Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said. In the meantime, the RUC discussions remain confidential.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, who is a medical oncologist in Atlanta.

“There's no doubt that primary care interests—family physicians and geriatricians in particular—are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

“It's not that the relative value system is screwed up or that CMS is made up of bad people,” Dr. Lichtenfeld added. “The problem is there's not enough money being appropriated by Congress, there's no new money coming in, and primary care gets beat up pretty badly as a result of that.”

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society (AGS), noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications. “These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility.”

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

The relatively small number of geriatricians in the United States—7,000 out of a total physician population of 650,000—is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

About 45 U.S. medical schools offer significant geriatrics curricula, he added, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

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