A Range of Provisions Designed to Enhance Elder Healthcare Take Effect This Year, But Challenges Lie Ahead

Barney S. Spivack, MD, FACP, AGSF, CMD Associate Physician Editor, Clinical Geriatrics

As I was readying this column for the January issue of Clinical Geriatrics, the big news was the December 15 Federal District Court ruling that a central mandate of the healthcare reform law—the mandate requiring most Americans to get health insurance by 2014—was unconstitutional. The decision made banner headlines, and opponents of the reform legislation hailed it as a major victory. But the ruling won’t halt further implementation of the law for a number of reasons. For starters, the judge who rendered the decision didn’t issue an injunction blocking further implementation of the healthcare reform law. And two other federal judges have upheld the coverage mandate. A final word on the mandate is likely to come from the Supreme Court.

In the meantime, the implementation of reform provisions proceeds—and this is good news for older adults and for all of those who care for them. The healthcare reform law includes a wide range of provisions, championed by the American Geriatrics Society (AGS) and other advocates for quality elder healthcare, that will significantly enhance the care that older adults receive. Many of these take effect this month (January 2011). Provisions taking effect in January 2011 shrink the Medicare prescription drug benefit “donut hole” coverage gap, enhance and expand preventive care coverage, and help address current financial disincentives to caring for Medicare beneficiaries.

More specifically, reform provisions effective this month require pharmaceutical companies to offer Medicare beneficiaries a 50% discount on brand-name prescription drugs. They also begin phasing in federal subsidies for generic drugs. The provisions eliminate beneficiary cost-sharing for preventive care recommended by the U.S. Preventive Services Task Force. They cover Medicare’s new “wellness visit” and waive the deductible for colorectal cancer screening. As of this month, beneficiaries are also entitled to a free, personalized prevention plan and a comprehensive health risk assessment.

In an effort to help address longstanding disincentives to caring for Medicare beneficiaries, healthcare reform provisions effective this month also provide a 10% Medicare bonus payment for primary care physicians through 2015. The AGS successfully advocated for explicit recognition of geriatricians as primary care physicians in the legislation—as is appropriate, given the care we provide. The bonus is certainly an important and much needed step. It must, however, be followed by additional steps to address current financial disincentives to providing care to Medicare patients. And this brings me to another matter that was making headlines in mid-December: the perennial turmoil caused by Medicare’s Sustainable Growth Rate (SGR) formula.

The draconian SGR mandates cuts in payments to physicians, and other professionals who bill under the physician fee schedule, whenever increases in annual outlays for their services exceed preordained limits. And it has called for cuts in payments to physicians every year for several years now. Congress has ultimately deferred these cuts either just before they were to take effect or shortly thereafter. Each year, physicians have been left in limbo to wonder whether the cuts will take effect and, if so, how steep they will be, and whether they will be permanent. Because Congress has simply deferred the cuts without coming up with an alternative to the SGR, the magnitude of the mandated cuts has increased every year. A potentially crippling 25% cut in physician payments was scheduled to take effect this January 1, but Congress ultimately voted in mid-December 2010 to defer the cut until December 31, 2011. The AGS and other organizations had called on Congress to postpone the cut until the end of this year, so lawmakers would have time to come up with a viable alternative to the SGR. And this—the replacement of the SGR with a workable protocol—simply must be accomplished before this year ends.

The last several years of SGR-induced uncertainty have taken a toll. Many physicians have stopped seeing new Medicare beneficiaries. Others, polls find, are strongly considering such a move, threatening much needed physician access for older adults. With the first of the nation’s 77 million baby boomers turning 65 this year, it is absolutely imperative that lawmakers come up with a lasting “doc fix.” I hope you’ll join me, the AGS, and many other organized medical groups in advocating for such a resolution—long before the December 31, 2011 deadline approaches.

Dr. Spivack is Associate Clinical Professor of Medicine, Columbia University, New York, NY; Consultant in Geriatric Medicine, Greenwich Hospital, Greenwich, CT; and Medical Director, LifeCare, Inc., Westport, CT.

Send comments to Dr. Spivack at: medwards@hmpcommunications.com.