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Last week the Senate failed to take action to avert a 21.5% reduction in Medicare fees to doctors scheduled to go into effect January 1, 2010.  Such a dramatic reduction in Medicare reimbursement will be devastating to the healthcare of older Americans.  Many physicians will stop seeing Medicare patients, in favor of younger patients whose insurance already pays much better than Medicare.   Older Americans’ access to healthcare will suffer.

Worse yet will be the impact on clinical geriatrics, which includes geriatric medicine and geriatric psychiatry.  Specialty geriatric practices depend almost entirely on reimbursement from Medicare.  These practices already are barely viable financially.  They cannot compensate by taking more young patients, so the impact on the geriatric sub-specialties will be catastrophic.  A staggering crisis already exists in the geriatric workforce (try finding a geriatrician or geriatric psychiatrist to appreciate how big a problem this is). The Institute of Medicine’s report of April 2008 Retooling for an Aging America: Building the Healthcare Workforce concludes that this predicament is an emergency for which immediate action is needed.  The IOM report concludes that inadequate reimbursement is the single greatest barrier to geriatric workforce development.  I can confirm that this so from my own experience.

Unfortunately, federal Medicare policy is not supporting the growth of clinical geriatrics.  To the contrary, the Medicare cuts scheduled for 2010 will devastate the field and set back the cause of geriatric healthcare by a decade or more.  The most vulnerable elder patients will suffer the most, and the cost of their care will increase as a result.

In addition to the looming 21.5% fee cut, the Centers for Medicare and Medicaid Services plans to cut specialists’ payments under Medicare in favor of a commensurate six to eight percent increase in payments to primary care physicians.  While this increase will apply to geriatricians, it will not apply to geriatric psychiatrists.  This further cut will be another nail in the coffin for geriatric psychiatry.  The federal government ought to use Medicare reimbursement in every way possible to support growth of geriatric psychiatry.  Instead, they seem to be doing everything possible to weaken the field when it is most needed. Federal healthcare policy is heavily invested in primary care.  But it fails to recognize the central role geriatric psychiatry plays in the primary care of elders with mental disorders.  The IOM report points out that primary care physicians are not prepared to meet the challenge of geriatric care.

Urgent legislative action is needed to prevent devastating damage from being done to geriatric psychiatry and to ensure that geriatric psychiatrists will be available to meet the needs of the rapidly growing ranks of the oldest Americans.  This action should include the following:

• Permanently eliminate the Sustainable Growth Rate Formula for annual Part B fee updates.  Another one-year temporary fix is not good enough.  Year-to-year unpredictability regarding annual Part B updates makes planning and recruitment all but impossible for geriatric practices.  Until fundamental reform of physician payment occurs, Medicare Part B fee updates should be tied to annual changes in the healthcare market basket, as recommended by the Medicare Payment Advisory Commission, the body that advises congress about Medicare policy.

• The CMS should be required to apply any reimbursement increase for primary care physicians to mental health specialists for services they provide to Medicare beneficiaries ages 65 and over.

• Congress should direct Medicare B and Medicare Advantage plans to pay a 10% added payment for all covered geriatric services provided by designated, sub-specialty geriatric practices that exclusively serve geriatric patients. This conforms to recommendations in the IOM Report for a supplemental payment for geriatric specialists.

• Funding for Medicare demonstration programs for community-based, geriatric-specific advanced medical homes.  These homes should be comprised of geriatricians and geriatric psychiatrists collocated within the home and working collaboratively to fulfill the potential of such programs.

• Require PACE programs that employ physicians to hire geriatric psychiatrists so that they comprise 25% of the physician staff.

• Fund Medicare demonstration projects for telephone consultation by geriatric psychiatrists to primary care physicians.

Ultimately more fundamental reform is needed.  The current fee-for-service reimbursement system is deeply flawed and fails to take advantage of geriatric mental health expertise.  Models such as medical homes, PACE programs, and collaborative care in primary care practices all offer potential.  To be viable, all will need to be supported by reformed reimbursement methodologies.   Regardless of how innovative geriatric healthcare reform is, it will all be for naught if there is not a workforce available with the requisite expertise to address the mental healthcare needs of older Americans.   As the IOM urges, urgent action is needed.

Consider the following case vignette, a composite of the recent experience of two patients in my practice.  A 79 year-old woman with severe depression and anxiety was hospitalized for pneumonia.   The hospital doctors made a change in her psychiatric medication.  Drug A was replaced with drug B.  After she returned home, she had the prescription for Drug B filled.  About a week later, the pharmacy called to tell her that her prescription for Drug A, which had been on automatic refill, was ready to be picked up.  She picked up Drug A and took it, according to the directions on the bottle, along with Drug B, effectively causing an overdose.  Within a few days she became toxic and ended up back in the hospital.  Fortunately, there was no permanent harm.  She later explained, “When the pharmacy called to tell me my prescription was ready I just assumed I was supposed to take it”.

This scenario illustrates the inadvertent trouble that can result when programs are conceived without consideration of the cognitive or behavioral disabilities of elderly consumers who utilize them.   Such schemes are devised ostensibly to improve customer service.   One pharmacy touts its automatic refill system as an aid for forgetful patients who might miss needed medication because they forgot to refill prescriptions.  But the program fails to consider broader cognitive deficits that can lead to the type of mistake described in my scenario.   Many older people with late-life psychiatric disorders are more than just a little forgetful.  They sometimes also get confused or exhibit poor judgment.

Our society has many protections for people with various vulnerabilities.  Child-proof bottles protect children from taking medications.   Healthcare providers are required to provide translators for patients who do not speak English.  The Americans with Disabilities Act safeguards access for those with disabilities.

It is time for Congress to amend the Older Americans Act to include provisions to ensure that healthcare programs that serve the elderly be required to ensure the safety of elderly people with cognitive disabilities who use their systems.  As a practicing physician, I’m not sure automatic refill programs are a good idea.  Some of my sharpest patients – retired judges, engineers, and teachers – complain about the reminder calls that they insist they never requested.  Until the US healthcare system has a universal electronic health record that ensures that pharmacies have up-to-date knowledge of patients’ current medications, automatic refill programs seem ill advised to me.

I was sitting in the nursing station at the rehabilitation hospital recently when a new admission arrived.  She was a very old looking woman who came for rehabilitation after a surgical repair of a broken hip.  She was sitting up on the gurney, amiably chattering at the ambulance drivers who had transporter her.  She was gushing about how safe she felt in the hands of such big and strong, and handsome young men.  A number of nurses were present in the nursing station as she arrived.  On seeing them, she assured her “boys” that they could leave her off and, in a loud, indiscrete voice, encouraged them to “go make time” with the nurses.  The nurses were immediately enchanted with her and praised her for being so “cute”.   Each hoped to have her as part of their assignment for the shift.

What was it about her that made her cute?  Given the setting and circumstances, her incongruous lightheartedness, and cheerful disposition stood out.  She also was mildly socially indiscreet and inappropriate, but without being aware of it.  According to Dictionary.com, the definition of cute involves a dainty attractiveness, affected cleverness, and being precious, endearing, or adorable.  Older patients with these qualities often have mild dementia.  This causes them to behave in ways that would not have been part of their personalities when they were mentally healthier.

Finding such older people to be cute, in my experience, is a common reaction among people in general and healthcare workers in particular.  What troubles me is that there’s a patronizing quality to their praising her cuteness.  Albeit unintentional, it undermines proper respect for the dignity older people deserve.   Geriatric workers and healthcare providers owe a special duty to respect frail, dependent elders’ dignity.

Feeling that an older person is cute represents a failure of empathy.  It is a failure to be mindful of the self-image most people would want to maintain were they capable. Healthcare professionals and caregivers have an obligation help frail elders maintain their dignity.  An aspect of this is recognizing and respecting the self-image a person maintained, and would have liked to continue to maintain, were they capable.  Old people do not consider old age cute.  I doubt very many firefighters, construction workers, high school principals, librarians, or corporate CEOs ever aspire to an old age of cuteness.   Most would find it mortifying rather than amusing or endearing.

I suspect that seeing cuteness in a frail elder probably reflects a defense against empathically experiencing this mortification for the older person.  It also holds off anxiety of becoming, frail, decrepit, unaware of oneself, and helpless oneself, some day.

You may think that I am making too big a deal of this, but the problem is that staff who refer to frail, older patients as cute, in my experience, are highly prone to use elderspeak more generally in their interactions with patients.  Elderspeak refers to a style of patronizing, infantilizing communication with elders that often includes elements of baby talk.  For further discussion of elderspeak and its real impact on the lives of geriatric patients, see the July issue of the Moak Aging & Mental Health Report.  Use of elderspeak represents an inadvertent failure to provide professional care consistent with goals of maximizing the treatment and wellbeing and patient satisfaction of older patients.

Opponents to a single-payer healthcare system often invoke the specter of government intruding into the medical examination room and directly meddling in the doctor-patient relationship.  Such objections usually include dire warnings about the government restricting the choice of personal physician and dictating which treatments doctors can provide.   From my vantage point as a practicing geriatric psychiatrist, this transparent demagoguery is a straw man propped up by defenders of the insurance industry.

Don’t get me wrong.  I am not an apologist for government healthcare. Medicare, a government-run program that happens to be the largest insurance company in the world, certainly has more than its share of problems.  In future posts, I intend to discuss the numerous obstacles that Medicare imposes to the delivery of geriatric mental healthcare.   And I have little confidence that the government can implement a single-payer system that will promote access to the geriatric psychiatry services older Americans increasingly need but cannot find.   It’s just that I doubt that a government-run, single payer system could be any worse than our current system.  From my vantage point, fears what a government-run healthcare system might do pale in comparison with what the commercial insurance companies already do.   In this series of posts, I intend to cite examples of this from my practice.

Practicing geriatric psychiatry affords an unusual perspective on this issue. On one hand, many geriatric psychiatry practices, mine included, to some extent already exist in a single payer universe.  The vast majority of our patients are Medicare beneficiaries (about 95% for my practice), making Medicare the de facto single payer.   On the other hand, Medicare patients usually have some form of supplement plan that covers their Medicare co-payment.  Commercial insurance companies are the largest sponsors of such Medicare supplement insurance.  Thus, a typical geriatric practice might receive 75% of its revenue from Medicare and face fighting with a dozen or more commercial insurance companies to collect the other 25%.   Try to imagine the effort required to negotiate this mess, day to day.  This brings me to the example I want to cite in this post.

Recently I hired a nurse practitioner for my practice.  The processes for obtaining the requisite National Provider Identifier number (NPI) and Drug Enforcement Agency (DEA) controlled substance registration and enrolling her as a provider in Medicare and Medicaid were simple, straightforward, and reasonably quick.  The government bureaucracies and contractors turned out to be fairly easy to deal with!   The commercial insurance companies, in contrast, have been impossible.  Each has its own byzantine provider enrollment procedure.   And it’s not that the personnel in the provider relations departments don’t want to help.  The problem is that the system is so confusing that they don’t understand all the issues; too often they do not know the answers or provide wrong information.

My experience with one particular plan is illustrative.  This plan has a line of commercial HMO products, a Medicare Advantage plan, and two Medicare supplement plans.  The provider relations department was very knowledgeable about the HMO and Medicare Advantage products, but they were unaware of the existence of the company’s Medicare supplement plan.  It found myself in the position of needing to convince them of the existence of their company’s own product.

The next hurdle was even more vexing.  They gave me clear instructions for submitting claims for the nurse practitioner to their HMO and Medicare Advantage plans, and told me to apply the same procedure for Medicare supplement claims.  The instructions they gave me were incompatible with Medicare billing procedures.  They directed me to submit claims to Medicare in a manner that would cross over to their plan without problems but would be tantamount to filing a false claim with Medicare.   The people working for the insurance company were not conversant with the Medicare requirements related to the Medicare supplement product they sell. I am still waiting for clarification from the insurance company regarding the proper procedure.

Scenarios like this one are typical.  There are too many plans with idiosyncratic and often contradictory rules and requirements that are constantly subject to change.  If the plans’ own personnel do not understand their products, how are their members or Medicare beneficiaries supposed to?  And what about providers?  Medical practices may deal with ten insurance companies, each of which might offer five to ten plans.  Frequently these plans’ mental health coverage policies are in conflict with Medicare regulations.  Keeping up with all these payers is impossible.

The Obama administration has taken a helpful first step by requiring Medicare Advantage plans to offer fewer options that are less confusing to beneficiaries.  This will also help providers by lessening the hassle they encounter and the expense they incur finding their way through the health insurance plan maze.   Much of the administration’s hopes for financing healthcare reform depend upon savings realized by eliminating waste in healthcare.  Consolidating the system ultimately to a single payer system, with one set of rules and one set of procedures, will accomplish this goal by eliminating the waste associated with the administrative costs of this confusing patchwork quilt of a non-system we currently live with.