A recent article featured on The New Old Age blog, “Walking Away from Medicare,” describes one geriatrician’s decision to switch gears. She resigned her position as the medical director of a Federally Qualified Health Center and launched her own patient-centered outpatient geriatric practice. The features incorporated by Dr. Leslie Kernisan include making house calls, developing comprehensive care plans that incorporate both medical services and personal aspirations and goals, and using every modern tool to communicate with patients. (See the work in action on her website and on The Hastings Center’s ‘Over 65’ blog.)
Her model provides one reliable way to serve patient and family needs and priorities in late old age. Indeed, this approach is what a minority of far-sighted physicians and other providers (e.g., those engaged in promoting “culture change” practices in nursing homes) are working to build. But we cannot expect to build the future following Dr. Kernisan’s lead, since her approach cannot be accomplished under Medicare as we know it today. Although she is a self-proclaimed supporter of universal Medicare, the fee-for-service program will not adequately reimburse her model of clinical practice. To get the features that make her practice appealing, beneficiaries must pay out-of-pocket, an expense most middle- and low-income families cannot afford.
Readers who commented on the original article were harsh in their criticism of Dr. Kernisan’s decision, with few recognizing the underlying issues and structures that propelled her move and that make her solution nearly impossible for most geriatric care professionals. Many factors affect the judgment of whether this is an appealing path to encourage, or one that would best be left very limited.
Medicare is an immense and useful program: In 2012, it accounted for 16 percent of federal spending, at $3.5 trillion for its 43.3 million beneficiaries.[1] As health care costs continue to spiral higher, and as people live longer—and sicker—than ever, Medicare coverage is an essential element of a secure old age. Leaving it to founder is simply not an option. In 2010, as part of the Affordable Care Act (ACA), Congress took a bold first step in establishing the Centers for Medicare and Medicaid Services Innovation Center (CMMI) in the Department of Health and Human Services—which has the authority to re-design these two publicly financed programs through research, testing, and evaluation. The investment is $10 billion per decade into perpetuity.
Despite this investment, the promising innovations now being tested do not yet include anything like Dr. Kernisan’s model of a reformed outpatient geriatric practice operated by a solo practitioner. CMMI can and probably should test such a model of care to understand the impact on geriatric patient experience and other measures of quality of care. Maybe with a more appropriate payment stream, private physician care could have a strong role in improving care.
Good care of frail elderly people can be challenging to organize and deliver. For example, the eldercare workforce shortage means that many frail elders do not have access to good geriatric care. Low pay for geriatricians (and, in fact, for most providers who serve this population) does not attract professionals and lay people. When internal medicine and family practice physicians join geriatric fellowships, training leads to positions with an average starting salary of about $150,000[2]. Compare that with the average starting salary of an anesthesiologist (about $250,000, or gastroenterologists, who start at about $235,000). According to The American Geriatrics Society (AGS), geriatricians train at least one year longer than their primary care colleagues, and yet their compensation is lower than an average general internist’s. Per the ACA requirement, Medicare has already started paying a 10 percent bonus to physicians for evaluation and management, but that does not cover the entire existing gap.
The salary gap runs counter to what we know about the value that geriatricians bring to their patients. A 2012 study from RAND and the University of Pittsburgh Medical Center found that geriatricians are more efficient in caring for elders and are fundamental to reducing cost of care. The analysis indicated that geriatricians’ patients had shorter lengths of hospital stays (1.1 days less on average), lower costs per admission (about $895 less), and greater surplus for the hospitals ($850 saved per admission). These savings occur despite the substantially more complex and advanced illnesses that geriatricians manage and treat. Although these incomes are generous in comparison to the wages of, say, a direct care worker (about $10 per hour, or the average taxpayer, which is about $30,000/yr), they are unattractive to recent medical school graduates with heavy debt loads.
Many additional factors limit the availability of geriatricians. Too few American medical schools have departments of geriatrics, and medical students generally receive inadequate training in the basics of geriatric care–which necessarily differs from the cure-oriented approach for younger populations. Those drawn to the field find their expertise and skills undervalued, much like the prevailing cultural attitudes about age. The work itself is challenging for clinicians and other professional caregivers, precisely because the outcomes are different. Unlike in obstetrics, for example, which generally leads to a wonderful outcome, frail elderly people face increasing disability and death. Of course, the rewards of working closely with people in situations where the work makes a real difference keep some dedicated people in the field, but respect for the work, as well as reasonable compensation for it (for everyone, from aides to physicians) would be very helpful.
On the low-payment end of the geriatric workforce are direct care workers, who are usually women, earn an average of $10 an hour, lack health insurance, and have training or credentialing requirements that have not been updated in more than two decades. These workers do difficult and hazardous work, yet they live at near-poverty levels. The workforce turnover is high, and many sustain work-related injuries. Addressing provider stress and compassion fatigue would be essential to strengthening the workforce, particularly in terms of collegiality and respect. Dr. Kernisan writes that although she enjoyed working with her colleagues, the work ultimately required too much time spent managing her administrative duties, and too little time helping patients. (A 2010 study found that the geriatric care workforce reports institutional factors as creating greater stress than patient interaction.) Attending to the workplace issues that challenge providers is essential.
No one is interested in abandoning Medicare, but no one should be willing to keep it so dysfunctional for this core population. Policy solutions can and must develop a different system of care in which care planning and care coordination services naturally reach across the many practitioners and social services providers that elderly people most need. CMMI’s current work in promoting such models as medical homes and better integrated care for dually eligible beneficiaries is an excellent start. But we must go further. For example, rules that bar rapid access to needed services must fall; quality metrics must address care plans and care planning; family caregivers and direct care workers need a fair deal on income, health care, training, and respite; and communities must be able to take on an active role in managing the services for their own frail elders. In short, without more robust innovation, we will go into the remarkable expansion of aging that is due in the next two decades with only the dysfunctional tools of the past, running up bills too high to pay for services that are too poorly designed to be worth paying for.
[1] Medicare benefit payments amounted to $536 billion and federal spending on Medicare was $551 billion in 2012.
[2] This is an average figure and may vary, depending on the geographical area.
Republished with permission of the Altarum Institute