Medicare Advantage: Better option for the sickest seniors

08/06/2014 2:46 PM

08/06/2014 2:47 PM

I recently had a patient, J.S., visit me in the clinic. He is an older gentleman with congestive heart failure and stage 3 renal failure, two chronic and complex conditions.

After examining him, I admitted him into the hospital. After two days, he was discharged and handed a few sheets of paper with instructions for medications and follow-up with his primary care physician. Upon returning home, he was almost entirely on his own, relying on friends and neighbors for occasional support.

Like many seniors I treat, J.S. is depressed. He has multiple medications from before and during his hospital stay. J.S. is one of the many patients I see who has traditional Medicare. There is a high likelihood he will wind up back in the hospital, perhaps multiple times, because in this fragmented delivery system he is pretty much on his own.

Now picture a patient in a coordinated care system. Before hospital discharge, a care management team springs into place. A hospital discharge planner makes appointments with a care coordinator. The care coordinator calls the patient and ensures they are seen in the physician’s office within 24-48 hours of discharge. Pharmacists help the patient reconcile medications from before and after the hospital stay to prevent potentially life-threatening duplication.

A care manager visits the patient’s home to make sure it’s safe; checking that carpeting is secure and installing handrails in the bathroom to prevent falls. A behavioral health provider makes sure the patient is recovering from the stress of hospitalization. The entire team reports back to the primary care physician.

This system exists today, and it is called Medicare Advantage.

It doesn’t take a physician to tell you which experience patients and their families prefer. Today, nearly 40 percent of California’s Medicare seniors are enrolled in Medicare Advantage. Nationwide, more than half of all seniors aging into Medicare are selecting Medicare Advantage over traditional Medicare.

How can we ensure that even more patients are treated in a coordinated care model?

First, we have to move away from the fee-for-service payment model used in traditional Medicare. In fee-for-service, physicians are paid for every service rendered. The more services and procedures performed, the more the payment. Payment is not tied to quality of care or the health of the physician’s patients. There are no incentives to work with a care team. The result is a fragmented system in which patients like J.S. are left to fend for themselves.

We can do better; patients deserve better.

Second, we need to use payment models that encourage care coordination. In Medicare Advantage, health plans pre-pay a set amount to a physician organization to care for a patient population. The result is a physician organization working within a budget with incentives to keep patients healthy and out of the hospital. In Medicare Advantage there are rigid requirements for quality performance as a condition of payment and physicians are encouraged to work with a care team to make sure the patient is getting the right care, at the right place and at the right time.

I encourage policymakers to think of Medicare Advantage as an investment in care coordination infrastructure.

The investment in Medicare Advantage has led to electronic health records systems, disease registries, 24-hour nurse call centers, and numerous other benefits that accrue directly to patients and their families in the form of better health care. This investment in Medicare Advantage has provided the backbone for coordinated care, especially for chronically ill and low-income seniors.

Recent regulatory and legislative changes have resulted in significant cuts to Medicare Advantage. These cuts impact physicians and, most importantly, patients that rely on coordinated care. More cuts are likely to disrupt this coordinated care system, making patients vulnerable to fragmented and low-quality care.

Policymakers should be investing in what works in Medicare and providing our seniors access to the best available options. That is Medicare Advantage.

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