For most people, the term “Preventive Care” suggests age appropriate cancer screenings, flu shots and childhood vaccinations. What about appropriate regular monitoring of symptoms that prevents the worsening of a chronic illness? Or timely interventions that reduce or prevent complications due to a medication or a stressful life event?
Preventive care is a much broader concept that includes (but not limited to) activities that lead to the overall reduction of adverse events (e.g. fewer life-threatening complications due to a chronic illness) and the promotion of overall health in the entire population.
The “Annual Wellness Exam” (aka Annual Physical, Annual check-up, Health Maintenance Visit, Preventive Care Visit, etc.) is perhaps one of the most underutilized benefits in a health plan even though it is available at no out-of-pocket cost to the covered individual (with most federal, state and commercial plans).
Getting an Annual Wellness Exam regularly offers two main advantages:
- An individual who does not proactively seek care (often referred to as a “non-utilizer”) gets monitored for any new and/or existing physical and emotional problems, assessed for various risks and guided to close relevant care gaps (e.g. BMI, Mammogram, Blood Pressure check)
- Establishes a relationship between the member (including his/ her family) and the Primary Care Provider (PCP)’s office making it more likely for the PCP to be the first point of contact for any health issue - rather than an Urgent Care or ER
From a Payer (Employer, Health Plan, other) and Provider (individual Physician, Group Practice, Health System, other) standpoint, there is also a financial advantage in ensuring all members get a Wellness Exam every year as described below.
What does the data show?
In looking at the Professional component of medical claims data for the last 3 years, HDMS saw an overwhelming trend among our customers. We classified members into two groups:
- Those that HAD received an Annual Wellness Exam during the reporting year
- Those that had NOT had an Annual Wellness Exam during the reporting year
Adult members in both groups were then compared for ER Utilization, particularly for Avoidable ER usage using the NYU Emergent Status & AHRQ Prevention Quality Indicator (PQI) methodologies.
The results showed:
- Members who have NOT had an Annual Wellness Exam within the last reporting year, consistently incurred higher overall Cost AND higher number of Visits to the ER for complaints (conditions) that are classified as: “Non-Emergent”, “Primary Care Appropriate” and “Preventable/ Avoidable.”
- There were a higher number of members WITHOUT an Annual Wellness Exam within the last reporting year, with one or more visits to the ER for diagnoses, that qualify as “Ambulatory Care Sensitive Conditions”
What does this mean?
These reports show a clear pattern. Members who get an Annual Wellness Exam are less likely to use the ER for conditions that can be treated and/ or managed at a less expensive site of care. Hence, it is in the best interest of the organization to encourage and incent all their members to establish a relationship with a PCP and get regular Wellness exams.