Managing the chronic care of patients is not being captured in today's reimbursement system

Nov 19 2007

Full-time physicians spend an average of one full day a week providing services for patients that are not reimbursed by Medicare, according to a new study conducted by Jeffrey Farber, MD, Assistant Professor of Geriatrics at The Mount Sinai Medical Center, and published the journal Annals of Internal Medicine.

The study results could potentially prod insurance companies and Medicare to catch up to physicians' current levels of productivity by reimbursing them for the care that is increasingly taking place outside of formal office visits.

“These services that are going un-reimbursed are not unusual or luxury services,” explained Dr. Farber. “These are basic elements of good patient care and include such things as talking with adult children, managing pain over the telephone, calling pharmacies, coordinating home care services like physical therapy and visiting nurses, and ordering equipment like canes and wheelchairs.”

In 1965, when Medicare was first established, elderly and even middle-aged patients often died from their first heart attacks, strokes, or bouts with cancer. However, today, diseases that were once considered acute are now treated as chronic conditions, and geriatricians are spending more of their time helping these patients treat long-term, but manageable medical problems.

In 2006, people aged 65 and older represented 37.3 million of the U.S. population, according to the U.S. Department of Health and Human Services. That figure is expected to double to 71.5 million by 2030. While the need for physicians specializing in the care of older adults grows, the number of medical students entering the fields of geriatrics and primary care is declining, says Dr. Farber.

“Primary care physicians are finding it increasingly difficult to practice the kind of medicine that their patients need,” Dr. Farber explains. “Our findings illustrate the inequities that exist in the current reimbursement system and the barriers that exist to promoting good medical care for older adults.”

To measure how much time doctors worked outside of formal office visits, Dr. Farber and his colleagues Albert Siu, MD, the Ellen and Howard Katz Professor of Geriatrics and Chairman of the Brookdale Department of Geriatrics and Adult Development, and Patricia Bloom, MD, Associate Professor of Geriatrics and Adult Development, designed a form to document interactions with patients, including the type of interaction, how much time they'd spent, what it was about (a medication refill, family counseling, pharmaceutical pre-approval, or other task) and the outcome of the interaction, such scheduling an appointment, referring the patient to a specialist, or changing the type or dose of a medication.

Doctors in the study all worked at the Coffey Geriatrics Practice at Mount Sinai. The researchers collected data from 16 doctors, documenting 472 separate interactions with patients ranging from 67 to 101 years old.

The study showed that the average episode of non-reimbursed care lasted just 10 minutes, but they happened often enough to add up to 7.8 hours every week. A full 36 percent of the interactions involving a new medical symptom resulted in either a new prescription or a change of medication. Twenty-seven percent resulted in an office visit that had not been previously scheduled. “These are real medical decisions being made, and all of this work is not captured in the current reimbursement system,” Dr. Farber says.

The study results underestimate the time physicians spend performing work that is not reimbursed because the Coffey Geriatrics Practice schedules patient visits to last 30 minutes, longer than other physician practices, explains Dr. Farber. Other physicians with a larger patient load would have to do more care coordination, he says, a term doctors use to describe consultations with a patient's specialist doctors, nurses, home care providers and conversations with family members.

“The work involved with caring for older adults is complex and lengthy and not boiled down to the typical nine-to-five day,” says Dr. Farber. “This is widely assumed to be true, but it had never been formally studied. Traditional office visits are all that Medicare pays for, but if non-traditional care was covered, it might eliminate a significant barrier to medical students entering an otherwise desirable and fulfilling field.

The Mount Sinai Medical Center encompasses The Mount Sinai Hospital and Mount Sinai School of Medicine. The Mount Sinai Hospital is one of the nation's oldest, largest and most-respected voluntary hospitals. Founded in 1852, Mount Sinai today is a 1,171-bed tertiary-care teaching facility that is internationally acclaimed for excellence in clinical care. Last year, nearly 50,000 people were treated at Mount Sinai as inpatients, and there were nearly 450,000 outpatient visits to the Medical Center.

Mount Sinai School of Medicine is internationally recognized as a leader in groundbreaking clinical and basic-science research, as well as having an innovative approach to medical education. With a faculty of more than 3,400 in 38 clinical and basic science departments and centers, Mount Sinai ranks among the top 20 medical schools in receipt of National Institute of Health (NIH) grants.