourHealth.org and the Medicare health risk assessment).
HOWSYOURHEALTH.ORG AND THE MEDICARE HEALTH RISK ASSESSMENT
While a number of health risk assessments for the Medicare annual wellness visit (AWV) may be in development, Family Practice Management is aware of only one source so far. HowsYourHealth.org, a not-for-profit service of the Dartmouth Co-Op Project, offers two interactive questionnaires that meet the requirements for the AWV:
A brief questionnaire simply asks the required questions and summarizes the results for the practice as a personalized action plan for the patient. It takes less than 10 minutes to complete. Practices may refer their Medicare patients to the site and ask them to print out the summary action plan before their wellness visit or ask them to complete it on paper. A PDF of this version is available for download.
A longer questionnaire, available at http://www.medicarehealthassess.org and at http://www.howsyourhealth.org, offers a more comprehensive health checkup. This survey adds to the required items of the AWV a full assessment of the patient’s problems and priorities (“what is the matter” and “what matters”). It requires more time to complete, but it offers more information to patients and practices. It is available for patients of all ages.
A sample of patient and clinician output from the short-form questionnaire is available at http://www.medicarehealthassess.org/checklist, as is information on the use of short-form, patient-reported information to improve care. A sample of output from the comprehensive questionnaire is available at http://www.howsyourhealth.org/medicare.
There is no charge for use of either questionnaire, although practices that wish to take advantage of available enhancements to the longer-form questionnaire are asked to pay a fee to help support the HowsYourHealth.org website. According to John Wasson, MD, who supervises both HowsYourHealth.org and http://www.medicarehealthassess.org, a practice can customize the assessment, receive real-time aggregate information about its patients’ needs and experiences of care, and use a patient-loaded registry. Practices who choose to customize HowsYourHealth.org for patients of all ages may test the tool on as many as 50 patients without charge. If satisfied with the results of testing, practices are asked to pay a fee of $350 per year for up to 10 clinicians to support the maintenance and further development of the tools.
So what does this mean to physicians who provide AWVs? Before the face-to-face encounter, your patient needs to complete an HRA. Some patients may need encouragement and assistance from your staff. To compensate for this added staff time, CMS increased the relative value units of the AWV to 4.89 for the initial AWV and 3.26 for subsequent AWVs, thus increasing average reimbursements by an underwhelming $5.39 for the initial AWV and $3.59 for subsequent AWVs.
Other than adding the HRA component, CMS did not change the content of the AWV. Some questions that are required in the HRA are already required elements of the AWV.
Some patients may object to being asked to fill out yet another form; in such cases, your best bet is to document the patient’s reasons for not completing the questionnaire and get as much from the visit as you can, keeping in mind that CMS’ overarching goal is that Medicare beneficiaries receive a personalized prevention plan. Once a patient has completed the HRA, you need only review and update the answers in subsequent AWVs. After adding an HRA to your process, you can continue to use the FPM encounter form and related articles as references for the rest of the AWV (see “ FPM resources for the Medicare annual wellness visit”).
FPM RESOURCES FOR THE MEDICARE ANNUAL WELLNESS VISIT
“What You Need to Know About the Medicare Preventive Services Expansion.” Hughes C. January/February 2011:22-25. This article features an annual wellness visit encounter form).
“Answers to Your Questions About Medicare Annual Wellness Visits.” Hughes C. March/April 2011:13-15.
“Medicare Annual Wellness Visits Made Easier.” Hughes C. July/August 2011:10-14.