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Comprehensive geriatric assessment in medicare managed care: The geriatrician's calling card
Comprehensive Geriatric Assessment in Medicare Managed Care: The Geriatrician’s Calling Card Paul D. Roller, MD, Richard M. Allman, MD, Birmingham, Alabama lder people need and deserve special care. Most physicians, however, have found that the man0 agement of the chronic medical, functional, and psychosocial problems of the elderly is far too time and resource intensive to allow for a full-time care geriatric practice given the current Medicare-reimbursement system. Geriatricians, general internists, and family practitioners with fellowship tmining or a certificate of added qualifications in the care of older adults have been seeking ways to make such a practice of geriatrics possible in the real world. At this time, most formal geriatric care programs are found in academic settings and at hospitals affiliated with the Department of Veterans Affairs. The reality of health care for many of America’s older population, however, is quickly becoming HMOs and Medicare risk plans. In the future, these programs may provide the incentives required for the implementation of the most important principles of geriatric care: comprehensive geriatric assess ment (CGA), interdisciplinary approaches to care, and a focus on functional outcomes. As a new breed of Americans age, we are seeing a more sophisticated, better informed, “AARP-ized” generation. This group of elderly (or the designated family member who makes health-care decisions for an older adult) is more savvy and in touch with health care service options than ever before. For this population, HMO selection is by individual choice rather than through employer-contracted programs. They choose to enroll in managed care plans for a variety of reasons, particularly the menu of services provided by the plan, reduced out-of-pocket expenses for health care, and reduced paperwork.’ This new generation of older adults will likely drive the move to managed care. Products that include CGA as a component of a continuum of health care service incorporating the principles of geriatric care have an attractive marketing advantage among these Medicare beneficiaries. Less fragmented, comprehensive pro grams have the potential to provide higher quality, more cost-effective care for their enrollees.
From the Division of Gerontology and Geriatric Medicine (PDR, RMA), University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center (RMAI, Birmingham, Alabama. Requests for reprints should be addressed to Paul D. Roller, MD, Division of Gerontology/Geriatric Medicine, University of Alabama at Birmingham, 933 19th St. South, CHSB-19 Rm 219, Birmingham, Alabama 35294-2019. Manuscript submitted February 27,1996, and accepted February 27,1996.
CGA has been a fundamental component of the geriatrician’s training. Through multidisciplinary evaluation of the patient’s medical, psychosocial, and functional status, management strategies for the complex health care problems of the frail elderly can be better refined to address the needs identified. The assessment has been made for hospitalized patients through Geriatric Evaluation and Management units and through consultative geriatric services. CGA has also been employed in ambulatory clinics and even in home-based programs. Team approaches to CGA have included, to various degrees, geriatricians or other clinicians with geriatric training, nurse practitioners, social workers, pharmacists, occupational and physical therapists, and nutritionists. The different models of assessment practices tend to be de signed according to their particular function of consultation and/or management of care. Impacts from CGA have varied with the setting, type of assessment, and follow-up.2 Ambulatory assess ment, in particular, has been shown to identify previously unrecognized problems3 promote higher selfhealth ratings, improve functional status, improve decisions made concerning “placement” issues2 and reduce medical care costs mostly through reduced hospitalizations and nursing home admissions4 Although ambulatory CGA has been widely studied in multiple settings, few controlled trials have been attempted in managed care settings. Epstein and colleagues3 randomized 666 HMO elderly patienls to compare 3 systems of care: 1) consultation by a. geriatric assessment team, 2) consultation by a second opinion internist, and 3) traditional HMO services (control patients). The CGA team identified previously unrecognized problems in 35% of patients and advised medication changes in 46%. No other differences in health status measures were noted among the groups. Epstein and colleagues3 employed CGA in a consultative model. This type of assessment is used to identify and evaluate problems with recommendations passed on in the form of letters or reports to the primary provider with minimal follow-up by the assessment team. In this study, patient continuity of care with the assessment team including telephone follow-up was limited in duration. Although his model was not designed to capture these effects, Epstein notes that prolonged contact with the geriatric assessment team undoubtedly facilitates the imple mentation of their recommendations and the ongoing adjustment of health care plans. April
1996
The American
Journal
of Medicine*
Volume
100
383
Several publications, including the 1988 “National pear to be at risk for high utilization are offered the Institutes of Health Consensus Development Confer- opportunity of obtaining their primary care in this coence Statement: Geriatric Assessment Methods for ordinated system. They subsequently undergo a streamClinical Decision Making,” have indicated that assess lined assessment followed by “care” manag,ement in an ment closely linked to management shows the great- integrated, nurse practitioner-run system. Members est benefit.&’ As Reuben et ala mentions in this issue, are also assessed on referral from practitioners in the this enables the consultative team to take the CGA rec- HMO. If appropriate, these patients are given the opommendatons one step further and promote adher- portunity of joining the “care” management system. ence to the recommendations. Reuben and colleagues This is an altogether different intervention than also mention in this and previous articles that the most the CGA consult models. The addition of case mansuccessful CGA programs have been those that cou- agement by the evaluating team eliminates the imple ple assessment to case management. Previous barri- mentation problem that occurs due to physician ers to the acceptance of CGA in practice may thus be resistance (even though Reuben et al8 heave demonrelated to the inability of the health delivery system to strated this may be less of a factor in HMOs). provide effective assessment and management.7 Although the problem of patient adherence to recCGA coupled with management in a Medicare risk ommendations still exists, it appears that a system of program may be an answer to real world geriatric assessment with concurrent case management will medicine, offering a chance for the geriatrician to improve compliance. leave a calling card and make significant contribuMedicare risk plans offer a gateway for seniors to tions to the health care of the most expensive seg- access such delivery systems. The majority of patients ment of the population. First of all, a capitated envi- enrolling in Medicare HMOs will be new to the prodronment eliminates the financial constraints previuct. This will typically prompt a change from their ously hindering implementation of CGA and other previous primary provider to a new provider within core principles of geriatrics. The interdisciplinary the HMO panel. The time of enrollment to the HMO geriatric team manages these frail, high-utilizing thus provides a unique opportunity for risk profiling patients, thus relieving the primary care providers of and redirecting these patients to appropriate systems some of the financial risk. In exchange, the costs of of care. (It should be noted that the HCFA prohibits the assessment and management are shared by all health screening prior to enrollment to avoid any faproviders in the capitated plan. Although the assess- vorable selection.) What about those patients referred for CGA from ment may be front-loaded with additional tests and home health referrals, Williams et al4 have demonother providers (consult model)? Will the referring strated that this initial spending is an investment provider lose out by reassigning these patients to anwith cost-saving returns coming to the system in the other physician? Not in a capitated system where the form of reduced hospitalizations, a higher level of risk is shared. These patients exemplify the paradigm shift needed for managed care to be successful. If functional independence for the patient, and greater satisfaction among enrollees. Such outcomes justify CGA identifies high-risk, frail older adults who are the shift from acute, inpatient based healthcare to likely to benefit from subsequent case management assumed by a specific geriatric oriented care team, ambulatory, primary care oriented toward preveneverybody wins. The primary provider shifts the care tion and maintenance of functional status. Secondly, through Medicare risk plans, new as- of selected labor-intensive patients, creating more sessment strategies and innovative pathways for fol- room in the panel for other patients. The geriatric orilow-up can emerge, which tie the assessment and care ented case management team provides efficient, qualplan development to further case management. For ity care directed at the needs deiined in the CGA, thus reducing utilization costs and focusing on improved example, Fallon Community Health Plan, Group Health Minneapolis, and Medcenters Health Plan function and other appropriate geriatric issues. The patient benefits from comprehensive, closely manMinneapolis have all used screening tools to identify high-risk patients and refer them for ambulatory CGA. aged care tailored to his or her individuall needs. It is important to note that most HMOs represented Group Health Cooperative of Pugent Sound has used a specially designed history and physical exam that in- in Reuben’s study did not have geriatricians available.* Unfortunately, this is the case in many programs. It corporates much of the assessment into a self-adminis hard to imagine a health-care product designed to istered questionnaire.g At the University of Alabama at Birmingham, we are employing a coordinated care care for the elderly without involvement of those physicians most highly trained in geriatrics. Rven so, system of targeting, assessment, and case management of new Medicare HMO enrollees. At the time of an effective delivery system can be developed that is enrollment, a screening tool is administered that tar- not geriatrician driven. The bulk of the screening, of a patient care gets the frailest new members. Those patients who ap- management, and implementation 384
April 1996 The American Journal of Medicine@ Volume 100
CGA AND MEDICARE MANAGED CARE/ROLLER AND ALLMAN
plan can be provided by non-physician personnel and physician extenders like geriatric nurse practitioners. Where geriatricians are in short supply, their role in the system may be to provide leadership and education to other primary care providers who perform the assessment and care. It should also be pointed out that CGA is not suitable for all Medicare enrollees. Without careful selection of appropriate patients for CGA, valuable resources may be wasted on unnecessary assessments. Therefore, accurate screening of these patients is essential. Targeting criteria seeking to identify the frail elderly should be sensitive enough to capture those subtle, high-risk elderly who possess potential for high utilization, yet specific enough to identify only those patients who are capable of benefiting from assessment and intervention. Also in this issue of Th,e American Journal of Medicine, Moore and colleagueslo demonstrate a screening tool created for targeting frail elderly. The screening package includes measures of physical, mental, and psychosocial impairments that may provide the clinician with an indication of the patient’s severity of illness overall. Taken one step further, this screening tool, which is administered by non-physician office staff, may provide an objective measure by which primary care providers can identify the frail elderly with a potential for increased utilization who would benefit from CGA and case management. Other tools have been designed and tested with various degrees of success in predicting future utilization.“J2 In summary, managed care for the elderly is viewed as a possible solution to the spiraling costs of the Medicare program. To achieve success, geriatricians need to take the leadership roles in education, management, and program development for innovative approaches to risk assessment and extended care pathways within Medicare managed care plans. CGA
performed by geriatricians or trained primary care providers may prove to be a valuable tool and should be closely linked to subsequent case management delivery systems. Careful screening should be performed to identify the patients most likely to benefit from such a coordinated system. Additional randomized controlled trials are needed to further demonstrate the benefits of such systems on the quality, utilization, outcomes, and costs in Medicare risk plans.
REFERENCES 1. Langwell ML, Hadley JP. Capitation and the Medicare program: history, issues, and evidence. Health Care Financ Rev. 1986 Annual Supplement:%19. 2. Rubenstein LZ, Stuck AE, Siu AL, Wieland D. Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. J Am Geriatr Sot. 1991;39fsuppl):8S-16s. 3. Epstein AM, Hall JA, Fretwell M, et al. Consultative geriatric assessment of ambulatory patients: a randomized trial in a health maintenance organization. JAMA. 1990;263:538-544. 4. Williams ME, Williams TF, Zimmer JG, et al. How does the team approach to outpatient geriatric evaluation compare with traditional care: a report of a randomized controlled trial. J Am Geriatr Sot. 1987;35:1071-1078. 5. National Institutes of Health. National lnsbtutes of Health Consensus Development Conference Statement: geriatric assessment methods for clinical decision making. J Am Geriatr Sot. 1988;36:342-347, 6. Rubin CD, Sizemore MT, Loftis PA, Loret de Mola. A randomized, controlled trial of outpatient geriatric evaluation and management in a large public hospital. J Am Geriatr Sot. 1993;41:1023-1028. 7. Werner MJ. Medicare managed care: how to ensure qualify. Recommendations of The American College of Physicians Task Force Ion Aging. ACP OnLine. 1995. 8. Reuben DB, Wolde-Tsadik G, Pardamean 13, et al. The use of targeting criteria in hospitalized HMO patients: results from the demonstration phase of the hospitalized older persons evaluation (HOPE) study. J Am Geriatr Sot. 1992;40:482-488. 9. Reuben, DB, Maly RC, Hirsch SH, et al. Physician implementation of and patient adherence to recommendations from comprehensrve geriatric assessment, Am J Med. 1996;100:444-451. 10. Moore AA, Siv AL. Screening for common problems in ambulatory elderlys clinical confirmations of a screening rnsbument. Am J Med. 1996;100:438-443 11. Kramer AW, Fox PD, Morgenstern N. Geriatric care approaches in health maintenance organizations. J Am Geriatr Sot. 1992;40:1055-1067. 12. Boult C, Boult L, Murphy C, et al. A controlled trial of outpatient geriatric evaluation and management. JAm Geriatr Sot. 1994;42:465-470.
April
1996
The American
Journal
of Medicinea
Volume
100
385
From the Division of Gerontology and Geriatric Medicine (PDR, RMA), University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center (RMAI, Birmingham, Alabama. Requests for reprints should be addressed to Paul D. Roller, MD, Division of Gerontology/Geriatric Medicine, University of Alabama at Birmingham, 933 19th St. South, CHSB-19 Rm 219, Birmingham, Alabama 35294-2019. Manuscript submitted February 27,1996, and accepted February 27,1996.
CGA has been a fundamental component of the geriatrician’s training. Through multidisciplinary evaluation of the patient’s medical, psychosocial, and functional status, management strategies for the complex health care problems of the frail elderly can be better refined to address the needs identified. The assessment has been made for hospitalized patients through Geriatric Evaluation and Management units and through consultative geriatric services. CGA has also been employed in ambulatory clinics and even in home-based programs. Team approaches to CGA have included, to various degrees, geriatricians or other clinicians with geriatric training, nurse practitioners, social workers, pharmacists, occupational and physical therapists, and nutritionists. The different models of assessment practices tend to be de signed according to their particular function of consultation and/or management of care. Impacts from CGA have varied with the setting, type of assessment, and follow-up.2 Ambulatory assess ment, in particular, has been shown to identify previously unrecognized problems3 promote higher selfhealth ratings, improve functional status, improve decisions made concerning “placement” issues2 and reduce medical care costs mostly through reduced hospitalizations and nursing home admissions4 Although ambulatory CGA has been widely studied in multiple settings, few controlled trials have been attempted in managed care settings. Epstein and colleagues3 randomized 666 HMO elderly patienls to compare 3 systems of care: 1) consultation by a. geriatric assessment team, 2) consultation by a second opinion internist, and 3) traditional HMO services (control patients). The CGA team identified previously unrecognized problems in 35% of patients and advised medication changes in 46%. No other differences in health status measures were noted among the groups. Epstein and colleagues3 employed CGA in a consultative model. This type of assessment is used to identify and evaluate problems with recommendations passed on in the form of letters or reports to the primary provider with minimal follow-up by the assessment team. In this study, patient continuity of care with the assessment team including telephone follow-up was limited in duration. Although his model was not designed to capture these effects, Epstein notes that prolonged contact with the geriatric assessment team undoubtedly facilitates the imple mentation of their recommendations and the ongoing adjustment of health care plans. April
1996
The American
Journal
of Medicine*
Volume
100
383
Several publications, including the 1988 “National pear to be at risk for high utilization are offered the Institutes of Health Consensus Development Confer- opportunity of obtaining their primary care in this coence Statement: Geriatric Assessment Methods for ordinated system. They subsequently undergo a streamClinical Decision Making,” have indicated that assess lined assessment followed by “care” manag,ement in an ment closely linked to management shows the great- integrated, nurse practitioner-run system. Members est benefit.&’ As Reuben et ala mentions in this issue, are also assessed on referral from practitioners in the this enables the consultative team to take the CGA rec- HMO. If appropriate, these patients are given the opommendatons one step further and promote adher- portunity of joining the “care” management system. ence to the recommendations. Reuben and colleagues This is an altogether different intervention than also mention in this and previous articles that the most the CGA consult models. The addition of case mansuccessful CGA programs have been those that cou- agement by the evaluating team eliminates the imple ple assessment to case management. Previous barri- mentation problem that occurs due to physician ers to the acceptance of CGA in practice may thus be resistance (even though Reuben et al8 heave demonrelated to the inability of the health delivery system to strated this may be less of a factor in HMOs). provide effective assessment and management.7 Although the problem of patient adherence to recCGA coupled with management in a Medicare risk ommendations still exists, it appears that a system of program may be an answer to real world geriatric assessment with concurrent case management will medicine, offering a chance for the geriatrician to improve compliance. leave a calling card and make significant contribuMedicare risk plans offer a gateway for seniors to tions to the health care of the most expensive seg- access such delivery systems. The majority of patients ment of the population. First of all, a capitated envi- enrolling in Medicare HMOs will be new to the prodronment eliminates the financial constraints previuct. This will typically prompt a change from their ously hindering implementation of CGA and other previous primary provider to a new provider within core principles of geriatrics. The interdisciplinary the HMO panel. The time of enrollment to the HMO geriatric team manages these frail, high-utilizing thus provides a unique opportunity for risk profiling patients, thus relieving the primary care providers of and redirecting these patients to appropriate systems some of the financial risk. In exchange, the costs of of care. (It should be noted that the HCFA prohibits the assessment and management are shared by all health screening prior to enrollment to avoid any faproviders in the capitated plan. Although the assess- vorable selection.) What about those patients referred for CGA from ment may be front-loaded with additional tests and home health referrals, Williams et al4 have demonother providers (consult model)? Will the referring strated that this initial spending is an investment provider lose out by reassigning these patients to anwith cost-saving returns coming to the system in the other physician? Not in a capitated system where the form of reduced hospitalizations, a higher level of risk is shared. These patients exemplify the paradigm shift needed for managed care to be successful. If functional independence for the patient, and greater satisfaction among enrollees. Such outcomes justify CGA identifies high-risk, frail older adults who are the shift from acute, inpatient based healthcare to likely to benefit from subsequent case management assumed by a specific geriatric oriented care team, ambulatory, primary care oriented toward preveneverybody wins. The primary provider shifts the care tion and maintenance of functional status. Secondly, through Medicare risk plans, new as- of selected labor-intensive patients, creating more sessment strategies and innovative pathways for fol- room in the panel for other patients. The geriatric orilow-up can emerge, which tie the assessment and care ented case management team provides efficient, qualplan development to further case management. For ity care directed at the needs deiined in the CGA, thus reducing utilization costs and focusing on improved example, Fallon Community Health Plan, Group Health Minneapolis, and Medcenters Health Plan function and other appropriate geriatric issues. The patient benefits from comprehensive, closely manMinneapolis have all used screening tools to identify high-risk patients and refer them for ambulatory CGA. aged care tailored to his or her individuall needs. It is important to note that most HMOs represented Group Health Cooperative of Pugent Sound has used a specially designed history and physical exam that in- in Reuben’s study did not have geriatricians available.* Unfortunately, this is the case in many programs. It corporates much of the assessment into a self-adminis hard to imagine a health-care product designed to istered questionnaire.g At the University of Alabama at Birmingham, we are employing a coordinated care care for the elderly without involvement of those physicians most highly trained in geriatrics. Rven so, system of targeting, assessment, and case management of new Medicare HMO enrollees. At the time of an effective delivery system can be developed that is enrollment, a screening tool is administered that tar- not geriatrician driven. The bulk of the screening, of a patient care gets the frailest new members. Those patients who ap- management, and implementation 384
April 1996 The American Journal of Medicine@ Volume 100
CGA AND MEDICARE MANAGED CARE/ROLLER AND ALLMAN
plan can be provided by non-physician personnel and physician extenders like geriatric nurse practitioners. Where geriatricians are in short supply, their role in the system may be to provide leadership and education to other primary care providers who perform the assessment and care. It should also be pointed out that CGA is not suitable for all Medicare enrollees. Without careful selection of appropriate patients for CGA, valuable resources may be wasted on unnecessary assessments. Therefore, accurate screening of these patients is essential. Targeting criteria seeking to identify the frail elderly should be sensitive enough to capture those subtle, high-risk elderly who possess potential for high utilization, yet specific enough to identify only those patients who are capable of benefiting from assessment and intervention. Also in this issue of Th,e American Journal of Medicine, Moore and colleagueslo demonstrate a screening tool created for targeting frail elderly. The screening package includes measures of physical, mental, and psychosocial impairments that may provide the clinician with an indication of the patient’s severity of illness overall. Taken one step further, this screening tool, which is administered by non-physician office staff, may provide an objective measure by which primary care providers can identify the frail elderly with a potential for increased utilization who would benefit from CGA and case management. Other tools have been designed and tested with various degrees of success in predicting future utilization.“J2 In summary, managed care for the elderly is viewed as a possible solution to the spiraling costs of the Medicare program. To achieve success, geriatricians need to take the leadership roles in education, management, and program development for innovative approaches to risk assessment and extended care pathways within Medicare managed care plans. CGA
performed by geriatricians or trained primary care providers may prove to be a valuable tool and should be closely linked to subsequent case management delivery systems. Careful screening should be performed to identify the patients most likely to benefit from such a coordinated system. Additional randomized controlled trials are needed to further demonstrate the benefits of such systems on the quality, utilization, outcomes, and costs in Medicare risk plans.
REFERENCES 1. Langwell ML, Hadley JP. Capitation and the Medicare program: history, issues, and evidence. Health Care Financ Rev. 1986 Annual Supplement:%19. 2. Rubenstein LZ, Stuck AE, Siu AL, Wieland D. Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. J Am Geriatr Sot. 1991;39fsuppl):8S-16s. 3. Epstein AM, Hall JA, Fretwell M, et al. Consultative geriatric assessment of ambulatory patients: a randomized trial in a health maintenance organization. JAMA. 1990;263:538-544. 4. Williams ME, Williams TF, Zimmer JG, et al. How does the team approach to outpatient geriatric evaluation compare with traditional care: a report of a randomized controlled trial. J Am Geriatr Sot. 1987;35:1071-1078. 5. National Institutes of Health. National lnsbtutes of Health Consensus Development Conference Statement: geriatric assessment methods for clinical decision making. J Am Geriatr Sot. 1988;36:342-347, 6. Rubin CD, Sizemore MT, Loftis PA, Loret de Mola. A randomized, controlled trial of outpatient geriatric evaluation and management in a large public hospital. J Am Geriatr Sot. 1993;41:1023-1028. 7. Werner MJ. Medicare managed care: how to ensure qualify. Recommendations of The American College of Physicians Task Force Ion Aging. ACP OnLine. 1995. 8. Reuben DB, Wolde-Tsadik G, Pardamean 13, et al. The use of targeting criteria in hospitalized HMO patients: results from the demonstration phase of the hospitalized older persons evaluation (HOPE) study. J Am Geriatr Sot. 1992;40:482-488. 9. Reuben, DB, Maly RC, Hirsch SH, et al. Physician implementation of and patient adherence to recommendations from comprehensrve geriatric assessment, Am J Med. 1996;100:444-451. 10. Moore AA, Siv AL. Screening for common problems in ambulatory elderlys clinical confirmations of a screening rnsbument. Am J Med. 1996;100:438-443 11. Kramer AW, Fox PD, Morgenstern N. Geriatric care approaches in health maintenance organizations. J Am Geriatr Sot. 1992;40:1055-1067. 12. Boult C, Boult L, Murphy C, et al. A controlled trial of outpatient geriatric evaluation and management. JAm Geriatr Sot. 1994;42:465-470.
April
1996
The American
Journal
of Medicinea
Volume
100
385