The Senate and House are now considering legislation that would fill a major gap in traditional "fee-for-service" Medicare by authorizing coverage of geriatric assessments and care coordination for beneficiaries with multiple chronic conditions.

Lawmakers in both houses introduced the legislation, the Geriatric Assessment and Chronic Care Coordination (GACCC) Act, on May 9, the same day the Senate convened a hearing to examine the need for care coordination for beneficiaries with multiple illnesses, such as diabetes, arthritis, heart disease and dementia.

The American Geriatrics Society (AGS) worked closely with Sens. Blanche Lincoln (D-AK) and Susan Collins (R-ME), who introduced the bill in the Senate, and with Reps. Gene Green (D-TX) and Fred Upton (R-MI), who introduced it in the House. Original Senate cosponsors of the bill are: Barbara Boxer (D-CA), Robert Casey (D-PA), Hillary Rodham Clinton (D-NY), John Kerry (D-MA), Herb Kohl (D-WI) and Barbara Mikulski (D-MD). AGS President Todd P. Semla, PharmD, provided key testimony during the May 9 hearing before the Senate Special Committee on Aging.

"Currently, about 20% of Medicare beneficiaries have five or more chronic conditions, and these individuals account for almost 70% of all Medicare spending," Dr. Semla told legislators, noting that multiple health problems are increasingly common with age, and that such problems significantly complicate treatment.

For patients with multiple chronic health problems, a geriatric assessment -- a comprehensive evaluation of a patient's healthcare needs that results in a coordinated care plan -- can improve the quality and cost-effectiveness of care, he explained. So can having a care coordinator - typically a physician, nurse practitioner, or physician's assistant - oversee implementation of the care plan by the healthcare providers involved, the patient, and, when applicable, his or her caregivers, he noted.

"Studies show that care coordination raises the quality of care, improves health outcomes and reduces healthcare costs for individuals with chronic conditions," Dr. Semla explained. "This means fewer hospital visits are needed, duplicative services or appointments are eliminated, and sudden health crises are avoided. When a comprehensive geriatric assessment is combined with coordinated care, studies have shown even better outcomes."

The GACCC Act would apply to fee-for-service Medicare insurance. More than 85% of beneficiaries have this kind of traditional Medicare insurance. While traditional Medicare does not cover geriatric assessments and care coordination, some Medicare Advantage and other programs do reimburse for some of these services.

The proposed legislation would cover geriatric assessment for beneficiaries whose medical costs rank in the top 10% of all Medicare beneficiaries' and who also have multiple chronic health problems, or dementia and at least one other chronic condition. It would exclude beneficiaries who already receive care coordination services, such as hospice patients, skilled nursing facility residents, and patients with end stage renal disease. Beneficiaries who qualify could choose to have the assessment performed by a Medicare-approved physician, physician's assistant, nurse practitioner, or clinical nurse specialist. All assessments would have to be performed under the direction of a physician. The legislation lays out the required components of such an assessment, which include a comprehensive history and physical exam, a review of the beneficiary's clinical and functional status and need for care giving.

Under the Act, beneficiaries who qualify for a geriatric assessment and who would benefit from care coordination could opt for that service, choose a chronic care manager and meet with the care manger to develop a comprehensive care plan. The care manager would have to be a Medicare-approved physician, physician's assistant, nurse practitioner, clinical nurse specialist or clinical social worker. If the services were provided by a professional other than a physician, the provider would have to work in collaboration with a physician. Components of care coordination would include management of and referral to medical and other health services; medication monitoring and management; education and counseling for the patient and family caregivers; self-management services; and management of transitions among professionals and settings of care.

"Studies indicate that when patients are linked with a physician or other qualified health professional to coordinate care, the results are improved quality of care, increased efficiency and greater cost-effectiveness," Sen. Lincoln told those at the May 9 hearing.

"Medicare is a wonderful program, but it has some gaps," added Rep. Green. "What we're doing with this bill is bridging the gap between what Medicare was intended to do for seniors and what it has done in the real world."

The GACCC Act has already won the endorsement of 33 national organizations including the American College of Physicians, the American College of Nurse Practitioners, the National Association of Social Workers and the National Rural Health Association.