What the New Year Will Bring

I’ve been searching for something upbeat to say about health care for older people in 2017. It’s been difficult to find anything newsworthy. The best I could come up with was that the direst predictions might not come to pass. Speaker of the House Paul Ryan says he wants to privatize Medicare by instituting “premium support,” which means giving people fixed amounts of money to buy health insurance on the private market instead of using government-run Medicare. But he might not get his way; after all, there are 46 million older people on Medicare and they like their program. Assurances that any changes won’t go into effect for several years may not be good enough. The nomination of Georgia Representative Tom Price to serve as head of the Centers for Medicare and Medicaid Services strongly suggests there will be a push toward substituting block grants for the federal Medicaid program, which would mean large cuts to Medicaid in many states. It might not happen; there are roughly 6 million older people who are dually eligible—they qualify for both Medicare and Medicaid, and they survive thanks to the current arrangement.  And then there’s the vaunted repeal of the Affordable Care Act, which might mean axing the Center for Medicare and Medicaid Innovation, an institute that has been testing strategies to improve quality and save money, as well as PCORI, the Patient Centered Outcomes Research Institute, a major source of grants for studies of innovative health care programs. Congress might leave those parts of the ACA intact, but CMMI was budgeted $10 billion for the period 2010-2019, of which about $3.5 billion remains. This money looks to me to be ripe for cutting by an administration that touts ideology as the basis for decision-making, not science. But surely there must be something uplifting to say about the new year. Judith Graham of Kaiser Health News suggests there is.

Beginning in January, 2017, Medicare will introduce new rules that offer incentives for physicians to change the way they care for the sickest, most vulnerable older patients, those with multiple serious chronic conditions, those with dementia, and those suffering from mental illness, especially depression. Medicare is changing its reimbursement system for “complex chronic care management.” Basically, it will pay more for coordination of care and require jumping through fewer hoops to get the extra payments. Medicare is also going to be more generous in paying for comprehensive dementia assessment—if physicians follow a number of rules. They have to assess their patient’s ability to perform activities of daily living, they have to evaluate behavioral symptoms, they need to review medications, and they need to use standardized tests for assessing cognition. Finally, they will have to elicit the patient’s goals and values and determine the caregiver’s knowledge and resources to develop a care plan for the patient—including plans for what to do when the patient becomes acutely ill. Medicare will offer an incentive for primary care doctors and behavioral health specialists to work together to deliver effective care for older patients with mental illness. Finally, Medicare will recognize that taking care of elderly patients involves more than classic “visits” consisting of a doctor sitting opposite a patient, taking a history, doing a physical exam, and prescribing tests or treatment: it entails such activities as talking to family members and reaching out to community service providers. Recognizing the value of physician work that doesn’t involve face time with patients means reimbursing physicians for their time and that’s exactly what Medicare will initiate.

These are all good developments. Physicians do need to coordinate complex chronic disease management and they ought to properly assess patients with cognitive impairment and develop an advance care plan for them. Similarly, they have to be able to spend time working with families, caregivers, and other professionals to do a good job for their oldest patients. But whether tweaking the fee-for-service system to achieve these ends will work is another question. What we know works are special programs for eligible patients, programs such as GRACE (Geriatric Resources for the Assessment and Care of Elders) or PACE (Program of All Inclusive Care for the Elderly) or Guided Care. These are comprehensive programs with a dedicated staff of physicians, social workers, nurse practitioners, and others who already provide complex care management,  who already know how to evaluate memory, and who often work with behavioral health as well as caregivers. Whether encouraging primary care doctors to adopt these approaches simply by offering to pay extra for incorporating these strategies into routine practice will be equally effective is far from clear. But it might be a step in the right direction. And if there’s money available to measure whether it works or not, we might actually find out.