By Carey Vinson, M.D., M.P.M

Medical Director of Highmark Blue Cross Blue Shield

Published April 1997

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Health care coverage for the geriatric population is one of the toughest challenges society and the federal government face. The increasing pressure to hold the line on Medicare spending is evident. President Clinton and the Congress are looking at reducing hospital and physician reimbursement for providing care to Medicare beneficiaries. Medicare HMOs offer a feasible solution to growing concerns about costs, and provide an alternative to the inefficient and fragmented traditional fee-for-service system.

In contrast to the barriers created by the fee-for-service Medicare program, HMOs furnish the elderly population with an approach that supports their core wishes: to stay in their homes, to maintain autonomy and to maintain maximum levels of physical, social and cognitive function.

Comprehensive approaches to geriatric care, which are in early stages of implementation, are available and have been demonstrated in other parts of the country. These strategies value ambulatory care, improvement of the home and community environment, preventive care and functional assessment and coordination of clinical services.

The geriatric population is increasing across the country, and especially in western Pennsylvania. People over the age of 65 now account for 14 percent of the population with over 34 million Medicare beneficiaries. People over age 85 are the fastest growing segment of older adults. The opportunity exists for western Pennsylvania to be an innovator in developing managed care programs to meet the medical needs of older adults—a move that holds promise for improving their quality of life.

A New Approach to Care Delivery

The traditional Medicare system is ill-equipped to serve the multiple needs of the elderly. It undervalues community and home-based care settings, preventive services and the use of functional assessment tools. In addition, current Medicare reimbursement offers little incentive for providers to manage the chronic medical, functional and psychosocial problems the elderly encounter.

In contrast, disease state management programs—a vital part of some Medicare HMOs—target specific medical conditions or disorders for intense treatments and support. These programs help to improve the care of patients and reduce costs. Examples of successful implementation include chronic obstructive pulmonary disease, diabetes mellitus, asthma, stroke, coronary artery disease and breast cancer. Disease state management focuses on early intervention, home services, patient education, teaching patients to manage their conditions and monitoring patient compliance with treatment programs. The most successful programs involve close cooperation with the patient’s physician; therefore, enhancing the physician’s treatment program and reinforcing the patient-physician relationship.

Another advantage of Medicare HMOs is the increased emphasis on case management. Historically, case management was handled by hospitals and dealt with post-discharge placement. Now, physician groups and managed care organizations are expanding the role of case management. Case managers are not only helping patients with catastrophic illness, but assisting with care of patients with chronic illness, too. The case managers arrange for appropriate home care, coordinate skilled and lower-level long term care and identify community resources to support the patient’s social situation. By expanding the role of case management, Medicare HMOs balance acute inpatient care with a focus on care outcomes and improved functional capabilities.

Successful Working Models

A number of care delivery programs have been successful at reducing complications and symptoms of chronic disease. A common feature of these programs is using a multi-disciplinary team approach to care-giving.

For example, the EverCare HCFA demonstration project provides team-based services and promotes onsite care at nursing homes. Results thus far indicate that the project achieves lower costs and shorter inpatient stays. In addition, EverCare patients have better clinical outcome indicators than the national average and have given the project high marks for service.

The Program of All-inclusive Care for the Elderly (PACE) serves enrollees in day centers and clinics, their homes, hospitals and nursing homes through a multi-disciplinary team approach. These demonstration projects help the elderly maintain maximum levels of physical, social and cognitive function. Medicare and Medicaid pay the facilities a capitated fee for all medical services.

From a cost standpoint, the results of the program have been promising. Seven out of eight pilot sites have saved money when compared to regular Medicare reimbursement. Patient and family satisfaction rates also have been very high at all sites.

Current knowledge about the care of the elderly is based on hospitalization data. Before implementing any of these programs, doctors must accumulate more information about elderly patients’ home environment, functional status, and use of OTC medications. Risk profiling surveys administered post-enrollment in a Medicare HMO have identified persons at high risk for functional decline.

PRA Plus is a health risk assessment tool developed at the University of Minnesota. PRA Plus accurately predicted high risk patients using hospital days twice the rate of low risk patients. The survey also identifies the patients’ current functional status, social supports and medication use. The survey results can be used to prioritize the scheduling of initial physicals with the primary care physician, and identifies patients who would benefit from case management or disease state management programs.

Ten percent of Medicare recipients generate 70 percent of health costs. By identifying this high risk group the medical community can target them for comprehensive evaluation and management. Health care systems need to concentrate on improving the quality of life for geriatric patients. Although positive results have been demonstrated in limited settings, these types of programs need to be implemented on a larger scale.

Highmark Blue Cross Blue Shield’s SecurityBlue program (a Medicare HMO) has started to develop or use some of the innovative core delivery ideas discussed in this article. This year, all current and newly enrolled SecurityBlue members will be surveyed using PRA Plus. Health Education Centers at a variety of western Pennsylvania sites have numerous educational programs designed to help improve the health and function of SecurityBlue members.

SecurityBlue has a dedicated case management program assisting physicians and patients. Also, a geriatric education program, which was developed in partnership with the American Geriatric Society, will be offered to many physicians in the Keystone Health Plan network. Moreover, SecurityBlue is developing collaborative programs with local nursing homes to improve continuity of care to institutionalized patients. Finally, Cellulitis, CHF, COPD and diabetes mellitus disease state management programs are either in place or being readied for implementation this year.

Indeed, care of the geriatric patient has never been easy, but all geriatricians and other physicians caring for the elderly know the rewards can be great. As medical care systems change and the number of elderly patients grows, doctors need to think creatively and look for ways to give the elderly the care they deserve.

"What I wouldn’t give to be 70 again." — Oliver Wendell Holmes, Jr. (1841-1935)