Member Evaluations Don’t Replace the PCP

For obvious (and very good) reasons, Medicare Advantage plans want to maximize the unique opportunity afforded by in home evaluations of their members.  There is no question that these evaluations can yield diagnostic information that is essential to risk adjustment revenue management.  The opportunity to collect clinical information and merge it with data from claims and Medicare return files makes it possible for MA plans to positively influence care in a way that fee for service Medicare cannot.  Direct member evaluations also provide a way to quantify and improve measurable standards of care such as those included in HEDIS, ADA standards of care for diabetics, ACC standards of care for cardiovascular disease, and Star ratings.

 One question that comes up repeatedly in our conversations with plans is whether we can collect even more data during these encounters. Specifically, plans are interested in having our physician evaluators collect specimens for laboratory studies that factor into HEDIS and Stars measures.  On the face of it, this seems like a natural extension of the service, but there are a couple of not so obvious drawbacks.  

First, we are very hesitant to do anything that might be seen as coming between a member and his or her treating physician.  That is a unique and valuable relationship and we want to make sure that what we do only enhances it.

Second, we are concerned about the chain of responsibility in collecting that information.  First, a physician or other licensed provider has to order the test in question.  Our physicians can certainly do that, but then someone has to take the responsibility of checking the result and providing appropriate care based on the results.  That our doctors cannot do since that would require establishing an ongoing clinical involvement that would directly conflict with our determination not to interfere with the member’s relationship with their treating physician.  An alternative would be for the plan medical director to accept responsibility for ordering and following up on the lab studies, but most plan CMOs are not willing to do that.

For those reasons, we have been hesitant to collect lab specimens as part of our evaluations, although we willing to discuss alternatives with our clients who need that service.