Small Solutions for Primary Care Are Part of a Larger Problem

“At a time when patients require whole-person care to improve their overall health and well-being, efforts to improve the quality of narrow processes in the primary care setting may instead lead to fragmentation of care and clinician burnout. We believe that truly patient-centered, integrated, whole-person care in the primary care setting would comprehensively address patient concerns during any given office visit, whether those concerns include chronic disease management, acute issues, or preventive health care. [..]

The annual wellness visit exemplifies a piecemeal initiative focused on specific components of care that fails to meet patient expectations of comprehensive care. [..]

Widely touted and promoted, the Medicare annual wellness visit provides an opportunity to advance patient wellness and increase use of important preventive health care services. This outpatient office visit is free to the patient, and Medicare offers it as a yearly benefit. The premise is that it gives clinicians dedicated time to devote to screening and prevention activities. Practices and clinicians benefit because they receive payment for the visit and for additional screening and counseling services performed. The visit does not include a physical examination, which theoretically leaves clinicians with more time to focus on other activities. [..]

Annual wellness visit requirements, like many well-intentioned efforts to improve primary care, risk fragmenting care rather than supporting its vital role as a force for integration. Clinicians must separately bill for included counseling services, such as advance care planning, and for any acute or chronic issues addressed. Practices frequently need to implement new workflows to identify and schedule patients for annual wellness visits and need training on visit procedures, Medicare documentation requirements, and billing strategies to ensure complete reimbursement. These efforts are time-consuming and cumbersome for all parties involved.

[..] most patients did not understand that a physical examination, chronic disease management, and attention to acute concerns were not part of the annual wellness visit. Practices reinforced these beliefs by creatively adapting the visits to address these additional issues, often billing separately for these services. This inclusive approach helped to integrate care and make it more convenient and accessible. However, patients who expected the annual wellness visit to include comprehensive care were sometimes confused and vexed by the separate billing that seems to fly in the face of the “free” framing of the visit. [..]

The annual wellness visit is just 1 of many examples of well-intentioned, piecemeal mechanisms designed to enhance a narrow aspect of patient care and promote certain services. Yet, similar to other initiatives, the visit adds to the administrative burden on clinicians and practices and fails to meet patient expectations for care. Furthermore, a culture change is required for full implementation of these visits—for practices, clinicians, and patients. A cumulative unintended consequence of implementing 1 process at a time to improve primary care is to overwhelm practices, confuse patients, and fragment care. Thus, while providing small solutions for discrete problems, these initiatives contribute to a larger problem. [..]

The fragmentation, administrative burden, and moral injury of trying to improve care 1 initiative at a time has reached a tipping point that could soon spell the end of primary care. Supporting primary care’s role as a force for integration is crucial to meeting the needs of patients and effective health care systems.”

Full editorial, DM Tarn, NS Wenger and KC Stange, Annals of Internal Medicine, 2022.6.28