The Annual Wellness Visit was designed to be a starting line. Most practices treat it as the finish.
CMS (Center for Medicare & Medicaid Services) introduced the AWV in 2011 under the Affordable Care Act. The intent was clear. Give Medicare beneficiaries a yearly encounter focused entirely on prevention. Not a physical, or a problem visit, but rather a structured assessment that surfaces risks, identifies care gaps, and produces a personalized prevention plan the patient carries forward for the rest of the year.
The visit works. The follow through does not.
Adoption is no longer the problem. AWV utilization has climbed from single digits in 2011 to roughly seventy percent of Medicare beneficiaries reporting an AWV in the past twelve months as of early 2024. The industry spent a decade solving access. The question now is what happens after the note is signed, the Health Risk Assessment (HRA) is filed, and the $175 claim is paid.
In most practices, the answer is nothing.
What the AWV Produces
AWV generates a specific set of outputs:
- A health risk assessment:
- covering medical history
- psychosocial risks
- behavioral risks
- functional status
- A cognitive screening.
- A depression screen.
- A fall risk assessment.
- A review of current medications and providers.
- A personalized prevention plan that maps screenings, referrals, and follow up intervals for the next twelve months.
That prevention plan is supposed to be the operational document. CMS requires it to be furnished to the patient, either as a physical copy or through the patient portal. It lists risk factors identified, conditions flagged, and interventions recommended.
The problem is structural. The AWV itself has no built-in mechanism to ensure anything on that plan actually happens. The visit ends. The plan exists. No one owns the next step.
The Space Between Visits
Between the signed note and the next visit is where outcomes are decided. That space belongs to no one in most practices. And what belongs to no one gets done by no one.
Consider what the AWV commonly surfaces.
A depression screen scores above threshold. The PHQ-2 flags, the PHQ-9 confirms. The note documents it. The prevention plan recommends follow up. The patient leaves. Who calls in two weeks to check whether the referral was made? Who confirms the patient filled the prescription? Who asks how they are doing on a Tuesday in March when no visit is scheduled?
A medication reconciliation identifies three discrepancies between what the patient reports taking and what the chart shows as active. The AWV documents the gap. Who resolves it? Who contacts the pharmacy? Who follows up to confirm the patient is on the correct regimen before the next refill?
A fall risk assessment flags a seventy eight year old living alone with balance concerns. The plan recommends physical therapy. The patient nods. Who schedules the referral. Who confirms the appointment was kept? Who checks back after four sessions to assess whether the risk profile changed?
These are not clinical failures. The physician identified the problems. The AWV did its job. The failure is operational. No person. No workflow. No closed loop.
The Prevention Plan Is a Document, Not a Workflow
The personalized prevention plan is the most important output of the AWV and the most consistently ignored.
CMS designed it as a longitudinal tool. At each subsequent visit during the twelve months after the AWV, providers should address elements of the problem list and prevention plan. That is the regulatory intent. The operational reality is different.
In most practices, the prevention plan lives in the EHR as a completed note. It is not converted into a task list. It is not assigned to a care coordinator. It does not generate automated follow up sequences. It does not trigger outreach when a screening goes unscheduled or a referral goes unfulfilled.
The plan was built to be a roadmap. It functions as a receipt.
This matters because the conditions that the AWV surfaces do not pause while the practice waits for the next visit. A1C continues to drift. Blood pressure remains uncontrolled. The depression deepens. The fall happens. The ED visit that could have been prevented becomes a hospitalization that shows up in the next quality report.
Medication nonadherence alone contributes to an estimated 125,000 preventable deaths and ten percent of hospitalizations in the United States annually. The AWV is supposed to catch adherence problems early. It does. What it cannot do is fix them from inside a PDF.
Adoption Solved. Execution Broken
The data on AWV adoption tells a success story. Utilization grew from seven percent in 2011 to sixteen percent in 2014, thirty two percent in 2018, and continues climbing. Practices figured out how to schedule, bill, and staff the visit. Health systems built workflows for the encounter itself.
The data on post-AWV follow through tells a different story.
Research from two primary care physician-led accountable care organizations showed that patients who received an AWV experienced a 5.7 percent reduction in adjusted total healthcare costs over the following eleven months, with the greatest effect for patients in the highest risk quartile (Beckman et al., 2019). The AWV works when connected to downstream action.
But that same research exists because most practices do not connect AWV findings to longitudinal follow through. The reduction in cost is notable precisely because it is uncommon. The default state is a completed visit with an orphaned prevention plan.
Practices that link AWV findings to chronic care management, remote patient monitoring, or transitional care management see compounding returns. The AWV becomes the entry point for sustained engagement. The ones that treat the AWV as a standalone billing event see a completed note and an unchanged patient twelve months later.
Why the Gap Persists
Three structural problems keep AWV follow-through broken in most practices.
First, the AWV is designed as a visit, not a trigger. The billing structure rewards the encounter. G0438 for the initial. G0439 for subsequent. Payment happens when the visit is complete. Nothing in the reimbursement model incentivizes what happens after. The visit is the product. Everything downstream is overhead.
Second, staffing models do not account for post-AWV work. The physician or nurse practitioner conducts the visit. The care coordinator, if one exists, manages chronic care management patients. The prevention plan referrals, screening follow ups, and medication reconciliation tasks fall into an operational gap between roles. Nobody’s job description says “own the AWV prevention plan for the next twelve months.”
Third, EHR workflows end at documentation. Most electronic health records treat the AWV as a note type, not a workflow engine. The prevention plan is completed as part of the encounter documentation. It is not automatically translated into pending orders, outreach tasks, or monitoring triggers. The system captures the information and files it. Retrieval requires someone to go looking.
These are not technology problems. They are ownership problems. The visit has an owner. The follow through does not.
What the AWV Should Trigger
The AWV should function as a trigger for at least five downstream workflows.
One. Screening completion tracking. Every screening recommended in the prevention plan should generate a pending task with a deadline and an assigned owner. Colonoscopy referral. Mammogram scheduling. A1C lab order. If the screening is not completed within a defined window, outreach fires automatically.
Two. Medication reconciliation resolution. Discrepancies identified during the AWV should be resolved within seventy two hours, not deferred to the next office visit. This means pharmacy outreach, patient confirmation, and chart update with a closed loop documented.
Three. Behavioral health follow up. Depression and cognitive screening results above threshold should trigger a defined follow up cadence. Not a single referral. A sequence. Initial outreach within one week. Follow up at two weeks. Confirmation of engagement at thirty days.
Four. Chronic care management enrollment. CMS estimates that chronic care management services could benefit seventy percent of Medicare beneficiaries with two or more chronic conditions. The AWV is the natural entry point. Every AWV that identifies qualifying conditions should trigger an enrollment conversation, not six months later, but within the same week.
Five. Risk stratification update. The AWV produces the most comprehensive annual snapshot of a patient’s health status. That data should update the practice’s risk stratification model immediately, not sit in a note until someone manually reviews it.
None of these are new ideas. All of them require someone to own the work.
The Cost of Orphaned Plans
The financial and human cost of broken post-AWV follow-through compounds quietly.
Practices investing in AWV programs generate revenue from the visit itself. Initial AWVs reimburse approximately $175. Add on services like advance care planning and SDOH screening increase the yield. Subsequent AWVs create a recurring annual revenue stream.
But the real financial opportunity sits downstream. Practices that connect AWV findings to chronic care management generate additional monthly revenue per enrolled patient. Practices that improve quality scores through gap closure earn performance bonuses in value-based contracts. Practices that reduce avoidable ED utilization and hospitalizations capture shared savings.
The practices capturing only the visit revenue are leaving the majority of the value on the table. They paid for the map and left it in the glove compartment.
The human cost is harder to quantify but more consequential. A patient who completes an AWV believes they have been assessed. They trust that the practice knows their risks and will act on them. When six months pass and no one follows up on the depression screen or the medication discrepancy, that trust erodes silently. The patient does not call to complain. They simply stop expecting the system to work.
Once trust erodes, language stops working. The next AWV becomes a checkbox the patient tolerates, not a conversation they value.
The Ownership Fix
The fix is not another dashboard. The fix is not better documentation templates. The fix is not another platform that gives your team more data to look at.
The fix is a system that owns the execution so your team does not have to.
One named process responsible for the post-AWV prevention plan. A defined workflow that converts plan items into tasks with deadlines. A closed loop that confirms completion or escalates non-completion. A reporting mechanism that tracks follow through rates alongside visit completion rates.
The visit completion rate measures whether the AWV happened. The follow through rate measures whether it mattered.
Most practices track the first number. Almost none track the second. That gap is the problem.
Ownership does not require a large team. It requires clarity. Who converts the prevention plan into tasks. Who monitors completion. Who escalates when a screening referral goes unfulfilled for thirty days. Who contacts the patient when the medication reconciliation reveals a safety concern.
If no one can answer those questions, the AWV is a billing event dressed as prevention.
What Ownership Looks Like in Practice
Enter Pear. Not just the AWV. The space after.
Pear is a value-based care operating system powered by conversational AI. It sits between the AWV and the next visit, and between every care event and its follow through. It does not replace clinical judgment. It does not diagnose. It does not treat. It watches the prevention plan and makes the follow through unavoidable.
The AWV is the entry point. What Pear builds from it is a continuous workflow. Gaps identified during the visit trigger outreach sequences. Outreach sequences generate documented encounters. Documented encounters feed chronic care management, remote patient monitoring, and transitional care management billing. The AWV stops being a standalone visit and becomes the first step in a value-based care cycle that compounds month over month.
Here is how the workflow runs.
The AWV can happen two ways. The practice conducts the visit as usual, and Pear ingests the structured data from the EHR note. Or Pear conducts the entire AWV over the phone with the patient, completing the health risk assessment, screenings, and medication review through conversational AI before the patient ever walks in. Either path produces the same output: a prevention plan with tagged action items ready for physician review.
The physician reviews. Approves, modifies, or adds. From that point, Pear owns the execution.
Every action item on the prevention plan becomes a tracked task with a defined trigger. Depression screen above threshold triggers behavioral health outreach within one week. A1C not drawn within the specified window triggers lab follow up. Medication discrepancy flagged triggers pharmacy outreach and patient confirmation. Care gaps identified during the AWV enter a monthly outreach cycle that continues until the gap closes or the provider changes the plan.
The outreach is not a reminder. It is a conversation. Pear’s conversational AI calls the patient from the clinic’s own number or a dedicated line. It gathers information, educates based on what the physician has documented in the chart, confirms understanding, and produces a full telephonic encounter note or SOAP note that writes back directly into the physician’s EHR. The physician sees the result the same place they see every other encounter. No separate portal. No dashboard to check. The work shows up where work already lives.
When a medication discrepancy is flagged, the sequence runs in order. The provider reviews the flag. If a follow up call is indicated, Pear contacts the patient to address the discrepancy. If new medications are prescribed, Pear contacts the pharmacy to confirm the prescription is ready for pickup. The patient is called again to confirm they picked it up. Each step documents. Each step has an owner. The loop closes or escalates.
When a patient does not answer, Pear calls and texts multiple times over the following weeks. Within two weeks of failed contact, the patient is added to an unable to reach list and the clinic receives a task to verify contact information. Attempts continue for a month before the outreach pauses and the practice decides next steps. Pear does not abandon the patient. It names the constraint and hands responsibility to someone who can act on it.
The Numbers
Across live workflows, the pattern holds. Consistency compounds. Here is what the data shows.
Pear identified 1,384 care gap events originating from AWV and chronic care workflows. Of those, 658 closed. That is a 47.5 percent overall closure rate. Early months ran between 33 and 42 percent. After the system reached operational maturity, monthly closure rates climbed to 53 through 68 percent. The inflection did not come from a feature release. It came from the outreach cadence compounding over time. Patients who were reached once became easier to reach again. Trust built through repetition.
A1C testing backlog: 324 pending reduced to 34. An 89.5 percent reduction
Hypertension screening backlog: 460 pending reduced to 42. A 90.9 percent reduction
Medication refill gaps: 814 identified, 591 confirmed pickups. A 72.6 percent closure rate
Peak monthly refill closure: 84.6 percent in October
Average time to first outreach: 4.1 days overall, 3.2 days at peak
These numbers come from the same type of practice described throughout this post. Medicare patients. Chronic conditions. Limited staff. The difference is not resources. The difference is that someone owned the follow through.
Where Pear Stops
Pear does not diagnose. It does not prescribe. It does not override or modify a treatment plan. It will not give a patient medical advice that is not explicitly documented in their chart by their physician.
Pear is a fact gathering and educational tool operating under the strict supervision of the clinic. The physician decides what good care looks like. Pear makes sure the defined actions happen on time, every time, and documents the result where the physician expects to find it.
Clinical judgment stays with the clinician. Operational execution becomes reliable.
That boundary matters. AI in healthcare does not create value by making decisions for clinicians. AI creates value by enforcing consistency at scale. The AWV already tells practices what needs to happen. Pear makes those actions unavoidable. Not through intelligence. Through persistence.
Between Visits Is Where Outcomes Are Decided
The AWV was one of the better ideas to come out of the Affordable Care Act. A fully covered preventive encounter that gives physicians time to step back from acute management and focus on the whole patient. A structured assessment that surfaces problems before they become emergencies. A reimbursement model that pays for prevention instead of only paying for treatment.
The design is sound. The execution gap is enormous. But the gap has a fix.
The fix is not clinical. Both practices that succeed and practices that stall identify the same risks during the visit. The difference is what happens next. Who owns the follow through. Who closes the loop. Who makes the prevention plan unavoidable instead of optional.
Across practices using Pear, the answer to each of those questions is specific. The follow through is owned by a value-based care operating system that does not forget, does not fatigue, and does not let a task slip between roles. The loop closes with documented outreach, confirmed actions, and encounter notes written back to the EHR. The prevention plan stops being a document and starts being a workflow with deadlines, owners, and accountability.
Optional workflows fail. The AWV follow through in most practices is optional. It does not have to be.
The fix is simple. The fix is persistent. The fix requires reliable consistency applied to every patient, every task, every follow through, without exception and without fatigue. It requires someone to decide that what happens after the visit matters as much as the visit itself. And then to build a system that makes that decision hold, patient by patient, month after month, without relying on anyone to remember.
Between visits is where outcomes are decided. It is time to build like it.