Medicare and the Aging Population - Q&A with Barney S. Spivack, MD, FACP

First Report Managed Care conducted an interview with Barney S. Spivack, MD, FACP, one of our Editorial Advisory Board members, to discuss how the aging population will affect Medicare coverage and spending now and in the future. Here you will find Dr. Spivack’s take on current events related to the healthcare system.

Q: Spending on Medicare is projected to account for 20% of the federal budget in the next 20 years. How will the government deal with the rising costs? Will Medicare be revamped?

A: The Patient Protection and Affordable Care Act (ACA) has already had an impact on the organization, delivery of care, and payment structure of the Medicare program, as there has been much more of a focus on finding innovative ways to better reward quality care and the value of care rather than volume of care. Ongoing demonstration projects through the Centers for Medicare & Medicaid Services (CMS) Innovation Center, involving Medicare accountable care organizations, coordination of care, better coordination and integration of Medicare and Medicaid services, primary care transformation, and bundled payment for care improvement, are some of the initiatives that are being investigated to try to achieve the triple aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.  

Q: Polls indicate that most people are satisfied with Medicare. How do you think older adults will react to changes in Medicare? Will there be opposition?

A: Medicare recipients do value the current Medicare program and are reluctant to give it up or to adopt changes that will affect their ability to continue to receive care that they enjoy and expect to continue with their physicians. They enjoy the freedom to be seen by any physician participating in the Medicare program without barriers or administrative hassles. Newer care arrangements that are viewed as having an undesirable impact on this choice or that limit the available choices within a community are viewed negatively.

Although there is no good data that indicates that many physicians are choosing to opt out of Medicare, due to the failure of Medicare reimbursement to keep up with practice realities or due to the many administrative changes required in Medicare, this has been a concern. [This is a concern] especially given the continued failure to definitively address the sustainable growth rate, or the “doc fix,” legislatively, and the many uncertainties regarding continued physician participation in the program. The physician workforce is aging, especially in some states more than others, further threatening our ability to continue to provide easy access to care that patients desire.

In addition, the physician and healthcare workforce is understaffed to meet the challenges of our rapidly growing aging population, and these workforce challenges (ie, requiring enhanced training, skill building, financial incentives) have been increasingly recognized. Older adults are an especially vocal and powerful voting [group] as history has shown and as recognized by our elected leaders. Proposed changes in the structure or delivery of the program needs to be promoted thoughtfully and effectively given the political realities.

Q: Physicians treating Medicare patients are expected to see a shift from the fee-for-service payment system to more of an emphasis on paying for improved quality of care and reducing costs. Are doctors embracing these changes? How are they preparing for the anticipated changes?

A: Many physicians in practice are very uneasy regarding the newer payment models, especially if they are practicing solo or in small practice settings, as is the case for the majority of physicians in practice. Younger physicians or those who are in large medical groups that already have the necessary administrative and practice management supports needed to fully participate in the new models may be more enthusiastic about the payment changes, given their ability to more easily transition to that approach.

For most physicians, however, traditional fee-for-service models have been the expectation and usual arrangement, and many are reluctant to adopt newer approaches, which involve significant risk and for which the data demonstrating effectiveness and better quality are not yet available. More small practices are being merged into larger practice arrangements, creating further uncertainties for many physicians, as well as a loss of independence. This is a very difficult time for many physicians who may see their livelihood and careers jeopardized although they want to continue their professional practice, serve their patients well, and deliver high quality, high value, and effective care.

Q: Through your experience, what are the most effective ways to manage and prevent chronic diseases in older adults? Are wellness programs successful at keeping them healthy and out of the hospital?

A: There is a much greater recognition of the importance of prevention for population health, and evidence-based preventive health interventions are promoted and incorporated within the ACA. For older adults, a focus on the well-known basics (ie, exercise and physical activity, a healthy diet, avoiding tobacco use, moderation of alcohol intake, continued engagement in stimulating and cognitively enhancing leisure activities, socialization, and having a sense of purpose) has been associated with successful aging and maintenance of well-being and quality of life. There is much that can and should be done to optimize health and well-being throughout the lifespan to encourage well-being in older age and to minimize the burden of physical and other disability in older age. 

Wellness programs need to focus more on maintaining a healthy lifestyle within the context of multimorbidity, given the prevalence of ≥3 chronic diseases in many older adults. The American Geriatrics Society (www.americangeriatrics.org) has had an important focus on the recognition and impact of multimorbidity in older adults, and its resources for physicians and other health professionals on this and other common health issues affecting the care of older adults are strongly recommended. 

And, we have learned much more about the importance of recognizing the impact of socioeconomic factors and limited community resources on admission and readmission risk for older adults, independent of specific chronic diseases, that have been associated with a high risk of readmission to the hospital. There has been a greater recognition of the “post-hospital syndrome” and much greater vulnerability among older adults during the transition from acute care, as well as the importance of maintaining nutrition, restorative sleep, and physical activity to decrease the risk of hospital readmission.

Q: Another concern for the healthcare system is treating "dual eligibles," patients who are eligible for Medicare and Medicaid. How are payers and others dealing with "dual eligibles" and attempting to treat them at lower costs?

A: Dual eligibles are well-known to be among the most challenging of patient groups to treat, given the prevalence of significant comorbidities, behavioral health disease, decreased health literacy, substance abuse, limited socioeconomic supports, and the high utilization of healthcare resources by this group.

Efforts underway are attempting to better coordinate payment streams from Medicare and Medicaid to be able to provide innovative care and care delivery structures, including managed care programs, [which] have been promoted in a number of states. Which of the different approaches seem to work best will be better understood in the near future, and much work is underway through the CMS Innovation Center.     

Q: In long-term care (LTC), there is a shift from treating patients in institutions to community-based and home settings. Are these changes good for patients in terms of keeping them healthy and happy? Are these being implemented to reduce costs?

A: One of the key principles in geriatric medicine is to enable people to function as independently as possible and in the least restrictive setting of care. Providing community-based LTC and support services for older adults who may not require LTC within an institutional setting is generally favored by patients, families, and health professionals. Unfortunately, many residents in LTC institutions require a level of care that is difficult, if not impossible, to replicate outside of an institutional setting. With appropriate assessment, planning, care coordination, resource development, and family and community efforts, necessary care can be provided outside of an institution for many, and the cost of this care, as well as the quality of life it can lead to, may be favorable compared with institutional level care.

Q: What are the trends to look for in caring for the aging population? 

A: [The following are important trends to consider]:  

    • Impact of multimorbidity

    • Avoidance of frailty

    • Greater focus on the appropriate recognition and role of palliative care

    • Major focus on maintenance of functional independence, while ensuring patient

       safety

    • Greater need for shared decision-making

    • Recognition and potential prevention of progressive cognitive dysfunction and

       mood difficulties

    • Greater recognition of the role of family and other caregivers as members of the

       care team

    • Ensuring higher value and more effective care outcomes

    • Challenges within the available geriatric workforce

    • Community and societal preparedness for an aging population