Mark Angelo, MD, MHA, FACP
Chief Medical Officer
Delaware Valley Accountable Care Organization

Messages from The Chief Medical Officer

May 2019

Diane Meier, M.D. Addresses DVACO Spring Conference

“Human relations are fundamental to health care. . . it’s the most important thing.”

Delaware Valley ACO’s Spring Conference, held May 2, 2019, featured an inspiring and informative presentation by Diane Meier, M.D., a leading national expert in palliative care and the management of the seriously ill population. Among the many key points made in her presentation, Dr. Meier stressed the following:

All providers have a role to play. Managing the care of the seriously ill population is the responsibility of all clinicians, and most services should be delivered by front line providers. One does not have to be a palliative care specialist to recognize and mitigate suffering and improve communication to allow patients to make their wishes known.
The challenge ahead is training. Having specific training in the core knowledge and skills of palliative care, especially communication skills, is a game changer. The need for adequately staffed and trained teams in the relevant health care settings is imperative.

As the nation’s health care system transitions from volume to value, Dr. Meier believes that palliative care will be of increasing importance, noting in her remarks that “few [healthcare triple aim] strategies work simultaneously.” For example, if not carefully managed, efforts to rein in health care costs can have a negative impact on health care quality. Citing numerous published studies, Dr. Meier highlighted the data regarding the positive impact of a robust strategy to manage the seriously ill population. This strategy unambiguously yields high quality as well as superior patient and caregiver experience, all while lowering total cost of care.

Meier noted an added benefit to providers as well – increased job satisfaction. She points out that human relations are the most important aspect of health care; and, providers can connect to their work through these meaningful interactions with patients.

To begin this all-important dialogue with patients, Dr. Meier suggests that we “ask patients what matters to them most.”

April 2019

“The Medicare Annual Wellness Visit”

The Medicare Annual Wellness Visit (AWV) has become a useful tool to facilitate care for patients in our primary care practices. Over the years, many physicians and other providers have inquired about the benefit of the AWV and how it differs from the periodic health examination (PHE) – sometimes more commonly known as the routine physical examination – the benefit of which has been questioned in the medical literature for many years now (1-4).

The PHE came under scrutiny in the 1990s when it was pointed out that a focus on these examinations led to non-beneficial laboratory and radiologic testing while hindering access for patients who may need to be seen for management of an acute or chronic condition (5-6). The annual PHE was removed from the recommendations from the Council on Scientific Affairs of the American Medical Association at the time and remains on the “don’t do” list from the Society of General Internal Medicine in the “Choosing Wisely” campaign (7).

The Medicare Annual Wellness Visit differs from the annual PHE in several important ways.

The AWV is a structured visit the affords an opportunity for providers to explore outstanding preventive health maintenance items and to request evidence-based screening tests such as mammograms, colonoscopies, vaccinations, etc. The AWV includes screening for risks such as falls, depression, and polypharmacy, all of which are known to greatly increase morbidity in this population. These visits are an excellent time to build stronger bonds with our patients and provide the individual with appropriate referrals to promote self-management such as: nutrition and weight loss, tobacco cessation, behavioral health intervention, as well as cognitive evaluation or physical therapy.

The AWV also helps your practice and the DVACO to identify who are the patients attributed to a particular practice or provider. The AWV helps to identify existing diagnoses or chronic illnesses that the patient may be facing. These diagnoses may not be otherwise captured by Medicare to properly understand the level of disease burden and severity in a given population. Hierarchical Condition Category (HCC) coding in this population provides the necessary information to the Center for Medicare and Medicaid Services (CMS) to understand the disease severity for patients in a physician’s attribution panel.

The DVACO Practice Transformation Team can provide educational tools for your practice to communicate with patients regarding the AWV. Since the components of an AWV may be different than what an individual may have noted in the past (i.e. not a typical physical or illness-based visit), managing patient expectations will yield the best result. Our staff can provide materials and scripting for office staff regarding these important visits.

The AWV allows providers to perform a health risk assessment and develop a personalized prevention plan for patients to keep them up to date with the latest evidence-based recommendations for preventive health as established by the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP).

And finally, the AWV affords an opportunity for our Medicare patients to discuss Advanced Care
Planning (ACP) with their trusted physician (8) and to potentially complete a POLST or other form of
advanced directive to ensure their wishes are known in the event of a catastrophe and the patient is
unable to speak for themselves. Our Practice Transformation Team at DVACO will gladly also help with
these resources for your practice.

For a comprehensive look at the Medicare AWV, please review the Medicare Learning Network booklet
on the topic by clicking HERE.


  1. Chacko KM, Anderson RJ. “The annual physical examination: important or time to
    abandon?.” The American Journal of Medicine 2007;120(7):581-583.
  2. Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, & Daumit GL
    Systematic review: the value of the periodic health evaluation. Annals of Internal
    Medicine, 2007;146(4): 289-300.
  3. Mehrotra, A, Zaslavsky AM, and Ayanian JZ. “Preventive health examinations and preventive
    gynecological examinations in the United States.” Archives of Internal Medicine
  4. Howard-Tripp M. “Should we abandon the periodic health examination?: YES.” Canadian Family
    Physician 2011;57(2):158-160.
  5. Jones RJ. “Medical evaluations of health persons” JAMA 1983;249(12):1626-1633.
  6. Gordon, PR, Janet Senf, and Doug Campos-Outcalt. “Is the annual complete physical
    examination necessary?.” Archives of Internal Medicine 1999;159(9):909-910.
  7. Choosing Wisely. Society of General Internal Medicine Recommendation. Accessed at on March 28, 2019
  8. Detering, KM, et al. “The impact of advance care planning on end of life care in elderly patients:
    randomised controlled trial.” BMJ 2010;340:c1345.
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