Aging Gracefully Part 4 Comprehensive Primary Care For The Elderly

Comprehensive primary care is essential to good health, wellness and needed medical care during our elder years. It is critical to Aging Gracefully.

In the last few posts I wrote that Aging Gracefully physically requires attention to lifestyle/behaviors to assure good nutrition, plenty of exercise, reduced stress, no tobacco and – for preserving cognitive function – intellectual challenge and social engagement. That is what each of us needs to attend to but we also need a good primary care physician (PCP) to assist us on our journey. That PCP needs to have adequate time to listen and listen fully.

The Erickson Living retirement communities have developed an approach that appears to work well for its residents. Let me use it as an example. The fundamental concept is to assure that everyone has comprehensive primary care. The Erickson leadership learned that healthcare was of paramount importance to their residents. A strong program would be good unto itself but also a strong marketing attraction. After substantial study and trial and error they set the resident/patient number per doctor at a remarkably low 400 for their in-house salaried PCPs. They found that this 400:1 ratio was the ideal number of elderly geriatric residents per doctor in order to assure the quality, humanistic and integrative approach to care desired. (For comparison, the usual patient to PCP ratio is about 3000:1.) They have clearly demonstrated that this approach to primary care with a low number of patients per doctor (and a team that functions akin to a medical home) not only gives superior care but that it results in much reduced total costs of health care overall. 

According to the medical director, Matthew Narrett, MD, residents can have same or next day appointments for as long as needed, they are offered extensive preventive care (“It is never too late to prevent,”)    the PCPs are well versed in gerontology issues  and there is a strong commitment to listening. Some of the results of this approach: Chronic illnesses can be managed usually quite successfully without the need for referral to specialists but, when needed, specialists are readily available (many conduct office hours on site on a rotating basis eliminating the need to travel to a distant office). Hospital admissions are down absolutely and markedly so in comparison to equivalent groups of elderly individuals. The length of stay in the hospital for those who must be admitted is lower and the 30 day unanticipated readmission rate has consistently been below 11% (the national rate is about 20%plus) despite the average age of their residents being about 82, i.e., one would expect their average rate to be higher than the national rate for Medicare-covered individuals overall. Dr Narrett reported that resident satisfaction was very high. I confirmed that when I was at the Charlestown community to give a talk organized by residents. With no staff present, I asked the 90 or so attendees their impression of the healthcare program. I received only positive accolades.

At the Charlestown and Riderwood communities where I have toured (and other locations) the onsite clinic includes not only the PCPs, but one or more nurse practitioners, a podiatrist, and a suite for a visiting dentist, for an optometrist and for an audiologist. The podiatrist is full time (at the larger communities) but the others are there commensurate with the need. Various outside medical and surgical specialists (e.g., cardiology, gastroenterology, dermatology, orthopedics, etc.) offer office hours on site on a scheduled basis. The clinic has an on-site nurse to coordinate special needs such as preparing for surgery, returning to the community from the hospital, transferring to assisted living, arranging in-home special needs care, etc.

A Medicare Advantage Plan is also offered by Erickson Living to residents of their group of 18 continuing care retirement communities. In the Erickson plans (administered through United Healthcare) one can choose the on-site PCPs or continue with one’s own PCP, can access a wide range of specialists when necessary, can use most any hospital, can be driven to most off-site doctors’ offices at no cost, etc. Unlike Traditional Medicare where one must spend three days in the hospital in order to be eligible for Medicare to pay for the first 100 days of residential skilled nursing care,  this Advantage plan waives the required three day stay. In other words, if the resident would benefit, the doctor can make the decision and can arrange immediate referral to their on campus site. This of course eliminates a very costly and potentially hazardous hospitalization. There is also an on-site benefits specialist to assist residents with their questions. The most common plan costs substantially less than one might pay for both Medigap and Part D policies yet it includes greater benefits (e.g., basic dental) with few co-pays and no deductibles. 

Older individuals perhaps even more than others need comprehensive primary care. It is a critical aspect of Aging Gracefully. Unfortunately, most older people do not have the benefit of a PCP who can spend the time they need.

My takeaway from the Erickson model is that when the PCPs are allotted the needed time and can listen and think, the care is excellent, satisfaction is strong and the total costs come down substantially. It also means that the PCP can get back to relationship medicine where trust builds and healing is possible.

I am not advocating for Erickson Living or that you move to a retirement community but my recommendation is definitely that you seek out a PCP who can and will offer the time you need to assure good healthcare so that you can Age Gracefully.

Disclaimer – I have no financial relationship with Erickson Living. It is used solely as an example to demonstrate the utility and value of a PCP (along with a well-functioning team) who can offer each patient the time necessary for comprehensive primary care.

Medicare Is Not Free, As Many Would Believe.

A retired couple can expect to spend about $6000 per year (or more) for Medicare. And since Medicare does not “cover” all costs, there will be added expenses as well. 

Part A, generally for hospitalization, is paid fully by the Medicare Trust Fund supported by the Medicare tax described in my last post, which you paid into all of your working life.  Part B, generally physician fees, is paid 50-50 by the individual and the federal government from general tax revenues, not the Trust Fund. In 2013 the enrollee fee is $105 per month, progressively higher for those of greater income.  

Since Medicare Part A and B pay for about 75% of covered services, most individuals purchase a Medigap policy sold by private insurers. There are multiple “levels” of Medigap coverage as specified by the government, each level costing more. Medigap policies only pay toward the part of covered services that Medicare does not pay for. Hence Medigap polices do not assist with services that are not covered by Medicare. [Those with a defined benefit federal, state or local government, company or union pension often have built in health care coverage which means that they have Medicare Part A plus pension-paid Part B and a pension-sponsored supplement that may also pay for non-Medicare covered services such as drugs, vision and hearing plus some or all of the various Medicare deductibles and co-pays.]  

Non-covered services would include extended stays in the hospital, many complementary medicine practitioners, certain at home care such as IV antibiotics, etc. In addition, Medicare (as with almost all commercial insurance) does not cover indirect healthcare expenses such as travel to a specialty center, overnight accommodations, parking, mileage, etc. Not to suggest that Medicare should pay for these expenses but of course these are costs nevertheless that may eat into a retired person’s savings rapidly. 

Part D, the drug coverage program, is paid jointly by the federal government out of general tax revenues and by the individual. Basically, the government gives private insurers a set amount per enrollee (“premium support”) which is equal to about 75% of the expenses of running the program and the insurer then collects whatever is needed to make up the difference from the enrollee. By offering different levels of coverage, an individual can spend more or less that the remaining 25%.  Part D premiums per person have a wide range among participating insurers with an average in 2013 of about $40 per month. However, the costs can still be high for the average person who needs multiple prescription drugs. Generics may be fully covered or have only a low co-pay. But brand name or newer medications may require very high co-pays or are not covered at all. And once a threshold of $2970 in total drug costs has been reached, Part D offers only partial coverage (the coverage gap) until an individual has reached a total out of pocket cost of $4700 after which “catastrophic coverage” kicks in and Medicare then pays 95%. This has been called the “donut hole” and is being largely eliminated over time by the ACA/Obamacare legislation.  

Thus Medicare is not free. A retired couple can expect to spend about $6000 per year (or more) for Part B ($1200/year X2), Part D ($500/year X2) and a Medigap policy (about $1200/year X2). Add to this the cost of non-covered services, deductibles and co-pays and uncovered drug costs and the total costs of care can be quite high. Indeed over 10% find they are spending over $8000 per year related to Medicare-covered services, perhaps substantially more for other services.  

There is another Medicare option known as Medicare Advantage or Part C. Basically private insurers provide the same coverage as traditional Medicare in a managed care approach with a limited physician and hospital network. Urgent and emergent care must be covered no matter where provided. The insurer receives an amount of money per enrollee from Medicare that approximates what Medicare calculates the average beneficiary would consume under Part A in a given year for that geographic area plus a bonus amount. This extra amount is set to decrease over time as a result of the ACA legislation. Private insurers then charge for Part B and have found that they can offer the Medicare-mandated coverage and have enough money left over that they can also offer added coverage such as dental, vision, hearing, etc. Usually these programs offer drug coverage at much lower rates than Part D or even no added cost to the individual. So a person can often save on what they would have paid for Medigap and Part D insurance and still have broader coverage.  

About 25% of Medicare enrollees have opted for Medicare Advantage, finding that they get more coverage yet spend the same amount or actually save money. Removing those with pension-related assistance with Medicare (see above), the percentage who opt for Medicare Advantage is very high. As fewer and fewer Americans will retire with defined benefit pensions in the future, it is likely that the numbers using Part C will increase much further. 

So, at $6000 or often substantially more, a retired couple may end up contributing a substantial amount of their annual income toward their health care insurance coverage. With rising annual health care expenditures per capita, and with seniors having many expensive-to-treat chronic illnesses, it can only be expected that the premium costs for Medicare Part B and Part D will continue to rise. There is nothing in the ACA or any other pending legislation that would significantly reduce these annual expenditures. The critical issue is to find ways to reduce health care costs so that insurance costs can be reduced or at least be maintained level. Some recommendations to do this will be offered in later posts.  

The next two posts will describe the opposing approaches of the two political parties.''

 

 

Care Coordination in a Retirement Community – Better Care at Lower Costs

Older individuals tend to have more complex chronic illnesses and they need lots of preventive care. The Erickson Retirement Communities determined to learn if attentive primary care would lead to better quality care, better quality of life and yet lower costs overall. By way of background, their basic goal was to improve the quality of life for their residents – good marketing. So they built in nutrition, exercise and other programs for the residents who live in a campus-like setting. Yet they found that their biggest failure from the retirees’ perspective was medical management. The Community hired a physician who initially spent about thirty minutes with each patient’s visit. The word got around and more and more residents signed up for his care. Once that happened he had to cut back until he was seeing each patient for about ten to twelve minutes per visit. And so the residents were again not satisfied. So the Community hired additional full time primary care physicians and paid them enough in salary over what Medicare paid so that they could afford to take the needed time with each patient. It quickly became apparent that the residents liked this approach but it meant only about 400 or so patients per physician rather than the national average of about 1500+ for a primary care doctor. It was more expensive up front but Erickson found that the number of hospitalizations for this group declined by about 50% suggesting that good coordination of care was effective in not only increasing satisfaction and quality but also in reducing costs. Of course, the reduction benefited Medicare but Erickson still had the extra expense of the added physicians to make the program work. Erickson then went to Medicare and petitioned for a demonstration project. To date over four thousand retirees in multiple retirement communities joined this Medicare Advantage program. The results again confirmed the value of good care coordination, the value of a computerized medical record and orchestration of chronic care by a primary care physician who could spend adequate time with each patient. At one retirement center, inpatient hospital days dropped from a national average of 2096 per 1000 Medicare enrollees per year to less than 500. And since these retirement communities generally have older residents, age adjusting the data meant that it was equivalent to only about 200 hospital days per enrolled resident. Another key metric is an unplanned return to the hospital shortly after discharge. The national rate for Medicare recipients is near 25% but the Erickson plan has kept these to less than 10%.They found that one key to success was having the primary care physician be the “orchestrator” among all of the patient’s specialists, being sure that the patient’s medications were appropriate, not mutually adverse, and in the correct dosage for a geriatric person. The primary care physician attends the resident when hospitalized, bringing the patient’s electronic medical record to the hospital on the doctor’s laptop. [They found that if the patients were cared for only by the hospital-based hospitalist, the tendency was for the acute problem to be well managed but for other issues to get out of control leading to longer lengths of stay and various complications.] As a result, they can assure that the individual continues to get appropriate care for all of their needs, not just the one problem that sent them to the hospital this time. Care coordinators are used as well but in tandem with the primary care physician who has the needed time with each patient. They conduct regularly scheduled programs of health management. There are behavior modification courses as in employer-based wellness programs but also specific programs for monitoring, coaching and prevention for specific high risk diseases. To reiterate, the program provides what a typical primary care physician either does not or cannot provide today [although most would like to provide.] It includes the behavior modification programs, plus the monitoring and coaching for patients with cardiac, chronic lung, diabetes and other diseases found in wellness programs sponsored by employers. To this is added aggressive management of these complex chronic diseases with close care coordination from their very beginning rather than when they become problematic later on. There is extensive use of non-physician providers which helps to keep the costs down but the contact level high. In short it is a wellness program, a care management program and a disease management program all rolled into one.