Medicare Reimbursement Must Come Into Focus for Geriatric Assessments and Care Coordination Services
The Medicare Payment Advisory Commission’s (MedPAC) March report to Congress was, in one respect, encouraging. While Medicare’s problematic Sustainable Growth Rate (SGR) formula dictates a 10.6% cut in payments to physicians starting July 1, the MedPAC report calls on legislators to increase Medicare physician reimbursement next year.
Now for the discouraging part: The report recommends a mere 1.1% increase in reimbursement in 2009. And it fails to propose a much-needed alternative to the SGR, which automatically mandates cuts in physician reimbursement whenever growth in these outlays outstrips growth in Gross Domestic Product (GDP).
Every clinician I know anticipates practice expenses to increase much more than 1.1% next year. Whether GDP is already declining and we are in a recession, or will begin to do so in the near future, is now a matter of serious national concern. This combination of factors doesn’t bode well for us in clinical care, or for older Americans.
It’s no secret that the number of older adults in the United States will follow an increasingly steep upward trajectory over the next two decades. The number of Americans age 65 and older will double—reaching 70 million—by 2030. We clearly need more recruits—many more—into elder healthcare. Continuing to offer below-market compensation to the geriatricians, family physicians, internists, and other professionals who provide the lion’s share of this care, however, will make it virtually impossible to attract the best and the brightest into the field. To the contrary, it will ultimately lead those who already care for Medicare beneficiaries to stop accepting new Medicare patients, or to cut back on those they’re already seeing. In fact, recent surveys find that this is already happening.
The end result: A growing—and costly—primary care access problem for older people.
We need a major overhaul of the imbalanced payment incentives in Medicare (and in the healthcare system in general, since many of the flaws in Medicare affect private insurance as well). The MedPAC report does recommend reducing payments to private Medicare Advantage plans so they’re aligned with those in traditional Medicare. And this would be a step in the right direction. But we need to go even further and shift the focus of Medicare compensation in fundamental ways.
Caring for older adults, particularly the frail elderly and others with complex medical problems, is time- and resource-intensive, and requires well-honed cognitive skills. Medicare, however, compensates for procedures and interventions, while offering insufficient, or, in many cases, no reimbursement for the more in-depth consultations, follow-ups, multiple meetings, and phone calls among members of the interdisciplinary geriatrics teams that are central to quality care—and cost-effective care—for complex elderly patients.
The proposed Geriatric Assessment and Chronic Care Coordination (GACCC) Act now before Congress would help address this shortcoming. It would fill a major gap in traditional Medicare by covering comprehensive geriatric assessments and care coordination services for beneficiaries with at least two chronic health problems. Research suggests that geriatric assessment can reduce the incidence of adverse drug events, the need for specialty services, diagnostic studies, ER visits, and hospitalizations—and may cut the costs of acute care.
A randomized controlled trial involving nearly 1000 seniors recently reported in The Journal of the American Medical Association found that geriatric care management in primary care improved the quality of medical care for geriatric conditions, boosted health-related quality of life, and reduced emergency department visits over two years.1 In the most complex older patients, hospitalization rates dropped more than 40% in the second year of the study. Linking geriatric assessment with coordinated care has also demonstrated substantial cost savings. In Harris County, Texas, the Evercare STAR + PLUS pilot program, which emphasizes care coordination and served roughly 65,000 older adults countywide in 2007, saved the state government $123 million over two years.2
A 1.1% physician pay increase in 2009, while better than a cut in pay, won’t address the systemic problems that are not only driving experienced practitioners away from the field, but also making it much less desirable as a field of practice for physicians in training. This will only make it harder for older Americans to find quality healthcare. We need structural reforms, like the GACCC Act, and we need an alternative to the SGR. We also need additional training in geriatrics for all practitioners—the kind of training provided by Title VII Geriatrics Healthcare Professions Programs, which would get no funding next year under the President’s 2009 budget plan.
The AGS has launched concerted advocacy campaigns on behalf of the GACCC Act, 2009 Title VII funding, a viable alternative to the SGR, and Congressional action to block cuts in Medicare fees for physicians, among other measures. I hope you’ll continue to support these efforts. It’s easy enough: Just visit www.healthinaging.org/advocacy/ and register with AGS’ Health in Aging Advocacy Center. Past Advocacy Center campaigns aimed at restoring Title VII funding and blocking SGR-mandated cuts have been successful. With your help we can, and must, build on those successes.
1. Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: A randomized controlled trial. JAMA 2007;298:2623-2633.
2. Texas Health and Human Services Commission. Star+Plus. Available at: www.hhsc.state.tx.us/starplus/starplus.htm. Accessed April 10, 2008.