Treatment for elderly patients and those with chronic conditions may not be well accounted for in the new Medicare system for reimbursing providers.
Some regulations for the Medicare Access and CHIP Reauthorization Act, which replaced the disliked sustainable growth rate formula for Medicare payment, were released this week. Most providers and advocates lauded the attempt to move toward value-based payment, but some of those who deal with patients who need long-term or end-of-life care are concerned the system won't be rewarding good performance in those fields.
MACRA has also been criticized as unsustainable for small and rural practices.
Joanne Lynn, director of Altarum's Center for Eldercare and Advanced Illness, spoke up this week at a meeting of the Physician-Focused Payment Model Technical Advisory Committee, which will be helping HHS evaluate payment models for the new system.
She said the elderly population is often disregarded in efforts of payment reform, even though about 25% of traditional Medicare healthcare spending occurs in the last year of life for beneficiaries 65 and older.
The quality metrics in the Merit-based Incentive Payment System do not reflect what is often the best course of treatment for the elderly and those with chronic diseases. For example, the number of screenings don't necessarily reflect the priorities of a person with multiple chronic conditions. They also don't do enough to encourage providers to get out in their communities or to ensure elderly people are having their basic needs met, Lynn said at the public meeting.
Alternative payment models will be difficult for providers and nursing homes that are not part of larger health systems and do not have the experience or infrastructure for creating them, she said.
“We really need the APMs that come out to be aware of this population and its costs,” she said.
A Kaiser Family Foundation study found that in 2011, Medicare beneficiaries 80 and older accounted for 33% of total Medicare spending while comprising only 24% of the population. In that year, per capita spending for people 85 years of age and older was $13,466 while it was $5,562 for 66-year-olds.
Dr. Luke Hansen, vice president and chief medical officer for population health for Amita Health, a Chicago-based health system, said older adults may benefit from the way MACRA encourages team-based care that includes social support and takes a more proactive approach. But older adults and other vulnerable populations may be more affected by social and environmental variables beyond medical claims-risk.
“Without consideration of these other forces, comparison of geriatricians to other classes of primary care providers might be biased,” he said.
Andrew Scholnick, a senior legislative representative with AARP's Federal Health and Family Team, said neither provider track in MACRA, MIPS or advanced alternative payment models, fully addresses long-term care needs.
Value-based payment models need to make sure that the measures used to evaluate how well care is provided are meaningful to patients and their families. This could be done by giving more weight to patient experiences and patient-reported outcomes as well as by considering burdens on caregivers, he said.
“This is particularly important for geriatric patients, who have multiple chronic conditions and functional limitations, and many of whom rely on caregivers for help,” Scholnick said. “In addition, MACRA needs to ensure that there is a process for evaluating and updating the measures so that the measure set for payment includes new and better measures that reflect the geriatric patients' unique needs and circumstances.”