- Email: [email protected]
Use of Welcome to Medicare Visits Among Older Adults Following the Affordable Care Act
RESEARCH ARTICLE
Use of Welcome to Medicare Visits Among Older Adults Following the Affordable Care Act Arpit Misra, PhD, MA, Jennifer T. Lloyd, PhD, MA, MS, Larisa M. Strawbridge, MPH, Suzanne G. Wensky, PhD, This activity is available for CME credit. See page A4 for information.
Introduction: To encourage greater utilization of preventive services among Medicare beneficiaries, the 2010 Affordable Care Act waived coinsurance for the Welcome to Medicare visit, making this benefit free starting in 2011. The objective of this study was to determine the impact of the Affordable Care Act on Welcome to Medicare visit utilization. Methods: A 5% sample of newly enrolled fee-for-service Medicare beneficiaries for 2005–2016 was used to estimate changes in Welcome to Medicare visit use over time. An interrupted time series model examined whether Welcome to Medicare visits increased significantly after 2011, controlling for pre-intervention trends and other autocorrelation. Results: Annual Welcome to Medicare visit rates began at 1.4% in 2005 and increased to 12.3% by 2016. The quarterly Welcome to Medicare visit rate, which was almost 1% at baseline, was increasing by 0.06% before the 2011 Affordable Care Act provision (po0.001). Immediately following the 2011 Affordable Care Act provision, the rate increased by about 1% in the first quarter of 2011 (intercept, po0.001), followed by an increase of 0.13% every subsequent quarter (slope, po0.001). This general trend was observed in subgroup analyses, although this trend varied by subgroups where the pre−Affordable Care Act trends of lower utilization persisted over time for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance. Conclusions: The Affordable Care Act, and perhaps the removal of cost sharing, was associated with increased use of the Welcome to Medicare visit; however, even with the increased use, there is room for improvement. Am J Prev Med 2018;54(1):37–43. Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
INTRODUCTION
T
he increasing amount of work required during a primary care visit, specifically because of the increasing number of diagnoses that need to be addressed, leaves little to no time to address prevention.1,2 The Welcome to Medicare visit (WMV), first made available to Medicare beneficiaries in 2005, focuses broadly on prevention and early detection as opposed to dealing with an illness that already exists.3 The WMV provides a billable opportunity to review beneficiaries’ health history, current health status, and risk factors, as well as provide education, counseling, and referrals.3,4 WMV is similar to the annual wellness visit (AWV), in
that both provide screenings for depression, substance abuse, fall risk/functional ability, as well as discussions about diet, physical activity, and end of life/advanced care planning. However, the WMV differs from the AWV (introduced in 2011) in that it is available as a single, introductory visit upon Medicare enrollment, as From the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Baltimore, Maryland Address correspondence to: Arpit Misra, PhD, MA, Rapid Cycle Research and Evaluation Group, Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Mail Stop 06-05, Baltimore MD 21244. E-mail: [email protected]. 0749-3797/$36.00 https://doi.org/10.1016/j.amepre.2017.08.030
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Am J Prev Med 2018;54(1):37–43 37
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opposed to annually like the AWV (beneficiaries cannot receive the AWV within the first year of entering Medicare or in the same year they had the WMV). Additionally, AWV also includes an assessment of cognitive impairment and can be billed by medical professionals (such as health educators), as well as physicians and qualified non-physician practioners.5,6 Historically, only 3%–6% of eligible beneficiaries received a WMV, even after changes extending benefit eligibility and waiving the annual deductible.7,8 Sections 4103 and 4104 of the 2010 Affordable Care Act (ACA) were designed to encourage greater use of the WMV, as well as other preventive services, by removing the coinsurance requirement and thereby eliminating cost as a barrier to access. Other than the initial research indicating low uptake, existing literature on WMV utilization is sparse. Recently, Chung and colleagues9 reported a significant increase after 2011 in the use of WMV among Medicare fee-for-service (FFS) beneficiaries compared with Medicare beneficiaries in an HMO and non−Medicare-aged individuals with private insurance. However, this study was limited to a single organization in Northern California and had limited generalizability to the broader Medicare population. This study overcomes this limitation by measuring WMV utilization among a national sample of older adults before and after the elimination of beneficiary out-of-pocket costs in 2011. The study hypothesizes that the ACA provision increased uptake of the WMV benefit.
METHODS Study Sample This analysis included newly enrolled Medicare FFS beneficiaries who were eligible for a WMV. The study sample was derived using 2005–2016 Medicare FFS enrollment and claims files representing a 5% random sample of Medicare FFS beneficiaries. The sample was limited to beneficiaries who were continuously enrolled in Medicare Parts A and B for the entirety of their first 12 months of Medicare eligibility and were alive at the end of those 12 months. The analysis further focused on beneficiaries who aged into Medicare and enrolled within the Medicare eligibility period. All data were de-identified and did not require IRB approval.
Measures WMVs were identified using Medicare’s Healthcare Common Procedure Coding System codes in claims records. Healthcare Common Procedure Coding System code G0344 was used for years 2005 through 2008 and G0402 was used for years 2009 onward. Because beneficiaries new to Medicare prior to 2009 could use this service only within the first 6 months of having Part B coverage, their WMV service date was restricted to the first 6 months following enrollment. For those beneficiaries newly enrolled in 2009 or later, the WMV service date was restricted to the first 12 months following enrollment.
Statistical Analysis The study used an interrupted time series (ITS) regression model to estimate changes in quarterly rates of WMV after 2011, when all cost sharing was waived, controlling for pre-intervention trends and other autocorrelation.10 The primary outcome was quarterly rates of WMV, defined as the number of beneficiaries who received the service per eligible beneficiaries in each quarter. The data were aggregated into 48 quarterly intervals. The model included a constant, a baseline slope term to control for secular trends (e.g., first-, second-, or higher-order correlation), and terms estimating changes in the level and slope of utilization rates. Y t ¼β0 þ β1 timet þ β2 policy changet þ β3 time af ter policy changet þ et There is no comparison group, as the policy change was designed to affect every new Medicare FFS beneficiary. Compared with a simple pre- and post-mean comparison, ITS offers a quasiexperimental research design with a potentially high degree of internal validity.10–13 ITS requires knowing the specific point in a series when an intervention occurred. Causal inference can be made from ITS analyses if the post-intervention outcome has a different slope or level immediately following an intervention that is sustained over time.12 The analysis was further stratified by sex, race/ethnicity (non-Hispanic white and non-white), dual-eligible beneficiariesa (compared to Medicare only beneficiaries), beneficiaries with Medicare supplemental insurance, such as Medigap or employersponsored supplemental insurance (compared to Medicare-only beneficiaries), and U.S. Census regions (Northeast, Midwest, South, and West). The time series model was conducted using ITSA from Stata, version 14.14 ACTEST was used to test for autocorrelation (Statistical Software Component, Boston College Department of Economics, number S457668). ACTEST utilizes the Cumby– Huizinga general test for autocorrelation. For the overall model, the test showed autocorrelation present at lag 5 (p¼0.031) but at no higher lag orders (up to 10 lags tested).b The model accounted for this autocorrelation. Newey–West SEs were used to account for possible heteroskedasticity. All hypothesis tests used a significance level (α) of 0.05.
RESULTS Annual WMV rates increased each year, from 1.4% in 2005 to 12.3% in 2016 (Table 1). Across all years, the majority of beneficiaries eligible for WMV were female and non-Hispanic white, and lived in the South region. The proportion of dual-eligible beneficiaries remained relatively unchanged at 7%−8% throughout the study period, while the proportion of beneficiaries with Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. However, for this analysis, beneficiaries were considered duals regardless of if they were full or partial duals anytime during the year. b Autocorrelation is a measure of the internal correlation within a time series. It is a way of measuring and explaining internal association between observations in a time series. An autocorrelation at lag 5 means that the error terms 5 data points apart are similar or correlated. a
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19 17 24 40 19 17 24 40 20 17 24 40 19 17 24 40 19 17 23 40 19 17 24 40 19 17 24 40 19 17 24 41
January 2018
Newly enrolled Medicare FFS beneficiaries aged 65 years. Includes black, Hispanic, and other races/ethnicities. Based on dual eligibility any time during the year. d Includes Medigap, and employer-supplemental policies. FFS, fee for service; WMV, Welcome to Medicare Visit. c
b
a
18 17 25 40 17 17 26 40
17 17 26 40
18 17 25 40
8 62 8 62 8 62 8 61 7 59 7 55 7 52 7 50 7 46 7 42
7 44
7 48
12 94,946 46 14 11 93,602 46 14 10 95,810 47 14 9 100,042 47 13 9 105,912 47 12 7 89,976 47 12 4 85,521 47 12 4 88,439 47 12 3 91,606 47 11
Annual use rate of WMV, % Denominator population, na Male, % Non-white,b % Supplemental insurance, % Dual statusc Medicare supplementald U.S. Census regions, % West Northeast Midwest South
1 89,415 45 11
3 89,181 46 11
4 94,036 47 11
2011 2010 2009 2008 2007 2006 2005 Characteristic
Table 1. Selected Descriptive Statistics for Medicare FFS Beneficiaries Eligible for WMV, 2005–2016
2012
2013
2014
2015
2016
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Medigap or employer-sponsored supplemental insurance increased from 42% in 2005 to 62% in 2016. The baseline WMV quarterly rate started at almost 1% (po0.001) and increased by 0.06% (po0.001, pre-ACA slope) every quarter prior to 2011 ACA provision (Table 2). Immediately following the introduction of the ACA provision (quarter one of 2011), there was a statistically significant increase in the WMV rate of almost 1% (po0.001, post-ACA intercept). The quarterly WMV rate then increased by 0.13% (po0.001, post-ACA slope) every quarter after the 2011 provision. Figure 1 provides a graphic depiction of this trend. Post-ACA utilization varied across sociodemographic subgroups (Figure 2), although most groups showed a marked increase in WMV utilization rates immediately after the ACA provision in January 2011. WMV utilization among women and men increased similarly across all study quarters, but women had a significantly higher increase immediately following implementation of the ACA provision. Significant pre-ACA differences in utilization between non-Hispanic whites and non-whites persisted in the post-ACA period, but did not widen further. Pre-ACA utilization did not differ by dualeligibility status; however, dual eligibles had a significant increase in WMV utilization immediately after the ACA and a faster pace of growth compared with non–dualeligible beneficiaries (Medicare only). Individuals with Medigap or employer-sponsored supplemental insurance, compared with Medicare-only beneficiaries, saw significantly greater growth in the quarterly utilization rate before and after the ACA as well as a significant increase immediately after the ACA. WMV utilization rates across the four regions were not statistically different during the baseline period or immediately following the 2011 provision. Quarterly WMV rate increases after 2011 were not statistically different between regions, with the exception of the Northeast (p¼0.049, post-ACA slope difference), where the rate increased at a faster pace when compared with increases in all other regions. Table 2. Effect of ACA 2011 Provision on Overall WMV Quarterly Rates, 2005–2016 Quarterly WMV rates Quarterly WMV utilization rate (level) at baseline (β0) Slope before 2011 provision (β1) Change in quarterly WMV utilization rate (level) immediately after 2011 ACA provision (β2) Slope after 2011 provision (β3)
Point estimates (95% CI) 0.84 (0.41, 1.26) 0.06 (0.04, 0.09) 0.86 (0.52, 1.21) 0.13 (0.12, 0.15)
Note: Boldface indicates statistical significance (po0.05). ACA, Affordable Care Act; WMV, Welcome to Medicare Visit.
40
4 2 0
Overall Quarterly Rate (%)
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Q1 2005
Q1 2011
Q4 2016
Quarters Actual
Predicted
Figure 1. WMV overall quarterly rates, 2005 through 2016. Note: Values for newly enrolled Medicare FFS beneficiaries, age 65 years eligible for WMV benefit, 2005 through 2016. FFS, fee for service; WMV, Welcome to Medicare Visit.
DISCUSSION
8
8
The study results indicate that the 2011 ACA provision was associated with significantly increased utilization of
WMV among newly enrolled Medicare FFS beneficiaries. Annual utilization rates almost doubled between 2010 and 2011 (4% compared with 7%, respectively) and continued to increase by about 1% in each of the 5 subsequent years examined in this study. Although the ACA’s removal of the coinsurance is associated with this change, other factors related to the ACA, such as outreach efforts focusing on prevention, could also have increased awareness and uptake of the benefit. The study results correspond with prior literature showing low utilization directly after the WMV benefit was implemented, as well as an increase in use after 2011.7,9 The results also correspond with research showing a positive association between beneficiary costsharing waivers and utilization of some preventive services.15–17 This is in contrast to several other studies showing a limited impact of the ACA on preventive service utilization, at least within the first several years after the ACA.16–19 This study extends previous work by providing a more comprehensive examination of the impact of the ACA on WMV use for the entire Medicare population with a longer study period. Non-Hispanic White
6 4
4
6
Female
Male
0
0
2
2
Non-White
Q1 2005
Q1 2011
Q4 2016
Q1 2005
Quarters (Q)
Q1 2011
Q4 2016
Quarters (Q)
8
8
Supplemental Insurance
6 4
Medicare Only
2
2
4
6
Dual-Eligible
0
0
Medicare Only
Q1 2005
Q1 2011
Q4 2016
Q1 2005
Q1 2011
Q4 2016
Quarters (Q)
8
Quarters (Q)
West
6
Northeast
4
South
0
2
Midwest
Q1 2005
Q1 2011
Q4 2016
Quarters (Q)
Figure 2. WMV quarterly rates by various subgroups, 2005 through 2016. Note: Values for newly enrolled Medicare FFS beneficiaries, age 65 years eligible for WMV benefit, 2005 through 2016. FFS, fee for service; WMV, Welcome to Medicare Visit.
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Subgroup analyses showed a similar trend of increased WMV utilization for most groups after implementation of the ACA, although this trend varied by subgroups. The ACA was intended to improve access to preventive services, particularly for vulnerable populations, such as dual eligibles.20,21 However, pre-ACA trends of lower utilization persisted for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance. As reported previously, men and minorities tend to have lower levels of healthcare utilization, including routine checkups, ambulatory services,22,23 and preventive services, such as mammograms and diabetes and cardiovascular-related screenings.24 Besides costs, having a usual source of care is an important factor associated with receipt of preventive services.22,25–28 However, men and minorities are less likely to have a usual place of care, which may explain why men and minorities are also more likely to delay their first use of outpatient services upon Medicare enrollment, particularly delaying visits with primary care providers.25,29,30 Such delays likely lead to an acute event that needs immediate attention, requiring costly emergency services.31 Providers and the healthcare system should consider targeted engagement of older men, especially considering that men may be more likely to avoid medical treatment, even when sick.24,32 Similarly, health interventions aimed at increasing access to preventive services for minorities need to consider whether there are language and cultural barriers that may inhibit utilization.33 Beneficiaries without supplemental insurance, which often covered most or all of the Medicare Part B coinsurance or deductible prior to ACA, stood to benefit the most from the ACA’s removal of coinsurance, which averaged $26 in 2010 (internal analysis of Medicare claims data). Contrary to expectations, however, utilization tripled among dual-eligible beneficiaries and quadrupled among individuals with Medigap or employer-sponsored supplemental insurance. These findings may have had less to do with cost-sharing changes and more to do with greater knowledge of the benefit and more positive attitudes and behaviors toward preventive care among those with supplemental insurance than among those without.34–39 Other factors related to the ACA, such as a higher exposure to preventive services through state-based Medicaid programs and efforts by health systems that incentivize providers’ use of preventive services, may have contributed to the higher post-ACA utilization among dual eligibles.40,41 An area of future research could be to assess whether the increased use and growth in WMV among dual eligibles varied by states, especially January 2018
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comparing Medicaid expansion and non-expansion states. Despite an increase in WMV rates over time, overall utilization of the benefit remains low among newly enrolled Medicare beneficiaries. Five years after the 2011 ACA provision, only one in eight eligible beneficiaries used this service in 2016. A number of beneficiary and provider factors may be driving this low uptake.19 Previously, Petroski and Regan7 found that more than 60% of beneficiaries reported in 2006 that the main reason for not receiving the WMV was that they did not know about the benefit. In 2011, about half of the beneficiaries surveyed still had not heard about the benefit (internal analysis of the Medicare Current Beneficiary Survey 2011 data). These results suggest that, although more beneficiaries have become aware of this benefit over time, there is room for improvement in educating newly eligible beneficiaries about the availability of this free benefit. The potential value of efforts to improve beneficiary awareness is supported by the finding that 78% of beneficiaries who did not receive the benefit in 2006 would have pursued the WMV had they known about it.7 Improving beneficiary awareness alone may not be sufficient, however. Physicians also can be a major driver of these visits, as indicated by the 34% of eligible beneficiaries surveyed who indicated they received the WMV because their doctor recommended it.7 Improving provider awareness of the benefits of WMV may further increase its use.42 Low WMV use may be due to multiple factors. First, some clinicians find the current WMV reimbursement amount to be insufficient motivation to update billing systems to use the new WMV codes, or for completing the long list of services required to be provided as part of the visit.8 As the healthcare system continues to move in the direction of team-based care, various strategies (e.g., templates, workflow tools, use of qualified non-physician practitioners to administer, bill, and coordinate reminders for the WMV) may help increase use of the benefit.5,6,9 Also, providers may not see a clinical need to provide the service because they are seeing previously established patients.9,29 However, most visits with providers focus on treating conditions that are already present, leaving limited time to comprehensively review patient’s medical history to determine whether subsequent screenings are needed. WMV offers an opportunity to take stock of the patient’s health, especially given that health conditions can escalate quickly, and it can strengthen patient–provider relationships.41,43 Interestingly, a large proportion (92%) of WMVs were billed along with routine evaluation and management (EM)
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visits (internal analysis of 2016 Medicare claims data)c; a trend that was also observed among AWVs.5 Additionally, the internal analysis showed no change in EM visits during the study period. If WMV and EM services are occurring during the same visit, it is possible that such visits create confusion among beneficiaries who were expecting to pay no copay but instead receive a bill for the EM services. An area for future research could be to investigate patient and provider behavior and factors associated with providing and using preventive care. Preventive services are associated with short- and longterm benefits, such as reduced acute care, hospitalizations, and emergency department visits, as well as lower healthcare expenditures.44 WMV can be a gateway for receiving preventive services, including aspirin prophylaxis, cancer screening referrals, immunizations, and screening and counseling on tobacco and alcohol use as well as depression.3,45 The benefit was created to provide an opportunity to focus solely on prevention, given that Medicare does not cover comprehensive physical exams, and visits for acute and chronic conditions do not allow much opportunity for discussing cancer screening. Research has shown that referrals for cancer screening are more likely to occur during a preventive visit and a provider referral is the most common reason an individual gets a cancer screening.17,18 Together, the WMV and AWV provide a preventive visit that includes education and counseling, risk assessments specifically for older adults, and referral opportunities to other free preventive services. While use of the AWV has also increased since it was introduced (from 7.5% in 2011 to 16% in 2014), it remains low.5 If these services are indeed effective, it may be worthwhile to encourage beneficiaries to request these services and to assist providers in incorporating these services without overburdening the primary care system.1,2 Major strengths of this study include results that are representative of newly enrolled Medicare FFS beneficiaries, the long study window that allowed for examination of WMV use since the benefit was introduced, and the use of ITS to examine the impact of the ACA policy change.
Limitations This study had two main limitations. First, the study did not have access to historical data on beneficiaries prior to Medicare. One likely reason for such low overall rates could be that physicians may not find it necessary to do a WMV checkup with already established patients. Having access to pre-Medicare data could help in adjusting for healthcare utilization, health insurance type, and having a usual source of care before entering the Medicare c Routine EM visits (not preventive specific) were identified using Current Procedural Terminology and Healthcare Common Procedure Coding System codes: 99201–99205 and 99211–99215.
program. Second, because ITS methodology requires a large number of data points both before and after an intervention to detect a trend, at this time the time series model can only test for differences in quarterly rates. With the passing of time, investigators should be able to analyze annual WMV rates, although findings are likely not going to be any different.
CONCLUSIONS The results of this study indicate that the use of WMV increased after the 2011 ACA provision, although overall utilization remains low. Additionally, post-ACA use of WMV increased more slowly among men, minorities, and beneficiaries without supplemental insurance. Improvements in provider and beneficiary education could lead to further uptake, although additional access barriers need to be considered, particularly related to differences in subgroup utilization rates. ACA, and perhaps the removal of cost sharing, was associated with increased use of WMV. However, even with increased use, there is room for improvement.
ACKNOWLEDGMENTS The authors thank David M. Bott for helpful comments. The findings and conclusions contained in this article are those of the authors and do not necessarily reflect the official position of Centers for Medicare and Medicaid Services. No financial disclosures were reported by the authors of this paper.
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Initiative. Prev Med. 2000;31(3):261–270. https://doi.org/10.1006/pmed. 2000.0697. Miller NA, Kirk A, Alston B, Glos L. Effects of gender, disability, and age in the receipt of preventive services. Gerontologist. 2014;54(3):473– 487. https://doi.org/10.1093/geront/gnt012. Sloan FA, Acquah KF, Lee PP, Sangvai DG. Despite ‘Welcome to Medicare’ benefit, one in eight enrollees delay first use of part B services for at least two years. Health Aff (Millwood). 2012;31(6):1260–1268. https://doi.org/10.1377/hlthaff.2011.0479. DeVoe JE, Fryer GE, Phillips R, Green L. Receipt of preventive care among adults: insurance status and usual source of care. Am J Public Health. 2003;93(5):786–791. https://doi.org/10.2105/AJPH.93.5.786. Gornick ME. A decade of research on disparities in Medicare utilization: lessons for the health and health care of vulnerable men. Am J Public Health. 2008;98(9 suppl):S162–S168. https://doi.org/ 10.2105/AJPH.98.Supplement_1.S162. Smith JA, Braunack-Mayer A, Wittert G, Warin M. “I've been independent for so damn long!”: independence, masculinity and aging in a help seeking context. J Aging Stud. 2007;21(4):325–335. https://doi. org/10.1016/j.jaging.2007.05.004. Minkler M, Schauffler H, Clements-Nolle K. Health promotion for older Americans in the 21st century. Am J Health Promot. 2000;14 (6):371–379. https://doi.org/10.4278/0890-1171-14.6.371. White E, Urban N, Taylor V. Mammography utilization, public health impact, and cost-effectiveness in the United States. Annu Rev Public Health. 1993;14:605–633. https://doi.org/10.1146/annurev.pu.14. 050193.003133. Rimer BK, Resch N, King E, et al. Multistrategy health education program to increase mammography use among women ages 65 and older. Public Health Rep. 1992;107(4):369–380. Rimer BK, Ross E, Cristinzio CS, King E. Older women’s participation in breast screening. J Gerontol. 1992;47:85–91 Spec No. Stein JA, Fox SA, Murata PJ, Morisky DE. Mammography usage and the health belief model. Health Educ Q. 1992;19(4):447–462. https://doi.org/ 10.1177/109019819201900409. Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med. 1995;332(17):1138– 1143. https://doi.org/10.1056/NEJM199504273321706. Fang J, Alderman MH. Does supplemental private insurance affect care of Medicare recipients hospitalized for myocardial infarction? Am J Public Health. 2004;94(5):778–782. https://doi.org/10.2105/AJPH.94. 5.778. Gates A, Ranji U, Snyder L. Coverage of Preventive Services for Adults in Medicaid. Menlo Park, CA: The Henry J Kaiser Family Foundation; 2015. Zimmerman S. Health systems embrace patient engagement communications to promote preventive care, manage chronic disease. Becker’s Hospital Review. May 26, 2015. http://www.beckershospitalreview. com/population-health/health-systems-embrace-patient-engagementcommunications-to-promote-preventive-care-manage-chronic-di sease.html. Accessed June 28, 2017. Beeker C, Kraft JM, Southwell BG, Jorgensen CM. Colorectal cancer screening in older men and women: qualitative research findings and implications for intervention. J Community Health. 2000;25(3):263– 278. https://doi.org/10.1023/A:1005104406934. Gold J. Physicians should make use of “Welcome to Medicare” visit. WMJ. 2007;106(6):351. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services. Am J Prev Med. 2006;31(1):52–61. https://doi.org/10.1016/j.amepre. 2006.03.012. Nicholas JA, Hall WJ. Screening and preventive services for older adults. Mt Sinai J Med. 2011;78(4):498–508. https://doi.org/10.1002/ msj.20275.
Use of Welcome to Medicare Visits Among Older Adults Following the Affordable Care Act Arpit Misra, PhD, MA, Jennifer T. Lloyd, PhD, MA, MS, Larisa M. Strawbridge, MPH, Suzanne G. Wensky, PhD, This activity is available for CME credit. See page A4 for information.
Introduction: To encourage greater utilization of preventive services among Medicare beneficiaries, the 2010 Affordable Care Act waived coinsurance for the Welcome to Medicare visit, making this benefit free starting in 2011. The objective of this study was to determine the impact of the Affordable Care Act on Welcome to Medicare visit utilization. Methods: A 5% sample of newly enrolled fee-for-service Medicare beneficiaries for 2005–2016 was used to estimate changes in Welcome to Medicare visit use over time. An interrupted time series model examined whether Welcome to Medicare visits increased significantly after 2011, controlling for pre-intervention trends and other autocorrelation. Results: Annual Welcome to Medicare visit rates began at 1.4% in 2005 and increased to 12.3% by 2016. The quarterly Welcome to Medicare visit rate, which was almost 1% at baseline, was increasing by 0.06% before the 2011 Affordable Care Act provision (po0.001). Immediately following the 2011 Affordable Care Act provision, the rate increased by about 1% in the first quarter of 2011 (intercept, po0.001), followed by an increase of 0.13% every subsequent quarter (slope, po0.001). This general trend was observed in subgroup analyses, although this trend varied by subgroups where the pre−Affordable Care Act trends of lower utilization persisted over time for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance. Conclusions: The Affordable Care Act, and perhaps the removal of cost sharing, was associated with increased use of the Welcome to Medicare visit; however, even with the increased use, there is room for improvement. Am J Prev Med 2018;54(1):37–43. Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
INTRODUCTION
T
he increasing amount of work required during a primary care visit, specifically because of the increasing number of diagnoses that need to be addressed, leaves little to no time to address prevention.1,2 The Welcome to Medicare visit (WMV), first made available to Medicare beneficiaries in 2005, focuses broadly on prevention and early detection as opposed to dealing with an illness that already exists.3 The WMV provides a billable opportunity to review beneficiaries’ health history, current health status, and risk factors, as well as provide education, counseling, and referrals.3,4 WMV is similar to the annual wellness visit (AWV), in
that both provide screenings for depression, substance abuse, fall risk/functional ability, as well as discussions about diet, physical activity, and end of life/advanced care planning. However, the WMV differs from the AWV (introduced in 2011) in that it is available as a single, introductory visit upon Medicare enrollment, as From the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Baltimore, Maryland Address correspondence to: Arpit Misra, PhD, MA, Rapid Cycle Research and Evaluation Group, Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Mail Stop 06-05, Baltimore MD 21244. E-mail: [email protected]. 0749-3797/$36.00 https://doi.org/10.1016/j.amepre.2017.08.030
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
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opposed to annually like the AWV (beneficiaries cannot receive the AWV within the first year of entering Medicare or in the same year they had the WMV). Additionally, AWV also includes an assessment of cognitive impairment and can be billed by medical professionals (such as health educators), as well as physicians and qualified non-physician practioners.5,6 Historically, only 3%–6% of eligible beneficiaries received a WMV, even after changes extending benefit eligibility and waiving the annual deductible.7,8 Sections 4103 and 4104 of the 2010 Affordable Care Act (ACA) were designed to encourage greater use of the WMV, as well as other preventive services, by removing the coinsurance requirement and thereby eliminating cost as a barrier to access. Other than the initial research indicating low uptake, existing literature on WMV utilization is sparse. Recently, Chung and colleagues9 reported a significant increase after 2011 in the use of WMV among Medicare fee-for-service (FFS) beneficiaries compared with Medicare beneficiaries in an HMO and non−Medicare-aged individuals with private insurance. However, this study was limited to a single organization in Northern California and had limited generalizability to the broader Medicare population. This study overcomes this limitation by measuring WMV utilization among a national sample of older adults before and after the elimination of beneficiary out-of-pocket costs in 2011. The study hypothesizes that the ACA provision increased uptake of the WMV benefit.
METHODS Study Sample This analysis included newly enrolled Medicare FFS beneficiaries who were eligible for a WMV. The study sample was derived using 2005–2016 Medicare FFS enrollment and claims files representing a 5% random sample of Medicare FFS beneficiaries. The sample was limited to beneficiaries who were continuously enrolled in Medicare Parts A and B for the entirety of their first 12 months of Medicare eligibility and were alive at the end of those 12 months. The analysis further focused on beneficiaries who aged into Medicare and enrolled within the Medicare eligibility period. All data were de-identified and did not require IRB approval.
Measures WMVs were identified using Medicare’s Healthcare Common Procedure Coding System codes in claims records. Healthcare Common Procedure Coding System code G0344 was used for years 2005 through 2008 and G0402 was used for years 2009 onward. Because beneficiaries new to Medicare prior to 2009 could use this service only within the first 6 months of having Part B coverage, their WMV service date was restricted to the first 6 months following enrollment. For those beneficiaries newly enrolled in 2009 or later, the WMV service date was restricted to the first 12 months following enrollment.
Statistical Analysis The study used an interrupted time series (ITS) regression model to estimate changes in quarterly rates of WMV after 2011, when all cost sharing was waived, controlling for pre-intervention trends and other autocorrelation.10 The primary outcome was quarterly rates of WMV, defined as the number of beneficiaries who received the service per eligible beneficiaries in each quarter. The data were aggregated into 48 quarterly intervals. The model included a constant, a baseline slope term to control for secular trends (e.g., first-, second-, or higher-order correlation), and terms estimating changes in the level and slope of utilization rates. Y t ¼β0 þ β1 timet þ β2 policy changet þ β3 time af ter policy changet þ et There is no comparison group, as the policy change was designed to affect every new Medicare FFS beneficiary. Compared with a simple pre- and post-mean comparison, ITS offers a quasiexperimental research design with a potentially high degree of internal validity.10–13 ITS requires knowing the specific point in a series when an intervention occurred. Causal inference can be made from ITS analyses if the post-intervention outcome has a different slope or level immediately following an intervention that is sustained over time.12 The analysis was further stratified by sex, race/ethnicity (non-Hispanic white and non-white), dual-eligible beneficiariesa (compared to Medicare only beneficiaries), beneficiaries with Medicare supplemental insurance, such as Medigap or employersponsored supplemental insurance (compared to Medicare-only beneficiaries), and U.S. Census regions (Northeast, Midwest, South, and West). The time series model was conducted using ITSA from Stata, version 14.14 ACTEST was used to test for autocorrelation (Statistical Software Component, Boston College Department of Economics, number S457668). ACTEST utilizes the Cumby– Huizinga general test for autocorrelation. For the overall model, the test showed autocorrelation present at lag 5 (p¼0.031) but at no higher lag orders (up to 10 lags tested).b The model accounted for this autocorrelation. Newey–West SEs were used to account for possible heteroskedasticity. All hypothesis tests used a significance level (α) of 0.05.
RESULTS Annual WMV rates increased each year, from 1.4% in 2005 to 12.3% in 2016 (Table 1). Across all years, the majority of beneficiaries eligible for WMV were female and non-Hispanic white, and lived in the South region. The proportion of dual-eligible beneficiaries remained relatively unchanged at 7%−8% throughout the study period, while the proportion of beneficiaries with Dual eligibles are often divided into “full duals” and “partial duals” based on the level of Medicaid benefits they receive. However, for this analysis, beneficiaries were considered duals regardless of if they were full or partial duals anytime during the year. b Autocorrelation is a measure of the internal correlation within a time series. It is a way of measuring and explaining internal association between observations in a time series. An autocorrelation at lag 5 means that the error terms 5 data points apart are similar or correlated. a
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19 17 24 40 19 17 24 40 20 17 24 40 19 17 24 40 19 17 23 40 19 17 24 40 19 17 24 40 19 17 24 41
January 2018
Newly enrolled Medicare FFS beneficiaries aged 65 years. Includes black, Hispanic, and other races/ethnicities. Based on dual eligibility any time during the year. d Includes Medigap, and employer-supplemental policies. FFS, fee for service; WMV, Welcome to Medicare Visit. c
b
a
18 17 25 40 17 17 26 40
17 17 26 40
18 17 25 40
8 62 8 62 8 62 8 61 7 59 7 55 7 52 7 50 7 46 7 42
7 44
7 48
12 94,946 46 14 11 93,602 46 14 10 95,810 47 14 9 100,042 47 13 9 105,912 47 12 7 89,976 47 12 4 85,521 47 12 4 88,439 47 12 3 91,606 47 11
Annual use rate of WMV, % Denominator population, na Male, % Non-white,b % Supplemental insurance, % Dual statusc Medicare supplementald U.S. Census regions, % West Northeast Midwest South
1 89,415 45 11
3 89,181 46 11
4 94,036 47 11
2011 2010 2009 2008 2007 2006 2005 Characteristic
Table 1. Selected Descriptive Statistics for Medicare FFS Beneficiaries Eligible for WMV, 2005–2016
2012
2013
2014
2015
2016
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Medigap or employer-sponsored supplemental insurance increased from 42% in 2005 to 62% in 2016. The baseline WMV quarterly rate started at almost 1% (po0.001) and increased by 0.06% (po0.001, pre-ACA slope) every quarter prior to 2011 ACA provision (Table 2). Immediately following the introduction of the ACA provision (quarter one of 2011), there was a statistically significant increase in the WMV rate of almost 1% (po0.001, post-ACA intercept). The quarterly WMV rate then increased by 0.13% (po0.001, post-ACA slope) every quarter after the 2011 provision. Figure 1 provides a graphic depiction of this trend. Post-ACA utilization varied across sociodemographic subgroups (Figure 2), although most groups showed a marked increase in WMV utilization rates immediately after the ACA provision in January 2011. WMV utilization among women and men increased similarly across all study quarters, but women had a significantly higher increase immediately following implementation of the ACA provision. Significant pre-ACA differences in utilization between non-Hispanic whites and non-whites persisted in the post-ACA period, but did not widen further. Pre-ACA utilization did not differ by dualeligibility status; however, dual eligibles had a significant increase in WMV utilization immediately after the ACA and a faster pace of growth compared with non–dualeligible beneficiaries (Medicare only). Individuals with Medigap or employer-sponsored supplemental insurance, compared with Medicare-only beneficiaries, saw significantly greater growth in the quarterly utilization rate before and after the ACA as well as a significant increase immediately after the ACA. WMV utilization rates across the four regions were not statistically different during the baseline period or immediately following the 2011 provision. Quarterly WMV rate increases after 2011 were not statistically different between regions, with the exception of the Northeast (p¼0.049, post-ACA slope difference), where the rate increased at a faster pace when compared with increases in all other regions. Table 2. Effect of ACA 2011 Provision on Overall WMV Quarterly Rates, 2005–2016 Quarterly WMV rates Quarterly WMV utilization rate (level) at baseline (β0) Slope before 2011 provision (β1) Change in quarterly WMV utilization rate (level) immediately after 2011 ACA provision (β2) Slope after 2011 provision (β3)
Point estimates (95% CI) 0.84 (0.41, 1.26) 0.06 (0.04, 0.09) 0.86 (0.52, 1.21) 0.13 (0.12, 0.15)
Note: Boldface indicates statistical significance (po0.05). ACA, Affordable Care Act; WMV, Welcome to Medicare Visit.
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4 2 0
Overall Quarterly Rate (%)
6
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Q1 2005
Q1 2011
Q4 2016
Quarters Actual
Predicted
Figure 1. WMV overall quarterly rates, 2005 through 2016. Note: Values for newly enrolled Medicare FFS beneficiaries, age 65 years eligible for WMV benefit, 2005 through 2016. FFS, fee for service; WMV, Welcome to Medicare Visit.
DISCUSSION
8
8
The study results indicate that the 2011 ACA provision was associated with significantly increased utilization of
WMV among newly enrolled Medicare FFS beneficiaries. Annual utilization rates almost doubled between 2010 and 2011 (4% compared with 7%, respectively) and continued to increase by about 1% in each of the 5 subsequent years examined in this study. Although the ACA’s removal of the coinsurance is associated with this change, other factors related to the ACA, such as outreach efforts focusing on prevention, could also have increased awareness and uptake of the benefit. The study results correspond with prior literature showing low utilization directly after the WMV benefit was implemented, as well as an increase in use after 2011.7,9 The results also correspond with research showing a positive association between beneficiary costsharing waivers and utilization of some preventive services.15–17 This is in contrast to several other studies showing a limited impact of the ACA on preventive service utilization, at least within the first several years after the ACA.16–19 This study extends previous work by providing a more comprehensive examination of the impact of the ACA on WMV use for the entire Medicare population with a longer study period. Non-Hispanic White
6 4
4
6
Female
Male
0
0
2
2
Non-White
Q1 2005
Q1 2011
Q4 2016
Q1 2005
Quarters (Q)
Q1 2011
Q4 2016
Quarters (Q)
8
8
Supplemental Insurance
6 4
Medicare Only
2
2
4
6
Dual-Eligible
0
0
Medicare Only
Q1 2005
Q1 2011
Q4 2016
Q1 2005
Q1 2011
Q4 2016
Quarters (Q)
8
Quarters (Q)
West
6
Northeast
4
South
0
2
Midwest
Q1 2005
Q1 2011
Q4 2016
Quarters (Q)
Figure 2. WMV quarterly rates by various subgroups, 2005 through 2016. Note: Values for newly enrolled Medicare FFS beneficiaries, age 65 years eligible for WMV benefit, 2005 through 2016. FFS, fee for service; WMV, Welcome to Medicare Visit.
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Subgroup analyses showed a similar trend of increased WMV utilization for most groups after implementation of the ACA, although this trend varied by subgroups. The ACA was intended to improve access to preventive services, particularly for vulnerable populations, such as dual eligibles.20,21 However, pre-ACA trends of lower utilization persisted for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance. As reported previously, men and minorities tend to have lower levels of healthcare utilization, including routine checkups, ambulatory services,22,23 and preventive services, such as mammograms and diabetes and cardiovascular-related screenings.24 Besides costs, having a usual source of care is an important factor associated with receipt of preventive services.22,25–28 However, men and minorities are less likely to have a usual place of care, which may explain why men and minorities are also more likely to delay their first use of outpatient services upon Medicare enrollment, particularly delaying visits with primary care providers.25,29,30 Such delays likely lead to an acute event that needs immediate attention, requiring costly emergency services.31 Providers and the healthcare system should consider targeted engagement of older men, especially considering that men may be more likely to avoid medical treatment, even when sick.24,32 Similarly, health interventions aimed at increasing access to preventive services for minorities need to consider whether there are language and cultural barriers that may inhibit utilization.33 Beneficiaries without supplemental insurance, which often covered most or all of the Medicare Part B coinsurance or deductible prior to ACA, stood to benefit the most from the ACA’s removal of coinsurance, which averaged $26 in 2010 (internal analysis of Medicare claims data). Contrary to expectations, however, utilization tripled among dual-eligible beneficiaries and quadrupled among individuals with Medigap or employer-sponsored supplemental insurance. These findings may have had less to do with cost-sharing changes and more to do with greater knowledge of the benefit and more positive attitudes and behaviors toward preventive care among those with supplemental insurance than among those without.34–39 Other factors related to the ACA, such as a higher exposure to preventive services through state-based Medicaid programs and efforts by health systems that incentivize providers’ use of preventive services, may have contributed to the higher post-ACA utilization among dual eligibles.40,41 An area of future research could be to assess whether the increased use and growth in WMV among dual eligibles varied by states, especially January 2018
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comparing Medicaid expansion and non-expansion states. Despite an increase in WMV rates over time, overall utilization of the benefit remains low among newly enrolled Medicare beneficiaries. Five years after the 2011 ACA provision, only one in eight eligible beneficiaries used this service in 2016. A number of beneficiary and provider factors may be driving this low uptake.19 Previously, Petroski and Regan7 found that more than 60% of beneficiaries reported in 2006 that the main reason for not receiving the WMV was that they did not know about the benefit. In 2011, about half of the beneficiaries surveyed still had not heard about the benefit (internal analysis of the Medicare Current Beneficiary Survey 2011 data). These results suggest that, although more beneficiaries have become aware of this benefit over time, there is room for improvement in educating newly eligible beneficiaries about the availability of this free benefit. The potential value of efforts to improve beneficiary awareness is supported by the finding that 78% of beneficiaries who did not receive the benefit in 2006 would have pursued the WMV had they known about it.7 Improving beneficiary awareness alone may not be sufficient, however. Physicians also can be a major driver of these visits, as indicated by the 34% of eligible beneficiaries surveyed who indicated they received the WMV because their doctor recommended it.7 Improving provider awareness of the benefits of WMV may further increase its use.42 Low WMV use may be due to multiple factors. First, some clinicians find the current WMV reimbursement amount to be insufficient motivation to update billing systems to use the new WMV codes, or for completing the long list of services required to be provided as part of the visit.8 As the healthcare system continues to move in the direction of team-based care, various strategies (e.g., templates, workflow tools, use of qualified non-physician practitioners to administer, bill, and coordinate reminders for the WMV) may help increase use of the benefit.5,6,9 Also, providers may not see a clinical need to provide the service because they are seeing previously established patients.9,29 However, most visits with providers focus on treating conditions that are already present, leaving limited time to comprehensively review patient’s medical history to determine whether subsequent screenings are needed. WMV offers an opportunity to take stock of the patient’s health, especially given that health conditions can escalate quickly, and it can strengthen patient–provider relationships.41,43 Interestingly, a large proportion (92%) of WMVs were billed along with routine evaluation and management (EM)
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visits (internal analysis of 2016 Medicare claims data)c; a trend that was also observed among AWVs.5 Additionally, the internal analysis showed no change in EM visits during the study period. If WMV and EM services are occurring during the same visit, it is possible that such visits create confusion among beneficiaries who were expecting to pay no copay but instead receive a bill for the EM services. An area for future research could be to investigate patient and provider behavior and factors associated with providing and using preventive care. Preventive services are associated with short- and longterm benefits, such as reduced acute care, hospitalizations, and emergency department visits, as well as lower healthcare expenditures.44 WMV can be a gateway for receiving preventive services, including aspirin prophylaxis, cancer screening referrals, immunizations, and screening and counseling on tobacco and alcohol use as well as depression.3,45 The benefit was created to provide an opportunity to focus solely on prevention, given that Medicare does not cover comprehensive physical exams, and visits for acute and chronic conditions do not allow much opportunity for discussing cancer screening. Research has shown that referrals for cancer screening are more likely to occur during a preventive visit and a provider referral is the most common reason an individual gets a cancer screening.17,18 Together, the WMV and AWV provide a preventive visit that includes education and counseling, risk assessments specifically for older adults, and referral opportunities to other free preventive services. While use of the AWV has also increased since it was introduced (from 7.5% in 2011 to 16% in 2014), it remains low.5 If these services are indeed effective, it may be worthwhile to encourage beneficiaries to request these services and to assist providers in incorporating these services without overburdening the primary care system.1,2 Major strengths of this study include results that are representative of newly enrolled Medicare FFS beneficiaries, the long study window that allowed for examination of WMV use since the benefit was introduced, and the use of ITS to examine the impact of the ACA policy change.
Limitations This study had two main limitations. First, the study did not have access to historical data on beneficiaries prior to Medicare. One likely reason for such low overall rates could be that physicians may not find it necessary to do a WMV checkup with already established patients. Having access to pre-Medicare data could help in adjusting for healthcare utilization, health insurance type, and having a usual source of care before entering the Medicare c Routine EM visits (not preventive specific) were identified using Current Procedural Terminology and Healthcare Common Procedure Coding System codes: 99201–99205 and 99211–99215.
program. Second, because ITS methodology requires a large number of data points both before and after an intervention to detect a trend, at this time the time series model can only test for differences in quarterly rates. With the passing of time, investigators should be able to analyze annual WMV rates, although findings are likely not going to be any different.
CONCLUSIONS The results of this study indicate that the use of WMV increased after the 2011 ACA provision, although overall utilization remains low. Additionally, post-ACA use of WMV increased more slowly among men, minorities, and beneficiaries without supplemental insurance. Improvements in provider and beneficiary education could lead to further uptake, although additional access barriers need to be considered, particularly related to differences in subgroup utilization rates. ACA, and perhaps the removal of cost sharing, was associated with increased use of WMV. However, even with increased use, there is room for improvement.
ACKNOWLEDGMENTS The authors thank David M. Bott for helpful comments. The findings and conclusions contained in this article are those of the authors and do not necessarily reflect the official position of Centers for Medicare and Medicaid Services. No financial disclosures were reported by the authors of this paper.
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