Clinical Geriatrics

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.