Proposed Healthcare Reforms Would Enhance Care of Older Adults

These days, the biggest issue facing those of us who care for older adults is healthcare reform—and especially what’s in store for Medicare.

From a clinician’s point of view, it’s essential that reforms ensure that the growing number of older adults have access to high-quality, cost-effective care. To do so, reform provisions must do several things. They must address worsening nationwide shortages of geriatricians and other geriatrics healthcare providers. Given the growing numbers of older patients, reforms must expand training for geriatrics professionals and vigorously recruit and better prepare primary care physicians, as well as other professionals such as nurse practitioners and physicians assistants, to coordinate necessary care. Reforms should help better equip family caregivers to meet their loved ones’ unique care needs as well. It is also critical that there be appropriate Medicare reimbursement for essential elder healthcare— including services such as care coordination—in order to achieve quality care goals. In addition, reforms must adequately fund eldercare research and support the adoption of promising new models of care.

As of mid-October, the House reform bill and the two Senate reform proposals before Congress do include provisions that would help us make significant progress toward these goals. The American Geriatrics Society (AGS) has long advocated, and continues to advocate, for these provisions, both independently and in coalition with like-minded organizations. These reforms would both enhance Medicare coverage and make it more cost-effective, and, as a result, more sustainable.

This isn’t to say that current reform proposals do everything that needs to be done. While current proposals make some headway in addressing reimbursement problems, for example, they don’t solve them adequately. Given the breadth and complexity of healthcare reform, however, this and other unresolved issues will have to be taken up after lawmakers pass an initial omnibus reform bill.

The three reform plans now before Congress aren’t identical, and it’s still unclear which provisions will ultimately make it into final legislation. Here’s an overview of key reform proposals included in at least one plan:

Proposals designed to help recruit and train geriatrics healthcare professionals and primary care providers to meet the unique care needs of older adults, and better prepare direct-care workers and family caregivers to do the same, would:
• Provide grants to Geriatric Education Centers (GECs) to offer courses in geriatric care, chronic care management and long-term care, and to provide family caregiver training.
• Expand eligibility for Geriatric Aca-demic Career Awards (GACAs) to a wide range of healthcare professionals.
• Fund Geriatric Career Incentive Awards to foster greater interest in eldercare among health professionals.
• Increase the number of Graduate Medical Education (GME) training positions in primary care.
• Establish federal traineeships for nurses pursuing advanced training in geriatrics.
• Fund training opportunities for direct-care workers.
• Establish either a Workforce Advisory Committee to develop a national healthcare workforce plan addressing the need for eldercare providers, or a national center charged with ensuring an adequate healthcare workforce.
• Establish loan forgiveness programs for physicians, physician assistants, pharmacists, advanced practice nurses, psychologists, and social workers who complete training in geriatrics or gerontology.
• Create a graduate nurse education demonstration program to train advanced practice nurses to provide primary, preventive, and transitional care, and chronic care management for the elderly.
• Support the development of curricula and best practices in geriatrics.

Proposals aimed at addressing problems with Medicare reimbursement for essential elder healthcare—including services such as care coordination—would:
• Block the Sustainable Growth Rate (SGR) formula-mandated 21% cut in Medicare payments to physicians slated for next year; substitute a new formula that would base payments on physician practice costs in 2011; then create two separate spending formulas for 2012—one, for evaluation and management services and preventive care, based on Gross Domestic Product (GDP) plus 2%; another, for other physician services, based on GDP plus 1%. In addition, make geriatricians eligible for a proposed primary care incentive payment of 5-10% by adding “specialization in geriatrics” to a list of qualifications for designation as a primary care practitioner.
• Replace the mandated pay cut with a 0.5% increase; establish a panel of healthcare providers, experts, and stakeholders to identify physician services that are overvalued; and offer primary care practitioners, including geriatrics healthcare providers, a 10% payment bonus for five years.

Reforms intended to foster research and innovations in eldercare, and support the adoption of promising new models of care, would:
• Establish a Medicare “Innovation Center” to test new provider payment models―including models providing care coordination for older adults at risk of functional decline―to identify models that improve quality and reduce costs.
• Fill a gap in traditional Medicare by covering comprehensive geriatric assessment and care coordination services for high-risk and high-cost beneficiaries with multiple chronic health conditions.
• Create a new Medicaid plan option under which beneficiaries with chronic conditions could designate a healthcare provider as their “medical home.”
• Track and reduce hospital readmission rates for high-cost conditions associated with a high incidence of avoidable readmissions.
• Establish a voluntary pilot program to both encourage hospitals, doctors, and post-acute care providers to achieve savings through increased collaboration and improved care coordination, and allow these providers to share in any resulting savings.
• Create a chronic care coordination pilot project to provide at-home primary care services to the highest-cost Medicare beneficiaries with multiple chronic conditions. Interdisciplinary teams of healthcare professionals caring for these patients would be eligible for a share of savings if they meet quality and patient satisfaction standards.
• Fund eligible hospital and community-based healthcare organizations that provide patient-centered, evidence-based transitional care services to Medicare beneficiaries at highest risk of rehospitalization.
• Launch initiatives to reduce the spread of hospital-acquired infections among older patients.

Reading through the proposals above, it’s clear that AGS’ concerted and ongoing policy advocacy campaigns on behalf of reforms supporting quality eldercare, as well as the professional practice of geriatric medicine, are beginning to pay off. Although we may not agree on all reform proposals under current consideration in the Congress, it’s important that we continue to advocate strenuously for those provisions that are critical to good geriatric care, and to make sure they remain on the table.

The reform plans now under consideration in Congress are far from perfect. They don’t resolve every issue that needs to be addressed, such as the need for professional liability reform and the primary care physician workforce shortage. But if these provisions are included in a bill that makes it to the President’s desk, geriatric care and our patients will benefit significantly. We’ll have something substantial and very positive to build on when we take up those unresolved issues we’ve identified in the next go-round.

I hope you’ll join the AGS in its continued efforts on behalf of key provisions, like the ones above, that will enhance care for America’s older adults—and enhance our professional standing. If you haven’t done so already, I urge you to register with the AGS’ Health in Aging Advocacy Center (http://capwiz.com/geriatrics/home/), which makes it easy to effectively advocate for these reforms. For AGS’ quick and easy-to-follow, side-by-side comparison of Congress’ three reform plans, visit http://www.americangeriatrics.org/policy/side.by.side.pdf.

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.