Preventive Care in the Modern Era

A physician signs off on a prevention plan. It names what screenings are overdue. It flags depression. It catches a medication interaction the chart missed for two years. It documents a fall risk that, left alone, ends in a hip fracture and a hospitalization.

Then the plan sits in the chart. No one calls the patient. No one orders the labs. No one schedules the referral. By day seven, the visit is memory. By month three, the gaps it found are invisible again.

I have watched this happen in practice after practice. The visit ends. The physician moves to the next patient. The staff moves to the next task. And the most comprehensive snapshot most Medicare patients receive in a given year sits in a chart, producing nothing.

The Annual Wellness Visit generates a written blueprint for the next decade of a patient's health. In the majority of cases, nothing happens after the visit ends.

For the majority of chronic care patients, physicians already know what good care looks like. The failure is operational. No one owns the follow-through.

I wrote previously about who holds that ownership. The answer in most practices is no one. This chapter goes deeper. It breaks down what the AWV actually produces, maps how those components build a twelve-month patient journey, and lays out a model where every finding has an owner, a deadline, and a closed loop.

Where This Visit Came From

The AWV entered Medicare on January 1, 2011, through the Affordable Care Act. It replaced nothing. It created a new category of encounter with no direct precedent in fee-for-service Medicare.

Before the AWV, the closest comparable visit was the Initial Preventive Physical Examination, also called the Welcome to Medicare Visit (G0402). The IPPE is a one-time benefit available during the first 12 months of a beneficiary's Part B coverage. It includes a review of medical history, education on preventive services, screening for depression and functional ability, and an overview of what Medicare covers. National average reimbursement sits at approximately $161.

The AWV picks up after that window closes. A beneficiary becomes eligible for the initial AWV (G0438) at least 12 months after their Part B effective date, and for a subsequent AWV (G0439) every 12 months after that. The IPPE and initial AWV are separate encounters with separate billing codes. They share a common logic: invest time in the patient's baseline before problems drive every encounter.

What the Visit Produces

CMS designed the AWV with specific required elements codified in 42 CFR 410.15. Each element generates structured data. Together, they form the most comprehensive longitudinal profile most Medicare patients receive in any given year.

The question is what happens to all of this after the visit ends.

The Prevention Plan Is a Promise

CMS requires the AWV to produce a Personalized Prevention Plan of Services. The regulation is specific. The plan must include a written screening schedule for the next five to ten years. A list of risk factors and conditions with recommended interventions. Treatment options with risks and benefits. Health advice and referrals covering weight loss, physical activity, smoking cessation, fall prevention, and nutrition.

That is a longitudinal operating plan for the patient's health.

The AWV is the only Medicare encounter specifically designed to produce this kind of forward-looking document. Problem visits address today. The AWV addresses the next decade.

When a physician signs off on that plan, they are making a commitment. The depression screen that flagged a PHQ-9 of 14 implies follow-up. The fall risk assessment that identified gait instability implies intervention. The medication review that found three drugs with interaction potential implies reconciliation. The screening schedule that shows a colonoscopy overdue by two years implies a referral.

Every line in the prevention plan implies a next step. Without execution infrastructure, those next steps live in the chart as intentions. Intentions without owners become debts the patient pays later, usually in an emergency department.

The Twelve-Month Journey

The AWV is one visit. The patient journey it initiates runs for twelve months.

Here is what that journey looks like when the prevention plan has an owner.

The Numbers

The AWV itself reimburses at different levels depending on encounter type and geography.

The downstream value is larger. A patient enrolled in CCM generates approximately $42 to $83 per month depending on the code used and who delivers the service. APCM generates $55 to $110 per month depending on complexity tier. Over twelve months, that is $500 to $1,320 per patient per year in care management revenue. Behavioral Health Integration adds approximately $50 per month for qualifying patients.

These are revenue projections, not profit figures. The cost to deliver monthly care management for 420 patients includes staff time, technology infrastructure, documentation overhead, and quality assurance. Practices evaluating this model need to calculate their per-patient delivery cost against these revenue figures to determine true margin.

The numbers scale with the panel. They also scale with execution discipline.

Published research supports an association between AWVs and cost reduction, but the evidence carries important caveats. In two Aledade ACOs that had invested heavily in AWV infrastructure, including dedicated scheduling support, EHR templates, practice transformation coaching, and performance monitoring, AWVs were associated with a 5.7% reduction in total healthcare costs over the following eleven months, approximately $456 per member per year. The highest-risk patients showed the greatest cost reductions.

Two limitations matter. First, AWVs in that study were not associated with reductions in ED visits or hospitalizations. The cost savings came from reduced spending on hospital acute care and outpatient services, and the mechanism driving those savings remains unclear. Second, AWV recipients in published studies tend to be healthier, more engaged, and more likely to receive care from practices already invested in prevention. Some portion of the observed cost reduction may reflect the characteristics of patients who receive AWVs rather than the effect of the visit itself. Association, not causation.

Separate research shows AWV recipients are more likely to receive guideline-recommended preventive services, with receipt of preventive care roughly 62% higher among AWV recipients compared to non-recipients. That finding is more robust.

The AWV is the foundation of a sustainable clinical and financial model. The evidence supports its role in closing care gaps and generating downstream revenue. The evidence on cost reduction is promising but context-dependent. Practices should build their financial case on the revenue side and the quality improvement side, where the data is strongest.

What Ownership Looks Like When Technology Supports the Workflow

Here is a concrete model.

Who This Model Misses

Every model has boundaries. Naming them protects the people who trust it.

Behind every utilization statistic in this section is a patient who either received a prevention plan or did not. The numbers describe populations. The consequences land on individuals.

The patients who need preventive care most are the least likely to receive it. AWV utilization has grown substantially since 2011. In fee-for-service Medicare, rates rose from approximately 7% in 2011 to about 16% in 2014 and continued climbing, reaching an estimated 45% by 2020. Medicare Advantage plans show consistently higher AWV completion rates, driven by quality bonus structures and Stars measure alignment.

The growth hides a deeper pattern. Utilization remains deeply uneven across populations.

What Changes This Week

For a practice reading this and wondering where to start, the sequence is short.

First, audit your AWV completion rate. How many of your Medicare beneficiaries received an AWV in the past twelve months. Break the number down by race, ethnicity, and geography if your data allows. The total number matters. The distribution matters more.

Second, look at what happens after the visit. Pull ten charts of patients who had an AWV in the last six months. Check whether the prevention plan items were executed. Were labs ordered. Were referrals sent. Were depression screens followed up. Were medications reconciled. Count the gaps.

Third, assign ownership. One person or one system responsible for converting the prevention plan into tracked tasks with deadlines. The technology can be simple or sophisticated. The ownership must be explicit.

Fourth, measure follow-through. Track what percentage of prevention plan items are completed within 30, 60, and 90 days of the AWV. That metric tells you more about the value of your AWV program than the completion rate alone.

The Future of This Workflow Is Already Here

The model described in this chapter is what Pear Health builds. Pre-visit chart review. AI-assisted HRA. Automated care plans. Closed-loop follow-through. Monthly care management documentation. The full AWV lifecycle.

The model above is not a thought exercise. It is a live workflow running in early-adopter practices today, with measurable results at each stage.

The AI agent calls the patient before the visit and completes the Health Risk Assessment by phone. It reviews the chart and flags gaps the physician needs to see. It generates the draft care plan. After the physician signs off, it owns the follow-through. Every task gets a deadline, an owner, and a closed loop. Every patient who does not answer gets contacted again. And again. Outreach calls document directly into the EHR. Medication discrepancies trigger sequences that run until the loop closes or escalates.

The physician stays in control of every clinical decision. The system owns the execution that makes those decisions stick.

This is what value-based care looks like when consistency becomes infrastructure. When the right action happens every time, for every patient, without relying on someone remembering to check a list on a Monday morning.

Pear owns the space between the plan and the outcome. The follow-through that most practices lose.

If your practice is leaving AWV follow-through to memory, manual tracking, or hope, we should talk. Not about vision. About what changes in your workflow next week.