What is the Medicare Annual Wellness Visit?

The Medicare Annual Wellness Visit (AWV) is a patient appointment with primary care clinicians that is designed to create a preventive health plan for the patient. All Medicare Part B beneficiaries are entitled to one free (no out-of-pocket cost) AWV every twelve months.

Clinicians must perform a series of health risk evaluations in the AWV, including a cognitive assessment that might indicate mild cognitive impairment or dementia. Patients newly enrolled in Medicare Part B are also entitled to a one-time   “Welcome to Medicare Visit,” (formally known as the Initial Preventive Physical Examination, IPPE) that includes a brief cognitive assessment at no out-of-pocket cost. Neither the AWV nor the IPPE covers a full physical examination, despite the expectations of many patients (NOTE: Annual physical examinations are not a covered Medicare benefit, although many Medicare Advantage plans do offer coverage of an annual physical as a supplemental benefit).

The Medicare AWV and cognitive assessment

At present, the Medicare AWV is the only Medicare benefit designed to screen  Medicare beneficiaries for cognitive impairment and dementia, whether or not a suspicion of either  is present. By way of contrast,  the United States Preventive Services Task Force (USPSTF)  does not recommend cognitive assessment screening of adults  as an essential preventive health measure, so cognitive assessment is not subject to mandated, zero out-of-pocket coverage by Medicare and health insurance plans regulated by the Affordable Care Act.  Recent published evidence suggests that the AWV may increase diagnosis of mild cognitive impairment by over 20 percent compared to diagnosis among patients who do not receive an AWV.

Limitations of the Medicare AWV for Detection of Early Alzheimer’s Disease

In practice, the Medicare AWV has several limitations as an intervention for cognitive assessment:

Uptake : A 2023-2024 survey  of a representative patient panel suggests that uptake of the AWV may have reached  about 80 percent of Medicare Part B beneficiaries.  The same survey indicates that uptake among beneficiaries aged 65-69 is about 72 percent, compared to uptake of about 84 percent among older Medicare patients --- suggesting that mild cognitive impairment and dementia is somewhat more likely to remain undetected among individuals who are new to Medicare or “young Medicare patients”. Uptake of the Welcome to Medicare Visit (IPPE) among new or recently enrolled beneficiaries is significantly lower.  A 2018 study suggested that uptake had reached 12.3 percent of Part B beneficiaries by 2016.

Disparities in uptake:  Longstanding disparities in AWV uptake among Black and Hispanic Americans and lower-income patients have persisted, even after targeted promotion within health care systems.  Uptake is lower among beneficiaries covered under Traditional (fee-for-service) Medicare,  compared to beneficiaries covered under Medicare Advantage.

Continuity of AWVs Among Patients: Little is known about how consistently patients use the AWV from year to year. A recent study of patients in a large health care system indicated that nearly 60 percent of patients (58.6 percent) were “regular users” who received four or five visits within a five-year period. Nearly 30 percent (27.7 percent) received 2-3 visits over the same period, and about 14 percent (13.7 percent) received either one or no visits.

Clinician time constraints: Medicare regulations mandate that clinicians attest to completion of nine separate evaluations during the AWV, including a medication review. Patients with complex conditions may require additional evaluations. While data is limited, published evidence suggests that a rigorous set of evaluations requires thirty to sixty minutes of clinician time. Time constraints dictate that the required cognitive assessment be extremely brief.

Frequency of cognitive assessments conducted within the AWV: Limited data is available on the extent to which cognitive assessments are (1) actually performed, and (2) documented in medical records. Medicare requires clinicians to ask patients about any memory or cognition concerns and elicit self-reported concerns known clinically as evidence of subjective cognitive impairment. A 2016 CDC analysis of a national patient survey (2011 data) suggested that less than half of patients with a memory concern (47 percent) discussed their concern with a physician during any visit, and only 16 percent reported receipt of a brief cognitive assessment.

Clinical rigor of cognitive assessments conducted within the AWV:  Recent analysis has suggested that, in the aggregate, subjective cognitive complaints may be 60 percent predictive of “true positive” cases of dementia in large patient populations. Structured cognitive assessment tests have been validated at a higher degree of accuracy in use with individual patients. The MiniCog©  is a free (public domain) three- minute test that has been validated for sensitivity and specificity exceeding 70 percent and 80 percent, respectively. The MiniCog© has found acceptance in larger health care systems but evidence of uptake among primary care clinicians overall  is limited.  Brief, digital cognitive assessment tools promising high accuracy are in rapid development, including tools with capabilities predictive of amyloid burden associated with Alzheimer’s disease.   

Implications and Potential Improvements in Performance

Several potential changes in policy, clinical practice, payment and primary care workflow design might render the Medicare Annual Wellness Visit more effective for timely detection of early Alzheimer’s disease, including:

Provider incentives for completing AWVs with patients: At present there are no operative quality improvement measures in place that provide payment incentives for AWV completion in either Traditional (fee-for-service) Medicare or Medicare Advantage, (e.g. HEDIS, MIPS, or Star Rating measures), although an estimated 20 percent of Medicare Advantage provider contracts offer provider incentives for AWV completion .

Incentives for use of structured cognitive assessment tests or other objective tests for screening patients for dementias, including Alzheimer’s disease:  At present the Medicare program encourages use of structured cognitive assessment tests, but there are no active proposals to mandate their use. The Alzheimer’s Association recommends a protocol of cognitive assessment for the AWV that includes administration of structured cognitive assessment tools chosen by the provider. .  Consistent use of structured tests would enable more rigorous evaluation of patients and potential progression over time to dementias, including Alzheimer’s disease. Notably, the Alzheimer’s Association recently endorsed proposed legislation to enhance Medicare coverage of blood biomarker testing for Alzheimer’s disease,  a development that could accelerate adoption of biomarker testing as an alternative or complementary screening method.

Combine the AWV with chronic care management encounters: :  While uptake of the Welcome to Medicare Visit remains low and the regularity of patient Annual Wellness Visits is variable,  Medicare beneficiaries make an average of  three visits to primary care clinicians in a given year, and many more if they have chronic or complex care needs. Risks of dementia are known to be elevated among patients suffering from multiple chronic conditions, and include higher risks for the onset of Alzheimer’s disease. Targeted identification of patients without updated preventive health plans to facilitate scheduling of combined AWV and problem-based physician encounters could increase uptake of the AWV and the delivery of cognitive assessments to Medicare beneficiaries.