IMPROVING OUTCOMES AND PROFITABILITY Improving Patient Outcomes and Private Practice Profitability Michelle Lenée Hill Edson College of Nursing and Health Innovation, Arizona State University Author Note Michelle L. Hill is a registered nurse in Arizona. The author has no known conflict of interest to disclose. Correspondence should be addressed to Michelle L. Hill, Edson College of Nursing and Health Innovation, Arizona State University, Health North Suite 301, P.O. Box 873020, Tempe, AZ 85287-3020. Email: MLHill6@asu.edu 1 IMPROVING OUTCOMES AND PROFITABILITY 2 Abstract Medicare implemented a yearly Annual Wellness Visit (AWV) to improve quality patient care through early detection of declining health. However, there has been only partial provider participation since its inception, which potentially delays treatment and negatively impacts patient outcomes. The aim of this quality improvement project was to assess the feasibility of implementing a standardized electronic AWV template into private primary care practices to improve the consistency of delivery and documentation. The project designer utilized the theory of transitions (TOT) to facilitate the project execution. An electronic Excel-based template was designed to capture and calculate all aspects of the AWV, including billing codes, to allow for ease and consistency of use within a small primary care practice over two weeks. A provider performed the AWVs using the electronic template after completing a hands-on tutorial and reviewing an educational handout. Data were retrieved from a 7-question, 5-point Likert scale questionnaire given to the provider to assess the effectiveness of the electronic template versus a paper assessment. The results of this study indicated overall satisfaction with using leveraged technology to provide consistency of AWVs to improve patient outcomes, provider satisfaction, and increase revenue through uniform charting and billing. The outcomes of this project provide a basis of existing evidence for using standardized methods to perform and track Medicare AWVs. Keywords: Annual Wellness Visit, Medicare, MIPS, primary care, financial sustainability, profitability IMPROVING OUTCOMES AND PROFITABILITY 3 Improving Patient Outcomes and Private Practice Profitability The United States is faced with managing an aging population like nothing it has seen before. With age comes increased healthcare costs due to longer life spans and more chronic illness than in the past. Many people today are affected by multiple comorbidities, which can be costly to patients, their families, healthcare organizations, and the country. The key to a productive aging society is to maintain good health through prevention and education, manage chronic disease with regular primary care visits and practical self-management skills, and improve quality of life. Many programs and models are designed to promote quality health care and cost-effectiveness lack uniformity, which may negatively impact the financial sustainability of private practice and lead to poor patient outcomes through decreased quality care and disease prevention (Basu et al., 2015). Problem Statement The management of patients with chronic and complex health problems is a significant challenge in primary care. The current care model is reflexive and imbalanced, with an uncoordinated system of multiple providers managing one patient (Bleijenberg et al., 2016). Small primary care practices struggle to deliver individualized patient-centered care while keeping up with current advancements in quality of care, as guided by Medicare, and maintaining a financially sustainable business (Basu et al., 2018). In a continually changing healthcare system, the emphasis is on providing evidence-based care and prevention without extensive costs. Value-based care models centered on pay-forperformance have become the programs of choice. These models require a considerable amount of upfront training relating to how coding and billing work, the types of services needed at each visit, and how best to transition while still conducting business (Basu et al., 2018). Researchers IMPROVING OUTCOMES AND PROFITABILITY have demonstrated that such value-based systems can increase revenue without increasing costs and can improve quality, and management of disease prevention provided and healthcare provided to patients (Basu et al., 2018). There is a paucity of literature examining the initial cost and labor burdens placed upon smaller private practices when implementing process changes. Primary care providers have concerns about providing the reimbursable services due to time constraints. The number of administrative duties takes staff away from managing the practice's daily needs (Berdahl et al., 2019). These concerns are valid and may directly impact provider, staff, and patient satisfaction. Unless the implementation of these valuebased systems is streamlined, small private practices will continue to suffer financially and perhaps have to close their doors, directly impacting the population they are attempting to serve. Purpose and Rationale This paper reviews the benefits of chronic disease management and value-based care models in primary practice. The goal is to understand whether these models promote improved patient outcomes for prevention and chronic disease education and management, increase organizational profitability while minimizing costs, and assist private primary care practices with quality healthcare delivery improvements and financial sustainability. Background and Significance Private Internal Medicine Practice In their landmark review, Wagner et al. (1996) discussed the lack of incentives encouraging primary care providers to spend time assessing health status and quality of life, and 4 IMPROVING OUTCOMES AND PROFITABILITY 5 educating patients for self-management. The review found delays in detecting clients’ declining health, the lack of education in managing chronic illnesses, and ineffective interventions not addressing psychosocial distress all led to poor outcomes for chronic disease in primary practice (Wagner et al., 1996). Today, Medicare is attempting to initiate chronic illness care and preventive measures to improve healthcare quality. As part of the Quality Payment Program, Medicare wants primary care organizations to provide scientifically acceptable evidence-based services. Through meeting these expectations, organizations are paid based on how well they provide these quality measures (Centers for Medicare & Medicaid Services [CMS], 2020). One such program implemented on January 1, 2017, is the Merit-Based Incentive Payment System (MIPS) (Berdahl et al., 2019). The MIPS program incentivizes providers in primary care to improve the quality of care provided to adults aged 65 years and older (Chung et al., 2018). The MIPS program includes an Annual Wellness Visit (AWV), which is 100% paid by Medicare. These are high yield appointments that help meet meaningful use guidelines and practice revenue goals (Hatcher, 2020). Appointments are approximately 30-45 minutes and provide an opportunity to collect information from the health risk assessment for chronic disease and other health related topics. This information is useful for timely screening for disease prevention and management. AWVs also allow time for cognitive screening, advanced care planning, and personalized health advice. If problems are discovered, referrals are ordered for services such as physical therapy, psychological services, and nutritional interventions for diabetes or weight management if appropriate (CMS, 2021). Value-Based Interventions IMPROVING OUTCOMES AND PROFITABILITY 6 Health care interventions for older adults in the early stages of decline are promising, primarily when targeted at populations with specific risk factors, such as individuals with lower levels of education (Bleijenberg et al., 2016). In an ongoing randomized controlled trial study, researchers evaluated the effectiveness of how the implementation of behavioral science could improve health outcomes using an electronic health record (EHR)-based deprescribing tool. The tool protects older adults from the unintentional consequences of overprescribing, drug interactions, or potentially hazardous drugs, which could lead to falls or additional health risks (Lauffenburger et al., 2021). Streamlining available technologies to meet the needs of patients and providers can go a long way toward improving health outcomes through preventive care measures. Braillard et al. (2018) described the impact of chronic disease management (CDM) from the perspectives of primary care doctors. The doctors reported feelings of powerlessness and frustration with the limited time they had to address all that was needed during the visit. The extensive tasks that needed to be performed in the limited time left providers struggling with initiating the relationships needed to manage chronic illness long term. Physicians expressed frustration over the possibility of missing essential steps with assessments or detailed medication reviews due to time constraints. CDM, comprehensive medication management (CMM), MIPS, and AWV are all examples of value-based models of care. Concurrent use is possible depending on the patient's age and whether the need arises. Basu et al. (2018) discussed the need to remain competitive by adapting strategies to remain financially stable in a continually changing healthcare market. Incentive programs have played a significant role in influencing quality care delivery by connecting it to pay-for-performance. IMPROVING OUTCOMES AND PROFITABILITY 7 Practice Transition Evaluations of evidence-based and quality of care provided are inconsistent with how they are measured; thus, the reliability and validity of these interventions are unknown (Khadjesari et al., 2017). In an article detailing the MIPS program's first year, the authors found high rates of only partial participation in the program (Apathy & Everson, 2020). In some cases, primary care physicians worried that the administrative burdens were detracting from patientcentered care, thus impacting patient and physician satisfaction (Berdahl et al., 2019). As with a systematic approach to research, the standardization of outcome measurements within the healthcare field for new evidence-based tools is a critical issue to address (Khadjesari et al., 2017). Desired Outcomes In a Houston area clinic group, physicians and pharmacists evaluated the effectiveness of a CMM system implementation. The analysis found that the CMM addressed medication problems for its participants. Medication errors were reconciled, patients were protected, and the organization saved more than a million dollars in medication costs (Chung et al., 2020). Ultimately, these outcomes are desirable in healthcare. Holstein (2018) proposed the need for nurse practitioners (NPs) to promote policy changes within the legislative branch to allow them to practice in all 50 states at the level trained. The author notes that NPs have unique expertise in managing chronic health conditions, and educating patients on self-care management techniques (Holstein, 2018). As with the AWVs, the management of chronic conditions requires sufficient time to recognize potential problems and develop trusting relationships. NPs are perfectly positioned to take up the challenges of time during organizational changes to meet the current and future healthcare paths. IMPROVING OUTCOMES AND PROFITABILITY Internal Evidence In the private primary care practice described in this project, more than 95% of the patient demographic consisted of people over the age of 65 utilizing Medicare as primary insurance. Providers needed to address quality improvement and pay-for-performance through the MIPS. The MIPS program includes an AWV fully covered by Medicare. These are highyield appointments that help providers meet meaningful use guidelines and practice revenue goals (Hatcher, 2020). The author proposed creating a tool designed to work with the existing EHR system to capture all services performed during the AWV and link each service to its proper code for facilitated reimbursements and tracking. The purpose of this tool is to increase income while providing the evidence-based practice (EBP) quality improvements Medicare requires. The recent implementation of an EHR system was a significant financial undertaking for this relatively small practice. Since its inception, the business has experienced problems utilizing the EHR to its full potential, including capturing and recording appropriate codes for reimbursement purposes. The costs and challenges of navigating a new system and learning the Medicare reimbursement requirements while maintaining enough financial revenue to sustain the practice have been difficult. The potential for financial return exists within the MIPS program and AWV if time permits. In 2020, the practice recorded 2,347 patient visits over 44 weeks. When calculating the same number of patients coming in for an AWV and adding incidental charges for services met outside of the AWV coverage, the projected annual income would increase by approximately 62% (Hatcher, 2020). Pairing financial incentives with quality preventive care is associated with increased compliance with value-based services (Navathe et al., 2019). Financial return is an important aspect 8 IMPROVING OUTCOMES AND PROFITABILITY 9 of practice change, providing for the practice owners, employees, and their patients during improvements while helping individuals with their chronic health conditions. PICO(T) Practice change is a recurring theme in healthcare. There can be problems reconciling the continued desire to provide the best quality care and with the need to keep pace with advances in technology while remaining fiscally conservative. This inquiry has led to the formulation of a clinically relevant PICO(T) question, “In a primary care clinic (P), how does the implementation of value-based care models (I) compared with standard systems (C) affect the financial sustainability of the practice (O)? Search Strategy An exhaustive search of the literature was performed to answer the PICOT question. The databases searched were PubMed, ABI/Inform, CINAHL, ProQuest, Scopus, Cochrane Library, and Arizona State University's digital repository. Keywords included: primary care, private practice, primary care provider, Medicare, Annual Wellness Visit, MIPS, chronic disease management, value-based care models, pay-per-service, pay-for-performance, incentive payments, financial sustainability, profitability, income and financial stability. MeSH terms were utilized, further studies were retrieved from data mining sources within related articles, and government websites were searched for related gray literature. Inclusion criteria were studies evaluating incentives or reimbursements to practitioners meeting value-based quality measures and outcomes related to the primary care practice's financial viability in providing these services. Exclusion criteria were salaried providers without the possibility of incentive pay or bonuses for performance, any non-preventive Medicare-related IMPROVING OUTCOMES AND PROFITABILITY services, and studies that did not include private practice. Works written before 2016 were filtered. Scopus An initial search yielded 10,398 articles. With revised keywords and the exclusion of research published before 2016, 58 results remained and one article was chosen. A secondary revision of keywords adding profitability and defining the population as a providers rather than a patients resulted in 15 articles, none of which were relevant. PubMed After revising the search keywords several times, 68 articles yielded two possible results, and additional filters led to 23 reports. Six high level articles were retained for further evaluation. A secondary search was needed answer the PICO question further. Refining the keywords to relay value-based care and financial viability initially yielded 51 articles, and with additional filters for age and study type, 16 more articles were selected for further review. ABI/Inform An expansion of keywords applied to this database resulted in 1153 articles. With applied limits and refining keywords, the database produced 119 results. Several articles were retrieved for relevance but none were higher than level III evidence to support the PICO question. One article of gray literature was retained for the final review. Critical Appraisal and Synthesis The manuscripts chosen were subjected to a rapid critical appraisal checklist relative to the study type (Melnyk & Fineout-Overholt, 2011). They were subject to additional scrutiny through a breakdown of descriptive and inferential statistical analysis and were then placed 10 IMPROVING OUTCOMES AND PROFITABILITY 11 within an evaluation table for further review (see Appendix A, Table A1). Ten quality studies were retained for this manuscript. All articles included level I-III evidence. The studies comprised one meta-analysis, one randomized controlled trial, three cohort studies, one systematic review, three retrospective studies, and one observational quasi-experiment. Each study was placed in a synthesis table to evaluate common themes and note any outliers (see Appendix A, Table A2). The table demonstrates the three types of incentives used within valuebased care models. In the United States, MIPS and AWVs are used by the Medicare system. Due to the large degree of heterogeneity of P4P schemes, single-payer type entities were used as a comparative measure to Medicare. These included the Veteran’s Administration, Canada’s Medicare system, and evidence from 12 other countries worldwide. Quality indicators included chronic disease or medication management improvements, all-cause quality improvements, increased preventive care visits, and reduced hospital readmissions and ER visits. Due to the nature of subject matter, all 10 studies were retrospective, thus potentially limiting validity through bias while performing chart reviews. Apart from one systematic review reporting results in a narrative form, studies reported findings in terms of significance, odds ratios, and confidence intervals, leading to the reliability of the evidence presented. Of the 10 studies, 9 demonstrated evidence of improved quality outcomes at some level. One outlier stressed the importance of using a more homogenous approach to reporting findings within research assessing P4P schemes, allowing for an easier understanding of what works, why it works, and how to employ a similar design (Zaresani et al., 2021). Another common theme among the articles was the concern for cherry-picking patients from the healthiest and most compliant to receive quality care interventions. The concern appeared to be that the healthcare provider would then achieve more of the required markers to ensure maximum P4P. Although IMPROVING OUTCOMES AND PROFITABILITY 12 this concern is valid, the 10 studies in this manuscript did not show any evidence of promoting health service inequities. Discussion The evidence indicates that value-based care models have a positive impact on quality care measures. P4P schemes, whether paid in bonuses, MIPS reimbursements, or AWV incentives, increase the likelihood that a primary care provider will ensure these measures are met. The evidence presented showed improved treatment for hypertension, diabetes, and multicomorbidities, as well as medication management. Preventive care visits, including AWVs, help providers meet quality measures in one visit, leading to increased prevention screenings, earlier problem detection, and decreased hospital readmissions and ER visits. The discussion of private practice profitability did not appear in many articles; rather, P4P schemes tended to focus on a more individualized provider approach. In theory, this may be advantageous for smaller private practices if a clear guide is made available to facilitate quality implementation measures and allow for full utilization and participation. P4P schemes are particularly beneficial for the older population who have the most comorbidities across all populations. Helping private practices to meet all quality measure expectations can improve the overall health and quality of life for seniors. Theory Application Utilizing a theoretical framework is helpful for organizing research findings and explaining conceptual evidence in a structured, systematic way. As a middle-range theory, the theory of transitions (TOT; see Appendix B, Figure 1) fits well with the complex variations in organizational change (Smith & Liehr, 2018). TOT focuses on change, support through transition, and the promotion of optimal outcomes through preparation and knowledge. Changing IMPROVING OUTCOMES AND PROFITABILITY 13 environmental conditions that affect people's lives in a work environment are considered organizational transitions (Smith & Liehr, 2018). Organizational transitions may affect the structure, function, or dynamics of a practice (Schumacher & Meleis, 1994) and following the steps of TOT can lead to a smoother transition. The framework requires an understanding of the needs of the practice and the stakeholders involved in the transition. A plan to address unanticipated barriers is practical, as is a well-organized management plan to help develop connectedness and confidence. A former Arizona State University doctoral student supported the transition of patient medical records from paper charting to a new EHR system for her doctoral project (Long, 2021) for the above-mentioned private practice. The project managed to implement significant organizational change by utilizing the TOT framework. Therefore, it is with this theory that an innovative idea led to organizational change. The lead project investigator developed an electronic AWV template utilizing leveraged technology to meet the needs of financially strapped small private practices. The electronic AWV template is designed specifically to address consistency when performing the AWV by meeting all CMS requirements. Diagnosis codes and screening codes including current MIPS requirements, are embedded into each section. The template provides consistent, reliable charting due to its ability to auto-populate billing and screening codes into a summary section once the AWV is completed. The auto-capture of codes is paramount to the success of an electronic AWV template, as the codes can be easily copied from the summary section and placed into the billing section of the patient EHR allowing for a significant time savings, decreased coding transcription errors, and the ability to now track all aspects of the AWV. Implementation Framework IMPROVING OUTCOMES AND PROFITABILITY 14 The continuous quality improvement (CQI) model is a quality improvement model geared toward implementing EHR systems in healthcare practice (National Learning Consortium [NLC], 2013). CQI explicitly supports the practice of utilizing meaningful use guidelines and Medicare’s EHR incentive program, which has transitioned into MIPS. The evidence derived from the 10 articles describes the benefits of quality care through provider usage of P4P programs. MIPS is, in and of itself, the very essence of a P4P scheme, naturally leading to choosing CQI for the project (see Appendix B, Figure 2). The project design aims to move from an area in need of improvement to a desired future state. Through the application of continuous quality improvements, this goal is possible. The CQI framework model begins with the desire to continually improve quality. By moving through the steps laid out in the CQI framework, the electronic AWV template can be optimized as a quality improvement tool. From the structure process ensuring that the technology is adaptable for use to a broad range of individuals through to the outcome stage where the project is completed, the CQI framework is a perfect fit for a project of this caliber. CQI works with a continuous feedback loop allowing the project manager to return to the beginning and continue improving the electronic AWV tool to achieve the best possible template with the easiest workability. Planning and Intervention The AWV is essential for smaller private practices to stay current with the most effective evidence-based care for patients and augment practice revenue. As stated previously the above practice in question was struggling with financial concerns. This inquiry led to the evaluation question: For a geriatric primary care practice, does IMPROVING OUTCOMES AND PROFITABILITY 15 implementing an AWV checklist within the EHR system improve practice profitability at eight weeks post-intervention? The project designer remained in close contact with the site champion to ensure the continued alignment of goals and project approval. Initial steps included coordinating schedules with the EHR representative, reviewing secure storage alternatives, and ensuring that appropriate methods to maintain the anonymity of all protected data related to the project were in place. Once these initial measures were achieved, the AWV tool was assessed for readiness and implementation. An educational handout was constructed before implementation of the AWV tool. Finally, a review of the project team and an assessment of additional members were undertaken. Potential Outcomes A streamlined approach to support the goals of Medicare’s AWV and address the challenges for optimum use in private practice is paramount. As the evidence suggests, P4P schemes increase the quality of care given to patients, address preventive measures, and decrease hospital readmissions and ER visits (Cross et al., 2017). A tool that allows for easy tracking and implementation of paid-for-services, which are often performed but not billed, can have longlasting implications for the financial bottom line. Potential barriers to this project exist for the very reason the practice needs this tool: a genuine hurdle of financial burden. The goals of providing the highest quality care and maintaining the viability of smaller private practices go hand in hand. The focus moving forward should be on increasing quality patient outcomes without negatively affecting private practice profitability and sustainability. Methods IMPROVING OUTCOMES AND PROFITABILITY 16 To assess the feasibility of improving the consistency and documentation of Medicare’s AWV to improve patient outcomes, improve provider satisfaction, and potentially increase future revenue, an electronic AWV template was developed for implementation into a single small private practice. Education and support were given to all participants involved during the project implementation period. There was one evaluation period at the end of the project utilizing an electronic AWV template evaluation questionnaire. Ethical Considerations Human subject protections and all requirements laid out within the Collaborative Institutional Training Initiative (CITI Program) course work were complied with, as required by Arizona State University’s Internal Review Board (IRB). Both the project investigator and coinvestigator have successfully completed this training. Approval from Arizona State University’s IRB (see Appendix C) was obtained prior to project implementation. The feasibility evaluation questionnaire for the electronic AWV template was the only evaluation undertaken in this project. The evaluation form was anonymous, and due to the small sample size, the questionnaire was kept in a locked safe along with the signed informed consent forms (see Appendix D) at the primary investigators home. The primary investigator was the only person with access to the completed questionnaire and signed consent forms. The investigators did not have access to the completed AWV forms, nor did they know any specific patient information. Completed electronic AWV templates were kept by the provider within the respective secured patient charts inside the practice’s EHR for future use. The template was uploaded as an external document inside the tab “Medical Forms Report”. Under HIPAA policies and procedures, the above-stated project site remains fully compliant IMPROVING OUTCOMES AND PROFITABILITY 17 with regard to secured data storage, encryption, and confidentiality, and all accessible electronic computers, including desktops, and laptops, have individual password protections. Population and Setting The project site, located in the Southwestern United States, is a small private primary care practice consisting of three providers: two physicians and one family nurse practitioner. The practice specializes in internal and geriatric medicine, serving the local community. Approximately 95% of the practice`s patients use Medicare insurance. The project site does not require any specific regulations or review board processes. Inclusion criteria were any participants employed at or affiliated with the project site who could provide an AWV to a patient within their scope of practice. Participants had to be English speaking and 18 years or older. Exclusion criteria were individuals not affiliated with the project site and those who did not wish to participate. Objectives The goal of this quality improvement project was to find an affordable, sustainable method to improve patient outcomes while maintaining private practice profitability through consistent charting and billing using the electronic AWV template. Medicare sets out a list of quality measures it wishes providers to meet, yet it has no set process or template of how to achieve these measures consistently. The Medicare policy MIPS is meant to increase patient outcomes by incentivizing providers to adopt quality care preventive measures. With an increase in meeting MIPS scores through the utilization of the project template, providers should be able to increase their reimbursements at a higher rate, thus resulting in a desirable situation in which providers maintain profitability and patients receive the best quality care. Project Description IMPROVING OUTCOMES AND PROFITABILITY 18 This project aimed to assess the feasibility of use by implementing an electronic AWV template into a small private practice over a two-week intervention period. Prior to the intervention period, the author reviewed the electronic AWV tool for compatibility and efficiency and edited it as needed. Several check-ins with stakeholders occurred prior to project implementation to assess goals and schedule a convenient intervention time period. An educational printed handout with snap shots of the electronic tool and directions was given to the provider to keep after an in-person hands-on tutorial was conducted by the author (see Appendix F). A questionnaire was given to the participant at the end of the two-week intervention. Instrumentation The Electronic Annual Wellness Visit Template Evaluation Questionnaire consists of a seven-question survey designed by the primary investigator (see Appendix G). The questionnaire has not been recognized for validity and reliability indicators; however, the survey was evaluated positively for face validity via the project mentor and IRB representatives. The questionnaire was used to assess the provider’s opinions regarding the template after using the tool for two-weeks. The questions focused on ease of use, convenience and time management, consistency, affordability, and revenue potential, and ultimately, factors related to patients’ health outcomes. The questions were delivered using seven questions on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The participants were also encouraged to voice their opinions, suggestions, or concerns related to the intervention. Data Collection and Analysis The completed questionnaire was collected at the end of the intervention period. Data remained anonymous and kept in a locked safe for analysis. Due to the single sample size, questionnaire results were hand tabulated, and the results were verified by uploading the data IMPROVING OUTCOMES AND PROFITABILITY 19 into Intellectus StatisticsTM software. Descriptive statistics were used to analyze the survey results. The electronic AWV template was designed using leveraged technology to provide an affordable alternative to costly EHR upgrades that are not accessible for smaller private practices. Therefore, other than time, the project implementation involved no monetary costs to the practice or the project investigators. Results Data analysis was conducted using descriptive statistics. The one provider who participated in the project intervention responded to the survey questions about the electronic AWV template with overall satisfaction. All responses were marked as either “strongly agree” or “agree” on a 5-point Likert scale. Of the seven questions, the provider strongly agreed that the template was easy to learn, easy to use, and more consistent, and that auto-population of codes improved revenue. The participant answered “agree” in response to remaining questions about the AWV template aiding in time management with regard to the convenience of the billing code summary section, the ability of the electronic AWV template to help improve patient health outcomes, and the provision of an affordable and convenient option for small private practices to implement into their regular yearly AWV assessments. The participant also added commentary related to the template, noting that modifiability would help them meet future goals that may change over the years. The participant reported that the electronic template would remain in use within the practice due to its convenience and the ability to upload the template into the existing EHR as an external document. The provider also stated that the template would then be accessible to other providers in the future, thus allowing for sustainability. IMPROVING OUTCOMES AND PROFITABILITY 20 The potential to consistently assess whether a patient has had their recommended vaccinations, cancer screenings, and cognitive screenings can have a great impact for providing consistent assessments and detecting declines in health early in the aging process. The electronic AWV template primarily assists the provider through consistent assessment, charting, and billing of the AWV, adding the potential for financial return by utilizing the billing summary for reimbursements of services rendered, and time management related to utilizing a simple systematic approach with each patient who is eligible for their yearly AWV assessment. The system benefits patient outcomes through preventive care that leads to improved health outcomes, benefits the provider and practice through improving income potential, and benefits overall Medicare costs through quality care patient health management. The potential impact on policy has yet to be seen. The author hypothesizes that the utilization of a simple tool using leveraged technology, such as the electronic AWV template, will allow for better tracking of patient outcomes through preventive care, thus allowing for a clear analysis of future recommendations related to affordable quality senior healthcare. Discussion Summary This quality improvement project aimed to assess the feasibility of an electronic AWV template using leveraged technology to provide an easy and affordable method of improving uniformity for yearly assessments in a small private practice. Although the sample size was small, the intervention demonstrated the potential for the implementation of this type of template. Medicare involvement with similar template support may be the catalyst for improving small private practice compliance with the performance of consistent AWVs. Limitations, Barriers, and Challenges IMPROVING OUTCOMES AND PROFITABILITY 21 The limitations of the project included the small sample size. Although the project site had three providers, only one engaged in testing the intervention. The nurse practitioner provider worked mainly as a partner to one of the physician providers and generally performed the AWVs for about half of the practice’s patients, assisted with patient follow-ups, and provided outside support to existing patients admitted to skilled nursing facilities after hospitalization. Because of this partnership, there were only two providers in the practice performing AWVs. The nurse practitioner was the project’s champion, so their participation was paramount to the project’s success. Despite a recent transition to a new EHR from paper charting, one physician provider refused to participate in electronic charting and therfore the project intervention. Literature Findings To date, there remains a paucity of literature evaluating patient health outcomes and healthcare spending in relation to the effects of providing an AWV (Moore et al., 2021). Research is also lacking in the area of small practice income when providing reliable CMS-level quality care. In a study assessing the benefits and costs of implementing innovative methods to increase the rates of AWVs, one method implemented a standardized AWV template into an Epic EHR system for a provider group of more than 150 serving over 34,000 patients. They focused on ease and efficiency when conducting the AWVs. Results of the study showed a significant increase of 63% in AWVs after the first year, and a 68% increase at a similar organization in the second year, indicating a great benefit for patients. A total of 87% of the providers met the target goals (Moore et al., 2021). Early disease identification and prevention measures managed through health screenings prevent chronic disease progression and save hundreds of thousands of dollars in Medicarerelated costs (Fragala et al., 2019). An assessment of data from health systems focused on AWV IMPROVING OUTCOMES AND PROFITABILITY 22 patient engagement and education found that there were significant CMS quality care gap closures in areas, where they were missing prior to the AWV. The report also indicated increases in downstream revenue with referrals, thus driving revenue, closing care gaps, and improving patient health outcomes (Linnert, 2021). Furthermore, a study examining the Medicare AWVs performed by providers in physician-led accountable care organizations found that organizations that prioritizing AWVs for their patients may improve healthcare quality and reduce costs due to the increase in preventive care delivery (Beckman et al., 2019). The utilization of the AWV improves preventive care for the elderly population, thus improving healthy aging (Jiang, et al., 2018). Recommendations for Further Research Future goals and research could include examining the participation rates of AWVs in larger studies of small private practices. Within these studies, assessment of goal markers achieved with each visit, including the impact on MIPS score capture, the percentage of screenings in comparison to past years without an electronic template, and the ability to detect illnesses early in their progression, is needed to gauge patient outcomes. Due to the complexities and inconsistencies when performing AWVs, future studies should address the financial impact on private practice. A recommendation for a Medicare-led national study with a comparison of a standardized AWV template versus current practice may provide meaningful information about whether this type of support is necessary for small private urban, rural, and remote practices to remain in sustainable business in the future. Finally, assessing patient outcomes related to the consistent use of a standardized AWV template in a national longitudinal study is paramount for evaluating patient health and healthcare costs in the long term. Conclusion IMPROVING OUTCOMES AND PROFITABILITY 23 In conclusion, this author found a problem with the lack of consistency in the delivery of Medicare AWVs in a small private primary care practice. The challenges facing the practice in their attempts to meet the needs of their patients while maintaining a sustainable practice included hardships due to the considerable financial burden of transitioning to a new EHR from paper charting. Training staff, managing MIPS scores electronically, learning how to utilize an entirely new billing system, learning the ins and outs of preventive care through CMS requirements of an AWV, and understanding how to maximize patient benefits and reimbursement income continued to cause difficulties for the practice. Planning an intervention to provide relief was one step in assessing the needs of small private practices that provide care to the nation’s senior citizens. The next step is to explore the measures Medicare can take to meet the goals it sets for patients, while supporting small private practices with the tools to succeed and provide the best quality care possible. IMPROVING OUTCOMES AND PROFITABILITY 24 References Apathy, N. C., & Everson, J. (2020). High rates of partial participation in the first year of the Merit-Based Incentive Payment System. Health Affairs, 39(9), 1513–1521. https://doi.org/10.1377/hlthaff.2019.01648 Basu, S., Phillips, R. S., Bitton, A., Song, Z., & Landon, B. E. (2015). Medicare chronic care management payments and financial returns to primary care practices: A modeling study. Annals of Internal Medicine, 163(8), 580. https://doi.org/10.7326/M14-2677 Basu, R., Schmidt, R. N., & Harth, K. (2018). 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BMC Health Services Research, 21(1), 175. https://doi.org/10.1186/s12913-021-06118-8 IMPROVING OUTCOMES AND PROFITABILITY 30 Appendix A Evaluation and Synthesis Table Table A1 Evaluation Table Quantitative Studies Citation Theoretical/ Conceptual Framework Design/ Method/ Purpose Sample/Setting Variables Measurement/ Instrumentation Data Analysis Results/ Findings Chung et al. (2018). Preventative visit among older adults with Medicare’s introduction of Annual Wellness Visit: Closing gaps in underutilization Inferred: Nola Pender’s Health Promotion and Illness Prevention Design: N=456,281Total person years n=108,734unique patients Demographics: Medicare patients ages 6585 Setting: PC in mixed payer outpatient healthcare organization in northern CA Exclusion: <65or85>yearold range IV1: Medicare beneficiaries CPT codes from EHR DV1: 32% with 19% increase after Medicare expansion DV2: Age Multilevel logistic regression model, stratified sample analysis, Chisquare, random effects model, DV3: CCI Stata 11.1 Country: U.S. Funding: Grant funds by AHRQ & HCSRN- Retrospective study Purpose: Assess how gaps in the underutilization of preventative healthcare visits can be reduced and utilization of preventative care services with a PCP before and after expansion of Medicare’s DV1: Made a preventative visit D4: Visit frequency per year DV5: primary insurance (1Medicare FFS vs 2-HMO) Covariates: sex, race/ ethnicity DV2: 20% visit increase age70-74, 18% age 80-85, 17% age 7579,15% increase age 65-69 DV3: CCI=20% increase, CCI2+=17% increase DV4: 0 visit:20%, 1:16.1%, 2:16.7%, Level of Evidence; Application to practice/ Generalization Level of Evidence: Level IIIRetrospective comparative study Strengths: large sample size, long term assessment Weakness: 1 single organization evaluated, healthy population on average, observational data, assessed the AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation Theoretical/ Conceptual Framework OAICs AGING Initiative Bias: Ages 6585 Apathy et al. (2020) High rates of partial participation in the first year of Inferred: Nola Pender’s Health Promotion and Illness Prevention Design/ Method/ Purpose Sample/Setting Variables preventative visit coverage Attrition: N/A Definitions: N: number of visits years 2007-2016 pre and post Medicare expansion and indicators of year assessed for variance within the major variables Design: Retrospective study Demographics: CMS Physician Compare database Setting: Outpatient Measurement/ Instrumentation Data Analysis 3:15.6%, and 4+:14% DV5: FFS-80.7% of participants with a 22% increase of preventative visits after expansion HMO-19.3% with 17% after expansion Covariates: all race/ethnicities showed an increase after expansion with the highest for Asians at 20% and AA lowest at 13% increase. Definitions: Indicators of year include the years before and after Medicare expansion N=1,631,647total physicians participating in MIPS 2017 Results/ Findings Data cleaning and validation Validity/ Reliability: Physician Multiple linear regression DV1: 45.7% did not participate in at least one category and 54.3% participated in all 31 Level of Evidence; Application to practice/ Generalization rate of AWV w/o content of visit including interventions addressed, no follow-up on long term outcome Feasibility: AWV coverage with Medicare expansion increased the rate of visits with primary care reducing disparity in preventative health visits Level of Evidence Level III Strength: Large data set, varied throughout the US AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation the MeritBased Incentive Payment System Country: U.S. Funding: National Library of Medicine, AHRQ Bias: CMS measurement values use of participation scores rather than performance scores in any given category Theoretical/ Conceptual Framework Design/ Method/ Purpose Sample/Setting Variables Measurement/ Instrumentation Purpose: Study examines the MIPS participation and clinician scores to comprehend how eligible providers attained payment adjustments and composite scores in the first year of MIPS primary care organizations and individual practices Exclusion: MIPS eligible clinicians who did not submit a claim within 6 months between 2017-2018 Attrition: n/a IV1: Eligible clinicians for MIPS program DV1: overall composite score of participation 100% DV2: quality measures 60% weighted DV3: advancing care information25% weighted DV4: improvement activities15% weighted Compare data were incomplete with categorical breakdown, validation performed by weighting each MIPS performance category Definition: Weighted: indicating the percentage of total physicians participating in the individual measured components of MIPS usage Data Analysis Results/ Findings categories, 10.9% skipped all 3 categories DV2: 26.5% nonparticipation DV3:34.8% nonparticipation DV4:16.9% 32 Level of Evidence; Application to practice/ Generalization Weakness: Unknown reasons for provider participation or non-participation under select categories; MIPS combined 3 separate quality programs leading to indeterminant variation; missing data of individual performance metrics Feasibility: Full participation in MIPS continues to be a slow transition and with penalties coming in 2022 for non or partial use by providers AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation Theoretical/ Conceptual Framework Design/ Method/ Purpose Sample/Setting Variables Measurement/ Instrumentation Data Analysis Results/ Findings Navathe et al. (2019). Effect of financial bonus size, loss aversion, and increased social pressure on physician payforperformance: A randomized clinical trial and cohort study Country: U.S. Funding: Commonwealth Fund and Robert Wood Johnson Foundation; Bias: n/a Inferred: Theory of Bureaucratic Caring Design: RCT and cohort study N=99- Total physicians within three groups included in the final analysis IV1: Physician performance with quality measures DV1-LBS DV2-LA/LBS DV3-ISP/LBS Cohort DV4-LBS DV5-non-LBS Patient was unit of analysis; physician survey Logistic regression; sensitivity analysis; difference in differences method; t-test to compare mean Likert scale responses; linear model with binomial distribution; logit link function; adjusted pairwise P value SAS software DV1: 4.2% increase DV2: 3.8% increase; p =.31 DV3: 4-4% increase with adjusted pairwise testing: p =.81 DV4: 4.1% increase DV5: 2% increase Purpose: Test whether increasing bonus size or adding behavioral economic principles of increased social pressure or loss aversion improves effectiveness of P4P Demographics Setting: physician hospital organization, and other advocate practices as a comparison in cohort Exclusion:32 physicians due to not having the unique attributed patients for the study. 7 physicians terminated contracts Attrition11% of patients with missing followup Definition: Physician behavior outcomes evaluated using RCT -LBS alone, versus LBS with LA and LBS with ISP, and cohort study LBS versus non-LBS 33 Level of Evidence; Application to practice/ Generalization Level of Evidence Level I Strength: Relevant to P4P increasing expansion Weakness: Single institution setting exposed to LBS; relatively small final sample size of physicians, observational analysis subject to confounding Feasibility: Increased bonus size was associated with improved QC compared to control. Adding ISP and opportunities for LA did not improve quality AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation Theoretical/ Conceptual Framework Design/ Method/ Purpose Sample/Setting Variables Measurement/ Instrumentation Data Analysis Results/ Findings Citation: Gupta et al. (2019). Effects of payfor performance for primary care physicians on diabetes outcomes in single-payer health systems: A systematic review Country: Canada Funding: Bias: Only P4P within single payer systems reviewed. Short length of follow-up Stated: PICOS: Population, Intervention, Comparison, Outcomes, Study type framework Design: Systematic review with PRISMA N= 717,166 total DM patients across all 10 studies Demographics: Physicians receiving P4P for patient DM care within national single payer systems Setting: PC and CM in 7 countries Exclusion: Studies with no evaluation component, Studies lacking quantitative data, pilot project evaluations, qualitative studies Attrition: none Definitions: n/a IV1: 10 -articles reviewed encompassing 8 P4P schemes Studies from countries with single-payer healthcare coverage evaluating P4P, all income level countries included GRADE; narrative synthesis Narrative evidence reflecting P4P may result in reduced mortality risk over long term care when link to performance metrics Purpose: An assessment whether P4P for physicians in PC and CM leads to better diabetes outcomes in single-payer national health systems DV1: Patient DM outcomes with P4P DV2: Patient DM outcomes with no P4P 34 Level of Evidence; Application to practice/ Generalization Level of Evidence: Level I Strengths: Large inclusion base spanning 7 countries, general representative patient population with DM Weakness: only wealthy countries with P4P assessed Feasibility: P4P schemes show effectiveness when incentives are tied to clear metrics AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation Theoretical/ Conceptual Framework Design/ Method/ Purpose Sample/Setting Variables Measurement/ Instrumentation Data Analysis Results/ Findings Cross et al. (2017). Sustained participation in a pay-for-value program: Impact on highneed patients Country: US Funding: The Commonwealth Fund Bias: n/a Inferred: Donabedian’s Quality Framework Design: N= 17,443 patients Demographics: Patients with 2 or more chronic health conditions in BCBMS insurance and PCP over a 4year span. Setting: 1582 PCP/ practices in Michigan with or without PGIP participation Exclusion: Patients not continuously insured with BCBSM Attrition: IV1: High-needs patients with PCP using PGIP Practice claims data Generalized linear mixed models Robust standard errors, log-normal distribution, Poisson distribution, normal distribution DV1: Lower odds [OR] 30day-0.65 and 90day-0.63 with P<.01 N= 1460 patients split equally into intervention and control group IV1: Value-based contracting Mandal et al. (2017). Valuebased contracting innovated Longitudinal cohort study Purpose: To assess impact of PCP in P4V is associated with improved care for high-need patients, compared to patients with no P4V for PCP Inferred: Quality and Outcomes Framework Design: observational quasiexperiment DV1: hospital readmissions 30 & 90 day DV2: ER visits DV2: Lower odds [OR] 0.88; P<.01 DV3: Higher 1.6%; P<.01 DV3: overall quality care DV4: Higher 3%; P<.01 DV4: Medication managementspecific quality DV5: No difference; P=.123 DV5: Overall medical-surgical cost DV1: RAF Full encounter patient claims data Cox proportional hazards model, Kaplan-Meier, Propensity-score model, DV1: Increase by 6.1% averaging an additional $629.89 PMPY DV2: CI=2.734 with p<.001 35 Level of Evidence; Application to practice/ Generalization Level of Evidence: Level I Strengths: Weakness: Study sample in MI alone, only 1/3 of patients in MI insured with BCBSM Feasibility: Highneed patients with PCP-PGIP participation had lower odds of hospital readmissions, ER visits, and higher quality care Level of Evidence: Level III Strengths: Longitudinal AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation Theoretical/ Conceptual Framework Medicare Advantage healthcare delivery and improved survival Country: US Funding: None Bias: n/a Huang et al. (2016). Diseasespecific payforperformance programs: Do the P4P effects differ between diabetic Inferred: Quality and Outcomes Framework Design/ Method/ Purpose Sample/Setting Variables Purpose: Assess if there is a difference in value-based contracting with MAO versus F4S with MA alone with utilization and outcome improvements Demographics: Community dwelling MA members 65years and older Setting: Primary care setting in Pacific Northwest area Exclusion: <65 Attrition: none DV2: preventative care utilization Design: Retrospective comparative study N= 52,276-DM patients Demographics: aged 20 yrs or older Setting: ambulatory care setting Exclusion: persons w/o DM IV1: DM-P4P Purpose: Evaluate the effectiveness on DM-P4P program on Measurement/ Instrumentation DV3: Survival DV1: DM care with MCC DV2: DM care w/o MCC Health insurance data base Data Analysis Results/ Findings CCI, logistic regression model, nearest-neighbor matching, permutation testing, DID model, IRR, forest plot, R Foundation for Statistical Computing DV3: Increase 6% benefit Propensity score matching; MPR; GEE with logit link; Poisson distribution; DID, Reported as: DV1: Increased QC exams=0.86, P<0.001, visits=0.02, P<0.05; ACSCs= -0.016, P<0.001 36 Level of Evidence; Application to practice/ Generalization comparison a statistically similar control Weakness: Environmental and social factors not included DV2: Increased QC exams=1.10, Feasibility: Value-based contracting between MAOs and providers improve clinical outcomes and survivability, and promote cost effectiveness. Level of Evidence: Level III Strengths: 4 years of data analyzed Weakness: Age and MCC a factor in outcomes, P4P AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation Theoretical/ Conceptual Framework patients with and without multiple chronic conditions? Country: Taiwan Funding: Ministry of National Science and Technology of Taiwan Bias: n/a Petersen et al. (2016). Impact of a pay-forperformance program on care for Black patients with hypertension: Important answers in the Inferred: Quality and Outcomes Framework Design/ Method/ Purpose Sample/Setting quality of DM care in patients with DM&MCC vs DM& no MCC compared to no P4P or younger than 21 yrs and persons expired prior to study end. Attrition: death not calculated in final results Design: Cluster RCT-nested N=50intervention group, n=17control group Purpose: Evaluate effect of P4P on QC for HTN Demographics: Black patients Setting: VA hospital-PC setting Variables Measurement/ Instrumentation Data Analysis Results/ Findings P<0.001, visits=0.02, P<0.05; ACSCs= -0.009, P<0.001 IV1: Hypertensive patients treated per JNC 7 hypertension guidelines DV1: Blood pressure control Electronic chart review; Monte Carlo cycles, unit of measurement: PY/PI Linear regression; Akaike’s information criterion, loglikelihood function; chi square; variance inflation factor; BenjaminiYekutiele method; DV1: 6.3%: 95% CI; 0.8-11.7% increase with PY/PI over control 37 Level of Evidence; Application to practice/ Generalization incentive increases midevaluation period Feasibility: Long term positive impact on QC for all patient with a larger impact on MCC patients Level of Evidence: Level I Strengths: RCTs of payment methods not well researched, single payment approach, incentives more meaningful to AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation era of the Affordable Care Act Country: US Funding: The Veterans Affairs HSR&D, IIR, NIH, and Houston VA HSR&D Center of Excellence Bias: Study was based upon the relative differences in effective treatments for Black, nonHispanics however, other races and ethnicities were not evaluated which could be perceived as bias Theoretical/ Conceptual Framework Design/ Method/ Purpose Sample/Setting Variables Exclusion: any patient outside of Black nonHispanic race Attrition: none or appropriate treatment Definitions: Risk selection: physicians picking patients based on their health conditions in order to maximize performance incentives Measurement/ Instrumentation Data Analysis Bootstrap analysis; t-test; SAS 9.2 Results/ Findings 38 Level of Evidence; Application to practice/ Generalization salaried physicians studied, availability of large data Weakness: Not generalizable to private PCP, varying amounts of incentives not studied Feasibility: P4P improved BP control and appropriate HTN response w/o producing risk selection. AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation Theoretical/ Conceptual Framework Design/ Method/ Purpose Sample/Setting Variables Measurement/ Instrumentation Data Analysis Results/ Findings LeBlanc et al. (2017). Influence of pay-forperformance program on glycemic control in patient s living with diabetes by family physicians in a Canadian province. Country: Canada Funding: Centre for medical research at the University of Sherbrooke and the Canadian Institutes of Health and research along with the NB Inferred: The Conceptual Framework for Fidelity Implementation Design: Cohort study, repeated cross-sectional perspective N=83,580eligible diabetic patients Demographics: age>20 yrs, diabetic patients followed by practitioners eligible to receive incentives Setting: primary care Exclusion: under 20 Attrition: Definitions: IV1: PCP receiving P4P vs no P4P Retrospective provincial laboratory data repository records for patients with an increase HA1C level Linear regression; logistic regression; multilevel modelling; SPSS DV1: 1.23, 99% CI-1.18-1.28 and showing increase of 56% following incentive implementation; Purpose: To assess whether the implementation of an incentive program changes the quality of care for diabetes at a population level DV1: Receiving at least 2 HA1C tests per year DV2: Difference in HA1C values DV2: no difference with intervention: SD=1.4 vs SD=1.4 with control -0.01, 99% CI -0.03-0.02 39 Level of Evidence; Application to practice/ Generalization Level of Evidence: Level I Strengths: first study to assess glycemic control at population level, adequate comparison group for study, 10 years of data analyzed Weakness: comorbidities not considered, Feasibility: P4P show greater odds for receiving at least 2 HA1C tests per year, but without significant changes in level of glycemic control. With better follow-up, lowering patient’s AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Citation Health Research Foundation Bias: None Zaresani & Scott, (2021). Is evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a metaregression analysis Country: Canada Funding: NHMRC and PCHSS Bias: none 40 Theoretical/ Conceptual Framework Design/ Method/ Purpose Sample/Setting Variables Measurement/ Instrumentation Data Analysis Results/ Findings Level of Evidence; Application to practice/ Generalization HA1C levels is promising. Inferred: PICOS: Population, Intervention, Comparison, Outcomes, Study type framework Design: Metaregression N= 620- total reported effect sizes IV1: study (23) with P4P scheme (37) Generalized linear model; logit link function, DID, ITS, RCT, BA DV1: Proportion of 0.53 or 53% (326 of 620) Level of Evidence: Demographics: P4P schemes, 12 different countries, Setting: studies including outpatient and hospital Exclusion: studies without a control and studies not adjusting for covariates Attrition: none DV1: positive outcomes with statistical significance Data were extracted from studies meeting research design criteria including effect sizes within interrupted time series designs, DID designs, and RCTs Purpose: To study the effects of P4P schemes and evidence related to statistical significance of success across countries Level I Strengths: Studies from 12 countries reviewed, Weakness: masked heterogeneity of schemes Feasibility: P4P remains inconsistent and with poorly designed schemes, leading to a slow progression. AA-African American, ACSC-ambulatory care sensitivity conditions, AHRQ-Agency of Healthcare Research and Quality, APM-alternative payment models, AWV-Annual Wellness Visit, BA- before-after with regression, BCBSM-Blue Cross Blue Shield of Michigan, CACalifornia, CCI-Charlson Comorbidity Index, CM-community care, CPT-current procedural terminology, DCSI-diabetes complication severity index, DID-difference-in-differences, DM-diabetes, DV-dependent variable, EHR-electronic health records, F4S-fee-for-service, FFS-fee-for-service, GRADE- Grading of Recommendations, Assessment, Development and Evaluations, HCPCS-Healthcare Common Procedure Coding System, HCSRN-Health Care Systems Research Network, HMO-health maintenance organization, HSR&D-Health Services Research & Development, IIR- Investigator-Initiated Research, IRR-incident rate ratio, ISP-increased social pressure, ITS- interrupted time series, IV- independent variable, LA-loss aversion, LBS-larger bonus size, MA-Medicare Advantage, MAO-Medicare Advantage Organizations, MCC-multiple chronic conditions, MIPS- Merit-Based Incentive Payment System, MPR-medication possession ratios, N-sample, n/a-not applicable, NHMRC- National Health and Medical Research Council, NIH- National Institutes of Health, NIH-National Institutes of Health, NP4P-non -pay-for-performance, OAIC-Older Americans Independence Centers, P4P-pay-for-performance, P4V-pay-for-value, PC-primary care, PCHSS-Partnership Centre on Health System Sustainability, PCP-primary care provider/practice, PGIP-Physician Group Incentive Program, PMPY-per member per year, PRI- practice incentives, PY/PR-combined physician and practice incentives, PYI-physician incentives, RAF-Risk Adjustment Factor, VA-Veterans Affairs, w/o-without, yrs-years IMPROVING OUTCOMES AND PROFITABILITY Table A2 41 Synthesis Table Title Article Synthesis Chung, et Cross, et al. al. Gupta & Ayles Huang, et al. LeBlanc, et al. Mandal, et al. Navathe, et al. Petersen, et al. Zaresani & Scott Year Apathy & Everson 2020 2018 2017 2019 2016 2017 2017 2019 2017 2021 Design/LOE RS/III RCS/III COS/I SR/I RCS/III COS/CS/I OQE/III RCTCOS/I RCT/I MRA/I X X X Value-Based Models MIPS/AWV P4P X X X X X X X X Quality Improvement Indicators Chronic disease or medication management Preventative care visits or all- cause QI Hospital readmissions or ER visits AWV-Annual Wellness Visit, COS-Cohort study, CS-Cross-sectional, LOE-level of evidence, MIPS-Merit-Based Incentive Payment System, MRA-Meta-regression analysis, OQE-Observational quasi-experiment, P4Ppay-for-performance, QI-quality improvement, RCS-Retrospective comparative study, RCT-Randomised controlled trial, RS-Retrospective study, SR-Systematic Review IMPROVING OUTCOMES AND PROFITABILITY Appendix B Figure 1 Theory of Transitions (Smith & Lier, 2018) 42 IMPROVING OUTCOMES AND PROFITABILITY Figure 2 Continuous Quality Improvement Framework Model (The National Learning Consortium [NLC], 2013) 43 IMPROVING OUTCOMES AND PROFITABILITY Appendix C IRB Approval 44 IMPROVING OUTCOMES AND PROFITABILITY Appendix D 45 Informed Consent Study Participant Consent I am a graduate student under the direction of Professor Dr. Monica Rauton in the Edson College of Nursing and Health Innovation at Arizona State University. I am conducting a test study to improve the consistency of Medicare’s Annual Wellness Visit (AWV) performed by providers of small private practice to better patient outcomes. I am inviting your participation, which will involve using an electronic AWV template while performing the patient AWV for 5-10 patients. The template is a point and click Excel sheet which includes labeled tabs for ease of use. The expected duration of your participation shall be no more than 14 days to completion. Participation also involves filling out a survey including questions evaluating performing the AWV post project implementation. You have the right not to answer any question, and to stop participation at any time. Your participation in this study is voluntary. If you choose not to participate or to withdraw from the study at any time, there will be no penalty. You must be 18 years of age or older and a provider or supervised student-provider at the project site medical practice to participate in the study. Your responses to the post test survey will be used to assess the feasibility of using an electronically based, uniform template for the AWV in small private practice serving a majority of Medicare patients. There are no foreseeable risks or discomforts to your participation other than the time commitment spent training on the use of the AWV template and the additional time participating in expressing your opinions of the AWV template within the above-mentioned questionnaire. We will spend approximately 15-minutes to train you in the use of the template and will ask you to spend an additional10-15-minutes completing the survey after you have used the template. Your responses will be confidential. All participant surveys will be kept under lock and key in a safe at the co-investigator’s home. The de-identified study data will only be shared in aggregate form with the study investigators for the purpose of analysis. Furthermore, the raw study data will be solely used to perform and write an analysis and discussion of the results and shall not be shared outside of the written report of the post-study results. The results of this study may be used in reports, presentations, or publications. Questionnaires will be devoid of any identifying information regarding the participant, patient identifying data, or project site. If you have any questions concerning the research study, please contact the research team at: Dr. Monica Rauton- Primary investigator, monica.rauton@asu.edu or Michelle Lenée Hill, BSN, RN, coinvestigator, mlhill6@asu.edu (602) 295-2765. If you have any questions about your rights as a participant in this research, or if you feel you have been placed at risk, you can contact the Chair of the Human Subjects Institutional Review Board, through the ASU Office of Research Integrity and Assurance, at (480) 965-6788. Please let me know if you wish to be part of the study. By signing below, you are agreeing to be part of the study. Name: Signature: Date: IMPROVING OUTCOMES AND PROFITABILITY Appendix E Electronic Annual Wellness Visit Template Double click on icon to view 46 IMPROVING OUTCOMES AND PROFITABILITY Appendix F 47 Annual Wellness Visit (AWV) Excel Template Education Step 1: Open AWV template and “save as” Patient Last Name_First Initial_AWV_Date and Year. Depending on your preference of managing patient data within HIPAA compliance, save to a secure file to be accessed for the upcoming assessment. Step 2: Following the outlined instructions, start with inputting the patients name, gender, and date of birth at the top-left of the client summary. The age will auto-populate once the DOB has been input. The additional pages of the AWV will also auto-populate the patient information at the top-left of each page. IMPROVING OUTCOMES AND PROFITABILITY 48 Step 3: Use the navigation links at the top or bottom of the template to flow through the tabs and answer the series of questions highlighted in yellow. Step 4: Some of the questions may be input prior to meeting with the patient, such as recent lab values or known medications. These items are to be reviewed with the patient to ensure accuracy. If applicable, in a future scenario, a medical assistant may ask the patient the “mini cognition questions”, and input the most recent blood pressure into the template. To the right of the highlighted answers, there is drop-down icon once the highlighted section has been activated with a click of the mouse. The appropriate patient response is then recorded into the template and any corresponding scores will auto-populate to the right of the answers. These scores will either calculate an overall score within a series of questions or generate a billing code, or diagnosis code as indicated. IMPROVING OUTCOMES AND PROFITABILITY 49 Step 5: As you move through the template, you will notice a few areas where laboratory values or vitals will be requested. Simply click the mouse on the highlighted area and type in the values and dates. Edit by clicking on highlighted area with the mouse and pressing back space to erase. Step 6: All patients require medication reconciliation. Follow the prompts and utilize the drop-down menu to the right as shown below. Again, billing codes will auto-populate as indicated by the chosen answers. IMPROVING OUTCOMES AND PROFITABILITY 50 *Some diagnosis codes will auto-populate based upon answers given. This is to ensure the patient chart has the correct diagnosis within their EHR as indicated through previous screening results. Please verify at the completion of the AWV that the patient’s medical history has been correctly updated. Step 7: Ensure immunization status is updated either by indicating “already received” or “declined”. A value of “unavailable” indicates the vaccination status has not been addressed. IMPROVING OUTCOMES AND PROFITABILITY Step 8: Once the AWV assessment is completed the client summary page will display the codes 51 addressed during the visit and the diagnosis codes to ensure addition to the patient’s medical history. These codes may be copied and pasted into the billing section of the EHR for reimbursement purposes. The template may be saved in the patient’s EHR under the “other medical documents” tab. The template may facilitate future AWV assessments by pulling up the previous year and comparing for significant changes. Any questions or concerns can be directed to the author of the AWV Excel template at: Michelle L. Hill Mlhill6@asu.edu (602) 295-2765 IMPROVING OUTCOMES AND PROFITABILITY Appendix G 52 Electronic Annual Wellness Visit Evaluation Questionnaire This questionnaire is designed to assess the provider’s opinions after using the Annual Wellness Visit (AWV) Excel template for performing the yearly patient AWV assessment. This questionnaire should take no more than 10 minutes to complete. Responses will help us understand the feasibility of using an AWV template in independent private practices. Please read each statement and indicate how strongly you agree or disagree by marking the check box in front of your answer. Thank you! 1. I found the AWV template was easy to learn. Strongly agree  Agree  Neutral  Disagree  2. I found the AWV template was easy to navigate and use. Strongly agree  Agree  Neutral  Disagree  Strongly disagree  Strongly disagree  3. I found the AWV template aided with time management in relation to the convenience of the billing code summary section. Strongly agree  Agree  Neutral  Disagree  Strongly disagree  4. I believe the AWV template helps maintain consistency with performing Medicare’s Annual Wellness Visits. Strongly agree  Agree  Neutral  Disagree  Strongly disagree  5. I believe the AWV template can help improve patient health outcomes. Strongly agree  Agree  Neutral  Disagree  Strongly disagree  6. I believe the AWV template is an affordable and convenient option for small private practices to implement into their regular their yearly AWV assessments. Strongly agree  Agree  Neutral  Disagree  Strongly disagree  7. I believe the AWV template has the potential to improve revenue through its auto-capture summary of billing codes. Strongly agree  Agree  Neutral  Disagree  Strongly disagree 