“The Medicare Pyramid of

Personalized Preventive Services

and a Case for Annual Wellness Visits

to Drive Adoption”

George Marmo

GM Consulting LLC

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“The Centers for Medicare & Medicaid Services (CMS) recognizes the crucial role that health care providers play in educating Medicare beneficiaries about potentially life-saving preventive services and screenings, and in providing these services.”

“While Medicare pays for a variety of preventive benefits, many Medicare beneficiaries do not fully realize that using preventive services and screenings can help them live longer, healthier lives. As a health care professional, you can help your Medicare patients understand the importance of disease prevention, early detection, and lifestyle modifications that support a healthier life.”

CMS, ICN 907786 July 2012

Although most of the 35.5 million Original Medicare (Part B) enrollees used one or more free Preventive Service in 2012, less than 9% utilize the Annual Wellness Visit or AWV

Only Cardiovascular Disease Screening Blood Tests and Seasonal Influenza Virus Vaccination were utilized by more than half the enrollees

Of the 10 most populated states, half were below the national average of 9% in AWV usage with a range between 6–12%

New Jersey has the 10th largest Medicare population and is slightly above the national average utilizing AWV

3* The Affordable Care Act – A Stronger Medicare Program, 2012 Annual Report

By advocating the Initial Preventive Physical Exam (IPPE) and Annual Wellness Visits (AWV) as a first step, Medicare will greatly increase the adoption of the pyramid of Personalized Preventive Services to achieve their goal of “disease prevention, early detection, and lifestyle modifications that support a healthier life”.

In particular, the AWV includes Risk Factors which help identify intervention as part of the mandatory Screening Schedule for the physician and Personalized Health Advice for the patient.

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The Medicare Pyramid of Personalized Preventive Services

Seasonal Influenza VirusPneumococcal

Hepatitis B (HBV)

CardiovascularDiabetes and

Aortic Aneurysm

Screening Pap TestScreening Pelvic ExamScreening Mammography

Initial Preventive Physical ExamInitial Annual Wellness VisitSubsequent AWV

ObesityAlcohol

TobaccoDepression

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Service Description ProcCode

Par Fee

Initial Preventive Physical Examination (IPPE)

Also known as “Welcome to Medicare Preventive Visit”

G0402 $181.77

Initial Annual Wellness Visit Initial personalized prevention plan and review of Health Risk Assessment

G0438 $188.63

Subsequent Annual Wellness Visit Updated personalized prevention plan and review of Health Risk Assessment

G0439 $125.36

January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions

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Service Description ProcCode

Par Fee

Intensive Behavioral Therapy (IBT) for Obesity

Face-to-face behavioral counseling, 15 minutes per visit, 22 visits per year.

G0447 $27.95

Screening and Behavior Counseling to reduce Alcohol Misuse

Annual alcohol misuse screening, 15 minutes

G0442 $20.87

Screening and Behavior Counseling to reduce Alcohol Misuse

Brief face-to-face behavioral counseling, 15 minutes, 4 visits per year.

G0443 $27.95

Counseling to Prevent Tobacco Use Intermediate smoking and tobacco cessation counseling, 10 minutes, 8 visits per year

G0436 $15.34

Counseling to Prevent Tobacco Use Intensive smoking and tobacco cessation counseling, 10 minutes, 8 visits per year

G0437 $29.72

Screening for Depression Furnished in primary care setting with staff assisted depression care support

G0444 $20.87

January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions

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Service Description ProcCode

Par Fee

Screening Pelvic Examinations

Cervical or vaginal cancer screening, pelvic and clinical breast examination, annual for high risk or 24 months

G0101 $42.88

Screening Pap Smear Screening cytopathology, cervical or vaginal, annual for high risk or 24 months

G0124G0141

$35.35$35.35

Screening Mammography Screening Mammography, digital, annual

G0202 $161.01

January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions

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Service Description ProcCode

Par Fee

Cardiovascular Screening Blood Tests

Medicare beneficiaries without apparent signs of cardiovascular disease

80061824658371884478

tbdtbdtbdtbd

Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

Medicare beneficiaries with certain risk factors for AAA as a result of an IPPE

G0389 $128.55

Diabetes Screening Tests Medicare beneficiaries with certain risk factors for diabetes or diagnosed with pre-diabetes every 5 years

829478295082951

tbdtbdtbd

Diabetes Self-Management Testing

Up to 10 hours of initial training

G0108 $57.15

January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions

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Service Description ProcCode

Par Fee

Bone Mass Measurements Single Energy X-ray study G0130 $40.00

Colorectal Cancer Screening Flexible SigmoidoscopyHigh Risk ColonoscopyBarium Enema (alt to G0104)Barium Enema (alt to G0105)Low Risk ColonoscopyFecal Occult Blood Test

G0104G0105G0106G0120G0121G0328

$166.99$466.38$262.55$262.55$466.38

tbd

Prostate Cancer Screening Digital Rectal ExamProstate Specific Antigen (PSA)

G0102G0103

$22.94tbd

Glaucoma Screening By an Optometrist G0117 $63.45

January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions

Awareness about Annual Wellness Visits must be driven from top down and bottom up. Medicare has provided incentives but needs to enhance their current communications to better educate the beneficiary as well as the physician.

State and local governments have a vested interest in reducing health care costs and should implement metrics tied to results to earn program grants similar to CMS incentives for EHR adoption.

State level Mayor organizations can foster participation and issue policy to incorporate action at the local level. As part of the New Jersey Health Care Quality Initiative, Mayor Wellness Campaigns are emerging as a vehicle to convert policy into action.

For many of these Preventive Services, copayment and deductibles have been waived thereby eliminating barriers to the consumer. We all just have to meet in the middle.

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George MarmoGM Consulting LLC

Business Development Manager

(973) 524-5048

gmconsultllc@gmail.com