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The Importance of Annual Wellness Visits for Providers, Payers, & Patients

Why The Annual Wellness Visit is So Important

The Annual Wellness Visit (AWV) is an incredibly effective tool for consumer health management and is key to keeping people healthy now and in the future. This valuable time spent between provider and patient gives space to check in on progress, discuss health issues, and create a care plan–not to mention it allows for the opportunity to order conduct needed screenings and preventive care, making it an easy way to close multiple gaps in care at once.

Research has shown that establishing a stronger relationship between provider and patient can positively impact health. There are also multiple indirect benefits to plans, providers, and patients, such as reduced network leakage and education on proper ER and urgent care use.

Annual Well Visit Statistics: Underutilized, Underestimated

Unfortunately, AWVs are surprisingly underutilized. Only 25% of Medicare Advantage beneficiaries receive an AWV (even though 45% of all Medicare beneficiaries have four or more chronic conditions). Many hard-to-reach populations within Medicaid and Medicare are not taking the time to schedule and attend their AWV, and many patients do not understand the importance of this visit at all.

But it is important–to both the patient and healthcare organizations. Beyond the benefit of catching and controlling health issues, the AWV is a critical component of Hierarchical Condition Category (HCC) recapturing.

In fact, an 85% AWV completion rate can result in an 80% or higher HCC recapture rate. This can mean a significant power over reimbursement dollars for plans and providers.

Learn more about improving HCC Recapturing through cutting-edge engagement strategy by watching our on-demand webinar »

Example Scenario

Our 75-year-old male patient can have two different outcomes determined by his AWV. With proper coding of his full health status in the second scenario, you see a significant increase in reimbursement–over $5,000 annually for this one patient. If you multiply that by over 500 patients, you will see an increase of $2.5 million annually (or a loss if you neglect to code correctly).

But what happens if this patient never schedules his visit or if his visit isn’t coded correctly? You’re leaving good money on the table.

Patient Demographics HCC (Hierarchical Condition Category) Risk Adjustment Factor
75-Year-Old Male   0.428
E11.41 Type 2 Diabetes mellitus w/diabetic mono neuropathy HCC18 Diabetes w/chronic complications 0.625
Total RAF   1.053
Payment Per Month   $684.45
Payment Per Year   $8,213.4

Example scenario: If this patient never schedules his visit or if his visit isn’t coded correctly. Good money is left on the table.

Patient Demographics HCC (Hierarchical Condition Category) Risk Adjustment Factor
75-Year-Old Male   0.428
E11.41 Type 2 Diabetes mellitus w/diabetic mono neuropathy HCC18 Diabetes w/chronic complications 0.625
K50.00 Crohn’s disease of small intestine w/o complications HCC35 Inflammatory bowel disease 0.279
M05.60 Rheumatoid arthritis of unspecified site w/ involvement of other organs and systems HCC40 Rheumatoid arthritis and inflammatory connective tissue disease 0.423
Total RAF   1.755
Payment Per Month   $1,140.75
Payment Per Year   $13,689
Example scenario: With proper coding of this patient’s full health status, you see a significant increase in reimbursement.

Using Technology to Unleash the Power of Annual Wellness Visits

Suppose your goal is to increase the number of members or patients you have going in for their AWV and to recapture their HCC codes properly. In that case, it’s critical to have effective outreach to educate, motivate, and drive behavior change in those hardest to reach–a challenging but attainable goal.

Behavioral Science

One of the most important tools available to increase motivation and inspire behavior change is your approach to the conversation. With behavioral science, we take what we know about human behavior and tendencies and use that knowledge to not only predict the response to our outreach but to sway people toward one action or another.

When we reach out to members and patients regarding AWVs, saying, “Hi, Susie. You’re due for your no-cost annual wellness visit,” has a measurable impact on response.

In this message, we employ the Endowment Effect, a behavioral science principle that assigns higher value to objects and tasks when consumers feel a sense of ownership and personalization. By telling Susie it’s her no-cost visit, we are making it more likely she will take action.

AI Technology

Let’s go beyond the planned messages, though. Not everything can be scripted when you start a real conversation with a real person. With Conversational AI and Natural Language Understanding (NLU), plans and providers can communicate with patients in a personalized, conversational, and real way.

Instead of one-way interactions where the healthcare organization is talking at the patient, AI and NLU broaden out your abilities into a fully-fledged two-way conversation where the patient can freely respond the way they would naturally speak, and the system can understand and carry the conversation naturally in an almost human-like manner.

If a plan is reaching out to encourage an AWV and the member says, “I don’t have a doctor,” NLU can easily recognize that response and follow up with a list of in-network doctors near the patient.

Health Equity

This technology and ability for two-way interaction opens the experience to so many more possibilities–an important one being barrier analysis.

With the ability of NLU to interpret barriers to access (such as not having access to a doctor or not having transportation to the appointment) and uncover possible social determinants of health (SDoH), the healthcare organization gains more information about the circumstances of each individual.

With AI and NLU capabilities, the healthcare organization can respond accordingly with resources, education, and support to break down the barriers tied to inequity and provide a more accessible healthcare experience.

mPulse Mobile's two-way SMS technology identifies barriers and effortlessly guides patients to schedule their Annual Wellness Visit
Revolutionizing Patient Outreach: mPulse Mobile’s two-way SMS technology identifies barriers and effortlessly guides patients to schedule their Annual Wellness Visit. Transforming care, one text at a time.

Instructional Strategy

One barrier to health equity that we often encounter is the issue of health literacy. Many health consumers need help understanding what an AWV consists of, why it’s important, or how to find a doctor to obtain one. This is where education becomes an essential part of any outreach strategy.

The video below features Dr. Archelle Georgiou, a leading physician, healthcare executive, and author, explaining why annual wellness visits are critical to preventing chronic disease and keeping a person healthy.

Including this short three-minute video can answer many questions the patient may not know they have, raise their health literacy, and increase their motivation to schedule.

Putting it All Together

These individual strategies ultimately come together to form one highly effective solution aimed at increasing the number of members and patients who schedule and attend their AWV.

mPulse Mobile’s Annual Wellness Visit solution incorporates these and can effectively drive behavior change, even among unengaged and hard-to-reach populations. With AI technology to uncover and address barriers, an omnichannel outreach method to ensure you’re reaching every member possible (no matter how hard to reach), and both behavioral science and streaming health content to inspire self-efficacy and build knowledge, healthcare organizations deploying this solution have seen up to a 61% visit rate for targeted members living near in-network clients.

mPulse Mobile's optimized patient journey ensures a seamless, informed, and empowered healthcare experience
Experience the Transformation: mPulse Mobile’s optimized patient journey ensures a seamless, informed, and empowered healthcare experience. Every step, reimagined for you.

And though this can have an impressive impact on the bottom line of healthcare organizations, it also significantly and directly impacts people’s lives and health.

The ability to catch early signs of disease and the chance to educate someone about their health and lifestyle makes the AWV one of the more powerful tools in the healthcare industry’s arsenal–so let’s make sure we are using it to its full potential.

Join 200+ leading healthcare organizations leveraging our cutting-edge solutions to improve Annual Well Visits attendance and ensure optimal health engagement through our digital health solutions. Explore how mPulse Mobile can transform AWV experiences, drive behavior change, and elevate health outcomes for your members.

Avoidable & Unnecessary ER Visits: Emergency Room Diversion Strategies

Using the Emergency Department excessively is the fourth largest financial waste in US healthcare – it costs over $38 billion annually. Emergency departments are overwhelmed, and emergency physicians experience almost three times more burnout than other departments.

Health organizations are under increased scrutiny to lower non-emergent ER visits and implement solutions to encourage health consumers to seek the right level of care. Despite ongoing efforts and initiatives, emergency department overutilization continues to rise yearly.

Understanding and analyzing commonalities in ER utilization will enable deeper insight into how we can begin tackling this issue head-on.

Why do consumers go to the ER when it’s not an emergency?

There are many reasons why health consumers visit the ER. In more ways than not, the emergency department checks several boxes when it comes to convenience:

  • It’s open 24 hours, 7 days a week.
  • It offers patients immediate reassurance regarding their condition or ailment.
  • Patients receive a full range of services regardless of the severity of their condition or whether or not they can afford it.
  • Hospitals have financial and legal obligations to treat patients.

To deter consumers from visiting the ER, alternative care options need to become more accessible and outweigh the convenience of a visit to the ER. Shifting consumer paradigms is easier said than done, and health organizations need to adopt innovative solutions to educate and encourage patients to seek alternative care models.

Further consideration of commonalities in emergency room overutilization offers clues to designing solutions that address the why and offer insight into the how.

Commonalties in Avoidable or Unnecessary ER Visits

ER overuse is a nationwide issue with the highest prevalence among those who are uninsured or enrolled in government health programs, particularly Medicaid.

Nearly 53% of Medicaid members will have an avoidable or unnecessary ER visit this year. Those with health disparities are most likely to have an avoidable ER visit.

Risk factors include

  • being in a lower-income decile,
  • unemployed,
  • living in a single household,
  • less than high school educational attainment,
  • English speaking,
  • aged 27-54 or 65+,
  • limited internet access,
  • divorced or widowed,
  • female,
  • having a disability,
  • having one or more chronic conditions,
  • uninsured or having public health insurance, and
  • having limited or no transportation.

It is important to note that institutionalized and structural inequities cause these commonalities. Collecting data points and creating false attributions is easy; systemic racism and long-standing inequitable distribution of wealth and resources are to blame in this instance. Health organizations are taking responsibility for recreating a system in which diverse populations have greater access to the care and resources they need.

At the end of the day, health equity benefits all of us. Providing equitable opportunities for care availability and resources is foundational in lowering avoidable ER use, and understanding commonalities help address and overcome existing barriers.

The Difference Between Avoidable & Unnecessary ER Visits

There is an important distinction between the terms ‘avoidable’ and ‘unnecessary’ when it comes to the course of action and corresponding interventions needed for ED diversion.

For the purposes of this blog, avoidable ER visits are visits related to unmanaged conditions, such as diabetes or mental health/substance use disorders (MH-SUD). In fact, nearly 60% of all ER visits are from people with one or more unmanaged chronic conditions, with these individuals also having higher rates of ED recidivism.

Unnecessary ED visits are often due to a lack of accessibility and educational resources and typically account for visits that are urgent care or primary care treatable.

The top four ER diagnoses, in order, are as follows:

  1. Abdominal pain and digestive issues,
  2. Upper respiratory infections,
  3. Minor injuries, and
  4. Sprains.

Both avoidable and unnecessary ED visits require intervention; however, the methodologies and approaches vary. Healthcare isn’t one-size-fits-all, and meaningful behavior change requires personalization dependent on each consumer’s unique needs, preferences, and health status.

ER Diversion Strategies

Understanding why consumers seek care at emergency departments, coupled with commonalities in ER utilization, provides a deeper understanding of what’s needed to help support and educate consumers in seeking the right care for their health needs. The right education and support also depend on whether the ER visit is avoidable or unnecessary.


Meaningful education incorporates behavioral science principles to motivate and empower behavior change. Simply telling a consumer they shouldn’t go to the ER unless they have to won’t work. Engaging with consumers in frictionless and meaningful ways requires expertise.

mPulse Mobile’s in-house instructional strategists, behavioral scientists, and health equity researchers develop cinematic streaming content experiences designed for optimal behavior change. Short-form content is designed to be relatable and educational, enabling consumers to realize the benefits of seeking alternative care.

See an example animation below.

Want to learn more about how streaming health content can drive behavior change? Download the complete guide »

Accessibility & Convenience

Providing personalized resources and support through frictionless calls to action will promote the utilization of better care options. Many health plans have resources available such as ride-share services and telehealth or nurse line providers for non-emergent cases. Despite these resources, utilization remains low, primarily due to a lack of awareness that they exist.

Engaging with members through an omnichannel approach, such as SMS, Email, and/or IVR, enables health organizations to meet their consumers where they’re at frictionlessly while providing accessible links to resources and support at their fingertips. When health organizations leverage innovative technology as a vehicle of communication with their consumers, engagement rates rise along with better health outcomes.

Avoidable ER Visits: Condition Management Solutions

Reducing avoidable ER visits begins with creating and maintaining meaningful relationships with health consumers. Because one size doesn’t fit all, understanding each consumer’s needs and preferences and their conditions and health status are crucial. mPulse Mobile creates individual member profiles in which each consumer’s protected data is leveraged to send tailored and relevant cadenced touchpoints. This becomes increasingly important for better condition management and medication nonadherence, accounting for billions in avoidable ER spending.

mPulse Mobile provides integrated and meaningful solutions for condition management, such as hypertension and diabetes, as well as MH-SUD and routine appointment reminders and scheduling.

Our solutions leverage an omnichannel engagement approach incorporating conversational AI and streaming content to educate and empower members to own their health while adopting healthier behaviors, including:

  • eating better and exercising,
  • regularly communicating with their care team, and
  • taking their medications as prescribed.

Educating consumers on where to seek the right level of care and providing resources and support are critical components of ED Diversion, but understanding individual consumer health needs and support will help health organizations reduce avoidable and unnecessary ER visits.

Visit mPulse’s condition management solutions to learn more »

mPulse Case Study

One of the nation’s leading health plans partnered with mPulse Mobile to lower unnecessary ER visits and redirect members to better, more affordable care options.

Goals & Execution: Automate and optimize digital communications to members using SMS text messages to redirect members identified as high-utilizers of the ER and provide meaningful messages and streaming content to redirect them to more appropriate levels of care.

A population analysis was performed to assess the intervention impact for members outreached. SMS messaging was deployed to engage and educate members to seek the right level of care for their health needs. A group of approximately 12,000 high-utilizers were enrolled in the program.

Results: 69.7% reduction in ER visits. Before outreach, there were nearly 19,000 total ER visits. Post outreach, that number decreased to under 5,700 visits. Assuming the average ER visit cost is $1,082, the program saved over $14 million in health plan and consumer savings during the program’s duration.

In Conclusion

Health organizations are uniquely positioned to engage meaningfully with their members and patients and have invested time, money, and resources into providing services conducive to bettering health outcomes.

mPulse Mobile is the leader in innovative digital engagement solutions and partners with 200+ leading health organizations to deploy over 1 billion conversations annually to inform, educate and tailor conversational engagement designed for health action across diverse populations.


To learn more about how mPulse Mobile can lower avoidable and unnecessary ER visits, lower costs, and improve health outcomes for your consumers, contact us to schedule a consultation.