The Medicare Annual Wellness Visit- It’s Origin, Content, and Substance

1. The Medicare Annual Wellness Visit-It’s Origin, Content, and Substance Duke Internal Medicine Bruce Peyser, MD FACP, Scott Joy, MD FACP, Anne Phelps, MD, Kathleen Waite, MD FACP May 2012

2. Disclosures for all four physicians

3. Disclaimer Comments are from us as individuals and do not represent official recommendations from Duke University Medical Center. However, we are from the Department of Medicine at Duke. And most importantly, we are all BLUE DEVILS and we sure love basketball in Durham, NC.

4. The Medicare Annual Wellness Visit

5. Many Patients Want a Medicare Annual Wellness Visit

6. AWV Pitfalls-What to Watch out for?? Insufficient or incomplete documentation. Many rules and regulations, CMS does not have all the answers yet. Concurrent provision of E/M services seems like an easy way to get into trouble. These visits take time, and your staff need to help you. Its not really clear what records you must retain . How to do this with EPIC??

7. Common Questions and Course Objectives What to do when A test is abnormal? How did the AWV get developed? What are the Components of the AWV? What’s a HRA? What are common Errors made with AWV’s?? How to Bill for the AWV? How to teach learners To do this properly?

8. Today’s outline-We have a really great show! AWV-Background and Politics- Dr. Scott Joy Component overview w/ focus on HRA- Dr. Kathleen Waite What to do when an abnormality is discovered-Dr. Anne Phelps Billing 101-How to bill correctly-Dr. Bruce Peyser Question and Answers Session Evaluation

9. The Magic of the AWV Be prepared for surprises! It’s hard to anticipate what you will find. This is an incredible opportunity that we must not squander.

10. Sources for Our Work

11. Coming to You Fall 2012-Exciting New Websites !!

13. The Political History of the Affordable Care Act and the Annual Wellness Visit Scott V. Joy, MD, FACP Associate Professor of Medicine Duke Primary Care

14. White House

15. Presidential Power • President Obama said that fixing health care would be one of his priorities if he won the presidency • President Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform.

16. Understand The Game: How OurLaws Are Made

17. United States Congress

18. Committees of Importance:U. S. Senate • Finance • Chairman, Max Baucus, D-MT • Ranking Member, Orin Hatch, R-UT • HELP (Health, Education, Labor and Pensions) • Chairman, Tom Harkin, D-IA • Ranking Member, Michael Enzi, R-WY • Appropriations • Chairman, Daniel Inouye, D-HI • Ranking Member, Thad Cochran, R-MS

19. Genesis of the AWV *Senators Max Baucus (D-Montana), Chuck Grassley (R-Iowa), Kent Conrad (D-North Dakota), Olympia Snowe (R-Maine), Jeff Bingaman (D-New Mexico), and Mike Enzi (R-Wyoming http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act • Beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican Senate Finance Committee Members* met for a series of 31 meetings over 60 hours to discuss the development of a health care reform bill • The principles that they discussed became the foundation of the Senate's health care reform bill.

20. Committees of Importance:House of Representatives • Ways and Means Chairman, Dave Camp, R-MI Ranking Member, Sander Levin, D-MI • Appropriations Chairman, Harold Rogers, R-KY Ranking Member Norman D. Dicks, D-WA • Energy and Commerce Chairman, Fred Upton, R-MI Henry Waxman, D-CA

21. The Legislative History of the Affordable Care Act http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act • Introduced in the House asthe "Service Members Home Ownership Tax Act of 2009" (H.R. 3590) by Charles Rangel (D–NY) on September 17, 2009 • Committee consideration by: Ways and Means • Passed the House on October 8, 2009 (416–0) • Passed the Senate as the "Patient Protection and Affordable Care Act" on December 24, 2009 (60–39) • “Cornhusker Kickback” • January 19, 2010, Scott Brown elected Senator from MA

22. Understand The Game: How Our Laws Are Made House agreed to Senate amendment on March 21, 2010 (219–212)

23. WASHINGTON, March 23, 2010 - President Obama signed the health care bill into law today, calling its historic expansion of insurance coverage "reforms that generations of Americans have fought for and marched for and hungered to see.”

25. The Implementation Phase • Once the ACA was passed, it became the responsibility of CMS (under Department of Health and Human Services, Secretary Kathleen Sebelius, to create policies • Each year, CMS issues regulations in the Federal Register • Generally the Proposed Rule comes out in the summer for a 90 day comment period and then the Final Rule is issued, effective January 1, 20XX

26. Department of Health and Human Services

27. Pages 454-457

28. Health Risk Assessments

29. U.S. Alters Rule on Paying for End-of-Life Planning http://www.nytimes.com/2011/01/05/health/policy/05health.html?_r=2 Published: January 4, 2011 • WASHINGTON — The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law, administration officials said Tuesday. • The move is an abrupt shift, coming just days after the new policy took effect on Jan. 1.

30. Supreme Court

31. Supreme Court and ACA http://www.hfma.org/Templates/Print.aspx?id=24263 • The Supreme Court has granted review of four issues from challenges to the Affordable Care Act that have been pursued in the federal courts since passage of the act in March 2010. • The four issues on which the court has granted review are: • Whether the Anti-Injunction Act prevents challenges to the Affordable Care Act at this time • The constitutionality of the individual mandate, requiring most Americans to purchase health insurance by 2014 • Whether the individual mandate is severable if it is found to be unconstitutional, or whether the entire Act would have to fail • Whether the Affordable Care Act's expansion of the Medicaid program is constitutional

32. Supreme Court and ACA http://www.hfma.org/Templates/Print.aspx?id=24263 • The Affordable Care Act does not contain a severability clause. • Severability clauses provide that the failure of one provision in an act of Congress does not affect the remaining portions of the act. • The absence of a severability clause does not mean that provisions are not severable, but it can leave the decision regarding severability up to the courts.

33. The Citizens Speak

34. Public Opinion of ACA http://www.kff.org/kaiserpolls/upload/8302-C.pdf

35. Medicare’s Annual Wellness Visit: The benefit nobody knows John A. Hartford Foundation Public Poll: “How Does It Feel? The Older Adult Health Care Experience” http://www.jhartfound.org/learning-center/hartford-poll-2012/ *Medicare’s records suggest that uptake is only 6.5 percent

37. Components of Medicare Annual Wellness Visit (AWV) Kathleen Waite, MD, FACP Assistant Clinical Professor of Medicine Division of General Internal Medicine Duke Primary Care

38. Medicare Preventive Services Initial Preventive Physical Examination (IPPE) One time benefit Must be provided within the first 12 months of the patient’s Medicare Part B coverage Initial Annual Wellness Visit (AWV) Once in a lifetime benefit If patient has received an IPPE then need to wait a full 12 months from that date of the IPPE before performing an AWV Subsequent Annual Wellness Visit (AWV) Provided yearly Must scheduled at least 11 full months from the last AWV

39. Goals of the AWV Patient to review with their health care provider overall health status and maximize the preventive services that are available to Medicare beneficiaries. Components dictated by Medicare. Create a personalized prevention plan. It is NOT a physical exam.

40. Components of First AWV Establish Medical History Past medical and surgical history Allergies Medication list INCLUDING supplements Establish Family History Includes parents, siblings and children List of current medical providers/suppliers Depression screening Review current and past experience with mood disorders. If no history then screen with available “standard screening test” recognized by national professional medical organizations. (PHQ-2)

41. Components of First AWV Review patients functional ability and level of safety Hearing (Whisper test) Ability to perform ADLs (Consider Katz or other instrument) Fall Risk (Get up and go test) Home safety Include instrumental activities of daily living (iADLs) Examination Height, Weight, BMI or waist circumference, BP Other PE deemed appropriate per medical/family history Detection of any cognitive impairments Not specified – consider testing such as Mini Cog Health Risk Assessment (CHANGE for 2012)

42. This way to complete your HRA……

43. Health Risk Assessment (HRA) Center for Medicare and Medicaid Services (CMS) requires that a HRA be completed as part of the Medicare AWV effective Jan. 1, 2012. CMS does not require a specific HRA. Written at a 5th grade reading level. Should take no more than 20 min to complete. Can be complete before or during the AWV. Can be web based, telephonic or paper based.

44. CDC Guidance on HRA Demographic information Self assessment of health and physical functioning Biometric Assessments Height, weight, BP, lipids, glucose Psychosocial risks Depression, social isolation, pain, stress/anger Behavioral risks Physical activity, nutrition, sexual practices, home safety, motor vehicle safety, tobacco use, alcohol use. ADLs and Instrumental activities of daily living (iADLs)

45. HRA Resources Center for Disease Control and Prevention published online a “Framework for Patient-Centered Health Risk Assessment”. Appendix A contains a 7 page paper HRA. http://www.cdc.gov/policy/opth/hra Dartmouth Co-Op Project is a non-profit organization that has an online free HRA. Short and long online HRA. The short HRA takes approximately 10 min to complete. Patient is given a summary “Action and Planning Form” which they are asked to print and bring to the AWV. www.medicarehealthassess.orgwww.HowsYourHealth.org

46. http//www.medicarehealthassess.org

47. FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March/April 2012

48. FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March/April 2012

49. Sample HRA Printout http//www.medicarehealthassess.org

50. http//www.medicarehealthassess.org