Emphasizing the need for coordinated care led by a family physician, the AAFP is asking a major insurer to review its policies on intervention by nurses and third parties in patient care.
Insurers that have a contract to offer Medicare Advantage plans are rated on how well their plans perform on measures such as health screenings, including whether patients receive an annual wellness visit. This has led UnitedHealthcare (UHC) in some areas to begin sending nurses to visit patients without contacting the patient's primary care physician. The nurses are employed by the insurer, however, and not by the physician, which often leads to communication gaps and fragmentation of care. Physician who are not aware that their patients have been seen at home by nurses for annual wellness visits might schedule duplicate office visits, wasting valuable time.
AAFP officials spoke to UHC executives about the issue during an annual meeting on patient care and insurance procedures in September. Later, Texas AFP members reported that nurses employed by UHC were visiting Medicare Advantage patients and installing monitoring equipment without informing the patient's physician. The insurance company was not informing physicians that such visits were being made, and it did not communicate about the new equipment.
Even though this issue was not directly related to annual wellness visits, it was part of the broader problem of care being provided without the primary care physician's knowledge, which could result in suboptimal patient outcomes.
In response, the AAFP wrote a follow-up letter(2 page PDF) to UHC on Dec. 7 seeking to improve care coordination.
"The AAFP is concerned that UHC is financially supporting these external third parties to care for patients without coordinating the care with the patient's primary care physician," the letter states. "This type of care undermines the doctor-patient relationship, damages continuity of care and may put the patient at increased risk."
The AAFP asked the insurer to review its policy of allowing nurses to deliver care without coordinating those efforts with a primary care physician.
"Patients are also telling our members they are being regularly contacted by nurses from UHC, and monitoring equipment is being placed in their home with wireless updates going directly to the insurance case manager or a remote specialist," says the letter. "Family physicians need to be kept informed of interventions so chronic disease management and care coordination can be optimized."
In ongoing communication with the insurer, the AAFP stated that nurses who provide services in a patient's home need to communicate with the primary care physician. A UHC official responded that the nurse should submit a summary of care report to the physician.
Noting that insurance payment systems need to change along with delivery of care, the letter emphasized the need for increased investment in primary care given the expectation that family physicians take on greater responsibility for care coordination.
"Services such as patient education; medication management and adherence support; risk stratification; population management; coordination of care transitions; and care planning are typically not reimbursed under traditional, fee-for-service models," the letter notes. "These types of services are best performed by the family physician and the practice team rather than external third parties."
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