Adoption of annual wellness visits increasing at a moderate rate

Trends in annual wellness visits (AMV) indicate a modest increase in the percentage of Medicare beneficiaries receiving an AWV from 7.5 percent in 2011 to 15.6 percent in 2014, according to a study of the trends related to annual wellness visits (AWV) published in the Journal of the American Medical Association (JAMA) on April 19, 2017. The study found that “adoption of AWV was concentrated in ACOs [accountable care organizations] and among certain PCPs [primary care physicians] and regions of the country.”

Addition of the AMV to Medicare benefits

The AMV was added to Medicare benefits by section 4103 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) as part of its preventive care measures for Medicare beneficiaries. Medicare pays for 100 percent of the visit. The AWV became effective in January 1, 2011. According to the study, the AWV “has been promoted as a way for physicians and other clinicians to encourage evidence-based preventive care and mitigate health risks in aging patients.”

Study findings

Among the results of the study are the following findings: (1) white individuals, urban residents, and those from higher income areas and with one or two comorbidities were more likely to obtain an AWV; (2) beneficiaries that received an AWV in previous years were more likely to receive an AWV; (3) 44.4 percent of all AMVs had a concurrent problem-based visit; (4) most AMVs were performed by primary care physicians; and (5) physician practice groups or regions using more AWVs did not deliver more health care overall. The researchers also noted that beneficiaries reported unexpected out-of-pocket costs when AWVs are billed concurrently billed with problem-based visits.

The study conclusions

The study concluded that the decision to perform an AWV was primarily driven by practice factors and noted that this conclusion aligned with reports of physicians and health systems having incorporated templates, workflows, or dedicated nonphysician health care professionals to complete, document, and bill for AWVs. According to the researchers, the study had limitations, including: (1) whether AWVs increase the use of preventive care or mitigate health risks, (2) claims data could not show how often AWVs were performed by nonphysicians under physician supervision, and (3) the extent to which AWVs represent delivery of additional visits versus substitution for other visits..

Highlight on New York: State guidance supports ACA initiatives

The New York Department of Financial Services (NYDFS) recently released guidance to ensure that insurers are following through on Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and CMS mandates to provide preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) at no charge to patients and to facilitate enrollment during special enrollment periods (SEPs). Specifically, it circulated guidance requiring issuers to provide coverage for maternal depression screening and to allow victims of domestic violence to apply for health insurance coverage, both on and off the exchange, year-round.

Maternal Depression Screening

Section 1001 of the ACA amended section 2713 of the Public Health Service Act (42 U.S.C. § 300gg-13) to require nongrandfathered health plans to provide certain preventive services, without copays, to plan recipients. The services fall into four categories, one of which covers evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the USPSTF.  In 2009, the USPSTF recommended screening all adults for depression when staff-assisted depression care supports were in place and suggested selective screening based on professional judgment and patient preferences when such supports were not in place.  Since that time, depression care supports have become more commonplace.  As a result, the task force updated its recommendations in 2016 to omit the recommendation regarding selective screening and recommend depression screening for all adults, specifically including pregnant and postpartum women; the rating carries with it a ‘B’ recommendation. The USPSTF noted that the American Academy of Pediatrics recommends postpartum depression screening at infants’ one-, two-, and four-month visits, while the American College of Obstetricians and Gynecologists recommends screening at least once during the perinatal period.

The NYDFS issued guidance to insurers on April 25, 2016, reminding them that the USPSTF granted maternal depression screening a ‘B’ rating and that they are required to covers such services pursuant to 42 U.S.C. § 300gg-13. According to Governor Cuomo’s office, issuers should begin providing coverage as soon as possible, but no later than six months from the date of the notice. Furthermore, the NYDFS noted, Chapter 199 of the Laws of 2014 (which added §§ 3217-g, 4306-f, and 4406-f), requires that insured women are entitled to direct access to screening and referral  for maternal depression treatment by an obstetrician/gynecologist (OB/GYN) or pediatrician of their choice. In addition, existing law requires that mental health services have parity in insurance coverage.

SEPs for Victims of Domestic Violence

Qualified individuals or enrollees and their dependents are eligible for special enrollment periods, pursuant to 45 C.F.R. 155.420(d)(9), if they meet specified exceptional circumstances. As of July 27, 2015, CMS opened a permanent SEP for any household members victim to domestic abuse, victims of spousal abandonment, and their dependents, for 60 days following an individual’s request for enrollment. CMS also noted that victims who are married to their abuser or abandoner and are applying for coverage separately may be eligible for advance premium tax credits (APTCs) and cost-sharing reductions (CSRs); the federally-facilitated marketplace will  allow them to indicate that they are unmarried without fear of penalty, but other marketplaces may also elect to attest to an expected filing status of Married Filing Separately.

The NYDFS notified all insurers and health maintenance organizations (HMOs) offering comprehensive health insurance coverage in the individual market that they should honor this SEP, whether they offer coverage on or off New York State of Health (NYSOH), the state exchange. The governor’s announcement noted that the SEP began April 15, 2016. Coverage for applications received through the 15th of any month will go into effect on the first day of the following month, while applications received after the 15th will be effective the first day of the second following month.  Although insurers and HMOs may request a separate statement or include an item on the application regarding eligibility, they may not require proof of eligibility or other overly burdensome requirements, nor may they require that applicants have been a victim of domestic violence or spousal abandonment with a specific timeframe.

ACA has another good year with prescription drug savings and preventive care

Medicare beneficiaries continued to see savings as a result of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) in 2015. Since 2010, when the health law was enacted, almost 11 million Medicare beneficiaries have received discounts totaling over $20.8 billion on prescription drugs. Additionally, in 2015 an estimated 39.2 million people with Medicare took advantage of preventive services made possible through the ACA.

Prescription drugs

The ACA’s efforts to narrow Medicare Part D’s “donut hole” continued to show promise in 2015. The outlook is promising for plans to close the coverage gap by 2020. Under the ACA, individuals who are in the donut hole in 2016 will receive discounts of 55 percent on the cost of brand name drugs and 42 percent of the cost of generics. The total savings of the ACA’s measures to close the donut hole have saved an average of $1,945 per beneficiary since 2010. The impact of the discounts varies somewhat among the states, but, across the board, the results are significant.

Preventive services

The ACA also took steps to incentivize the use of preventive services by adding coverage of an annual wellness visit and eliminating coinsurance and the Part B deductible for certain Medicare preventive services, including many cancer screenings. While 39.2 million benefited from the increased access to preventive screenings in 2015, an increase from the previous year, another 9 million Medicare beneficiaries took advantage of the annual wellness visit in 2015.