A Medicare Annual Wellness Visit (AWV) is a preventive service for Medicare beneficiaries designed to create or update a personalized prevention plan. It focuses on preventive care and screening services, such as reviewing medical and family history, updating a list of current providers and prescriptions, creating a personalized prevention plan, and assessing risk factors for certain diseases. At least in theory, this service is designed to reduce the total cost of care via preventive services, however we would like to test this theory with real world data, specifically looking at whether it has an impact on Emergency Department (ED) utilization.
With the goal of understanding the potential relationship between preventive services like AWVs and ED utilization, we conducted the following study to test this hypothesis: AWVs can help reduce ED utilization among Medicare beneficiaries.
- Study design: A retrospective cohort study using several statistical analytic methods to compare ED utilization differences between members with and without an AWV.
- Methods: To ensure we have comprehensive data, we used eligible Medicare members’ claims and EHR data spanning three-years (2020 - 2022) across 14 primary care clinics in a primary care network for the analysis. Specifically, we wanted to test the effect of an AWV on subsequent years’ ED utilization. We first identified eligible Medicare MSSP ACO members who did not have an AWV in 2020. This provided a good baseline population, as most members did not have an AWV in 2020 due to COVID-19. Next, we took random samples of 6,156 members and separated them into two groups: with AWV or without AWV in 2021, while ensuring the two groups did not have a significant difference in the number of ED visits at the beginning of 2021. Finally, we compared the two groups' ED utilization differences in 2022.
- Results: We found a significant difference in ED utilization between members with and without an AWV among Medicare beneficiaries. Furthermore, we had similar, but more nuanced findings by looking at the difference with other factors such as gender, age group, avoidable ED, and patient risk.
- Other considerations: The findings assume that a completed AWV is the main factor that contributed to the difference in ED utilization. There are likely other confounding factors such as ability to access primary care, convenience to ED, different levels of engagement with primary care, etc.
We found a significant difference in ED utilization between members with and without an AWV among Medicare beneficiaries.
In the visual below, we can get a sense of how large the ED utilization difference is between members with and without an AWV. Each dot represents the total number of ED visits a member had in 2022. Most members without an AWV in 2021 had between 0 and 6 ED visits in 2022, while that number is between 0 and 3 for members who had an AWV. To make sure this difference is statistically significant, we performed a non-parametric statistical test and found strong evidence that members with an AWV had significantly less ED visits compared to members without an AWV. To be more specific, we are 95% confident that members with an AWV would have between 25% and 38% fewer ED visits compared to members without an AWV.
One interesting observation was that there were 49% more Females than Males with 3 or more ED visits in the group of members without an AWV, and such gender disparity was not present in members with an AWV. Could it suggest females who currently have high ED utilization would benefit more from preventive services like AWVs than males? Further research and a larger data set would be needed to explore that.
Members with an AWV would have between 25% and 38% fewer ED visits compared to members without an AWV.
There appears to be a difference in ED utilization between members with and without an AWV. Let’s take it one step further and explore other factors like age, ED types, and patient risk.
The visual below shows the ED distribution by AWV and age groups. Overall, we found a significant difference in ED utilization between members with and without an AWV in all age groups. The most significant difference occurred in the age group ‘<50’. The members without an AWV group exhibited a descending trend in ED utilization as age increased, though this trend was not present in the members with an AWV group. This seemed to suggest that an AWV was more effective at reducing ED visits for younger members than for older members. Also, notice the slight bump in ED count for members with AWV in the age group ’70-79’ and ‘>=80’. This may be because older members have more age-related health issues and/or complex health needs that required ED services, regardless of if they’ve had an AWV.
The Johns Hopkins Adjusted Clinical Groups (ACG) classifies avoidable ED visits into 3 categories: Non-Emergent (NONEMERG), Emergent/Primary Care Treatable (EMERGPC), and Emergent – ED Care Needed/Potentially Avoidable (EMEDPA). Let’s take a closer look into avoidable ED visits in the visual below.
In red box #1, the dashed line in the right group is the upper quartile line, which is missing in the left group, and the left tail is significantly shorter than the right tail. Combined, they tell us that the two groups’ ED distributions are significantly different and there is a larger proportion of patients with 2 or more non-emergent ED visits in members without an AWV than members with an AWV. In box #2, the upper quartile line is still only present in the right group, but the left tail is now longer than box #1, which indicates there is still a large proportional difference between the two groups with EMERGPC ED visits, but not as significant as the NONEMERG ED visit type. Compared to box #3, where both sides now do not have upper quartile line, statistically speaking, there is no difference between members with and without an AWV for the EMEDPA ED visit type. This seems to suggest a possible trend: AWV’s effect at reducing avoidable ED visits becomes less significant as the severity of the ED visit diagnosis increases.
AWV’s effect at reducing avoidable ED visits becomes less significant as the severity of the ED visit diagnosis increases.
What about patient risk? Does higher risk lead to higher ED utilization? We used Hierarchical Condition Category (HCC) risk to explore this. We factored in members’ HCC risk by dividing their RAF Actual Risk scores into 4 quartiles: 1st quartile being the lowest HCC risk, 4th quartile being the highest HCC risk.
The findings were a bit more nuanced. In both AWV groups, there was no clear trend that higher risk correlated with higher ED utilization. For members without an AWV, the distribution appeared to be bimodal with the main peak around the 2nd quartile and a lower peak around the 4th quartile. The most significant ED count difference occurred in the 2nd and 3rd quartiles, suggesting AWVs were more effective at reducing ED utilization for patients with moderate risk compared to patients with low or high risk.
My working theory is that patients with moderate risk conditions may perceive their symptoms as urgent or concerning enough to warrant immediate medical attention. Even though their conditions may not be life-threatening, they may still feel anxious or worried about their health, leading them to seek care in the ED. For this group of patients, AWVs may contribute to a reduction in unnecessary ED visits by providing patient education on preventive measures, ways to manage their conditions, and recognizing when to seek care from their primary care provider versus the ED.
AWVs may contribute to a reduction in unnecessary ED visits by providing patient education on preventive measures, ways to manage their conditions, and recognizing when to seek care from their primary care provider versus the ED.
In conclusion, our research suggests that AWVs have the potential to reduce ED utilization among Medicare beneficiaries. The findings underscore the critical importance of preventive care in reducing unnecessary healthcare costs and improving patient outcomes. As we work toward a future of value-based care, it's imperative that we prioritize preventive services like AWVs, enhance care coordination efforts, and address social determinants of health to ensure that all patients receive timely, appropriate, and cost-effective care.
