Clinical Geriatrics

The Medicare beneficiary is changing, and these changes are affecting how geriatric care providers practice. From the physical layout of the practice, to marketing, to management from an administrative and clinical aspect, all is about to change. The Medicare Payment Advisory Commission (MedPAC; www.MedPAC.gov) recently assessed for Congress the changing demographics of the Medicare beneficiary by identifying eight major changes,¹ as follow:

Increase in Number of Beneficiaries as Baby Boomers Age
Everyone is aware of the aging baby boomers becoming Medicare-eligible, but the true impact is worth continually stressing. It is for this reason that MedPAC led with this in its listing of changes affecting Medicare. The increase in the number of Medicare beneficiaries means greater demand on all physician services—especially primary care. This increasing pressure on geriatric healthcare services at a time when the number of geriatric-trained clinicians is decreasing will make the requirement to operate practices in a most efficient and effective manner vitally important. Practices may want to consider group visits, telemedicine, and “just-in-time” appointments as ways to deal most efficiently with the growing demand for their time.

Changing Profile of Beneficiaries
•Increased prevalence of being treated for several chronic conditions
•Decline in proportion of beneficiaries who are disabled

The health profile of the senior patient is changing, with a decrease in those Medicare beneficiaries who are disabled secondary to improved surgical procedures, therapy options, and environmental safety features all contributing to this decline. While the decline in disabilities is encouraging, the opposite has been the case with regard to chronic conditions. Since seniors are living longer they are more likely to have accumulated a wide variety of chronic conditions that require careful medical intervention and treatment. In addition to the increased longevity of seniors, technology has also played a role in the increased prevalence of chronic conditions. Technology for identifying the presence of conditions has advanced (eg, dual energy x-ray absorptiometry scan for osteoporosis). These advances have resulted in seniors being diagnosed for conditions that could not have been detected several years ago. Lastly, definitions have changed over time to increase the prevalence of disease. In 2004, the American Diabetes Association lowered the definition of abnormal fasting glucose levels from 110 milligrams per deciliter (mg/dL) to 100 mg/dL. This change increased the prevalence of metabolic syndrome among adults age 20 years or older by 20%. The management of these increased comorbid chronic conditions in most cases requires an interdisciplinary care team. Care teams can focus their attention on comorbid conditions rather than simply a single disease state through the involvement of multiple disciplines such as pharmacy, dietary, and physical, occupational, and speech therapy.

Increase in Number of Obese Beneficiaries
Obesity is a growing epidemic in the United States; even seniors are being affected by a growing number of Medicare beneficiaries who are entering Medicare obese. Data from the Agency for Healthcare Research and Quality indicate that the share of Medicare spending attributable to obese beneficiaries nearly tripled from 9.4% in 1987 to 24.8% in 2002. This new Medicare beneficiary will require in some cases a facility redesign to accommodate the obese senior. Changes such as reception area seating that can accommodate obese patients, exam tables that do not require “jumping” up, even gowns that are better suited for the obese patient will be increasingly needed. In addition to a facility redesign, practices will need to develop clinical practices to better manage metabolic disorders.