your path: Home > Policy >

Printer-Friendly Version

Geriatrics Background

Geriatricians are physicians who are board certified in family practice or internal medicine and who have additional training in the care of older adults. Since 1994 all geriatricians have been required to complete fellowship training in geriatrics beyond their residencies and pass a certifying examination in geriatrics. Patients of geriatricians are older, more medically complex, chronically ill, and frail than an average Medicare patient. Geriatric medicine promotes preventive care, coordination and management of chronic illness and functional decline in frail patients. Geriatric services aim to improve quality of life by reducing the likelihood of hospitalization, restoring or maintaining function when possible, or when not possible, decreasing the rate of functional decline.

The American Geriatrics Society (AGS) fully supports the notion of tying physician payment for performance to specific indicators of health care quality. Further we believe that indicators should assess the care of all Medicare beneficiaries, especially those for whom high quality of care has a proven record of improving health, decreasing hospitalization rates and decreasing mortality. The high-risk Medicare beneficiaries who consume a disproportionate share of Medicare costs are characterized by multiple chronic illnesses, functional deficits, advanced age and frequent adverse health events. Many aged and chronically ill persons are over the age of 75. This age group comprises fully 42% of Medicare beneficiaries. Hence, pay for performance measures should target not only care for specific diseases but also aspects of care that cross multiple illnesses and have been designed and tested in vulnerable older persons. Lastly, any pay for performance system should recognize the special needs of end of life patients. Physicians who care for these persons should be rewarded, not penalized when end-of-life care conflicts with disease-specific performance indicators. Below, we comment on the PPC quality indicators and propose an innovative claims-based solution to these issues.

Comments on NCQA - PPC Document and CMS PGP Measures

The PPC measures support the development and use of electronic health records including disease registries and performance reporting. Fundamentally these are structural attributes applicable to all practices and all populations, endorsed by the AGS. The CMS proposed PGP measures are performance-based but are of unproven benefit for vulnerable persons, especially those aged 75 or older. For these persons, evidence supporting these measures is scant because persons who are of advanced age or who have multiple chronic illnesses are seldom included in clinical trials testing therapies or quality of care. In addition, the PGP measures are largely disease-specific and do not include measures that are designed to assess the quality of care of these vulnerable elders. We are concerned about two issues. First physicians who provide high quality care to vulnerable elders will not be recognized by these proposed pay for performance measurement systems and may not share in any proposed financial rewards. Second, it is possible that physicians who care for vulnerable elders may be adversely affected by a system of performance measurement that does not make allowances for deviation from standards when patients' preferences or health status require modification of care. When end of life needs or frailty require "standards" to be modified or patients decline care, physicians should not be penalized. Lastly, we are concerned about the absence of mental health measures when the prevalence of cognitive impairment is almost 40% for persons over the age of 85.

We believe that additional measures are needed to assess the quality of care of persons over age 75, those who are frail and those who are receiving palliative care near the end of life. Fortunately, a set of such measures exists. The Assessing the Care of the Vulnerable Elders (ACOVE) measures were developed by the RAND Corporation in response to the needs of frail persons or persons over the aged 75 and older. We feel that the addition of ACOVE measures would strengthen the validity and utility of any pay-for-performance measurement in a geriatric aged population. The ACOVE measures parallel the measurement technology of indicators proposed by the NCQA and the National Quality Forum (NQF). Each applies to a specific target population (defined by age and gender) and has defined 'numerators' and 'denominators' that facilitate scoring and ranking of performance. They have been tested in a cohort of community-dwelling vulnerable older adults. Moreover, recent evidence shows that better performance on the ACOVE indicators is associated with improved two-year survival. Adoption of some or all of these indicators will assure that quality of care can be measured for all Medicare beneficiaries and that the providers who care for these patients have measures of accountability. Below we propose a method by which these measures can be captured.

Claims Based Measures using American Medical Association's (AMA) Current Procedural Terminology (CPT®) Category II codes.

The AMA's (CPT®) codes are used in all medical claims systems to capture the services provided by health care providers. Recently, the CPT editorial panel has sponsored the development of codes that can be used in medical claims to capture measures of quality of care. These are called CPT® category II codes, a HIPAA standard transaction set for reporting performance. These codes will allow CMS to use claims to capture data that would otherwise require costly chart review. Category II CPT® codes have been developed to capture some of the performance measures proposed by the NCQA and the National Quality Forum. Their definitions, inclusions and exclusions are directly translated from these measures. The CPT editorial panel has already approved approximately 50 codes and is continuing to approve others. AGS proposes legislation that will allow for administrative reporting of all our proposed measures. This simplifies the process and minimizes the costs of measurement for CMS and clinicians.

We propose the use of a limited set of CPT® Category II codes, which are based on the ACOVE measures, to foster pay for performance measurement for the vulnerable elderly over the age of 75. Use of these will extend pay for performance to all Medicare beneficiaries, instead of being limited to those under 75. In short, physicians who perform the functions below for appropriate patients would be eligible to receive bonus payments for the services.

1. Falls - We propose 3 measures incorporating these 4 attributes
   
   ALL person age 75 or older should have documentation that they were asked at least annually about the occurrence of recent falls.
   
   
   • IF a person age 75 or older reported 2 or more falls in the past year, or a single fall with injury requiring treatment, THEN there should be documentation of a basic fall history.
     
     
   • IF a person age 75 or older reported 2 or more falls in the past year, or a single fall with injury requiring treatment, THEN there should be documentation of a basic fall examination.
     
     
   • IF a person age 75 or older reports or is found to have new or worsening difficulty with ambulation, balance and/or mobility, THEN there should be documentation that a basic gait, mobility, and balance evaluation was performed within 3 months that resulted in specific diagnostic and therapeutic recommendations
     
     
2. Cognitive Screening. We propose one measure
   
   
   • IF a person age 75 or older vulnerable elder is admitted to a hospital or is new to a physician practice, THEN there should be documentation of a multidimensional assessment of cognitive ability.
     
     
3. Functional assessment
   
   
   • IF a person age 75 or older vulnerable elder is admitted to a hospital or is new to a physician practice, THEN there should be documentation of an assessment of functional status.
   
   
   
4. End of life counseling We propose one measure
   
   
   • ALL persons age 75 or older should have in their outpatient charts (1) an advance directive indicating the patient's surrogate decision maker/life-sustaining treatment preferences, or (2) documentation of a discussion about who would be a surrogate decision maker or a search for a surrogate/preferences, or (3) indication that there is no identified surrogate/preference.
     
     
5. Osteoporosis We propose one measure
   
   
   • ALL females age 75 or older should be counseled about osteoporosis risk and pharmacologic prevention at least once.
     
     
6. Medication Review We propose one measure that incorporates these 3 concepts
   
   
   • ALL persons age 75 or older should have a drug regimen review at least annually
     
     
   • IF a person is prescribed a new drug, THEN the prescribed drug should have a clearly defined indication documented in the record.
     
     
   • For ALL persons age 75 or older there should be an up-to-date medication list in the outpatient record of every physician and in the hospital medical record