Annual Wellness Visits (AWVs) allow an opportunity to focus on development of a disease prevention plan tailored to the member’s health and risk factors.    Yet, nationally, AWVs are conducted for only a quarter of the eligible population.

What is a busy practice to do to increase the proportion of Medicare enrollees who receive AWVs?   A compelling study Outcomes of A Virtual Practice-Tailored Medicare by Dr. Derjung Tunn from the UCLA Department of Family Medicine and colleagues have found great promise using a virtual practice-tailored approach.   In a recent Journal of the American Board of Family Medicine, they share tools and interventions that were key to increasing their AWV performance.  The tools and ideas for tailoring cover EHR-based tools, practice-based tools, and feedback reports among other areas.

In other news related to AWVs, earlier this year CMS updated its Medicare Learning Network guide to Medicare wellness visits Medicare Wellness Visits as another helpful tool to better understanding AWV requirements and gaining greater use of the AWV as a prevention and health improvement opportunity for patient care.

POs, practices, and payers have made a great deal of progress in lifting up and addressing social determinants of health (SDoH) in Michigan.  It is impressive that in many practices, SDoH screening is robust, with many also coordinating connection to community-based organizations.  As well, substantial progress has been made on adoption of the MiHIN SDoH and the Interoperable Referrals Use Cases.

It is worth noting that at a national level, there increasing interest and movement around measurement of SDOH screenings and interventions with an eye toward the use of “standardized, validated, evidence-based” tools.

It makes sense that we’re hearing more about standardization and harmonization of SDoH and social care data.  As Karen DeSilvo and Michael Leavitt of the National Alliance for Social Determinants of Health put it “Prospectively aligning measures for SDOH interventions will enable comparisons across demonstrations or programs, reduce the burden of data collection, and provide useful evidence to support a sustainable business model for addressing SDOH.”

The HEDIS Social Needs Screening and Intervention (SNS-E) measure introduced by NCQA in 2023, for example, focuses on screening and intervention the food, housing, and transportation domains.    Acceptable evidence-based screening tools for the SNS-E measure includes the following tools with documentation via LOINC codes.  There is flexibility in the SNS-E measure, as organizations can mix and match questions from several tools as long as they cover all three domains.

• Accountable Health Communities (AHC)
• AAFP Social Needs Screening Tool
• Health Leads Screening Panel®
• Hunger Vital Sign™
• Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE)
• Safe Environment for Every Kid (SEEK)
• We Care Survey
• WellRx Questionnaire
• Housing Stability Vital Signs™
• Comprehensive Universal Behavior Screen (CUBS)
• PROMIS
• USDA Food Security Survey

The 2024 proposed Physician Fee Schedule draft language includes a code and payment for SDoH assessment and mentions the AHC and PRAPARE tools as examples of evidence-based tools as well.  It also focuses on food, housing and transportation needs, as well as unreliable access to public utilities.  It specifies that: “clinicians are encouraged to utilize screening instruments where questions and responses are computable and mapped to health IT vocabulary standards (i.e., have available LOINC® coding terminology), to ensure that data captured through assessments is interoperable and can be shared, analyzed and evaluated across the care continuum.”

One thing is clear – there is a national movement by standard-setting organizations toward evidence-based, validated tools, and it is an important consideration for SDoH strategy for organizations across the state and beyond.

Every July, CMS releases the draft version of the Physician Fee Schedule, the listing of codes and requirements that Medicare uses to pay doctors and other providers.   The document is over 2,000 pages long, but we’ve taken a run at summarizing the highlights from a primary care and population health vantage point.

You may have already heard reactions from groups in the popular press about the 3.34% decrease in the conversion factor (the number of dollars assigned to a Relative Value Unit or RVU) from 2023.   However, there are several new elements in the proposed draft that offer good news for primary care and population health that you may not have heard about.   Key among them:

• An add-on code (G2211) and payment designed to capture “resource costs associated with E/M visits for primary care and longitudinal care of complex patients”.
• A new caregiver training code (9X015-17) to provide payment when practitioners train and involve caregivers to support patients with illnesses such as dementia, etc.
• Payment for SDoH Assessment (including assessment via telehealth). SDOH needs identified through the risk assessment must be documented in the medical record.  The code could also be used for assessments conducted during an annual wellness visit or other E&M visit.
  • GXXX5 — Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.
• Community Health Integration (CHI) Services via community health workers (CHWs), etc. to gain a deeper understanding of a patient’s circumstances and support their journey in navigating the health system and connection with community-based organizations to support unmet SDoH needs. CHI services would be initiated via a CHI Initiating Visit (E/M code).     CHI services could be billed monthly and the design of the code also seems similar to that of the CCM.   Cost-sharing would be applicable and advance consent is not required.
  • GXXX1 Community health integration services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month
  • GXXX2 – Community health integration services, each additional 30 minutes per calendar month
• Two codes for Principal Illness Navigation services via certified navigators to help patients navigate cancer treatment and treatment for other serious illnesses. These services are also designed to include care involving other peer support specialists, such as peer recovery coaches for individuals with substance use disorder . The design seems similar to that used for the Chronic Care Management (CCM) code.  Cost-sharing for patients is applicable, though as drafted, advance consent is not required.
  • GXXX3 Principal Illness Navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator or certified peer specialist; 60 minutes per calendar month
  • GXXX4 – Principal Illness Navigation services, additional 30 minutes per calendar month

The proposed 2024 PFS language will be finalized late this year but shows a strong start at better resourcing primary care and population health to better support and partner with patients for improved outcomes.

Read the full study here:

Milbank Memorial Fund Blog Post https://www.milbank.org/2021/01/what-makes-michigans-high-performing-primary-care-practices-work-well/

Since the advent of the patient-centered medical home and team-based care concepts, health reformers have sought to unearth the specific interventions and techniques in primary care settings that are most likely to improve patient outcomes and value.

For example, the Center for Medicare and Medicaid Services’ multipayer primary care demonstration projects, such as Comprehensive Primary Care Plus and Primary Care First, are using value-based payment and care delivery reforms to improve care quality and reduce unnecessary emergency department (ED) and inpatient utilization.

But what precisely makes a difference in primary care? To identify specific interventions or practice characteristics that are associated with high-performing practices, we leveraged the multipayer CPC+ Michigan dashboard made possible by the CPC+ participating payers (CMS, Blue Cross Blue Shield, and Priority Health) to find the practices in the top 20^th percentile of performance on both ED and inpatient utilization and conducted in-depth interviews with each. We also collected and collated insights from leading health providers groups such as Ochsner, Geisinger, Stanford, ChenMed, and Village MD.

We identified the following six themes:

1. Physician engagement drives patient and practice team engagement and promotes a practice culture that embraces adapting innovations to improve care. Physician engagement in care delivery reforms drove innovation among all of the high performers studied, regardless of setting (large or small practice; part of a health system or independent). Bay Area Family Physicians, for example, characterized “primary care physician attitude and team championing” as the pivotal factor behind their success. Similarly, at Stanford, the cofounder of the Stanford Coordinated Care model noted that staff empowerment was integral to high performance.
2. Co-located, engaged teams with care management at the core are key. The size of team does not matter. Co-located (rather than centrally housed) care management in a common space greatly improved practices’ ability to share information and coordinate team-based care. This was even more evident with full physical integration of the team in a single office space. The only exception was for transition of care outreach, defined as the contact that primary care practices make proactively to recently hospitalized patients and those who have visited emergency departments. In some of the practices and systems visited, care management and clinical teams literally bumped into each other during the course of a day given the close quarters, prompting opportunities for inter-team dialogue.At SMG Okemos, the care manager’s office space is near the checkout window by design, to maximize interaction with patients. Some practices were very successful at using instant messaging for team-based care delivery, a practice that might be useful in times of required social distancing, such as during the COVID-19 pandemic. In addition, in high-performing practices, longitudinal and episodic care management was always conducted by the practice team (instead of centrally). All high performers used daily huddles, whether scheduled or impromptu. At Alimenti Family Practice, not only are there physician/team huddles at 5:30 pm each day to prepare for the next day’s patients, but also there are twice-a-week clinical huddles with the full clinical team, and monthly all-team meetings where success is celebrated and any crises are reviewed.
3. Offloading routine tasks (e.g., medication refills, gap closures) from the primary care physician workstream frees them to focus on patient needs and championing team-based care. When practice teams “ready” the physician for a productive visit with a patient, physician satisfaction increases and so do outcomes. In high-performing practices, patient care gaps were closed prior to or during the visit by care team members. Examples of gap closure included ordering labs such as cancer screening, social determinants of health screenings, depression screenings, and medication refills. At Geisinger Health System, an “Anticipatory Management Program” is performed in advance of the visit. At Village MD, certified coders review patient charts before a visit, adding prompts in the electronic medical record to enhance accurate and complete coding.
4. Availability and responsiveness to patient needs as well as patient awareness of the availability mattered more than extended hours. Though hours outside traditional 8 am to 5 pm practice operations can be very helpful for certain patients, they are not useful if they are not consistently filled or are unable to accommodate an urgent need. More important is the patient’s ability to have quick clinical responses to their questions. At Dr. David Byrens’ practice, patient calls about clinical matters were returned by a clinician the same day, and when possible, within an hour. When patients know that they can get responses in a timely way, they can “count on the provider and practice having their back.” In all of the Michigan high-performing practices, teams went out of their way to “never turn away patients” with same-day needs.
5. Integrating performance reporting into regular team huddles or communication drives accountability for performance. Sharing provider-level performance regularly also motivated improvement among individual providers. Several practices interviewed noted that “no one wants to be at the bottom of the ranking.” At Ochsner Health, systematic and sophisticated reporting is shared regularly with teams to provide line-of-sight understanding of current metric performance. And, at our on-site practice visits, without exception, performance reporting charts could be seen in areas where team members congregated, such as the lunchroom or charting area.
6. High-performing practices had a method for identifying patients who would benefit from interventions (e.g., care management, self-management programs; remote patient monitoring; etc.) All high performers studied readily recited their “triggers” for intervention and care management. At SMG Okemos, a care manager is a part of patient visits for those with uncontrolled diabetes, chronic obstructive pulmonary disease, and congestive heart failure (CHF) patients to help identify a need for additional interventions. Alimenti Family Practice uses a complexity scoring system that considers factors such as whether the patient is age 85 or older, has uncontrolled diabetes, CHF, depression, cognitive issues, or an unmet need.Hospital discharges were also a common trigger for extra patient support. At one impressive high-performing practice, Kozmic Family Practice, a “bridging clinic” coordinated post-discharge experiences for recently hospitalized patients. In the practices and systems studied, admission, discharge, and transfer outreach calls and gap closure calls were the only two functions that, though often performed within practices, were sometimes performed centrally without compromising outcomes. Both models worked as long as they were used systematically and connected the patient to the primary care practice quickly for follow-up.

Better understanding how high-performing practices achieve success offers an opportunity to share best practices and learnings. In Michigan we are using this work to develop our capacity to achieve team-based care and provide improved experiences and outcomes for patients. We believe that these lessons can be applied around the country.