Year: 2014
Type: editorial
Abstract: Before assessing the merits of the solution that Resnick and Radulovich put forth,1 it is necessary to agree on the problem it is designed to fix. The rationale for a special payment system seems to rest on several assumptions: academic geriatrics is a special case, geriatrics is undervalued, someone has to pay for teaching, and geriatric research should be subsidized. The proposal harkens back to discussions about the resource-based relative value scale.2 The so-called “cognitive” specialties persistently claimed they were underpaid compared with the technically driven specialties. This gap has widened over the years. The underlying argument can be framed in two ways: philosophical–moral and economic. The former suggests that critical care decisions about diagnosis, prognosis, and treatment require careful delineation and time. The latter is about funding. In an era of patient-centered care, these decisions become increasingly complex. Presumably, patients value this time spent talking with them. The economic argument suggests that this effort to learn more about patients and their problems can pay dividends by reducing subsequent care—by avoiding the need for such care or deciding to forgo what is deemed futile care. In this case, the extra time and effort are viewed as an investment. So why is geriatrics special? Presumably geriatricians take care of the harder cases, but cardiologists or neurologists might disagree. Basically, the problem is that fee-for-service payment is not compatible with chronic disease care and especially not with multimorbidty. The answers lie not in proposing a new variant on the relative value unit but in reframing the issue to one of preventing subsequent expensive care. That is the underlying philosophy of accountable care organizations and several Centers for Medicare and Medicaid Services demonstration projects that test various forms of bundled payments. The problem is that we are not yet very good at delivering effective primary care. The evidence to support the economic contention is spotty at best. The studies cited in the article are selective and largely center on comprehensive geriatric assessment, but that is not the big challenge of today. That challenge comes from the need to manage chronic disease, especially multimorbidity. Ironically, geriatrics has been the model for such care. Geriatricians work well with interdisciplinary teams. They recognize the multidimensional needs of patients. The problem has been the lack of strong evidence from any quarter to suggest that better primary care reduces the demand for subsequent care. Although large-scale national comparisons suggest that countries with better primary care infrastructures do better in controlling healthcare costs, other factors also intervene. Clinical studies showing such effects are rare.3 The Program of All-Inclusive Care for the Elderly has a strong record of controlling institutional use but is a hard model to replicate.4 The Global Registry of Acute Coronary Events study is encouraging, but its effects were modest.5 Other efforts such as guided care were less successful.6 Enthusiasts for the Medical Home hope that it will change practice, but it seems like a modest intervention at best, typically not targeted at high-risk individuals. It is important to separate a payment system for geriatrics from the problems of supporting academic geriatrics. The academic challenge involves payment for other than clinical care. The old model of cross-subsidization from other earnings no longer works (if it ever did). Even the Department of Veterans Affairs, on whose shoulders many geriatric programs were built, no longer offers the support it did in years past. Graduate medical education support is dwindling. Every nontechnological specialty faces the same problem (and the technology specialties would claim it too). Who pays for teaching? Paying for research (including clinical and health services research) is another matter. Neither can reasonably be financed on the back of clinical care. The recruitment problem has to start by examining the stream. Geriatrics is an offshoot of primary care. When the latter dries up, geriatrics suffers, even without the aversion to treating complex old people. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: The author is solely responsible for the concept and writing. Sponsor's Role: There was no sponsor.
DOI: 10.1111/jgs.12697
Author: Robert L. Kane
Institutions: University of Minnesota, University of Minnesota System
Language: English
Subfield: Economics and Econometrics
Domain: Social Sciences
Open Access status: bronze
OpenAlex ID: W2024541878