Influence of Internet Use on Welcome to Medicare or Annual Wellness Visit Utilization Among Medicare Beneficiaries with Type 2 Diabetes: A Cross-Sectional Analysis

Abstract

Background/Objectives: The increasing availability of online health information underscores the importance of digital resources and internet use, especially for older adults. Despite the benefits, utilization of Welcome to Medicare (WTM) and Annual Wellness Visits (AWV) remains suboptimal, particularly for those with diabetes. This study examined the relationship between internet use and WTM/AWV utilization among Medicare beneficiaries with diabetes. Methods: The 2021 Medicare Current Beneficiary Survey was analyzed, which is a nationally representative survey of Medicare beneficiaries aged ≥65 years with self-reported type 2 diabetes (n = 1444). The binary dependent variable was self-reported WTM/AWV utilization. The 3 binary independent variables were whether beneficiaries used the internet to (1) look up health information; (2) schedule an appointment with healthcare provider; and (3) communicate with healthcare provider. A survey-weighted logistic regression model was used to examine their associations, adjusted for socio-demographics and comorbidities. Results: Of study beneficiaries, 57.5% reported WTM/AWV utilization. Among WTM/AWV users and non-users, 56.1% and 42.5%, respectively, looked up health information online. Additionally, among WTM/AWV users and non-users, 31.6% and 26.1%, respectively, scheduled appointments online, and 39.8% and 34.3%, respectively, communicated with providers online. Adjusted analysis found that looking up health information online was associated with higher odds of WTM/AWV utilization (OR: 1.76, 95% CI: 1.36–2.28), while the other internet use behaviors were not statistically significant. Conclusions: Approximately 40% of study beneficiaries did not report using WTM/AWV. Improving internet use for health information and digital literacy among at-risk Medicare beneficiaries with diabetes may have a positive influence on WTM/AWV utilization and may support broader use of digital tools in diabetes care.

1. Introduction

The prevalence of diabetes, particularly type 2 diabetes, among Medicare beneficiaries in the United States (U.S.) is estimated at a rate of approximately 30% of the population aged 65 or older, which poses significant risks for diabetes-related complications and overall healthcare costs [1]. In 2022, the U.S. economic burden of diagnosed diabetes reached an estimated $412.9 billion, with substantial direct and indirect costs attributed to the disease [2]. Medicare, the primary health insurance provider for individuals aged 65 and older, offers the Annual Wellness Visit (AWV) and the Welcome to Medicare Visit (WTM) as preventive measures aimed at reducing the burden of chronic conditions like diabetes [3]. These visits are designed to enhance early detection of potential health issues, facilitate preventive care, and ultimately, improve health outcomes [4].

Despite these initiatives, WTM/AWV utilization remains suboptimal among Medicare beneficiaries, particularly those with type 2 diabetes, a group that stands to benefit significantly from preventive services [5,6,7]. Prior research has shown that AWVs are associated with increased use of preventive services such as foot exams, eye exams, and HbA1c testing in patients with diabetes [8]. Furthermore, AWVs have been associated with improved diabetes control and lower total healthcare costs [9]. However, barriers to WTM/AWV utilization persist, including limited health literacy, lack of awareness, logistical challenges in accessing care, and disparities based on race and ethnicity, geography, and socioeconomic status [5,7].

The internet has become an essential source for health information, transforming how individuals seek information, prefer to receive care, and manage chronic conditions. Internet use can raise awareness of preventive services through health campaigns and online searches. By engaging with provider and healthcare organization websites, individuals are becoming aware of available services they have access to. Digital reminders can also further promote preventative service activation, which ultimately may increase preventive visit uptake such as WTM/AWV utilization. However, a systematic review on online health information seeking behavior identified several features that were considered as barriers such as limitations with health literacy and information retrieval skills, while other factors such as online communities, privacy features, and synchronous interactions may serve as facilitators to online health information seeking [10]. The authors provided several recommendations for future interventions or modifications to online content, such as a focus on making online data more accessible and understandable, with a focus by government agencies on taking into account health literacy when considering dissemination activities along with actions to monitor accuracy of information provided [10]. More generally, recommendations also included social media platforms providing discussion pages where health information seekers can post questions for health professionals to answer, having a focus on privacy and security, among other items [10].

Additionally, health literacy plays a critical role in shaping preventive care utilization among older adults. Prior studies among Medicare beneficiaries and older adults have demonstrated that lower health literacy is associated with significantly reduced use of preventive services, including vaccinations and cancer screenings [11,12,13], even after accounting for sociodemographic factors [14]. These findings suggest that limitations in health literacy may represent an important underlying barrier to engagement with preventive services such as the WTM/AWV.

For older adults, especially those with complex healthcare needs such as type 2 diabetes, the ability to access and utilize online health resources can significantly influence their health behaviors and outcomes [15]. The COVID-19 pandemic underscored the importance of digital literacy and access, as healthcare systems and patients alike increasingly relied on virtual platforms for information, communication, and care management [16,17,18], even among those with diabetes [19]. Given the increasing reliance on digital platforms for health navigation, it is crucial to understand how internet use may influence the utilization of preventive care services, especially for those with diabetes. Additionally, studies have shown that disparities in access to and use of the internet as well as other information communication technologies are especially prevalent among Medicare beneficiaries and older adults who are disadvantaged by sociodemographic factors [17,20].

Recent research has highlighted the potential for internet use as a tool to enhance access to healthcare services, including preventive care [15]. The internet offers a platform for patients to learn about their health, manage their conditions, and access telehealth services [16]. A growing body of literature suggests that increased confidence in using the internet for health-related activities is associated with better health outcomes and greater engagement in preventive care [15]. However, the relationship between internet use and the WTM/AWV utilization among Medicare beneficiaries with type 2 diabetes remains underexplored. While some studies have examined the general use of AWVs and their benefits [5,7], to the best of our knowledge, none have investigated how internet use might influence WTM/AWV utilization in this high-risk Medicare population along this timeline with national data. Understanding this relationship is crucial, as it could inform strategies to increase WTM/AWV utilization and potentially improve preventive care among older adults with diabetes.

Thus, this study aims to investigate the relationship between internet use and WTM/AWV utilization among Medicare beneficiaries with type 2 diabetes. Specifically, we examine whether accessing health information, scheduling appointments, and communicating with providers via the internet are associated with WTM/AWV utilization. Our research seeks to contribute to the development of targeted interventions that leverage digital tools to improve preventive care engagement and health outcomes for Medicare beneficiaries with diabetes; thereby addressing an important gap in the literature.

2. Materials and Methods

2.1. Study Design and Data

This study utilized a cross-sectional design, analyzing data from the 2021 Medicare Current Beneficiary Survey Public Use File (MCBS PUF). The MCBS PUF is designed to represent the Medicare population, including those aged 65 years and older, as well as individuals under 65 with certain disabilities. The MCBS PUF includes data on beneficiaries’ sociodemographic characteristics, health conditions, healthcare utilization, use of digital resources, and access to health-related services [21].

For this study, we focused on a subset of beneficiaries aged 65 years and older with self-reported type 2 diabetes. Our analysis examined associations between internet use for healthcare-related activities and the WTM/AWV utilization, which are key preventive services offered under Medicare. The STROBE checklist was adopted for the reporting of the study (Supplementary S1).

2.2. Study Participants

The 2021 MCBS PUF only included community-dwelling beneficiaries. Participants were selected based on the following inclusion criteria: being aged 65 years or older, and having self-reported type 2 diabetes. Beneficiaries with reported type 2 diabetes were identified based on the following two questions:

(1) “Has a doctor ever told [you/Sample Person (SP)] that (you/he/she) had any type of diabetes, including: sugar diabetes, high blood sugar, (borderline diabetes, prediabetes, or pregnancy-related diabetes/borderline diabetes, or prediabetes)?”

(2) “Please tell me which type of diabetes the doctor said that [you have/(SP) has].”

A complete-case analysis was applied, and the final analytic sample consisted of 1444 community-dwelling Medicare beneficiaries aged 65 years and older with self-reported type 2 diabetes (Figure S1—A consort diagram).

2.3. Measures

2.3.1. Dependent Variable

The dependent variable in this study was the WTM/AWV utilization. Utilization was assessed using a binary indicator based on beneficiary responses to whether they had attended either of these services based on the following question. “Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has sample person (SP)] had either a “Welcome to Medicare” or an “Annual Wellness” visit?” The MCBS used a single survey item to assess the utilization of the WTM/AWV by beneficiaries.

This question captures whether the respondent used WTM/AWV during the fall round reference period, which reflects utilization within the past 12 months. Those who reported attending either the WTM/AWV were coded as 1, and those who did not attend either were coded as 0.

2.3.2. Independent Variables

The primary independent variables were measures of internet use for health-related activities. Three key binary indicators were used to assess different aspects of internet use based on the following questions:

(1) “DURING THE PAST 12 MONTHS, [has anyone/have you/has (SP)] used the Internet to look up health information (for [you/(SP)])?”

(2) “DURING THE PAST 12 MONTHS, [has anyone/have you/has (SP)] used the Internet to schedule an appointment with a health care provider (for [you/(SP)])?”

(3) “DURING THE PAST 12 MONTHS, [has anyone/have you/has (SP)] used the Internet to communicate with a health care provider (for [you/(SP)])?”

Each of these variables was coded as 1 if the beneficiary reported engaging in the specified Internet activity and 0 if they did not.

2.3.3. Covariates

To control for potential confounding factors, the analysis adjusted for several sociodemographic and health-related variables. These included: age (65–74 years and ≥75 years), sex (male or female), race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, or other), educational attainment (less than high school, high school or vocational, more than high school), income poverty ratio (categorized as ≤120% of the federal poverty level, >120% and ≤200% of the federal poverty level, >200% of the federal poverty level), marital status (married, widowed, divorced/separated, or never married), geographic location (metro or non-metro area), household composition (lives alone or not alone), body mass index (BMI) (categorized as underweight/healthy [BMI < 25], overweight [25 ≤ BMI < 30], or obese [BMI ≥ 30]), functional limitations (no limitations, only instrumental activities of daily living [IADLs] limited, or ≥1 activities of daily living (ADLs) limited), and number of chronic conditions (0–1, 2–3, or ≥4 conditions). The following health conditions were included in the count of chronic conditions: hypertension/high blood pressure, high cholesterol, myocardial infarction, angina pectoris/coronary heart disease, congestive heart failure, other heart conditions including valvular or arrhythmias, stroke, arthritis, osteoporosis, depression, emphysema/asthma/COPD, Alzheimer’s disease/dementia, and non-skin cancer.

2.4. Statistical Analysis

Bivariate analyses were conducted to understand characteristics of Medicare beneficiaries aged 65 years and older with self-reported type 2 diabetes, by WTM/AWV utilization. Logistic regression was conducted to examine the association between internet use and the WTM/AWV utilization, adjusting for the sociodemographic and health-related covariates. As the MCBS used a multi-stage cluster sample design, the survey weights were applied to account for the complex sampling design. A p-value of <0.05 was considered statistically significant. All statistical analyses were performed using SAS Enterprise version 8.3 (SAS Institute, Cary, NC, USA).

2.5. Ethical Considerations

The MCBS PUF is a de-identified, publicly available secondary data source; this study was determined as not human subjects research from institutional review board.

3. Results

Of the study population, 57.5% reported using a WTM/AWV (

Table 1. Characteristics of Medicare beneficiaries with type 2 diabetes, by Welcome to Medicare or Annual Wellness Visit utilization.

Variable	Total	WTM/AWV Used by Beneficiary	WTM/AWV Not Used by Beneficiary	p-Value
Unweighted, n	1444	862	582
Weighted, n	8.3 million	4.8 million	3.5 million
Overall (weighted %)	100	57.5	42.5
Sociodemographic Characteristics
Age Group				0.018
65–74 years	58.8	56.1	62.5
≥75 years	41.2	43.9	37.5
Sex				0.896
Male	47.5	47.3	47.7
Female	52.5	52.7	52.3
Race and Ethnicity				0.268
Non-Hispanic White	67.5	70.1	64.0
Non-Hispanic Black	13.9	12.2	16.1
Hispanic	12.4	11.7	13.3
Other	6.2	6.0	6.6
Marital Status				0.127
Married	53.5	55.9	50.3
Widowed	23.4	23.9	22.8
Divorced/separated	16.7	14.6	19.4
Never Married	6.4	5.6	7.5
Education				0.286
Less than high school	15.5	14.2	17.2
High school/vocational	31.9	31.7	32.3
More than high school	52.6	54.1	50.5
Income Poverty Ratio				0.066
≤120% Federal Poverty   Level	18.2	16.4	20.6
>120% and ≤200%   Federal Poverty   Level	22.1	23.8	19.9
>200% Federal   Poverty Level	59.7	59.9	59.5
Residing Area				0.136
Metro area	81.9	83.6	79.7
Non-metro area	18.0	16.4	20.3
Household Composition				0.035
Lives alone	29.1	26.6	67.4
Not alone	70.9	73.4	32.6
Co-morbidities and Health Status
BMI				0.594
Underweight/healthy,   BMI < 25	15.5	16.4	14.3
Overweight, 25 ≤   BMI < 30	34.5	34.3	34.8
Obese/high-risk obese,   BMI ≥ 30	50.0	49.3	50.9
Functional limitations				0.584
No limitations	52.9	52.3	53.7
Only IADLs limited	13.0	12.4	13.8
≥1 ADLs limited	34.1	35.3	32.5
Chronic Conditions				0.838
≤1 condition	12.4	13.0	11.7
2–3 conditions	43.9	43.5	44.3
≥4 conditions	43.7	43.5	44.0
Internet use in past 12 months
Looked up health information via internet				<0.001
Yes	50.3	56.1	42.5
No	49.7	43.9	57.5
Scheduled an appointment with healthcare provider via internet				0.024
Yes	29.2	31.6	26.1
No	70.8	68.4	73.9
Communicate with healthcare provider via internet				0.049
Yes	37.5	39.8	34.3
No	62.5	60.2	65.7

). Among WTM/AWV users and non-users, there were differences in several characteristics. Higher proportion of WTM/AWV users were aged ≥75 years (43.9% vs. 37.5%, p = 0.018), and a smaller proportion of them were living alone (26.6% vs. 67.4%, p = 0.035). Regarding internet use, 56.1% of WTM/AWV users reported looking up health information via the internet compared to 42.5% of non-users (p < 0.001). Similarly, 31.6% of WTM/AWV users scheduled an appointment with a provider via the internet compared to 26.1% of non-users (p = 0.024). Additionally, 39.8% of WTM/AWV users communicated with a provider via the internet compared to 34.3% of non-users (p = 0.049).

The adjusted analysis revealed that looking up health information via the internet was associated with higher odds of WTM/AWV utilization (OR: 1.76, 95% CI: 1.36–2.28, p < 0.001) (

Table 2. Survey-weighted logit model of factors associated with Welcome to Medicare or Annual Wellness Visit utilization of Medicare beneficiaries with type 2 diabetes.

Variable	OR	95% CI	p-Value
Sociodemographic Characteristics
Age Group
65–74 years	0.74	0.58–0.95	0.018
≥75 years	Ref
Sex
Male	0.91	0.69–1.19	0.484
Female	Ref
Race and Ethnicity
Non-Hispanic White	Ref
Non-Hispanic Black	0.73	0.46–1.16	0.185
Hispanic	0.89	0.55–1.44	0.626
Other	0.89	0.51–1.56	0.676
Marital Status
Married	Ref
Widowed	1.03	0.69–1.54	0.876
Divorced/separated	0.80	0.49–1.30	0.361
Never Married	0.83	0.46–1.50	0.541
Education
Less than high school	Ref
High school or vocational	1.07	0.73–1.58	0.719
More than high school	1.04	0.67–1.62	0.858
Income Poverty Ratio
≤120% Federal Poverty Level	Ref
>120% and ≤200% Federal Poverty Level	1.28	0.88–1.85	0.199
>200% Federal Poverty Level	0.90	0.59–1.38	0.622
Residing Area
Metro area	1.38	0.96–1.97	0.084
Non-metro area	Ref
Household Composition
Lives alone	0.76	0.51–1.12	0.162
Not alone	Ref
Co-morbidities and Health Status
BMI
Underweight/healthy, BMI < 25	Ref
Overweight, 25 ≤ BMI < 30	0.89	0.60–1.30	0.531
Obese/high-risk obese, BMI ≥ 30	0.92	0.65–1.29	0.604
Functional limitations
No limitations	Ref
Only IADLs limited	0.88	0.62–1.26	0.485
≥1 ADLs limited	1.07	0.81–1.43	0.623
Chronic Conditions
≤1 conditions	Ref
2–3 conditions	0.86	0.55–1.32	0.478
≥4 conditions	0.80	0.51–1.27	0.345
Internet use in past 12 months
Looked up health information via internet
Yes	1.76	1.36–2.28	<0.001
No	Ref
Scheduled an appointment with a healthcare provider via internet
Yes	1.14	0.82–1.58	0.435
No	Ref
Communicated with healthcare provider via internet
Yes	0.95	0.67–1.35	0.769
No	Ref

Ref = Reference group.

). Age was also a significant factor, with individuals aged 65–74 years had lower odds of utilizing WTM/AWV compared to those aged ≥75 years (OR: 0.74, 95% CI: 0.58–0.95, p = 0.018). However, the associations between WTM/AWV utilization and scheduling appointments via the internet (OR: 1.14, 95% CI: 0.82–1.58, p = 0.435) or communicating with providers via the internet (OR: 0.95, 95% CI: 0.67–1.35, p = 0.769) were not statistically significant.

4. Discussion

This study found that 57.5% of Medicare beneficiaries with type 2 diabetes reported using either the Welcome to Medicare or Annual Wellness Visit. Internet use behaviors showed a mixed influence: looking up health information via the internet was significantly associated with increased WTM/AWV utilization, while scheduling appointments and communicating with providers online were not statistically significant factors.

The positive association between looking up health information via the internet and WTM/AWV utilization highlights the roles of digital and health literacy in promoting preventive care engagement among Medicare beneficiaries with type 2 diabetes. Beneficiaries who actively seek health information online may be more aware of the benefits of these visits, leading to higher utilization rates. The ability to look up health information online could potentially reduce barriers to care, improve health literacy, and enhance engagement in preventive services like WTM/AWV. This finding is particularly noteworthy in the context of the rising adoption of diabetes technologies (such as continuous glucose monitoring and smart phone applications), which have shown improved glycemic management, quality of life, and safety outcomes for older adults [22,23,24]. Improving digital and health literacy among Medicare beneficiaries with type 2 diabetes could have a dual benefit, not only enhancing their ability to access and utilize preventive services like WTM/AWV, but also equipping them to navigate other beneficial digital health tools related to diabetes, including possible AI applications.

Scheduling appointments and communicating with providers online were not significantly associated with WTM/AWV utilization. This could be because both behaviors depend heavily on portal availability, clinical workflow, or proxy assistance, rather than an individual’s activation and engagement. In contrast, online information-seeking behavior may lead to improved health literacy and increased use of preventive care. However, their lower WTM/AWV utilization rates suggest missed opportunities to leverage these behaviors for facilitating preventive care. Disparities in digital access and literacy among older adults may also exacerbate existing differences in healthcare utilization [15]. Older adults may face unique barriers, such as limited digital literacy, lack of access to reliable internet, or discomfort with technology, which could impede their ability to interact effectively with healthcare providers [25]. Addressing these barriers through targeted technology training programs, user-friendly and simplified digital interfaces, and digital and health literacy programs could further enhance engagement with WTM/AWV.

The finding that individuals aged 65–74 years were less likely to utilize WTM/AWV compared to those aged ≥75 years warrants further exploration. This result is consistent with prior research, which found age-related disparities in AWV utilization among Medicare beneficiaries, with older adults being more likely to engage in preventive care [7]. One potential explanation could be differences in healthcare-seeking behaviors or perceived need for preventive services between these age groups. Older beneficiaries (≥75 years) may have more frequent interactions with the healthcare system due to comorbidities, making them more likely to receive referrals or reminders for WTM/AWV. Similarly, given the likelihood of comorbidities among older adults, it may also be that with more complexity in managing multiple chronic conditions, individuals may be in need of more information to manage or prevent potential complications associated with diabetes. Strategies such as personalized outreach or education campaigns targeting younger Medicare beneficiaries (65–74 years) could potentially help to bridge this gap.

Limitations and Future Research

This study has several limitations. First, this analysis focused on community-dwelling Medicare beneficiaries aged 65 years and older with type 2 diabetes, limiting the applicability of findings to other populations. Second, reliance on self-reported data (which may include proxy responses) for internet use behaviors and WTM/AWV utilization introduce the potential for recall biases. Participants may have overestimated their engagement with online health activities or preventive service utilization to conform to socially desirable norms. Third, the MCBS PUF is cross-sectional, preventing determination of causal relationships between internet use behaviors and WTM/AWV utilization. Fourth, the survey combined both WTM/AWV use into one question; separate questions for WTM/AWV may yield different findings and insights. Fifth, the MCBS PUF did not have health literacy measures and did not assess digital literacy level among the study population. Finally, this study did not explore the specific barriers that older adults face in using digital tools for health-related activities. Additionally, we focused on main associations, rather than testing for multiple potential interaction associations. This means that, for example, when comparing non-metro to metro areas, we would be unable to additionally examine whether, for example, individuals residing in non-metro areas had different results by sex, marital status, income poverty ratio, etc. Future studies should consider a deeper dive into the data to elucidate these potential interactions, if any. Also, qualitative studies could reveal challenges such as digital literacy gaps and technology access issues. Addressing these limitations in future research will enhance the understanding of digital engagement’s role in improving preventive care for Medicare beneficiaries with type 2 diabetes.

5. Conclusions

This study found that 57.5% of Medicare beneficiaries with type 2 diabetes utilized either the Welcome to Medicare visit or the Annual Wellness Visit. Notably, individuals aged 65–74 years were less likely to use these services compared to those aged ≥75 years. Internet use for looking up health information online was associated with higher odds of WTM/AWV utilization, while online appointment scheduling and provider communication showed no significant association. These findings underscore the importance of digital and health literacy; the provider should incorporate digital and health literacy assessments and refer individuals to digital literacy programs, in enhancing preventive care engagement. Addressing barriers to digital tool adoption and health literacy could further improve preventive care outcomes in older patients with diabetes.