National Commission for Quality Long Term Care

1
National Commission for Quality Long Term Care

• Testimony of
• George Taler, MD
• Director, Long Term Care
• Washington Hospital Center
• Washington, DC
• Past President, American Academy of Home Care
  Physicians

2
Summary

• Primary Care Geriatric Medicine
• A different approach to the health care
  challenges of an aging population
• Restructuring health care delivery and health
  care financing

3
Median Compensation for Selected Medical
Specialties
Woo B. N Engl J Med 2006355864-866

• Bodenheimer T. N Engl J Med 2006355861-864

4
Family Medicine Residency Positions and Number
Filled by U.S. Medical School Graduates
Bodenheimer T. N Engl J Med 2006355861-864
5
Proportions of Third-Year Internal Medical
Residents Choosing Careers as Generalists,
Subspecialists, and Hospitalists
Bodenheimer T. N Engl J Med 2006355861-864
6
National Medical AssociationGallup Poll of
Membership, 2003
7
Maryland Academy of Family Physicians2005
Practice and Income Survey

• 663 Active Members (private practice 66)
• Median annual income 103,400
• 37 no change since 2001
• 41 decrease since 2001
• In response
• 16 have increased hours or of patients/wk
• 44 have decreased hours in clinical practice
• 35 plan to retire, relocate or change careers

8
Geriatricians Have GreatestCareer Satisfaction
9
Changes in Medicare Payments to Physicians
1999-2012
10
Concentration of Total Annual Medicare
Expenditures Among Beneficiaries, 2001

Percent
Source Congressional Budget Office based on data
from the Centers for Medicare and Medicaid
Services.
11
High-Cost Medicare Beneficiary Spending
Source Congressional Budget Office based on data
from the Centers for Medicare and Medicaid
Services. Note Spending reported in 2005 dollars
12
Yes, but

• Just because you have a bad year, does your bad
  luck persist and for how long?

13
Expenditure History of the Top 25 of Medicare
Beneficiaries, 1997
Source Congressional Budget Office based on data
from the Centers for Medicare and Medicaid
Services.
14
Distribution of High-Cost Months, 1997-2001
Source Congressional Budget Office based on data
from the Centers for Medicare and Medicaid
Services.
15
Concentration of Total Cumulative Medicare
Expenditures Among Beneficiaries, 1997-2001
16
Targeting the High-Cost User

• Diagnostic characteristics
• Functional characteristics
• Resource utilization history

17
Prevalence of Chronic Conditions
Notes COPDChronic Obstructive Pulmonary
Disease, ESRDEnd Stage Renal Disease. Data from
a 5 percent random sample of fee-for-service
(FFS) beneficiaries between 1989 and 1997.
Source CBO preliminary analysis.
18
Number of Chronic Conditions Predicts High-Cost
Status
Notes The 7 conditions considered were CHF,
CAD, COPD, ESRD, Asthma, Diabetes, and Cognitive
impairment. Source CBO preliminary analysis.
19
Spending for People with Chronic Illnesses and
Activity Limitations
Sources Partnership For Solutions, Chronic
Conditions Making the Case for Ongoing Care,
December 2002 MEPS, 1998.
20
Service Organization Structure Process Criteria

• Make the HOME the center of health care delivery
  and social supports
• Re-establish the Doctor-Patient relationship
• Continuity of care across all settings and over
  the natural history of illness
• Coordinate Medical, Social and Housing services
• Match patient goals and processes of care

21
Life Care Coordination Fees

• Layered fee for non-covered services
• Comprehensive Geriatric Assessment
• Team meetings
• Care coordination
• Enhanced urgent care services
• On-call services
• Gap-filling fund
• Renewable contingent on performance
• Adherence to evidence-based guideline targets
• Patient and caregiver satisfaction targets
• Reduced costs

22
Whose Ox Gets Gored?

• Sponsoring Hospitals
• Cover margin expectations
• Rate incentives for supporting innovation
• SNF/ICF
• Escalated payments for greater complexity
• Decreased payments for custodial care
• Incentives for community-based referrals

23
The Ask How You Can Help

• Advocacy for a focused, population-based health
  care delivery system transformation
• Development of population target criteria
• Development of new financing mechanisms
• Special interdisciplinary training programs
• Development of a public-private partnership
  towards common goals and incentives

24
You can judge a civilization by the care it
takes of its old and sick people. I want America
to pass this test well. Rep Claude D. Pepper