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Madame Chair and Members of the Subcommittee:

Thank you for allowing me to testify today on an important issue - eliminating barriers to chronic care management in Medicare.

I am Dr. George A. Taler, a Board certified geriatrician and Director of Long Term Care in the Department of Medicine at the Washington Hospital Center. I appreciate the opportunity to participate today on behalf of the American Geriatrics Society (AGS), an organization of over 6,000 geriatricians and other health care professionals dedicated to the care of older adults.

Today I will discuss the needs of the chronically ill Medicare beneficiary, particularly those individuals with multiple chronic conditions who are in need of care coordination services as well as some aspects of disease management that relate to this population.

Brief History of Geriatrics

Before I begin to discuss chronic care issues, it is necessary to place geriatrics in context. Geriatricians are physicians who are experts in caring for older persons. Geriatric medicine promotes preventive care, with emphasis on care management and coordination that helps patients maintain functional independence in performing daily activities and improves their overall quality of life. With an interdisciplinary approach to medicine, geriatricians commonly work with a coordinated team of other providers such as nurses, pharmacists, social workers, and others. The geriatric team cares for the most complex and frail of the elderly population.

Geriatricians are primary-care-oriented physicians who are initially trained in family practice or internal medicine, and who, since 1994, are required to complete at least one additional year of fellowship training in geriatrics. Following their training, a geriatrician must pass an exam to be certified and then pass a recertifying exam every 10 years.

The Frail Elderly/Chronically Ill Population

Americans are not dying typically from acute diseases as they did in previous generations. Now chronic diseases are the major cause of illness, disability and death in this country, accounting currently for 75% of all deaths and 80% of all health resources use. The Partnership for Solutions, a Robert Wood Johnson founded initiative of which we are a partner has found that about 78% of the Medicare population has at least one chronic condition while almost 63% have two or more. Of this group with two or more conditions, almost one-third (20% of the total Medicare population) has five or more chronic conditions, or co-morbidities.

In general, the prevalence of chronic conditions increases with age - 74% of the 65 to 69 year old group have a least one chronic condition, while 86% of the 85 years and older group have at least one chronic condition. Similarly, just 14% of the 65-69 year olds have five or more chronic conditions, but 28% of the 85 years and older group have five or more.

Utilization Patterns

There is a strong pattern of increasing utilization as the number of conditions increase. Using data again from the Partnership for Solutions, 55% percent of beneficiaries with five or more conditions experienced an inpatient hospital stay compared to 5% for those with one condition or 9% for those with two conditions. 19% of Medicare beneficiaries have an inpatient stay.

In terms of physician visits, the average beneficiary has just over 15 physician visits annually and sees 6.4 unique physicians in a year. There is almost a four-fold increase in visits by people with five chronic conditions compared to visits by people with one chronic condition. The number of unique physicians seen increases almost two and half times for people with five or more chronic conditions relative to those with just one chronic condition.

The average Medicare beneficiary fills almost 20 prescriptions. Within this average, the under 65 year old population fills on average 6.3 prescriptions and those 65 years and older fill 19.1 on average. We found that beneficiaries with no chronic conditions fill an average of 3.7 prescriptions per year while those with any chronic conditions fill an average of 22.7.

The Partnership for Solutions found that there is a strong trend in utilization of prescriptions when examined by number of chronic conditions.

• Average annual prescriptions filled jumps from 3.7 for all people studied with no chronic condition to 49.2 for people with five or more chronic conditions.
• Growth in usage between those with no chronic conditions and those with one chronic condition is over 180 percent - from 3.7 to 10.4 prescriptions filled.
• Usage grows 72% between one and two chronic conditions, from 10.4 to 17.9 prescriptions filled.
• There is a 48% growth in average annual usage between four and five chronic conditions (33.3 to 49.2).

Policy Implications

Individuals with 5 or more chronic conditions are a large portion of my patient base. Geriatricians tend to provide care coordination services to these patients based on their need for extensive family and patient telephone consultation, heavy pharmacological usage, and high need for transitional care as these patients move from different settings in the health care system. We are not reimbursed for providing these services and, in fact, most geriatricians are unable to sustain private practice because of their commitment to care for this patient base. At this time, I would like to discuss disease management and care coordination services in this context.

A portion of today's hearing focuses on disease management. We believe disease management is an appropriate practice for certain Medicare beneficiaries who do not have multiple chronic conditions, such as those with only diabetes, asthma or hypertension. However, disease management does not address several key issues involved with frail elderly patients that have multiple chronic illnesses and/or dementia.

First, disease management does not always address the needs of persons with more than one chronic condition. Imagine putting my patient with diabetes, hypertension, dementia, asthma, and COPD into a disease management program for each of these conditions. Most of the people who are most costly to Medicare have multiple conditions and the care for these people can not be segmented into different disease management programs. In fact, many of these individuals with one or more chronic conditions also have Alzheimer's disease or another dementia. Disease management focusing on diabetes without taking dementia into account wouldn't be successful.

Second, a major component of disease management involves self-management and patient education. These simply do not work for persons with Alzheimer's disease or a related dementia. Diabetes self management often involves patient education or patient self management which is inappropriate for a beneficiary with Alzheimer's disease or related dementia. Likewise, disease management for asthma and hypertension depends on patient compliance with treatment recommendations; this would not be effective for persons with Alzheimer's disease or related dementia.

Third, disease management does not always address functional issues brought on by old age or the complications that arise from multiple chronic illnesses.

Finally, when used for patients with multiple comorbidities, disease management can disrupt a patient's critical relationship with a primary care physician. Some disease management programs utilize specialists that focus only on specific interventions tailored to one condition. The nature of chronic illness requires a comprehensive, care coordination based approach that utilizes a variety of interventions which change over time and which contain both a clinical and a non-clinical component.

There are indications in the data that there is a lot of care provided to beneficiaries with chronic conditions - particularly those with multiple chronic conditions. There are also indications that the care may not be well-coordinated and that for beneficiaries with multiple chronic conditions there are adverse outcomes. We believe the lack of a care coordination benefit is a major reason for this outcome.

For instance, the Partnership for Solutions has found that as the number of chronic conditions increase, so too do the number of inappropriate hospitalizations for illnesses that could have received effective outpatient treatment. These poor outcomes are likely a result of poor care coordination among the many services used and providers seen. It may be that different providers are recommending conflicting treatments that result in poor outcomes including adverse drug events. It could be that one condition is receiving treatment, while other chronic conditions go unattended and then become acute episodes.

There is other data to support this theory. A recent national survey of people with serious chronic conditions completed by Gallup for the Partnership for Solutions found that:

• 26 percent report receiving contradictory advice from different doctors in the past year;
• 20 percent report they were often or sometimes sent for unnecessary or duplicate tests or procedures;
• 23 percent report that they often or sometimes received conflicting information from different health care providers; and
• 25 percent report that they were often or sometimes diagnosed with different medical problems for the same set of symptoms from different providers

Other Partnership for Solutions data shows that physicians think that care coordination is both important and difficult to do. A national survey of physicians who provide more than 20 hours of direct patient care during the week demonstrated that almost two-thirds of these physicians reported that their medical education training was not adequate to the task of caring for people with chronic conditions and 17 percent reported that they had problems coordinating care with other physicians. Most importantly, physicians in our survey think that poor care coordination leads to poor outcomes.

This data suggests that we must go beyond disease management for our Medicare population with multiple chronic conditions and consider other options worth exploring that will improve their care. These options would be modest, but important, steps to improve care for beneficiaries and modernize the Medicare fee-for-service program. As you can see, we know a great deal about Medicare beneficiaries and their conditions, as well as the lack of coordination within the system that affects them.

Thus, we believe that chronically ill Medicare beneficiaries will receive better care and have better outcomes if a new care coordination benefit is created. The AGS believes it is critically important to create this new benefit under the fee for service Medicare program. Doings so could make significant progress toward a more integrated system for all beneficiaries. For these reasons, we strongly support the Geriatric Care Act (H.R. 102/S. 387).

This bill would authorize Medicare coverage of geriatric assessment and care coordination for eligible Medicare beneficiaries. Eligible persons are categorized as those who: (1) have at least 2 activities of daily living limitations; (2) have a complex medical condition, as defined by the Secretary of Health and Human Services (HHS); or (3) have a severe cognitive impairment.

Eligible individuals will have a designated care coordinator who must enter into a care coordination agreement with the HHS Secretary. The coordinator may include physicians, physician group practices, or other non-physician health care professionals in collaboration with a physician.

Examples of appropriate care coordination services include: (1) multidisciplinary care conferences; (2) coordination with other providers, including telephone consultations with relevant providers; (3) monitoring and management of medications, with special emphasis on clients using multiple prescriptions (including coordination with the entity managing benefits for the individual; and (4) patient and family caregiver education and counseling (through office visits or telephone consultation), including self-management services.

Another modest change to Medicare would be to provide incentives to physicians and other providers to provide care coordination services to frail elderly beneficiaries. Unlike the traditional method of disease management, which targets enrollees with particularly high cost conditions, it may be useful to look at some of the people who are having the most difficult time with multiple medical conditions (whatever those conditions may be). We could focus on people with four or five chronic conditions who, for whatever reason, have difficulty self-managing one or more of their conditions. These are people who typically see many physicians, who fill a large number of prescriptions, who need an array of health care services, and who are at risk of poor outcomes if the clinical care and other care are not well-coordinated.

For this group of target beneficiaries, there could conceivably be a physician payment adjustment that compensates physicians for the additional visit and other office time necessary to work with these patients. This type of adjustment could be available to all physicians treating any Medicare patient who meets the criteria.

One other option that is not mutually exclusive with anything else discussed here has to do with physician training and physician ability to care appropriately for people with chronic conditions. One other component of the Geriatric Care Act would provide for limited changes to the Medicare graduate medical education (GME) program to train additional geriatricians who specialize in providing care coordination services and who also are in shortage across the nation. This would allow for a limited exception to the per hospital cap on GME for small numbers of geriatricians.

We would like to work with this Committee and the Congress to legislate these important changes and we thank you for including us in today's important hearing. Changes such as these should be strongly considered as the Congress debates how to modernize the Medicare system.