called a 360 exam and most MD's don't do it thoroughly enough to be accepted by the insurance company.
They will send out most likely a nurse practitioner who will do a head to toe, vitals, and meds. The idea is that they document every health problem you have or have had and document a plan of care or treatment for it. By documenting EVERYTHING in this thorough manner, you are allocated more appropriate funds for medicare next year.
So you go to your MD and he lists, say high blood pressure and high cholesterol. Okay great.
But the NP lists your old back surgery, kidney stones, osteoporosis, pre-diabetes...all these things that you may have had or currently have but aren't under treatment for.
So based on what your MD lists as high BP and high cholesterol, medicare says gee, she's pretty healthy. Let's allocate $10,000 for her care next year (2016). But your kidney stone acts up and you're in the hospital for that. Then, your osteoporosis gets the best of you and you break an arm going down the stairs so your'e in the hospital for that. That doesn't mean you pay more in 2016, it just means that medicare didn't allocate the proper amount for your care that you were anticipated to have. It means the hospital gets paid less and your MD gets paid less for your visits
But if you've got all these problems listed, then Humana says "gee, she could break an arm or have some issues with blood sugar" and they allocate $40,000 for your care. That means if you go to the hospital, the hospital gets a higher payout. Your DR gets more $$ per visit for you because you're assumed to have more health concerns than just high blood pressure and high cholesterol.
It's a way to anticipate your medical needs over the next year.
Medicare MD's are capitated. That means that they're paid $X for your visits, regardless of what you have done or not. So if you've got Asthma, and go to the doctor weekly and get duonebs and other breathing treatments, but these aren't documented in your yearly 360 exam, then that dr is going to get the $ per visit that he would get if you were just getting regular checkups and medicine follow-ups.
I know this because I work for a medicare advantage insurance company (one of the top 3) as an RN. We do 360's in our office, but we have NP's that go out and do them at home, as well as some visiting MD's.
It's also a good way to get a handle on what's going on in a patient's life that they may not tell the MD about, or think to tell them about. Do you have running water (you may, but many patient's don't). Is your house safe and habitable? Are there any reasons why how and where you live may negatively affect your health (have diabetes, but no refrigerator so no way to store insulin. Have restricted diet but no stove so have to buy take-out food, have osteoporosis but wobbly stairs which increase fall).
Many patients also have polypharmacy, which means they take more than 7 meds a day. Many people's heart Dr and lung dr and PCP and etc don't talk to each other, so patients may be on duplicate meds or meds that counteract with each other. He/She will go over the meds and make sure there's no duplicates or harmful combinations.
You may live in a great place with great support and only take 3 meds. But it's easier for Humana to do this wholesale for EVERYONE and have fewer people falling through the cracks than to do it on risk assessment alone. Risk assessment is only as good as the data that is provided, and what has happened in the past. The key is preventing bad things from happening in the future and to keep near misses and accidents from happening.
= new reply since forum marked as read
