The group of people who are the oldest of the old, those who are more than 85, is the fastest-growing segment of the population in the U.S. But the branch of medicine that specializes in the medical treatment of the elderly, geriatrics, is hamstrung by Medicare reimbursement policies that pay considerably less than private insurance.
The disabled and people over 65 in the U.S. are covered by Medicare. And while people later in life are most likely to need medical care, often for multiple healthcare issues, lower reimbursement to hospitals and physicians for healthcare for the elderly is a problem.
“It is a financial issue working in geriatrics because the Medicare system does not reimburse as well as private insurance,” said Dr. Holland Addison, an internist at the Jackson Medical Clinic who is board certified in geriatrics. “A lot of physicians stop seeing Medicare patients, and they become second-class citizens. Even if the patient has all the money in the world, you can’t bill more than Medicare allows.
The elderly require more time, have more complicated problems, take more medications, and are slower to understand issues. But from a business standpoint, financially you do better seeing younger patients without Medicare. Geriatrics is much more challenging. It just takes more time.”
Traditionally Medicare reimbursements have been higher for surgery than for office visits with primary care physicians. But Addison said in the past five years, Medicare fees for surgery have been cut more than those for primary care physicians.
“There is more recognition of the importance of rewarding primary care physicians,” Addison said. “But all those Medicare prices are all fixed by the government regardless of our cost of operations. That is what makes it difficult for patients in the geriatric population sometimes to find care.”
Dr. Mark Meeks, director of geriatrics at the University of Mississippi Medical Center, agrees seeing older patients is inherently more time consuming because they can have multiple problems, and clinical interaction tends to be slower for a variety of issues such as hearing loss and cognitive loss. And the lower reimbursement rates mean this is not one of the more popular specialties selected by U.S. medical graduates. In addition to finances, some people don’t enjoy working with older people.
“But people who go into geriatrics actually find it highly enjoyable to work with that age population,” said Meeks, who has been working in the field for 12 years. “It can be gratifying because sometimes you can improve a patient’s condition by, for example, finding a medical complication of a medication that has been overlooked. The elderly are a lot more susceptible to adverse reactions. It can be very satisfying to pick up one of these problems not noticed by anyone else, and cure it by simply stopping the medicine.”
He also finds it rewarding to interact with patients who often have rich personal histories due to having lived for so long. And he finds they can be very appreciative of a physician willing to take the time to assess their problems and help them be as healthy as possible — instead of just discounting their concerns by saying, “Well, you are getting older.”
Another undeniable part of geriatrics is that physicians are confronted with mortality and end-of-life issues more with this age population.
“You often realize, and the patient, as well, that they have surpassed a normal lifespan and there is a finite time to have left,” Meeks said. “But it is not as shocking as it might be with a 40-year-old person with cancer or who has a heart attack and dies suddenly. It is more expected by the patients, their families and physicians. For physicians, there is a big role for discussing advance directives so the manner of dying is with dignity and alleviation of pain. Even though death may be eminent, you still have a role to play supporting them in their dying process.”
Because of advances in healthcare, people are living longer on average. So there are more people out there who need care. The biggest issue is regarding Alzheimer’s disease and other forms of dementia. In the 85 plus range, an estimated 45% of the population has Alzheimer’s or another form of dementia.
“That creates a tremendous burden, especially for long-term care issues for where people are going to be living,” Addison said. “Today usually both spouses work, and there isn’t someone at home to take care of the aging parents. As a result, there has been a marked increase in the need for both skilled nursing home beds and assisted living facilities. We have seen a lot of new development for assisted living facilities in the state, particularly in the Jackson area.”
Currently there is no cure for Alzheimer’s, although two classes of drugs are available that help slow the progression of the disease. Addison said these drugs can improve daily living for patients who are suffering from Alzheimer’s, allowing people to be more independent and remain at home longer.
The search continues for a cure. Addison said people who control their blood pressure and cholesterol levels when they are younger are less likely to get Alzheimer’s disease. And some drugs are being investigated for preventing Alzheimer’s.
“But at this point in time there is really nothing that is a guarantee,” Addison said. “Everything being talked about in research now has to do with preventing the deposition of a protein called amyloid. Most research is focused on developing methods to inhibit deposition of that protein in the brain cells.”
Meeks said while there may not be a cure or dramatic treatment found in the next few years for Alzheimer’s, he believes that with as much research as is being done in the area, there will be a treatment that can either halt or reserve the disease process in the lifetime of medical students today.
As far as prevention, Meeks said studies have shown that keeping the mind actively engaged by reading, playing music, doing crossword puzzles, etc. has a beneficial impact. So does regular physical exercise.
Another important issue regarding geriatrics is good communication between different healthcare providers. There is a better medical outcome, and cost savings, from coordinating with a patient’s other physicians in order to prevent errors, avoid unnecessary tests and eliminate duplication.
Electronic medical records can help.
“A lot of practices and hospitals are evolving to electronic medical records,” Addison said. “Our clinic has been on electronic medical record for six or seven years. As we get to that phase, there will be improved efficiencies and transfer of information. Unfortunately, the recent HIPAA laws regarding patient privacy have made it much more difficult to transfer information from one person to another. HIPAA costs a lot of money and grief, and doesn’t help medical care much.”
Addison said the other big issue affecting elder care is an influx of lawsuits into the nursing home environment. Plaintiff attorneys who represent nursing home patients or their families are advertising widely for clients, and Addison said some nursing home companies have left the state because it has made the environment of taking care of patients in the nursing home more risky because of large malpractice exposure.
“That is changing with our new malpractice reform,” Addison said. “Tort reform improvement is expected, but that has been a big issue with nursing homes.”
Contact MBJ contributing writer Becky Gillette at firstname.lastname@example.org.