The Medicare Beneficiary of the 21st Century: Effect on Geriatric Practices
The Medicare beneficiary is changing, and these changes are affecting how geriatric care providers practice. From the physical layout of the practice, to marketing, to management from an administrative and clinical aspect, all is about to change. The Medicare Payment Advisory Commission (MedPAC; www.MedPAC.gov) recently assessed for Congress the changing demographics of the Medicare beneficiary by identifying eight major changes,1 as follow:
Increase in Number of Beneficiaries as Baby Boomers Age
Everyone is aware of the aging baby boomers becoming Medicare-eligible, but the true impact is worth continually stressing. It is for this reason that MedPAC led with this in its listing of changes affecting Medicare. The increase in the number of Medicare beneficiaries means greater demand on all physician services—especially primary care. This increasing pressure on geriatric healthcare services at a time when the number of geriatric-trained clinicians is decreasing will make the requirement to operate practices in a most efficient and effective manner vitally important. Practices may want to consider group visits, telemedicine, and “just-in-time” appointments as ways to deal most efficiently with the growing demand for their time.
Changing Profile of Beneficiaries
•Increased prevalence of being treated for several chronic conditions
•Decline in proportion of beneficiaries who are disabled
The health profile of the senior patient is changing, with a decrease in those Medicare beneficiaries who are disabled secondary to improved surgical procedures, therapy options, and environmental safety features all contributing to this decline. While the decline in disabilities is encouraging, the opposite has been the case with regard to chronic conditions. Since seniors are living longer they are more likely to have accumulated a wide variety of chronic conditions that require careful medical intervention and treatment. In addition to the increased longevity of seniors, technology has also played a role in the increased prevalence of chronic conditions. Technology for identifying the presence of conditions has advanced (eg, dual energy x-ray absorptiometry scan for osteoporosis). These advances have resulted in seniors being diagnosed for conditions that could not have been detected several years ago. Lastly, definitions have changed over time to increase the prevalence of disease. In 2004, the American Diabetes Association lowered the definition of abnormal fasting glucose levels from 110 milligrams per deciliter (mg/dL) to 100 mg/dL. This change increased the prevalence of metabolic syndrome among adults age 20 years or older by 20%. The management of these increased comorbid chronic conditions in most cases requires an interdisciplinary care team. Care teams can focus their attention on comorbid conditions rather than simply a single disease state through the involvement of multiple disciplines such as pharmacy, dietary, and physical, occupational, and speech therapy.
Increase in Number of Obese Beneficiaries
Obesity is a growing epidemic in the United States; even seniors are being affected by a growing number of Medicare beneficiaries who are entering Medicare obese. Data from the Agency for Healthcare Research and Quality indicate that the share of Medicare spending attributable to obese beneficiaries nearly tripled from 9.4% in 1987 to 24.8% in 2002. This new Medicare beneficiary will require in some cases a facility redesign to accommodate the obese senior. Changes such as reception area seating that can accommodate obese patients, exam tables that do not require “jumping” up, even gowns that are better suited for the obese patient will be increasingly needed. In addition to a facility redesign, practices will need to develop clinical practices to better manage metabolic disorders. Medicare pay-for-performance through the Physician Quality Reporting Initiative (PQRI) will increasingly drive payment to physicians who best manage those patients with metabolic disorders.
Decreasing Reliance on Employer-Sponsored Insurance
The decline in proportion of prevalence of employer-sponsored insurance will mean a greater reliance on federal and private insurance. The increased reliance on the federal system will result in pressure to control costs, which can only be accomplished through decreases in either the demand for services or prices of those services. While some of the costs will be shifted to beneficiaries (see “Income Issues” section below), the greater burden for these necessary cost reductions will be placed on providers. As a result, providers will be forced to do more with less. This will mean practicing in new ways such as without the overhead of an office or opting out of Medicare for a concierge-type practice.
Change in Racial and Ethnic Profile
The racial/ethnic mix may change, with an increase in the percentage of beneficiaries of Hispanic origin and, to a lesser extent, Asian origin, who may have different healthcare needs than other beneficiaries. The disparities in healthcare that are commonly reported today based on racial and ethnic lines will become even more of an issue as the percentage of racial and ethnic diversity becomes more apparent within each geriatric practice. A practice’s clinical and administrative teams will be called upon to be more racial- and ethnic-sensitive. Programs will need to be developed and implemented that not only educate all staff members, but also through electronic health records can monitor delivery across cultural lines.
Adult Children May Become a Less Reliable Source of Custodial Care for Their Parents
People are having fewer children, more women are having children after age 35, and adult children are living greater distances from their parents, which may reduce the availability of adult children of beneficiaries to provide long-term care (LTC) in the home. The result will put increasing pressure on a greater use of different forms of LTC such as home care services, adult daycare, and assisted living facilities. Practices may find success in searching out these LTC sites for practice development opportunities.
Beneficiaries Having More Formal Education
As the Medicare beneficiary becomes more likely to have formal education, there will be increased likelihood that channels such as the Internet will be available to practice. Not only will senior patients have the ability to handle new channels of communication, but they will increasingly demand it. These new channels through the Internet such as e-mail chats, online appointments, and even telemedicine will allow physicians to do more with less. Through systems such as those available for the restaurant industry through www.opentable.com, patients will increasingly be able to make appointments and seek interaction with their clinicians over the Internet.
But before these more advanced systems can be implemented, physician practices would be well served by the development of Internet sites that provide basic practice information such as office location, practice hours, insurances accepted, and practice patterns. These same sites can then provide patient education, directly communicate with patients via secure e-mail, and perhaps in the near future, enable the making of online appointments.
•Income has grown more slowly than healthcare costs
•Income distribution is less even
Previously we discussed the shift in Medicare funding (see “Decreasing Reliance on Employer-Sponsored Insurance” section). With regard to the beneficiary, we continue to see a “dumbbelling” of the population, with some benefits being on the more affluent side, while others are finding it increasingly difficult to pay their growing cost-sharing amounts. As the government attempts to shift part of the federal burden for Medicare costs onto individual beneficiaries, many will find it difficult to manage since their incomes have not grown at a rate to cover the increases in healthcare costs; the resulting shortfall will force many to go without or to come back to the federal government to provide coverage. The result will be that some areas of the country will be more apt to provide concierge medical care while others will likely be cared for in clinics and convenient care centers that are operated at lower overheads than traditional physician-run practices.
Obviously, these changes will mean that, in addition to practitioners adjusting their practices, the Medicare system will also need to make some major changes. In response to these changes, MedPAC has outlined five areas of focus to better accommodate the changing Medicare beneficiary and the increasing need to reduce costs within the Medicare program. These measures focus around improvements in the following:
1. Care coordination
2. Healthcare information technology
3. Comparative effectiveness analyses
4. Promotion of lifestyle changes
5. Restructuring of benefits and cost-sharing
Even before these recommendations were announced in April, the President had already signed an executive order that went into effect on January 1, 2007. This executive order focused on expanding the use of health information technology, increasing the transparency with regard to quality and price, and improving the incentives for beneficiaries and providers. The PQRI, which began on July 1, 2007, is the first response to this executive act, but clearly more are coming soon.
So in addition to the eight changes in the profile of the Medicare beneficiary of the future, the changing face of Medicare itself means that the traditional geriatric practice, where a solo practitioner delivered care for a small number of seniors being paid through Medicare and a supplemental insurance plan, are indeed numbered. The future practice of geriatric medicine will require much more efficient and effective operating to truly make more out of less, and fewer resources with an increase in volume and challenges of the Medicare patient of the 21st century.
Please send any questions or experiences about Medicare you would like to share with readers to: email@example.com Dr. Stefanacci served as a Centers for Medicare & Medicaid Services (CMS) Health Policy Scholar for 2003-2004. He is Founding Executive Director, Health Policy Institute, University of the Sciences, Philadelphia, PA. Dr. Spivack is Associate Physician Editor of Clinical Geriatrics.
1. MedPAC—Medicare Payment Advisory Commission. Report to the Congress: Promoting Greater Efficiency in Medicare. June 2007. Available at: www.medpac.gov/documents/Jun07_EntireReport.pdf. Accessed July 9, 2007.