Is Good Geriatric Care Affordable?

by Timothy Gieseke, MD                                                                         

As an internist trained in the ’70s, the common mantra was “the patient’s interests always come first.” This was far easier to provide at that time with no limits on work hours, very limited personal educational and start-up debt, and a low-overhead, fee-for-service system.  As I became more involved in the post-acute and long-term care sector in the ’80s & ’90s, my knowledge and expertise expanded through educational offerings of CAMD (California Medical Directors Association, the precursor to CALTCM), AMDA, and AGS. I found great fulfillment in applying this developing expertise on behalf of my patients and facilities.  However, I also found my work efficiency (# of patients seen each day) progressively declined while office overhead rapidly increased. Because of the latter, I gave up my office practice in 2005 to focus full -time on post-acute and SNF care. However, I have been able to continue servicing a geriatric clinic at my CCRC in large part due to a generous contract from this facility for my group’s provider services.   Here, my usual patient is > 85 y/o and medically complex and routine appointments are 25 min. to allow for team-based care and teaching. In this setting, I commonly bill higher-level codes for my services and have the documentation to support those codes built into my EMR notes. In fact, Blue Cross recently sent me a letter informing I was billing higher-level office based codes then most of my IM colleagues, which did not surprise me.

My office-based internal medicine colleagues, though, are having difficulty focusing on their traditional Medicare practice, because of much lower reimbursement for these patients than they receive for taking care of less complex patients with commercial insurance.  Two of my internal medicine geriatric colleagues have developed concierge practices that allow them to continue their geriatric practices. However, in my CCRC and the concierge model, where do clients who can’t afford those models access good geriatric care?

Some forward thinking hospital based health systems have developed and funded geriatric clinics for high risk geriatric patients and now have documentation that they are cost effective.  Unfortunately, the new Medicare Physician Fee Schedule Proposed Rule for 2019 may have an unintended consequence of closing such clinics. As you may be aware, CMS has responded to organized medicine’s appeal for relief from excessive documentation billing requirements ( e.g. 15-page redundant discharge summaries) by proposing to merge the current 5 level office based charge system (99211-99215) to 99211 and one code for the next 4 levels, with reimbursement significantly reduced for the previous 99214 and 99215.  Dr. Robert Schwartz at the University of Colorado, Denver calculated that the new rule would reduce payments in their successful senior clinic by 30% (Available on myGeriatricsOnline AGS members’ blog).  On this same blog, Dr. Elliot Stein, Director of Psychiatry at the Jewish Home of San Francisco, eloquently expressed with great detail concerns that these revisions and others will discourage the provision of high-quality psychiatric services for medically complex patients.  

AGS, AMDA, ACP, AAFP, and other stakeholder organizations are reviewing these proposals to create a constructive response that ultimately defends the provision of payment for good geriatric care.  Please see the initial recommendations from AGS’s taskforce (See AGS link below).  In addition, my documentation is not just for billing (no fluff), but to support good team care and to reduce allegations of substandard care from DHS/Federal surveyors and plaintiff attorneys.  

In this day of patient-directed care, will we have a health care system in this country that funds optimal care for our seniors who are becoming medically complex?  Now is the time to let your local health systems and CMS know the importance of funding good geriatric care not only in the clinic, but throughout their systems of care.  

Click here for the AGS link.