"With older patients you really can't ignore these services," said the study's lead author Elizabeth Landsverk, MD, geriatrician at the UCSF-affiliated SFVAMC. "For instance if you're not evaluating physical function and discussing the importance of exercise the patient may spend most of the day in the chair and lose the ability to walk well, and be at higher risk of falls."
"These preventive services are very important and if Medicare does not pay for them they are likely to be ignored," she added.
Landsverk examined how the time is spent during an elderly patient's initial visit to the doctor by tape-recording 21 such visits at Mt. Sinai Medical Center in New York. Reviewing the tapes, she logged the time in five-second increments, assigning each increment to one of 23 descriptive categories, such as history-taking, chatting, cognitive assessment, and so on.
She presented the results recently at the annual meeting of the American Geriatrics Society in Washington DC.
Although Medicare reimbursed for a majority of the doctor's time during an average visit, 37 percent of the time was not reimbursed. Medicare covers time spent on the physical exam, medical history, medication review, and planning of tests and treatments. However, it does not reimburse doctors for discussions of nutrition, exercise, preventive services, health education, or administrative tasks such as acquiring patient information from other sources and coordinating care, Landsverk said.
"These services can make a big difference in the health and functioning of older patients, and if Medicare isn't paying for them, and they are not performed, the patient may decline more quickly and need more services later on," she said.
"Typically Medicare reimburses more for doing things to the patient, such as a procedure or addressing a disease like heart failure. As a physician you can get more money from Medicare for cleaning out earwax or removing harmless skin growths than you can for spending 40 minutes evaluating the patient and figuring out how to keep them healthy," Landsverk said.
Future studies should address whether time spent on certain non-covered services actually translates into healthier patients, better outcomes or cost savings, she said.
Patients are likely to get better overall care through payment plans such as On Lok or a vertically integrated HMO like Kaiser Permanente, which try to offset future costs to the plan by preventing the patient's decline. However, even good plans like Kaiser's need more funding, she said.
Even though Medicare does not cover expenses for geriatric services that benefit many patients, some doctors can still take advantage the system, by doing less to help the patient and billing for more, Landsverk said.
Co-investigators on the study included: Carol Capello, PhD, assistant professor of geriatrics and adult development, Mt. Sinai School of Medicine; Lorraine Mion, RN, PhD, director of geriatric nursing at the Cleveland Clinic; and Rosanne Leipzig, MD, PhD, associate professor of geriatrics and adult development, Mt. Sinai School of Medicine.
The San Francisco Veterans Affairs Medical Center has been a primary affiliate of University of California San Francisco since 1974. The UCSF School of Medicine and the SFVAMC collaborate to provide education and training programs for medical students and residents at SFVAMC. SFVAMC maintains full responsibility for patient care and facility management of the medical center. Physicians at SFVAMC are employed by the Department of Veterans Affairs and also hold UCSF faculty appointments.