Putting Older People First

By Kate Jackson

The American Geriatrics Society (AGS) is taking aim at a new proposal by the Centers for Medicare & Medicaid Services (CMS) that would alter the manner in which payment is made to qualified health care providers for evaluation and management (E/M) services under Medicare.

In a letter to CMS as well as a sweeping editorial published October 4, 2018, in the Journal of the American Geriatrics Society, the AGS outlined its opposition to the Medicare Physician Fee Schedule Proposed Rule for 2019, issued in July 2018, which details proposed Medicare payment polices and rates for next year. While praising certain aspects of the proposal and the intention to simplify documentation for E/M services, the AGS declared that if the proposal were accepted as submitted, patient care, particularly that for older individuals with complex care needs, could be compromised.

The proposal aims to develop a single-rate payment for most E/M outpatient office visits regardless of how long they take or how complex the patients' problems. Physicians and other providers offering a team approach to person-centered care for older adults would be paid the same as those treating patients with less complex needs and who require less care time. The change, AGS charges, would significantly influence providers' ability to treat acute illnesses, manage chronic illnesses, create care plans for patients with multiple issues, and coordinate team care for those more challenging individuals. The society's experts fear the proposed changes would reduce the amount of time care team members spend with patients and, thus, compromise care.

The AGS, in addition to voicing its concern in its letter to CMS, coordinated a two-pronged response by a coalition of societies. Forty-one organizations signed a joint letter to CMS urging an effort to replace the proposal with a more equitable solution that supports high-quality, patient-centered care. Another letter, signed by 40 organizations, was directed to both houses of Congress, urging members, who were briefed by stakeholders and AGS, to intervene.

The editorial in the Journal of the American Geriatrics Society, published September 17, 2018, was written by Nancy E. Lundebjerg, MPA, CEO of the AGS, along with Peter A. Hollmann, MD, AGSF; Robert A. Zorowitz, MD, MBA, AGSF; Alanna C. Goldstein, MPH; and Alan E. Lazaroff, MD. The authors detail the 15-year effort to change the Medicare Physician Fee Schedule (MPFS) to include codes appropriate for the intensive, whole-person care geriatrics health professionals provide to the nation's oldest and most vulnerable patients. It points, as well, to a shortage of geriatricians, due in part, it notes, to reimbursement issues. "We have long known that one contributor to the shortage is that reimbursement for geriatrics health professionals, as with all of primary care, lags far behind reimbursement for procedural specialists. Our focus on reimbursement has been to ensure that the MPFS supports the type of expert primary care that all Americans will need as they age," the authors wrote. Of the new proposal, they said, "Although the AGS supports efforts to revise the documentation guidelines, this should not come at the expense of high-quality, person-centered care. Identifying ways that CMS might move forward with simplifying E/M documentation without affecting the care that our members provide for all older people, especially those who benefit from time‐intensive services and supports, is part of our ongoing review of the proposal."

According to an AGS press release, Lundebjerg expressed optimism, saying, "Our understanding from various stakeholder meetings is that CMS recognizes our significant concerns and is reflecting on potential ways to work collaboratively on a solution as a result of our collective efforts." She added, "We are hopeful this means CMS will not move forward with its proposed changes to E/M payment in 2019."

The AGS comment letters are available at www.americangeriatrics.org/where-we-stand/payment-services-older-adult-care; the related article describing the AGS process for assessing the fee schedule and providing AGS commentary is available for free from the Journal of the American Geriatrics Society at https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15651.

— Kate Jackson is editor of Today's Geriatric Medicine.