Geriatric Practice: Challenges for Technology

1
Geriatric PracticeChallenges for Technology

• Peter A. Boling, MD
• Professor of Medicine
• Virginia Commonwealth University

2
Selected Problem Areas

• Physician-agency regulatory interface
• Many providers
• Many different forms
• Information sharing across settings
• Many providers
• Many embedded data systems
• Much cost
• Formulary chaos

3
Bombarded!
Managed care discounts and carve-outs
Super groups and specialty centers
Compliance
OVERHEAD
Credentialing
Formularies
JCAHO
Standards guidelines
Pharmacy management services
4
Discontinuous Non-System
Medicare Choice
Medicare
Medicaid
LTC Insurance
Medigap
Medicare Drug Benefit
5
Medicares Prospective Payment Modalities
Home Care
Nursing Home
Hospital
DRGs RUGs HHRGs
6
Physician Regulatory Interface and Signature
Authority
7
A Physicians Nightmare
MSA
Medicare HMO 2
Drug Plan B
Medicare HMO 1

Drug Plan C
Physician
Medicaid HMO
LTC Ins.
Drug Plan A
Medigap plan
Medicare PSO
8
Physicians Orders

• Home health agency (reimbursed)
• Form 485, initial every 60 days, changes
• Home medical equipment
• CMNs (11 types)
• Special forms motorized devices (scooters)
• Handicapped parking tag
• Do Not Resuscitate order
• Disability, Work excuse, FMLA

9
Physicians Orders

• Supplies (Medicaid and other)
• Diabetic supplies (Medicare)
• Pharma discount programs
• Pharmacy orders
• Prescriptions (handwritten)
• FAXes from mail-away companies
• Controlled substances

10
Clinical Data Sharing Across Settings
11
Post-acute Care Information

• Hospital discharge summary
• Phone call
• Letter
• E-mail
• Intranet data within a health system
• Patient or family recollection

Provider Dependent
12
The Personal Data Chip

• Is the data correct?
• Human error
• Intentional falsification
• Is the data secure?
• Gets lost, stolen, etc.
• Who decides what goes on it?
• Choice of data types and elements
• Who decides what format is used?

13
The Central Data File

• Is the data correct?
• Human error
• Is the data secure?
• Access
• Who decides what goes in it?
• Choice of data types and elements
• Who decides what format is used?
• Many existing systems ( Billions)

14
Health Data
15
Informatics Problems

• Similar items do not cross walk well
• Software programs do not interface well
• Organizations use proprietary systems
• Data in EMR transfers poorly to paper
• Data in EMR often limited in readability and
  information content designed to satisfy
  regulators not help clinicians

16
HIPAA

• Misinterpretation (predictably) widespread
• Providers staff fear, resist sharing data
• Health care is therefore more difficult
• Lack of information leads to
• Errors
• Costly redundancy
• Corrective action is needed

17
Medicare Physician Payment

• RBRVS based on Relative Value Units
• Each service valued based on average total cost
• Work RVUs
• Pre-visit work
• Intra-visit work
• Post-visit work
• Practice Expense RVUs
• Malpractice RVUs

18
99214 Two Scenarios
Geriatrician
Generalist
19
Distribution of Visit Times
20
Medicare Part D (Drugs)The Formulary Problem

• Mr. Smith sees the doc they talk about
  condition, make decision, write prescription
• At pharmacy not first tier on your plan
• Patient wants lower cost option if possible
• Pharmacist calls doctor, need alternate choice
• Staff pulls office chart, leaves for doctor later
• Doctor makes second decision, calls pharmacy
• Pharmacy calls patient
• Patient returns, gets medicine
• Elapsed time 2 to 4 days

21
Medicare Part D PBMsWhich Formulary for This
Patient?
Plan E
Plan C
Plan A
Plan B
Plan D
Plan M
Plan F
Physician Office
Plan N
Plan L
Plan G
Plan H
Plan O
Plan J
Plan K
Plan I
22
The Systems Interface Problem
HHA 1
HME 3
HME 2
HHA 2
HME 1
HME 6
HHA 4
HME 4
HME 5
HHA 3
Physician Office
HHA 5
DM 2
PBM 2
PBM 3
PBM 1
DM 1
Hospital 2
PBM 4
Hospital 1
23
Advanced Chronic Illness
24
Chronic Diseases Costs (1999)
25
Medicare Expenditures (1999)by Subgroup
Rank among Utilizers
of Total Medicare Expenses

• Top 1 percent
• Top 5 percent
• Top 10 percent

• 12.8 percent
• 35.9 percent
• 53.8 percent

26
People With Advanced Chronic Illness

• Roughly 5-10 million people
• Need advanced primary care case managers
• Do not need disease state management
• Need mobile medical providers
• House calls
• Nursing home and assisted living visits
• Need integrated health care
• Use 50 of health care resources
• Are an underserved, marginalized population

27
What Might Help

• Accurate open formulary database on web
• Dont create thousands of software solutions for
  small portions of this mess
• If there is a mandatory central clinical
  database, make it broadly inclusive
• Educate providers accurately about HIPAA
• If necessary, pass clarifying legislation
• Avoid creating walled cities of information
• Substantial restructuring of Medicare and
  Medicaid
• Incentives for providers the engage in chronic
  care

28
Peter A. Boling, MDProfessor of
MedicineVirginia Commonwealth University

• pboling_at_hsc.vcu.edu
• 804-828-5323