Published on Nov 18, 2021
When Signify Health, Inc. (SGFY) schedules health plan members for a peripheral artery disease (PAD) screening test during an in-home health evaluation, clinicians are required to perform the test for patients who are covered by certain health plans even if they determine it is not clinically indicated, according to a Capitol Forum investigation.
Peripheral artery disease is a narrowing or blockage of the blood vessels that carry blood from the heart to the limbs. PAD symptoms include pain in the legs that worsens with activity and gets better with rest.
Signify’s main clients for its in-home health evaluations (IHEs) are Medicare Advantage health plans. Medicare Advantage plans are paid more by Centers for Medicare and Medicaid (CMS) to cover members with certain chronic diagnoses because it costs more to treat those members. A PAD diagnosis generates an increase over the base per-beneficiary CMS payment by about $2,800 every year, according to a Medicare policy expert who spoke to The Capitol Forum on background.
The Capitol Forum previously reported on Signify clinicians’ concerns over lack of professional autonomy and being required to perform Quantaflo PAD tests and diabetic retinopathy screenings when the clinicians determine the tests to be unnecessary.
“Signify practitioners have the discretion on which test to perform or not perform based on their physical assessment of the member,” a Signify spokesperson previously told The Capitol Forum in an email.
But the company’s comment runs contrary to company emails and company training materials The Capitol Forum reviewed and the experiences of clinicians who currently work for or formerly worked for Signify as told to The Capitol Forum.
Signify declined to provide any additional comment for this article.
In an email to a clinician last year, a Signify ancillary services coordinator reiterated that scheduled PAD tests “should be completed” for members who are insured by several of Signify’s clients, including Aetna (AET), Regence (ANTM), Priority, Wellcare (CNC), and other plans. The only exception, the email reviewed by The Capitol Forum explained, is Signify client Humana (HUM).
This policy has been repeated over and over in communications to clinicians over the past two years, according to materials obtained by The Capitol Forum, and is mentioned in a PAD Workflow Guide currently in use, a clinician told The Capitol Forum.
For example, an email sent to clinicians early last year said, “As always, the only time ‘Not Clinically Relevant’ should be selected is for Humana members. Please note: All Humana members are strongly encouraged to have the PAD test completed. All other plans are required if ‘PAD’ is listed in the product section [emphasis in original].”
A January 2020 email stated, “If the member is anything other than a Humana member and PAD is listed under their name, the PAD test is required to complete.” But even for Humana members, if the member is a septuagenarian or older, clinicians are told to consider the PAD test whether the member has symptoms or not. The PAD workflow guide reviewed by The Capitol Forum states, “If the member is 70 years or older, [consider the PAD test] even if no symptoms are present.”
Importantly, experts say there is insufficient data to recommend the screening of asymptomatic adults for PAD or to determine if performing the test could result in more harm than benefit to the patient.
“More research is needed to determine if screening with the ankle-brachial index (ABI) can help to identify PAD in adults,” the U.S. Preventative Services Task Force (USPSTF), an independent body of national experts in primary care and preventative medicine, told The Capitol Forum in an email. For the PAD test, Signify uses a digital screening tool, the Quantaflo made by Semler Scientific Inc. (SMLR), to measure the ankle-brachial index (ABI).
There is no recommendation for PAD screening for adults without signs or symptoms of PAD or a known diagnosis of peripheral or coronary vessel disease or severe chronic kidney disease, according to an American Family Physician journal article.
Oddly, clinicians told The Capitol Forum, when the PAD test was not on the schedule, they were prohibited from screening for PAD even when a member exhibited signs and symptoms and had multiple risk factors for PAD. Dating back to October 2019, Signify, in emails to clinicians wrote, “Remember: Only Members with a PAD note listed under ‘Products’ via the [app] schedule should be considered for a PAD test [emphasis in original].” The reminder is repeated in the company’s PAD workflow guide.
The American College of Cardiology (ACC), told The Capitol Forum by email that it has “a PAD guideline, but it addresses screening for at-risk individuals and disease management.”
While the direct harms of screening are minimal, other harms may include false-positive test results leading to anxiety and further expensive and potentially risker testing and treatment, according to the American Family Physician journal article. The Medicare policy expert who spoke with The Capitol Forum on background said that in addition to increasing costs, the PAD screening could potentially lead to unnecessary surgery.
Aetna—a client for whom Signify conducts in-home evaluations—has a clinical guideline that says Quantaflo is experimental and not reimbursed. Aetna did not respond to request for comment.
Priority Health declined to comment. Regence, Wellcare and Humana did not respond to a request for comment.