EXPERIENCE
Development and implementation of a pharmacist-delivered Medicare annual wellness visit at a family practice office Michelle Herbert Thomas and Jean-Venable “Kelly” R. Goode
Received October 28, 2013, and in revised form February 7, 2014. Accepted for publication March 10, 2014.
Abstract Objective: To describe the development and implementation of a pharmacist-delivered Medicare Annual Wellness Visit (MWV). Setting: Physician-owned, private family practice office. Practice innovation: Pharmacist-delivered MWV. Main outcome measures: Patient visits and practice income. Results: Because of time constraints in the practice, physicians, nurse practitioners, and a physician assistant had been unable to offer MWVs, a new service available to Medicare beneficiaries under the Affordable Care Act. A pharmacist who was previously providing patient care services 1 day/week at a fixed hourly rate was able to add an additional 1 day/week for provision of MWVs. These visits involve updating medical and medication histories; measuring weight, mass, and blood pressure; assessing cognitive and physical function; and screening the patient and recommending preventive services. From September 2012 to February 2013, 174 patients participated in the pharmacist-delivered MWV. Pharmacist visits were billed using codes G0438 and G0439, and the practice realized a positive net income for the MWVs. Conclusion: Pharmacist-delivered MWVs are financially viable and allow for greater pharmacist participation on the primary care team.
Michelle Herbert Thomas, PharmD, BCACP, CDE, is Clinical Pharmacist, Chickahominy Family Physicians, and Pharmacist Consultant, VHQC JeanVenable “Kelly” R. Goode, PharmD, BCPS, FAPhA, FCCP, is Professor and Director, Community Residency Program, Virginia Commonwealth University. Correspondence: Jean-Venable “Kelly” R. Goode, PharmD, BCPS, FAPhA, FCCP, Professor and Director, Community Residency Program, Virginia Commonwealth University, School of Pharmacy, PO Box 980533, Richmond, VA 23298-0533. E-mail: [email protected] Disclosure: Other than employment of Dr. Thomas by Chickahominy Family Physicians, the authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To Drs. Anup Gokli and Dennis Thomas at Chickahominy Family Physicians.
Keywords: Medicare, annual wellness visit, family practice. J Am Pharm Assoc. 2014; 54:427–434. doi: 10.1331/JAPhA.2014.13218
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The Patient Protection and Affordable Care Act of 20101 amended the Code of Federal Regulations to include provisions for increasing the focus on wellness and prevention. The Medicare Annual Wellness Visit (MWV) was one of these provisions for Personalized Prevention Plan Services. Enacted January 1, 2011, the newly covered Medicare benefit allows for a yearly visit with an emphasis on wellness.2 Two years after implementation, the service remained underused. Data released by the John A. Hartford Foundation poll of 1,028 Americans 65 years or older revealed that 68% of Medicare beneficiaries were not aware of the MWV, and only 17% reported they had received the MWV. In addition, Medicare claims data indicate that only 6.5% have had an MWV.3 Potential barriers to implementation of the MWV include lack of understanding about the benefit for both beneficiaries and physicians and physician practice unwillingness to offer or incorporate the visits because they are time consuming and disruptive to workflow. The health care reform law allows the MWV to be provided by one or more of the following health professionals: a physician who is a doctor of medicine or osteopathy; a physician assistant, nurse practitioner, or clinical nurse specialist; or a health professional (including a health educator, registered dietitian, nutrition
At a Glance
Synopsis: Helping patients focus on health and wellness through a pharmacist-delivered Medicare Annual Wellness Visit (MWV) is the focus of this Experience article. The Affordable Care Act provides for MWVs, yet the service remains underused. As described in this article, pharmacists successfully developed and delivered MWVs in a cost-justified manner within a physician-owned family practice setting. Physicians and physicianextender staff were not able to incorporate MWVs into their workload, and they were uncomfortable delegating the visits to registered and licensed practical nurses. The pharmacist proved the perfect intermediate-level professional with the knowledge and skills needed and the available time to see patients 1 day per week for MWVs. Analysis: As the pharmacy profession’s role in health care continues to evolve, more responsibilities in primary patient care services are being assumed by pharmacists. However, this growth has been inhibited by minimal cognitive service compensation by payers. MWVs present a new opportunity for pharmacists to provide a financially viable patient care service that is covered for Medicare beneficiaries through the Affordable Care Act. Pharmacists can successfully be integrated into the health care team to provide MWVs and thereby enhance the health and wellness of Medicare patients.
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professional, or other licensed practitioner, or a team of such health professionals) working under the direct supervision of a physician (i.e., in the office suite where the physician is available, if needed).4 In its consensus document for guidance on Health Risk Assessments in the Annual Wellness Visit, the Centers for Disease Control and Prevention (CDC) advocates for the use of physician extenders in the delivery of the MWV. Clinical pharmacists were specifically listed in this category.5
Objective In this article, we describe the successful development and implementation of pharmacist-delivered MWVs in a family practice setting privately owned by physicians.
Setting and background The MWV should not be confused with the Welcome to Medicare Initial Preventive Physical Examination (IPPE), which is offered during the first year of Medicare coverage.6 MWVs are available in subsequent years and are unique. The Centers for Medicare & Medicaid Services (CMS) has outlined the elements that must be included in the MWV.2 A notable difference between the MWV and the IPPE is the absence of a physical examination during the MWV. The first-time offering of the MWV is billed under a separate code and is covered only once; subsequent MWVs are covered annually thereafter. The required elements of each are listed in Table 1. The Health Risk Assessment form (Figure 1), which may be completed in writing or electronically, is the recommended method for gathering the required information. Guidelines for the content of this form are available in the CDC consensus document.5 In addition, a written, personal prevention plan must be provided to the patient at the conclusion of the visit. The experiences described in this article occurred at a family practice office in Quinton, VA; it served approximately 2,000 patients on Medicare at the time. Clinical staff comprised two physicians—one full-time and one part-time, three nurse practitioners, and one physician assistant. Ten nurses, two front desk attendants, and seven ancillary staff members also served patients at the practice. One pharmacist worked a single, 8-hour day per week. Once the MWV was incorporated into the practice, the pharmacist’s hours were extended to 16 hours per week. The practice was open 6 days per week with evening hours on 2 days.
Practice innovation When the new MWV service was proposed, the pharmacist was already integrated into the practice and providing patient care services. These included individual patient visits for disease management, with a focus on diabetes and dyslipidemia, as well as group diabetes and cardiovascular disease education programs. The Journal of the American Pharmacists Association
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Table 1. Elements of Medicare Wellness Visits (MWVs)
History
Examination
Counseling
Welcome to Medicare Initial Preventive Physical Examination (IPPE) (not billable by a pharmacist) Gather a history: Medical, surgical, and family history Medications, supplements, and allergies Lifestyle assessment (smoking status, physical activity, diet history) Review of potential risk for depression Review of functional ability, level of safety Physical examination, as appropriate, for patient Height, weight, BMI, blood pressure Visual acuity screening List of other providers, suppliers Assessment of cognitive function End-of-life planning (advance directives) Written screening schedule and recommended preventive services List of risks and recommendations Referrals to programs, as appropriate
Initial Annual Medicare Wellness Visit (billing code G0438) Gather a history: Medical, surgical, and family history Medications, supplements, and allergies Lifestyle assessment (smoking status, physical activity, diet history) Review of potential risk for depression Review of functional ability, level of safety Height, weight, BMI, blood pressure List of other providers, suppliers Assessment of cognitive function
Written screening schedule and recommended preventive services List of risks and recommendations Referrals to programs, as appropriate
physicians, nurse practitioners, and physician assistant were not offering the MWV but were being asked by patients for the service. The providers recognized it was needed, but were hesitant to commit to integration of MWVs into the schedule. Several barriers were slowing the implementation of the visits. Primarily, the providers avoided offering the service because the MWV required 30–45 minutes, and this did not fit in with the providers’ schedules. Existing patients were usually scheduled every 15 minutes. Other services that could be provided only by the physician, nurse practitioners, or physician assistant were deemed of greater importance than the MWVs. The complexity of MWVs did not warrant designation of this time slot with to the exclusion of other needed services. MWVs did not involve complex clinical tasks, yet the visits did require a level of clinical skills beyond that the providers were willing to delegate to the other nursing staff (registered or licensed practical nurses). Consequently, delegation of the activity to the part-time pharmacist was a welcome idea. Review and assessment of a patient’s medication list and immunization history were viewed as appropriate uses of the pharmacist’s expertise. Medication therapy management (MTM) services were additionally incorporated into the patient care process for a small population of patients at the practice. The providers wished to expand the availability of MTM in an economically feasible model. Cost-justification for the added 8 hours of pharmacist time each week was to include only the income from MWVs. The pharmacist continued to provide all preexJournal of the American Pharmacists Association
Subsequent Annual Medical Wellness Visit (billing code G0439) Update history: Medical, surgical, and family history Medications, supplements, and allergies Weight, BMI, blood pressure Updated list of other providers, suppliers Assessment of cognitive function Written screening schedule and recommended preventive services List of risks and recommendations Referrals to programs, as appropriate
isting services at the practice and added MWV timeslots to the schedule. For other visits, patients were checked in and brought to the examination room for a quick history gathering and vital-signs check by the nurse. The pharmacist then saw the patients in an examination room next to the physician provider. The physician provided direct oversight and spoke briefly with each patient at the conclusion of each pharmacist visit. Visits were scheduled for 30 minutes in 14 possible timeslots between 8:00 AM and 4:00 PM. The planned new service was to follow this same format, except the brief face-toface with the physician would not be required with the MWV. Implementation process Figure 2 depicts a schema of the process used to implement the MWV at the practice. This stepwise approach to implementation was followed over a 3-month planning period, as described below. The first stage of implementation included a review of all required elements of the visit and of available sample health risk assessment HRA forms. The sample form provided in the CDC consensus document served as a starting point.5 Multiple examples of HRA forms were collected from other facilities, practices, and organizations, and then reviewed for content. During the planning process, the electronic medical record (EMR) and practice policy were analyzed to determine which of the required elements of the MWV were already being collected and which would need implementation. For those needing implementation,
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HEALTH RISK ASSESMENT Name: ________________________________________________________________________________ Birthdate:________________________________________ Date:________________________________ This health risk assessment form helps us review your current health and needs. Please answer all questions on the form. During your annual wellness visit we will discuss your current health and illness prevention. This is a WELL visit. Please let us know in advance if you need to discuss new illnesses or symptoms, as this is not automatically included in the wellness visit. Yes No
Yes No
Have you had a colonoscopy in the past 10 years?
Have you had a flu vaccine this year?
Females: Have you had a mammogram this year?
Have you ever had a Zoster vaccine?
Have you had a pelvic exam in the past 2 years?
Males: Have you had a prostate screening this year?
Have you had a pneumonia vaccine since you turned 65?
Recently have you felt down, depressed, or hopeless?
Recently, have you felt little interest or pleasure in doing things?
Because of health problems, do you need the help of another person with your personal care needs?
How many times do you exercise during most WEEKS? never occasionally(1or 2) 3 times 5 times(or more) When you exercise, what level do you work at? slow moderate vigorous
(such as eating, bathing, dressing, or getting around the house)
Are you a smoker?
Have you fallen two or more times in the past year?
yes, NOT ready to quit yes, want to quit No
How would you rate your diet choices recently?
In the past four weeks did you drink alcohol?
very healthy
mostly healthy
none occasionally weekly daily
usually not healthy
do not know if it is healthy
Do you have WORKING smoke detectors in your home?
In the past year, has your weight changed? gained weight
lost weight
Yes No stayed the same
In the past year, about how many pounds have you lost or gained? ______pounds
Do you always fasten your seat belt when you are in a car? always usually sometimes never How often do you have trouble taking medicines the way you have been told to take them (as prescribed)? most always sometimes rarely do not take medicine
Figure 1. Health risk assessment form for pharmacist-provided Medicare Annual Wellness Visits
Review of MWV required elements
Identification or creation of each required element in the EMR
Provider consensus development for when interventions are needed
Patient identification and notification
Figure 2. Medicare Annual Wellness Visit implementation phases Medicare Annual Wellness Visit Electronic Medical Record
a
b
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Figure 3. Planning grid for pharmacist-provided Medicare Annual Wellness Visits Medicare Annual Wellness Visit
a
templates from the EMR were searched and analyzed for needed changes. Required elements in EMRs The first well-patient visit to the family practice for Medicare patients (IPPE) includes a physical examination conducted by the physician, nurse practitioner, or physician assistant. The data collected at this visit include an extensive review of the patient medical, surgical, and family history. Data obtained from each patient include a current medication list, drug allergy experience, and a list of preferred pharmacy, providers, and medical supply sources. This information is maintained in the EMR. At each visit, patients are asked by the nurse assistants whether there are any changes or needed updates to this information. Nurses also routinely collect vital signs at the initiation of every visit. Finally, colonoscopy history is recorded and checked at each visit. Some required elements for the MWV were not a routine part of patient visits and were addressed only as needed. These included a medication history and assessments of functional ability, cognitive function, and the potential for depression. A review of immunization needs and a history of health screenings other than colonoscopies were also performed inconsistently, rather than at set intervals. An HRA form was customized to incorporate each of the missing patient data elements for the visit. As a time-saving measure, the HRA form was developed for patients to complete at home and bring to the visit or Journal of the American Pharmacists Association
complete in the waiting area before the visit. A history of present illness template was also designed in the EMR to mirror the contents of the form. When the patient-stated reason for the visit was HRA/MWV, the nurse assistant could check the appropriate box on the EMR to trigger a pop-up screen. The EMR template enabled the nurse to quickly record the results of the patient-completed HRA form by checking prefilled boxes. The final HRA form (Figure 1) offered an initial brief screening for each problem and streamlined the patient interview process. The form provided quick assessments for depression, functional ability, recommended standard immunizations, health screenings, and lifestyle issues. More in-depth assessments were conducted by the pharmacist in the areas identified on the HRA form. The medication review is required as part of the MWV, and the expertise of a pharmacist enhances the quality of this task. Pharmacists possess the unique skill of performing integrated MTM, which is essential to wellness and a key element frequently missing from the primary care office setting. MTM is the process of comprehensively reviewing a patient’s medication therapy regimen. A consensus document by 11 national pharmacy organizations defined five core elements of MTM as follows7: medication therapy review (MTR), development of a personal medication record (PMR), development of a medication-related action plan (MAP), intervention and referral by the MTM provider, and documentation and follow-up. j apha.org
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The MWV does not designate MTM as part of the visit; however, the core elements of MTM were incorporated into the wellness visit at this physician office practice. Each of the five elements of MTM were implemented as follows: 1. MTR. Patients were instructed to bring all of their medications or a list of their medications to the visit. Before implementation of the MWV, office staff did not consistently record use of nonprescription medications, herbal products, and other dietary supplements. The MWV included an update of this list and a review of refill request dates. This allowed for assessment and discussion of medication adherence and persistence with the patient. 2. PMR. A listing of medications, patient allergies, and any medication-related concerns were included in the printed personal prevention plan required as part of the MWV. report. 3. MAP. Action steps for the patient, designed from the medication review, were also included in the personal prevention plan. This listing of patient recommendations was excerpted from the “plan” section of the EMR. 4. Intervention/referral. A template for recording a history of medication-related issues was added to the EMR to allow for recording, planning for resolution, and follow-up on medication-related issues. This information was incorporated into the chart notes and the personal prevention plan; it was sent to the provider immediately after the visit. 5. Documentation and follow-up. These steps were already addressed in the structure of existing visits; no changes were required to allow for completion of this element of MTM. Provider consensus development Upon successful identification of all required elements of the MWV, a protocol was developed using a stepwise consensus-building process. The list of required elements for the MWV was matched with a list of available screening tools. The pharmacist and providers selected screening tools and methods for interpretation of results. An additional evaluation was conducted to determine action steps after completion of the tools. A planning grid (Figure 3) was created and distributed to the providers.8 The grid listed all screening tools with suggested action steps for each result. Providers identified preferred action steps, and preferred referral sites and specialists. The responses were compiled and a template developed for patient intervention and personal prevention plan development. The existing EMR at the practice contained a predesigned template, which aided in administering and scoring the geriatric depression scale short form.9 This tool was selected for use after a two-question screening (found on the HRA form) and brief probing for potential 432 JAPhA | 5 4:4 | JUL /AUG 2 0 1 4
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depression issues. The cognitive function assessment selected by the practice was the Mini-Cog.10 This assessment, along with a practice-selected set of questions regarding functional ability (found on the HRA form), was added to the EMR template. The printable personal prevention plan report was incorporated into the EMR so it could be given to the patient at the conclusion of the visit.The template for preparation of the report included selected phrases to address each of the planned MWV and MTM components. This matrix included the options preferred by the participating providers. After the process was vetted with all providers and approved, all the practice staff were notified of the new service. All staff at the practice were trained on their role in the visit. Feedback was elicited from all members of the team before rollout of the program. Billing staff were consulted regarding process, billing tickets, and coverage of additional services, such as immunizations, which could arise. Patient identification and notification The final implementation step for MWVs was to identify eligible patients and invite them to participate. A search of the EMR was conducted to exclude patients younger than 66 years. This excluded patients up to and including the first year of Medicare coverage. While an IPPE is not required for coverage of the MWV, patients must wait 1 year before the MWV is available as a covered benefit. The EMR search also excluded any patient who may have had the wellness exam billed in the previous year under the billing codes G0438 (initial MWV) or G0439 (subsequent MWV). A draft letter was sent to the providers for approval. Letters of invitation and explanation of the new service were sent to patients in batches of 150–200 each month for 1 year. This provided for a steady stream of patients for the visits while avoiding an overfilled schedule. During the first 6 months, the letters were edited, as needed, to improve clarity. The practice site support staff were essential in gathering feedback from patients. Design of service One of the 2 days of the pharmacist’s weekly schedule was designated for MWVs. A reminder telephone call was placed to each patient the day before the visit. A $25 visit cancellation fee was enforced if patients did not notify the office 24 hours in advance, which resulted in a very low no-show rate. This article does not report on the rate of no-shows or the income from the associated cancellation fee. Visits were conducted in an examination room designated for the pharmacist. The nurse check-in step required 3–5 minutes, including collection and recording of the HRA form responses in the EMR. Upon visit com-
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Table 2. Cost of development and delivery of Medicare Annual Wellness Visit Expenses One-time initial start-up expenses Ongoing expenses
Personnel Pharmacist time (40 hours)a Pharmacist time (30–45 min/visit) Nurse time (3–5 min/visit) Provider time (5–10 min/visit)
Nonpersonnel Mailing supplies (2,000 patient letters with HRAb forms) Facility overhead expenses
a Electronic medical record (EMR) template development and integration steps were completed by the pharmacist. This time was included in the pharmacist start-up hours listed above. Due to the ease of use of the Nextgen EMR system and expertise of the pharmacist, a computer programmer was not needed. b Health risk assessment
pletion, patients were placed on the reschedule calendar for the next visit in 1 year. Visit EMR notes were sent to the patient’s primary provider for review and cosignature upon completion. Billing of the visit was completed using the Medicare codes G0438 for the initial wellness visit and G0439 for subsequent years under the cosigning provider. No particular diagnosis code is required for the visit, but the field on the billing form must be filled in. A code of V0.70 (routine examination without symptoms) was used to populate the field.
Results The pharmacist-delivered MWV service began in September 2012. More than 2,000 patients were identified as eligible. From September 2012 to February 2013, 174 patients participated in the pharmacist-delivered MWVs. The practice income exclusively from these wellness visits during the 6 months was $27,880.98. This figure is the actual reconciled monetary payment amount for MWVs identified by searching the integrated billing system for pharmacist visits with billing codes G0438 and G0439. All but one of the visits were for the initial MWV. Other visit types were conducted and billed using incident-to coding but are not included in this calculation. The pharmacist hours designated specifically for development and delivery of the wellness visits during the first 6 months totaled 20 full days, or 160 pharmacist– hours. The pharmacist was employed by the practice with a fixed hourly salary. Table 2 outlines the cost considerations included in the financial evaluation of visit revenue. Each initial MWV was Medicare-covered at a rate of $163.51. The practice determined that the revenue generated by the pharmacist-delivered MWV was financially viable, generating a profit margin for the practice.
Discussion This is the second report of pharmacist-delivered MWVs.11 The previous article summarizes the clinical outcomes of MWVs. Services were delivered in a similar manner; however, the focus on MTM was not emphasized. Another difference was the length of the MWV at 30–45 minutes, instead of a mean of 73 minutes for the AWV in the previous report. Time savings could be achieved through use of a streamlined EMR, ready
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availability of data from the IPPE, and completion of the HRA form in advance of the visit. In the absence of recognition as a provider, pharmacists in a family practice must bill the MWV through another provider who cosigns for the visit. This limits the viability of offering the service independently. Future studies could evaluate models that incorporate community pharmacists in this team approach to preventive services and integrating Medicare part D MTM services into the mix. Pharmacists offer a unique contribution to primary care and can use the MWV to cost-justify their time. Research on medication reviews by physicians in primary care reveal that a sequential discussion of each medication the patient is taking occurs in 32% of visits.12 Pharmacist participation in MWVs can increase medication reviews in primary care practice. Other practitioners may be qualified to deliver the service, but pharmacists can enhance attention to medication-related problems, expand the scope of the primary care team, and increase the extremely low level of MWV delivery across the country.
Conclusion With appropriate planning and protocol development, the MWV can be successfully implemented and conducted by a pharmacist in a busy private family practice. The MWV allows for pharmacist participation on the primary care team with financial sustainability. References 1. Patient Protection and Affordable Care Act of 2010. Pub. L. No. 111–148, 124 Stat 119, (March 23, 2010). 2. Quick reference information: the ABCs of providing the annual wellness visit (AWV). www.cms.gov/Outreach‐and‐Education/ Medicare‐Learning‐Network‐MLN/MLNProducts/downloads/ AWV_chart_ICN905706.pdf. Accessed January 21, 2014. 3. Beilenson J, Walker E. National poll: low cost, lifesaving services missing from most older patient’s health care (news release). April 24, 2012. www.jhartfound.org/image/uploads/resources/120420_JAHF_poll_release_FINAL.pdf. Accessed January 21, 2014. 4. Medicare Benefit Policy Manual: Pub 100-02 Chapter 15 section 42CFR 410.32(b)(3)(ii). www.cms.gov/Regulations‐and‐ Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 21, 2014. 5. Goetzel RZ, Staley P, Ogden L, et al. A framework for patientcentered health risk assessments: providing health promotion j apha.org
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and disease prevention services to Medicare beneficiaries. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. www.cdc. gov/policy/ohsc/hra/FrameworkForHRA.pdf. Accessed January 21, 2014. 6. Quick reference information: the ABCs of providing the initial preventive physical examination (IPPE). www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/downloads//MPS_QRI_IPPE001a.pdf. Accessed January 21, 2014. 7. American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (Version 2.0). J Am Pharm Assoc. 2008;48:341– 353.
9. Almeida OP, Almeida SA. Short versions of the geriatric depression scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry. 1999;14(10):858–865. 10. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–1454. 11. Warshany K, Sherrill CH, Cavanaugh J, et al. Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic. Am J Health-Syst Pharm. 2014;71:44–49. 12. Tam DM, Paterniti DA, Kravits RL, et al. How do physicians conduct medication reviews? J Gen Intern Med. 2009;24(12):1296– 1302.
8. Beauchet O, Fantino B, Allali G, et al. Timed Up and Go test and risk of falls in older adults: a systematic review. J Nutr Health Aging. 2011;15:933–938.
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San Francisco, CA
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Alan P. Chan
Journal of the American Pharmacists Association
Development and implementation of a pharmacist-delivered Medicare annual wellness visit at a family practice office Michelle Herbert Thomas and Jean-Venable “Kelly” R. Goode
Received October 28, 2013, and in revised form February 7, 2014. Accepted for publication March 10, 2014.
Abstract Objective: To describe the development and implementation of a pharmacist-delivered Medicare Annual Wellness Visit (MWV). Setting: Physician-owned, private family practice office. Practice innovation: Pharmacist-delivered MWV. Main outcome measures: Patient visits and practice income. Results: Because of time constraints in the practice, physicians, nurse practitioners, and a physician assistant had been unable to offer MWVs, a new service available to Medicare beneficiaries under the Affordable Care Act. A pharmacist who was previously providing patient care services 1 day/week at a fixed hourly rate was able to add an additional 1 day/week for provision of MWVs. These visits involve updating medical and medication histories; measuring weight, mass, and blood pressure; assessing cognitive and physical function; and screening the patient and recommending preventive services. From September 2012 to February 2013, 174 patients participated in the pharmacist-delivered MWV. Pharmacist visits were billed using codes G0438 and G0439, and the practice realized a positive net income for the MWVs. Conclusion: Pharmacist-delivered MWVs are financially viable and allow for greater pharmacist participation on the primary care team.
Michelle Herbert Thomas, PharmD, BCACP, CDE, is Clinical Pharmacist, Chickahominy Family Physicians, and Pharmacist Consultant, VHQC JeanVenable “Kelly” R. Goode, PharmD, BCPS, FAPhA, FCCP, is Professor and Director, Community Residency Program, Virginia Commonwealth University. Correspondence: Jean-Venable “Kelly” R. Goode, PharmD, BCPS, FAPhA, FCCP, Professor and Director, Community Residency Program, Virginia Commonwealth University, School of Pharmacy, PO Box 980533, Richmond, VA 23298-0533. E-mail: [email protected] Disclosure: Other than employment of Dr. Thomas by Chickahominy Family Physicians, the authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To Drs. Anup Gokli and Dennis Thomas at Chickahominy Family Physicians.
Keywords: Medicare, annual wellness visit, family practice. J Am Pharm Assoc. 2014; 54:427–434. doi: 10.1331/JAPhA.2014.13218
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The Patient Protection and Affordable Care Act of 20101 amended the Code of Federal Regulations to include provisions for increasing the focus on wellness and prevention. The Medicare Annual Wellness Visit (MWV) was one of these provisions for Personalized Prevention Plan Services. Enacted January 1, 2011, the newly covered Medicare benefit allows for a yearly visit with an emphasis on wellness.2 Two years after implementation, the service remained underused. Data released by the John A. Hartford Foundation poll of 1,028 Americans 65 years or older revealed that 68% of Medicare beneficiaries were not aware of the MWV, and only 17% reported they had received the MWV. In addition, Medicare claims data indicate that only 6.5% have had an MWV.3 Potential barriers to implementation of the MWV include lack of understanding about the benefit for both beneficiaries and physicians and physician practice unwillingness to offer or incorporate the visits because they are time consuming and disruptive to workflow. The health care reform law allows the MWV to be provided by one or more of the following health professionals: a physician who is a doctor of medicine or osteopathy; a physician assistant, nurse practitioner, or clinical nurse specialist; or a health professional (including a health educator, registered dietitian, nutrition
At a Glance
Synopsis: Helping patients focus on health and wellness through a pharmacist-delivered Medicare Annual Wellness Visit (MWV) is the focus of this Experience article. The Affordable Care Act provides for MWVs, yet the service remains underused. As described in this article, pharmacists successfully developed and delivered MWVs in a cost-justified manner within a physician-owned family practice setting. Physicians and physicianextender staff were not able to incorporate MWVs into their workload, and they were uncomfortable delegating the visits to registered and licensed practical nurses. The pharmacist proved the perfect intermediate-level professional with the knowledge and skills needed and the available time to see patients 1 day per week for MWVs. Analysis: As the pharmacy profession’s role in health care continues to evolve, more responsibilities in primary patient care services are being assumed by pharmacists. However, this growth has been inhibited by minimal cognitive service compensation by payers. MWVs present a new opportunity for pharmacists to provide a financially viable patient care service that is covered for Medicare beneficiaries through the Affordable Care Act. Pharmacists can successfully be integrated into the health care team to provide MWVs and thereby enhance the health and wellness of Medicare patients.
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professional, or other licensed practitioner, or a team of such health professionals) working under the direct supervision of a physician (i.e., in the office suite where the physician is available, if needed).4 In its consensus document for guidance on Health Risk Assessments in the Annual Wellness Visit, the Centers for Disease Control and Prevention (CDC) advocates for the use of physician extenders in the delivery of the MWV. Clinical pharmacists were specifically listed in this category.5
Objective In this article, we describe the successful development and implementation of pharmacist-delivered MWVs in a family practice setting privately owned by physicians.
Setting and background The MWV should not be confused with the Welcome to Medicare Initial Preventive Physical Examination (IPPE), which is offered during the first year of Medicare coverage.6 MWVs are available in subsequent years and are unique. The Centers for Medicare & Medicaid Services (CMS) has outlined the elements that must be included in the MWV.2 A notable difference between the MWV and the IPPE is the absence of a physical examination during the MWV. The first-time offering of the MWV is billed under a separate code and is covered only once; subsequent MWVs are covered annually thereafter. The required elements of each are listed in Table 1. The Health Risk Assessment form (Figure 1), which may be completed in writing or electronically, is the recommended method for gathering the required information. Guidelines for the content of this form are available in the CDC consensus document.5 In addition, a written, personal prevention plan must be provided to the patient at the conclusion of the visit. The experiences described in this article occurred at a family practice office in Quinton, VA; it served approximately 2,000 patients on Medicare at the time. Clinical staff comprised two physicians—one full-time and one part-time, three nurse practitioners, and one physician assistant. Ten nurses, two front desk attendants, and seven ancillary staff members also served patients at the practice. One pharmacist worked a single, 8-hour day per week. Once the MWV was incorporated into the practice, the pharmacist’s hours were extended to 16 hours per week. The practice was open 6 days per week with evening hours on 2 days.
Practice innovation When the new MWV service was proposed, the pharmacist was already integrated into the practice and providing patient care services. These included individual patient visits for disease management, with a focus on diabetes and dyslipidemia, as well as group diabetes and cardiovascular disease education programs. The Journal of the American Pharmacists Association
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Table 1. Elements of Medicare Wellness Visits (MWVs)
History
Examination
Counseling
Welcome to Medicare Initial Preventive Physical Examination (IPPE) (not billable by a pharmacist) Gather a history: Medical, surgical, and family history Medications, supplements, and allergies Lifestyle assessment (smoking status, physical activity, diet history) Review of potential risk for depression Review of functional ability, level of safety Physical examination, as appropriate, for patient Height, weight, BMI, blood pressure Visual acuity screening List of other providers, suppliers Assessment of cognitive function End-of-life planning (advance directives) Written screening schedule and recommended preventive services List of risks and recommendations Referrals to programs, as appropriate
Initial Annual Medicare Wellness Visit (billing code G0438) Gather a history: Medical, surgical, and family history Medications, supplements, and allergies Lifestyle assessment (smoking status, physical activity, diet history) Review of potential risk for depression Review of functional ability, level of safety Height, weight, BMI, blood pressure List of other providers, suppliers Assessment of cognitive function
Written screening schedule and recommended preventive services List of risks and recommendations Referrals to programs, as appropriate
physicians, nurse practitioners, and physician assistant were not offering the MWV but were being asked by patients for the service. The providers recognized it was needed, but were hesitant to commit to integration of MWVs into the schedule. Several barriers were slowing the implementation of the visits. Primarily, the providers avoided offering the service because the MWV required 30–45 minutes, and this did not fit in with the providers’ schedules. Existing patients were usually scheduled every 15 minutes. Other services that could be provided only by the physician, nurse practitioners, or physician assistant were deemed of greater importance than the MWVs. The complexity of MWVs did not warrant designation of this time slot with to the exclusion of other needed services. MWVs did not involve complex clinical tasks, yet the visits did require a level of clinical skills beyond that the providers were willing to delegate to the other nursing staff (registered or licensed practical nurses). Consequently, delegation of the activity to the part-time pharmacist was a welcome idea. Review and assessment of a patient’s medication list and immunization history were viewed as appropriate uses of the pharmacist’s expertise. Medication therapy management (MTM) services were additionally incorporated into the patient care process for a small population of patients at the practice. The providers wished to expand the availability of MTM in an economically feasible model. Cost-justification for the added 8 hours of pharmacist time each week was to include only the income from MWVs. The pharmacist continued to provide all preexJournal of the American Pharmacists Association
Subsequent Annual Medical Wellness Visit (billing code G0439) Update history: Medical, surgical, and family history Medications, supplements, and allergies Weight, BMI, blood pressure Updated list of other providers, suppliers Assessment of cognitive function Written screening schedule and recommended preventive services List of risks and recommendations Referrals to programs, as appropriate
isting services at the practice and added MWV timeslots to the schedule. For other visits, patients were checked in and brought to the examination room for a quick history gathering and vital-signs check by the nurse. The pharmacist then saw the patients in an examination room next to the physician provider. The physician provided direct oversight and spoke briefly with each patient at the conclusion of each pharmacist visit. Visits were scheduled for 30 minutes in 14 possible timeslots between 8:00 AM and 4:00 PM. The planned new service was to follow this same format, except the brief face-toface with the physician would not be required with the MWV. Implementation process Figure 2 depicts a schema of the process used to implement the MWV at the practice. This stepwise approach to implementation was followed over a 3-month planning period, as described below. The first stage of implementation included a review of all required elements of the visit and of available sample health risk assessment HRA forms. The sample form provided in the CDC consensus document served as a starting point.5 Multiple examples of HRA forms were collected from other facilities, practices, and organizations, and then reviewed for content. During the planning process, the electronic medical record (EMR) and practice policy were analyzed to determine which of the required elements of the MWV were already being collected and which would need implementation. For those needing implementation,
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HEALTH RISK ASSESMENT Name: ________________________________________________________________________________ Birthdate:________________________________________ Date:________________________________ This health risk assessment form helps us review your current health and needs. Please answer all questions on the form. During your annual wellness visit we will discuss your current health and illness prevention. This is a WELL visit. Please let us know in advance if you need to discuss new illnesses or symptoms, as this is not automatically included in the wellness visit. Yes No
Yes No
Have you had a colonoscopy in the past 10 years?
Have you had a flu vaccine this year?
Females: Have you had a mammogram this year?
Have you ever had a Zoster vaccine?
Have you had a pelvic exam in the past 2 years?
Males: Have you had a prostate screening this year?
Have you had a pneumonia vaccine since you turned 65?
Recently have you felt down, depressed, or hopeless?
Recently, have you felt little interest or pleasure in doing things?
Because of health problems, do you need the help of another person with your personal care needs?
How many times do you exercise during most WEEKS? never occasionally(1or 2) 3 times 5 times(or more) When you exercise, what level do you work at? slow moderate vigorous
(such as eating, bathing, dressing, or getting around the house)
Are you a smoker?
Have you fallen two or more times in the past year?
yes, NOT ready to quit yes, want to quit No
How would you rate your diet choices recently?
In the past four weeks did you drink alcohol?
very healthy
mostly healthy
none occasionally weekly daily
usually not healthy
do not know if it is healthy
Do you have WORKING smoke detectors in your home?
In the past year, has your weight changed? gained weight
lost weight
Yes No stayed the same
In the past year, about how many pounds have you lost or gained? ______pounds
Do you always fasten your seat belt when you are in a car? always usually sometimes never How often do you have trouble taking medicines the way you have been told to take them (as prescribed)? most always sometimes rarely do not take medicine
Figure 1. Health risk assessment form for pharmacist-provided Medicare Annual Wellness Visits
Review of MWV required elements
Identification or creation of each required element in the EMR
Provider consensus development for when interventions are needed
Patient identification and notification
Figure 2. Medicare Annual Wellness Visit implementation phases Medicare Annual Wellness Visit Electronic Medical Record
a
b
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Figure 3. Planning grid for pharmacist-provided Medicare Annual Wellness Visits Medicare Annual Wellness Visit
a
templates from the EMR were searched and analyzed for needed changes. Required elements in EMRs The first well-patient visit to the family practice for Medicare patients (IPPE) includes a physical examination conducted by the physician, nurse practitioner, or physician assistant. The data collected at this visit include an extensive review of the patient medical, surgical, and family history. Data obtained from each patient include a current medication list, drug allergy experience, and a list of preferred pharmacy, providers, and medical supply sources. This information is maintained in the EMR. At each visit, patients are asked by the nurse assistants whether there are any changes or needed updates to this information. Nurses also routinely collect vital signs at the initiation of every visit. Finally, colonoscopy history is recorded and checked at each visit. Some required elements for the MWV were not a routine part of patient visits and were addressed only as needed. These included a medication history and assessments of functional ability, cognitive function, and the potential for depression. A review of immunization needs and a history of health screenings other than colonoscopies were also performed inconsistently, rather than at set intervals. An HRA form was customized to incorporate each of the missing patient data elements for the visit. As a time-saving measure, the HRA form was developed for patients to complete at home and bring to the visit or Journal of the American Pharmacists Association
complete in the waiting area before the visit. A history of present illness template was also designed in the EMR to mirror the contents of the form. When the patient-stated reason for the visit was HRA/MWV, the nurse assistant could check the appropriate box on the EMR to trigger a pop-up screen. The EMR template enabled the nurse to quickly record the results of the patient-completed HRA form by checking prefilled boxes. The final HRA form (Figure 1) offered an initial brief screening for each problem and streamlined the patient interview process. The form provided quick assessments for depression, functional ability, recommended standard immunizations, health screenings, and lifestyle issues. More in-depth assessments were conducted by the pharmacist in the areas identified on the HRA form. The medication review is required as part of the MWV, and the expertise of a pharmacist enhances the quality of this task. Pharmacists possess the unique skill of performing integrated MTM, which is essential to wellness and a key element frequently missing from the primary care office setting. MTM is the process of comprehensively reviewing a patient’s medication therapy regimen. A consensus document by 11 national pharmacy organizations defined five core elements of MTM as follows7: medication therapy review (MTR), development of a personal medication record (PMR), development of a medication-related action plan (MAP), intervention and referral by the MTM provider, and documentation and follow-up. j apha.org
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The MWV does not designate MTM as part of the visit; however, the core elements of MTM were incorporated into the wellness visit at this physician office practice. Each of the five elements of MTM were implemented as follows: 1. MTR. Patients were instructed to bring all of their medications or a list of their medications to the visit. Before implementation of the MWV, office staff did not consistently record use of nonprescription medications, herbal products, and other dietary supplements. The MWV included an update of this list and a review of refill request dates. This allowed for assessment and discussion of medication adherence and persistence with the patient. 2. PMR. A listing of medications, patient allergies, and any medication-related concerns were included in the printed personal prevention plan required as part of the MWV. report. 3. MAP. Action steps for the patient, designed from the medication review, were also included in the personal prevention plan. This listing of patient recommendations was excerpted from the “plan” section of the EMR. 4. Intervention/referral. A template for recording a history of medication-related issues was added to the EMR to allow for recording, planning for resolution, and follow-up on medication-related issues. This information was incorporated into the chart notes and the personal prevention plan; it was sent to the provider immediately after the visit. 5. Documentation and follow-up. These steps were already addressed in the structure of existing visits; no changes were required to allow for completion of this element of MTM. Provider consensus development Upon successful identification of all required elements of the MWV, a protocol was developed using a stepwise consensus-building process. The list of required elements for the MWV was matched with a list of available screening tools. The pharmacist and providers selected screening tools and methods for interpretation of results. An additional evaluation was conducted to determine action steps after completion of the tools. A planning grid (Figure 3) was created and distributed to the providers.8 The grid listed all screening tools with suggested action steps for each result. Providers identified preferred action steps, and preferred referral sites and specialists. The responses were compiled and a template developed for patient intervention and personal prevention plan development. The existing EMR at the practice contained a predesigned template, which aided in administering and scoring the geriatric depression scale short form.9 This tool was selected for use after a two-question screening (found on the HRA form) and brief probing for potential 432 JAPhA | 5 4:4 | JUL /AUG 2 0 1 4
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depression issues. The cognitive function assessment selected by the practice was the Mini-Cog.10 This assessment, along with a practice-selected set of questions regarding functional ability (found on the HRA form), was added to the EMR template. The printable personal prevention plan report was incorporated into the EMR so it could be given to the patient at the conclusion of the visit.The template for preparation of the report included selected phrases to address each of the planned MWV and MTM components. This matrix included the options preferred by the participating providers. After the process was vetted with all providers and approved, all the practice staff were notified of the new service. All staff at the practice were trained on their role in the visit. Feedback was elicited from all members of the team before rollout of the program. Billing staff were consulted regarding process, billing tickets, and coverage of additional services, such as immunizations, which could arise. Patient identification and notification The final implementation step for MWVs was to identify eligible patients and invite them to participate. A search of the EMR was conducted to exclude patients younger than 66 years. This excluded patients up to and including the first year of Medicare coverage. While an IPPE is not required for coverage of the MWV, patients must wait 1 year before the MWV is available as a covered benefit. The EMR search also excluded any patient who may have had the wellness exam billed in the previous year under the billing codes G0438 (initial MWV) or G0439 (subsequent MWV). A draft letter was sent to the providers for approval. Letters of invitation and explanation of the new service were sent to patients in batches of 150–200 each month for 1 year. This provided for a steady stream of patients for the visits while avoiding an overfilled schedule. During the first 6 months, the letters were edited, as needed, to improve clarity. The practice site support staff were essential in gathering feedback from patients. Design of service One of the 2 days of the pharmacist’s weekly schedule was designated for MWVs. A reminder telephone call was placed to each patient the day before the visit. A $25 visit cancellation fee was enforced if patients did not notify the office 24 hours in advance, which resulted in a very low no-show rate. This article does not report on the rate of no-shows or the income from the associated cancellation fee. Visits were conducted in an examination room designated for the pharmacist. The nurse check-in step required 3–5 minutes, including collection and recording of the HRA form responses in the EMR. Upon visit com-
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Table 2. Cost of development and delivery of Medicare Annual Wellness Visit Expenses One-time initial start-up expenses Ongoing expenses
Personnel Pharmacist time (40 hours)a Pharmacist time (30–45 min/visit) Nurse time (3–5 min/visit) Provider time (5–10 min/visit)
Nonpersonnel Mailing supplies (2,000 patient letters with HRAb forms) Facility overhead expenses
a Electronic medical record (EMR) template development and integration steps were completed by the pharmacist. This time was included in the pharmacist start-up hours listed above. Due to the ease of use of the Nextgen EMR system and expertise of the pharmacist, a computer programmer was not needed. b Health risk assessment
pletion, patients were placed on the reschedule calendar for the next visit in 1 year. Visit EMR notes were sent to the patient’s primary provider for review and cosignature upon completion. Billing of the visit was completed using the Medicare codes G0438 for the initial wellness visit and G0439 for subsequent years under the cosigning provider. No particular diagnosis code is required for the visit, but the field on the billing form must be filled in. A code of V0.70 (routine examination without symptoms) was used to populate the field.
Results The pharmacist-delivered MWV service began in September 2012. More than 2,000 patients were identified as eligible. From September 2012 to February 2013, 174 patients participated in the pharmacist-delivered MWVs. The practice income exclusively from these wellness visits during the 6 months was $27,880.98. This figure is the actual reconciled monetary payment amount for MWVs identified by searching the integrated billing system for pharmacist visits with billing codes G0438 and G0439. All but one of the visits were for the initial MWV. Other visit types were conducted and billed using incident-to coding but are not included in this calculation. The pharmacist hours designated specifically for development and delivery of the wellness visits during the first 6 months totaled 20 full days, or 160 pharmacist– hours. The pharmacist was employed by the practice with a fixed hourly salary. Table 2 outlines the cost considerations included in the financial evaluation of visit revenue. Each initial MWV was Medicare-covered at a rate of $163.51. The practice determined that the revenue generated by the pharmacist-delivered MWV was financially viable, generating a profit margin for the practice.
Discussion This is the second report of pharmacist-delivered MWVs.11 The previous article summarizes the clinical outcomes of MWVs. Services were delivered in a similar manner; however, the focus on MTM was not emphasized. Another difference was the length of the MWV at 30–45 minutes, instead of a mean of 73 minutes for the AWV in the previous report. Time savings could be achieved through use of a streamlined EMR, ready
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availability of data from the IPPE, and completion of the HRA form in advance of the visit. In the absence of recognition as a provider, pharmacists in a family practice must bill the MWV through another provider who cosigns for the visit. This limits the viability of offering the service independently. Future studies could evaluate models that incorporate community pharmacists in this team approach to preventive services and integrating Medicare part D MTM services into the mix. Pharmacists offer a unique contribution to primary care and can use the MWV to cost-justify their time. Research on medication reviews by physicians in primary care reveal that a sequential discussion of each medication the patient is taking occurs in 32% of visits.12 Pharmacist participation in MWVs can increase medication reviews in primary care practice. Other practitioners may be qualified to deliver the service, but pharmacists can enhance attention to medication-related problems, expand the scope of the primary care team, and increase the extremely low level of MWV delivery across the country.
Conclusion With appropriate planning and protocol development, the MWV can be successfully implemented and conducted by a pharmacist in a busy private family practice. The MWV allows for pharmacist participation on the primary care team with financial sustainability. References 1. Patient Protection and Affordable Care Act of 2010. Pub. L. No. 111–148, 124 Stat 119, (March 23, 2010). 2. Quick reference information: the ABCs of providing the annual wellness visit (AWV). www.cms.gov/Outreach‐and‐Education/ Medicare‐Learning‐Network‐MLN/MLNProducts/downloads/ AWV_chart_ICN905706.pdf. Accessed January 21, 2014. 3. Beilenson J, Walker E. National poll: low cost, lifesaving services missing from most older patient’s health care (news release). April 24, 2012. www.jhartfound.org/image/uploads/resources/120420_JAHF_poll_release_FINAL.pdf. Accessed January 21, 2014. 4. Medicare Benefit Policy Manual: Pub 100-02 Chapter 15 section 42CFR 410.32(b)(3)(ii). www.cms.gov/Regulations‐and‐ Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 21, 2014. 5. Goetzel RZ, Staley P, Ogden L, et al. A framework for patientcentered health risk assessments: providing health promotion j apha.org
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and disease prevention services to Medicare beneficiaries. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. www.cdc. gov/policy/ohsc/hra/FrameworkForHRA.pdf. Accessed January 21, 2014. 6. Quick reference information: the ABCs of providing the initial preventive physical examination (IPPE). www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/downloads//MPS_QRI_IPPE001a.pdf. Accessed January 21, 2014. 7. American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (Version 2.0). J Am Pharm Assoc. 2008;48:341– 353.
9. Almeida OP, Almeida SA. Short versions of the geriatric depression scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry. 1999;14(10):858–865. 10. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–1454. 11. Warshany K, Sherrill CH, Cavanaugh J, et al. Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic. Am J Health-Syst Pharm. 2014;71:44–49. 12. Tam DM, Paterniti DA, Kravits RL, et al. How do physicians conduct medication reviews? J Gen Intern Med. 2009;24(12):1296– 1302.
8. Beauchet O, Fantino B, Allali G, et al. Timed Up and Go test and risk of falls in older adults: a systematic review. J Nutr Health Aging. 2011;15:933–938.
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