Annual Wellness Visits and Timing of Advance Care Planning Among Medicare Beneficiaries With Cognitive Impairment

Background: Advance care planning (ACP) allows older adults to document preferences for future medical care, but uptake remains limited and unequal, especially among those with mild cognitive impairment (MCI) or Alzheimer's disease and related dementias (ADRD). Since 2016, ACP discussions can be billed during the Medicare annual wellness visit (AWV), creating a policy-supported opportunity for timely ACP engagement. Participants and Setting: We studied 959,405 Medicare beneficiaries aged ≥ 68 years newly diagnosed with MCI or ADRD in 2018, using national claims data. Methods: We conducted a retrospective cohort study with 1:1 propensity score matching to compare beneficiaries with and without AWV receipt in 2018. Cox proportional hazards models with death as a competing risk estimated associations between AWV and ACP initiation over 4 years. Sensitivity analyses included censoring rules and time-dependent modeling. Subgroup analyses assessed variation by cognitive stage, race/ethnicity, sex, region, and education. Results: Among 118,174 beneficiaries who received an AWV, 27.62% initiated ACP within 4 years compared with 17.46% of nonrecipients (HR, 1.86; 95% CI, 1.84–1.89). Most ACP uptake among AWV recipients occurred on the same day as the visit (9.00%), with modest increases thereafter. Sensitivity analyses confirmed stronger associations when accounting for continued AWV use (HR, 2.51; 95% CI, 2.46–2.56) and with time-dependent modeling (HR, 2.27; 95% CI, 2.27–2.31). The positive association between AWV and ACP was consistent across subgroups and particularly strong among Hispanic beneficiaries and those in nonmetropolitan areas. Conclusions: AWV receipt was associated with significantly earlier and greater ACP initiation among older adults with MCI or ADRD. Incorporating ACP into AWV workflows could enhance timely engagement, reduce disparities, and strengthen alignment of care with patient preferences. System-level interventions and clinician training may further increase same-day ACP uptake.