Remedies for Medicare’s Chronic Ills
Common sense would dictate that by 2004, given the well-recognized prevalence of chronic illness among the elderly, coordination of geriatric care would be long established as billable under Medicare. As we know all too well, however, the incentives clearly lean toward acute, episodic care and do not encourage the sustained, extensive oversight that good primary care physicians and other health professionals must employ to successfully manage chronic disease in older adults. We are familiar with the manifestations of common chronic diseases. We know that diabetes, heart disease, and other chronic illnesses affect nearly 90% of Medicare beneficiaries, and that two-thirds have more than one of these conditions. In fact, 20% of the Medicare population has at least five chronic conditions.
The care of this group of patients is by far the most expensive, and accounts for 66% of Medicare spending. Limited management and coordination, encouraged by the structure and focus of Medicare payments, can lead to care gaps that contribute to increased morbidity. The large volume of complex and difficult-to-manage illnesses and hospitalizations, which could have been mitigated by coordinated care at an early stage, negatively impact not only the health and well-being of our patients but also the fiscal solvency of our health care system. We are confronted daily with the need to prioritize the many interacting complex medical, functional, and psychosocial problems in our patients and still remain constrained by the Medicare reimbursement system, which encourages neither timely coordination of care nor care planning. Although managed Medicare products may allow for a more systematic approach to care, the overwhelming majority of older adults we see continue to be managed within traditional Medicare.
We are called on to not only provide high-quality direct patient care but also to serve as the intermediary between the patient and other care providers in emergency room, acute hospital, nursing home, home care, and other settings. Our patients, their families, and our professional colleagues often call on us to provide this non- reimbursable but very time-intensive service. There is no question that our expertise in care is needed and can benefit patient management, but unfortunately, there is no simple way to obtain needed reimbursement for it. Fortunately, it appears that lawmakers may be more aware of the realities we face in practice, and of our long-standing efforts and attempts to realign the fee-for-service care model. Armed with scientific data and other evidence, and with endorsements from groups like the American Geriatrics Society, the Geriatric and Chronic Care Management Act was introduced in the Senate in late June. At the core of this legislation, a revised version of the stalled Geriatric Care Act of 2003 is a newly defined geriatric assessment and care management benefit for beneficiaries with multiple chronic conditions. Payments for the geriatric assessment services under the physician fee schedule will be determined by the Secretary of Health and Human Services. The Secretary will consult with physician and patient associations to develop care management payments based on either a per-member-per-month care management fee, a severity adjusted per-member-per-month care management fee, a global care management fee, or any other payment methodology that creates incentives for practice-based improvements based on quality and cost-effectiveness of patient care.
The AGS looks forward to playing a key role in these discussions. As written, care management services eligible for reimbursement in the bill would be paid outside the fee schedule. Included are many services that are well recognized key components of good geriatric care, but that as of now go unrecognized under Medicare: the development of a care plan; multidisciplinary team conferences; coordination with other providers; medication management; patient and family caregiver education; self-management services; telephone consultations, including 24-hour telephone availability; management of transitions across settings, including end-of-life care planning; and referral to and coordination with community resources. When you think of how important these services are to our patients with multiple and overlapping chronic conditions, and how many of us and our colleagues perform these services at no cost to Medicare despite the burden they impose on time and resources, it is clear that this legislation is long overdue.
The AGS has been actively working to improve the practices of those of us with high geriatric caseloads through a variety of measures. As our professional society, AGS has long recognized the challenges we face in our efforts to do “the right thing” for our patients and their families. In this column, we previously discussed the Practice Management Toolkit, a resource designed to help navigate the complexities unique to treating older adults. I hope you have had an opportunity to review this Toolkit, which can be accessed at www.myagsonline.org. I encourage you to take a more active role with us in our attempts to help tailor Medicare reimbursement, not only to serve the needs of our patients and their expectations for high-quality care but also to make our practice of geriatric care more sustainable. We know that inadequate reimbursement is a significant disincentive for students and trainees considering careers in geriatric medicine. A good way to help correct this disincentive is to become more active with your AGS state affiliate and with the national organization at the grassroots. Help us push public policy issues forward by learning more about the bill and taking our key Congressional contacts survey. Visit www.americangeriatrics.org/policy/ for additional information.
I welcome your feedback and can be reached at firstname.lastname@example.org. Barney S. Spivack, MD, FACP, CMD Associate Physician Editor Clinical Geriatrics