National Commission for Quality Long Term Care

Testimony ofGeorge Taler, MD

Director, Long Term CareWashington Hospital Center

Washington, DC

Past President, American Academy of Home Care Physicians

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

Woo B. N Engl J Med 2006;355:864-866

Median Compensation for Selected Medical Specialties

Bodenheimer T. N Engl J Med 2006;355:861-864

Bodenheimer T. N Engl J Med 2006;355:861-864

Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates

Bodenheimer T. N Engl J Med 2006;355:861-864

Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists

National Medical AssociationGallup Poll of Membership, 2003

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

Geriatricians Have GreatestCareer Satisfaction

Changes in Medicare Payments to Physicians 1999-2012

Concentration of Total Annual Medicare Expenditures Among Beneficiaries, 2001

Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

Perc

ent

High-Cost Medicare Beneficiary Spending

Medicare Spending

% of Total

Mean

Top Quartile

85% $24,800

Second Quartile

11% $3,290

Bottom Half

4% $550

Total 100% $7,310

Medicare Spending

% of Total

Mean

Top 5 % 43.1% $63,030

Top 6-10 % 18.4% $26,900

Top 11-25% 23.5% $11,430

Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

Note: Spending reported in 2005 dollars

Yes, but…

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

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.

Distribution of High-Cost Months, 1997-2001

Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

Concentration of Total Cumulative Medicare Expenditures Among Beneficiaries, 1997-2001

Targeting the High-Cost User

• Diagnostic characteristics

• Functional characteristics

• Resource utilization history

Prevalence of Chronic Conditions

Beneficiary Group(Spending pattern)

All Low Cost High Cost(Non-persistent) (Persistent)

Coronary Artery Disease 28.2% 19.1% 50.0% 53.7%

COPD 19.6% 13.9% 28.9% 37.5%

Congestive Heart Failure 18.5% 10.1% 33.0% 44.3%

Diabetes 16.7% 12.6% 23.5% 29.5%

Cognitive Impariment 8.8% 5.7% 13.9% 18.7%

Asthma 3.9% 2.9% 4.5% 7.3%

ESRD 2.3% 0.7% 4.2% 7.9%

Mean number of conditions 1.0 0.7 1.6 2.0

Notes: COPD=Chronic Obstructive Pulmonary Disease, ESRD=End Stage Renal Disease. Data from a 5 percent random sample of fee-for-service (FFS) beneficiaries between 1989 and 1997. Source: CBO preliminary analysis.

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.

Beneficiary Group(Spending pattern)

Low Cost High Cost(Non-persistent) (Persistent)

0 of the 7 conditions 89.5% 4.4% 6.1%

1 condition 71.5% 11.1% 17.3%

2 conditions 53.3% 15.0% 31.7%

3 conditions 34.5% 16.1% 49.4%

4 conditions 20.2% 13.8% 66.0%

5 conditions 10.8% 9.9% 79.3%

6 conditions 5.4% 6.0% 88.7%

7 conditions 0.0% 0.0% 100.0%

Spending for People with Chronic Illnesses and Activity Limitations

$2,890$3,830

$5,650

$7,800

$11,890

$13,420

$7,560

$5,650

$4,060

$2,550$1,500

$680

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

0 1 2 3 4 5+

Number of Chronic Conditions

Avg

. An

nu

al H

ealt

h C

are

Exp

ense

s P

er

Per

son

No Activity Limitation

With Activity Limitation

Sources: Partnership For Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” December 2002; MEPS, 1998.

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

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

“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

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

“You can judge a civilizationby the care it takes of its oldand sick people. I wantAmerica to pass this test well.”

Rep Claude D. Pepper