Clinical Geriatrics

“Many people, just as they become eligible for Medicare, discover that the insurance rug has been pulled out from under them,” The New York Times reported in April in a feature titled “Doctors Are Opting Out of Medicare.”1 “Some doctors—often internists but also gastroenterologists, gynecologists, psychiatrists and other specialists—are no longer accepting Medicare... The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.”

Among other things, the Times story cited the Medicare Payment Advisory Commission’s (MedPAC’s) June 2008 report to Congress,2 and the report’s finding that 28% of Medicare beneficiaries looking for new primary care physicians had difficulty finding one that year. That figure was up from 24% the previous year. The Times piece went on to focus on what new and soon-to-be beneficiaries might do to find primary care providers, offering helpful advice. But it didn’t examine longer-term, system-wide solutions.

The 2008 MedPAC report, however, does. It highlights changes that would help address financial disincentives to caring for Medicare beneficiaries, and inefficiencies built into Medicare’s current payment system. Nearly a year after the report came out, it’s worth taking a look at what Washington is doing in these areas.

The MedPAC report notes that nonprocedural “evaluation and management (E&M) services—the hallmark of primary care—are undervalued, potentially creating an imbalance relative to procedurally-based services.” As we all know, this disproportionately affects geriatrics healthcare professionals—physicians, advanced practice nurses, and physician assistants alike. According to the report, 65% of geriatricians’ payments, for example, are derived from nonprocedural primary care services such as office and home visits and visits to patients in nonacute settings such as nursing homes.

The MedPac report recommends a two-step approach to addressing these payment problems, which continue to pose disincentives to geriatricians in accepting new Medicare beneficiaries as patients, and to future trainees entering and remaining in geriatrics. The report calls for increasing fee schedule payments for primary care services provided by “clinicians focused on delivery of primary care.” And it proposes establishing a Medicare medical home pilot program. The pilot would “include primary care practices as well as specialty practices that focus on care for certain chronic conditions,” and would create “incentives for eligible medical practices to conduct care management and care coordination.” The American Geriatrics Society (AGS) endorses both approaches.

So where are we now, nearly a year after the MedPAC report came out? There is a strong consensus that healthcare reform is needed, and this effort is moving center stage in Washington. And we’re seeing progress with both MedPAC’s proposals, and related initiatives, also endorsed by AGS, that should make primary care and geriatrics care more viable and, as a result, accessible to more older adults.

As this issue of Clinical Geriatrics went to press in mid-April:

• The Centers for Medicare & Medicaid Services (CMS) had chosen the healthcare firm Thomson Reuters to help implement its Patient-Centered Medical Home (PCMH) pilot. The pilot is designed to help determine whether, in fact, the medical home model improves care coordination and outcomes for beneficiaries with chronic conditions and reduces healthcare costs. The PCMH approach, the AGS points out, provides for the same kind of team care that geriatrics healthcare professionals currently provide for their patients.

• Sen. Blanche Lincoln (D-AR) and Rep.