Is AI Coming to the Medicare Annual Wellness Visit?

Should Medicare’s annual wellness visit (AWV) be less physician-driven and more artificial intelligence (AI)-driven?

That’s the question being asked by CMS in its proposed physician payment rule, issued this past summer.

Although everyone agrees on the importance of prevention, “evidence regarding the impact of the AWV on outcomes is mixed,” the authors of the rule wrote. “Some studies have found that AWV receipt is associated with increased use of preventive services but may not sufficiently close gaps in preventive care. However, other studies have found no substantive association between AWV adoption and improvements in evidence-based screening, acute care utilization, or spending, or potentially increasing downstream low-value services.”

Because the findings are mixed, CMS said it wants to know whether use of clinical AI tools could change the AWV from a single, point-in-time assessment to “a more continuous, data-driven, and beneficiary-specific preventive care function.”

AI tools that might be used for the AWV include pre-visit collection of beneficiary-reported information such as in the health risk assessment, identifying beneficiaries who may warrant additional assessment, and generating suggested follow-up steps for clinicians to review.

Stephanie Carlton, CMS’s deputy administrator and chief clinical AI officer, echoed those thoughts last Friday at the Health Datapalooza conference in Washington, D.C.

“Only about half the seniors use [the AWV], and we don’t have good evidence that it’s actually resulting in better outcomes,” Carlton said. “That’s a huge opportunity for AI.”

CMS emphasized that “under current policy, the AWV must be performed by a physician or other health professional, or team of medical professionals directly supervised by a physician currently enrolled as a Medicare provider. We are interested in what barriers — if any — these requirements create to innovative AWV delivery models in which an AI technology company develops or operates these clinical AI tools and affiliates with a Medicare-enrolled provider or supplier.”

The agency is expected to release the final payment regulation around Nov. 1.

The American Academy of Family Physicians (AAFP), whose members are among the clinicians administering AWVs, is taking a cautiously positive approach to CMS’s ideas.

“AAFP supports the thoughtful use of AI to enhance Medicare AWVs, including tools that can help identify eligible patients, summarize health information, identify preventive care gaps, support documentation, and facilitate follow-up,” the academy said in an email. “Used appropriately, these technologies could reduce administrative burden and give physician-led care teams more capacity to provide timely, coordinated preventive care.”

“However, an AWV is more than a checklist of screenings and assessments; it is an opportunity to integrate preventive care with a patient’s medical history, chronic conditions, behavioral health needs, circumstances, and long-term health goals,” the AAFP added.

In its comment letter on the Medicare physician payment rule, the academy said that making decisions within this larger context “is only possible within an ongoing, trusted relationship between a patient and a physician-led care team.”

“We believe that technologies which improve access but undermine continuity, fragment care, or displace clinical accountability are inconsistent with the goals of primary care,” AAFP stated. “For this reason, the AAFP has concerns regarding any care model that would allow technology vendors, AI companies, or other third parties to independently furnish significant portions of preventive care services outside a patient’s established primary care relationship.”

“Separating preventive care activities from the patient’s primary care physician risks creating fragmented records, duplicative services, inconsistent recommendations, and uncertainty regarding responsibility for follow-up care,” the letter noted. “Most importantly, such models may weaken the continuity and accountability that contribute to better patient outcomes over time. CMS should therefore ensure that any technology-enabled AWV approach strengthens rather than bypasses the patient’s existing primary care team.”