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American Geriatrics Society (AGS) Position Statement Role of the Geriatrician in Managed Care AGS Health Care Systems Committee *Last Updated January 1, 1999* BACKGROUND Within the managed care arena, the role of the geriatrician is rapidly expanding as a result of the growth of Medicare risk programs. By January 1997, there were 4.9 million older adults enrolled in 350 managed care programs. Most of these programs had risk contracts in which the plan was capitated for the cost of care for these patients. The number of members enrolled in managed care capitated plans will most likely increase with the implementation of Medicare Added Choices in January 1999. This contractual arrangement allows for greater flexibility in the provision of care and has the potential to improve the quality of care using approaches not feasible in fee for service or cost reimbursement settings. In capitated Medicare systems, a small subset of members account for a disproportionate share of the high expenditures. Thus, there is a need to create new models of care that both allow for the higher cost member to receive needed services and distribute costs more equitably. The framework of a managed care program with a risk contract may include several features that enable this type of innovative program development in providing care for older people. Realizing the potential for Medicare risk programs necessitates a population perspective, comprehensive data systems, prospective capitated payment, an integrated delivery system, and variable incentive compensation methods. Most managed care plans have developed a service delivery program designed for acute or episodic care for healthy, younger adult members that comprise the vast majority of plan membership. However, older patients’ characteristics differ from those of younger members. Older adults have higher frequency of office visits, hospitalizations, pharmaceutical use, and use of home health services compared with younger members. Older members also have more chronic medical conditions, have a more complex presentation of illness, and are slower to recover from episodes of acute illness. Their clinical needs frequently require complementary social supports for maintaining their level of function. Geriatricians stand alone in their capacity to work within this framework to develop quality care and management systems that meet both the clinical needs of the member and the operational needs of the health plan.
POSITION 1 The geriatrician should serve in leadership positions within managed care organizations to drive the necessary changes in the delivery system to promote optimum care for all older adults. Rationale The geriatricians’ unique training allows them to function in a variety of capacities, which include: Designer of Special Geriatric Programs To provide quality affordable medical care, special programs are needed to care for older people. A geriatrician with managerial skills can lead the design and implementation of these programs. The geriatrician also provides the clinical perspective essential in designing these special programs. Examples of such programs include: screening and targeting programs; comprehensive assessment clinics; group care clinics; proactive discharge planning teams from acute and subacute venues; clinical pathways for care of chronic conditions (i.e., congestive heart failure); preventive outreach programs (i.e., influenza immunization); case management for special needs patients; home care programs; special inpatient units (i.e., GEM or Acute Care for the Elderly units); and health education programs in wellness and self-management. Administrator for Operational Geriatric Programs Placing the geriatrician as the administrative head of geriatric service delivery programs allows for necessary collaboration among managers that can impact the delivery of services to older people. A full time manager, equipped with either a masters level nursing or health care administrative background, should collaborate with the geriatrician. Together they can oversee efficient deployment of resources within the program. The scope of their oversight should include daily staff operations, utilization management of resources used by older people, supervision and evaluation of personnel, and oversight of clinical care delivered. They should have oversight of all of the clinical geriatric venues. This would include supervision of interdisciplinary teams that provide comprehensive geriatric assessments in acute, subacute, or ambulatory care settings; care delivered in the home by clinicians and home health agencies; and discharge planning teams from hospital or long-term care settings. Liaison to Other Departments The entire healthcare delivery system is touched by the older member. Facilities or systems of care serving older adults are required to interface internally and externally with many services for both clinical and business reasons. Careful adaptation of services to meet the needs of older people is crucial to the financial success of the organization. Such service networks include marketing, pharmacy contracts and formulary development, provider and payor contracts, internal and external quality review boards, and utilization review boards. The geriatrician can provide the insight and clinical experience to address the unique needs and issues for the older patient and member. Such input can help direct the optimal use of resources and outline meaningful outcome indicators that benefit not only the older person but the system of care as well. Organizational Executive At the governance level, the geriatrician can provide essential leadership to an organization by articulating service priorities, the allocation of resources, and the definition of outcome measurements that optimize clinical and financial performance of the organization. The geriatrician as executive can help move a system of care beyond a collection of independent services and facility-based approaches to cost accounting to an integrated process of care delivery with shared organization incentives, information systems, and flexible care delivery that meets the needs of the frail older population. POSITION 2 The geriatrician should be utilized as an expert resource for knowledge and training for clinicians and other health plan staff for geriatrics and gerontology. Rationale Educator for Geriatrics and Gerontology Across a healthcare system, in both inpatient and outpatient settings, there is a clear need for geriatric education. The majority of practicing clinicians have not had formal training in the field of geriatrics. This spans the areas of content from clinical management of the older patient (i.e., medication management or the presentation of geriatric syndromes) to functional and behavioral assessments (i.e., the use of physical restraints or creating an elder-friendly environment). The geriatrician is the ideal person to identify areas of need, create specific curricula, and provide direct teaching to other healthcare professionals. The geriatrician can use existing venues, including departmental meetings, organizational newsletters, consultation reports, and continuing medical education programs, to meet educational objectives. POSITION 3 The geriatrician should be utilized as the clinical expert in the care of complex/frail older adults. Rationale Provision of primary and consultative care for
complex/frail older people often involves practicing in a variety
of settings outside of the clinic and acute care hospital. These
settings include geriatric assessment clinics, subacute and traditional
skilled nursing facilities, assisted living and adult day healthcare
centers, residential care, and home health, hospice, and PACE programs.
Providing care in these locations differs not only by the logistics
of the site, but also by the roles of the healthcare team members.
Each setting requires knowledge of the services available and how
to manage the clinical, functional, and support needs of older people
at that level of care. As part of a geriatric fellowship, geriatricians
are trained to provide clinical expertise to care for complex/frail
older people in these settings with interdisciplinary teams. The
geriatrician can optimize care, minimize unnecessary transfers,
and direct a more appropriate utilization of resources while meeting
the special needs of the frail older person. Prepared by Adrienne D. Mims, MD, MPH, and approved by the AGS Health Care Systems Committee and the AGS Board of Directors, May 1999. AGS, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118.
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