The John A. Hartford Foundation blog

As I wrote a few days ago, the Medicare fee setting process of the RUC “bakes in” too much of what is common practice in medicine and makes it too hard to change. This is a major issue in primary care, where current low payments for evaluation and management services, based on often cursory visits, are insufficient to allow physicians to provide thorough services to complex older adults.

How are we supposed to fix this problem?  There are at least three different kinds of payment fixes advocates for improved care are considering.

1.  A common suggestion is creating new CPT (common procedural terminology) codes or paying for old codes that don’t currently have a payment.  For example, there are codes for telephonic consultation and for comprehensive geriatric assessment (S0250), but CMS (Centers for Medicare and Medicaid Services) does not pay anything for them.  There could be a code for measuring orthostatic hypotension or for complete medication review. For an added degree of difficulty, non-physician health professionals like social workers and nurses looking at “their” services that are not being provided, wish that they could bill Medicare independently for things like care coordination or patient education. This approach has the virtue of working well in the more-for-more culture of Medicare fee-for-service.  A specific procedure with an additional payment like one of these will get more assessment and management procedures done and billed.  The downside is that this would increase total spending. It also reinforces the micro-managed approach to health care in which providers do that which they can code, no more and no less.

2.  Another approach is to simply increase the payment for the existing “evaluation and management codes.”  This approach acknowledges that all of these services ARE supposed to be included in a professionally competent evaluation and management visit; we have just been dumbing such visits down, settling for lower quality services than we should.  However, in a fee for service world, raising the payment for the service still doesn’t mean that patients get more or better service.  Simply increasing take-home pay would clearly look like a very attractive option to most primary care providers, who perceive themselves to be underpaid, underappreciated, and very overworked.  But how would taxpayers know that the extra money would be well spent?

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Last week I was sitting in on a briefing for policymakers on the workings of the RUC, the controversial Relative Value Update Committee. The RUC is sponsored by the American Medical Association (AMA) to provide input into the Medicare physician fee schedule, the list of payment fees for the thousands of possible medical services.  These fees not only determine how much doctors and all those who work for them are ultimately paid by Medicare, but also influence many other payers.

The RUC looks at the medical procedures described with the CPT–Common Procedural Terminology (the coding system created and owned by the AMA) and makes recommendations for revisions due to changes in how procedures are performed as well as the introduction of new services.  Technically the RUC advises the Center for Medicare and Medicaid Services on assessments of the Work RVU (relative value unit), where work is a function of time spent and its “intensity.” The other two elements of the fee are the Practice Expense RVU (e.g., office staff time, tongue depressors, or sonogram gel) and the Professional Liability Insurance RVU (malpractice insurance).

The RUC asks member societies of the AMA to survey their members in specific specialties to get estimates of the time required for various treatments.  Intensity is assessed by considering the skill and training required to perform a service, the degree of physical difficulty, and the “stress” that it produces in the provider.  “Relativity” (in the jargon of the process) comes into play in that all of these decisions are not absolute judgments, but comparisons of a medical procedure to others. Because all physician payment under Medicare is essentially a zero-sum matter, an increased RVU for one procedure reduces the RVU for others.  Ultimately, an RVU translates into about $36 in 2010.

Many other commentators (see Health Renewal blog and Health Beat, for starters) have identified problems with this process and its outcomes, particularly the impact on payment for primary care services billed under the evaluation and management codes. But as I listened this time it came to me that the process also makes the fallacy of assuming that what IS, is what OUGHT to be.

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Every culture and organization has stories that cement the common understanding of its members as to what is important and what is dangerous.  At the Foundation, many of these stories are about the difficulty of getting honest feedback from grantees and people who might like to be grantees.  One of our former colleagues famously (to us) demonstrated this problem.  Sitting in a big conference room at plenary session at a professional meeting, s/he whispered to another staffer, “Watch this. I’m going to ask the stupidest question ever–see what happens.”  And lo, the speaker on the dais said, “Profound and excellent question….”  Simple politeness or the corrosive effect of the power differential between foundations and grantees?  How can we know?

In a story of my own from years ago, I recall negotiating a grant with a grantee for whom I have the highest regard.  I thought the Foundation should commit some additional funds to the successful project, but that the grantee should also commit to putting in grant applications to other funders down the road.  S/he pushed back a bit (unaccountably, I thought), but eventually agreed despite clear misgivings.

Realizing that there was some miscommunication, I asked the grantee to tell me what s/he thought had been agreed.  It turned out that the grantee thought that s/he had agreed to submit an NIH application before the proposal was reviewed by the Foundation’s board of trustees—only a month away.  I was shocked.  That wasn’t what I wanted, and I certainly knew that such a timeline for a federal application was impossible and likely to be counterproductive.  The lesson I took from this was that even in a strong and successful partnership, the power differential could amplify an ordinary misunderstanding into a serious mistake.

These problems in getting honest feedback and maintaining open communication are part of the reason we have once again asked the Center for Effective Philanthropy to survey our grantees.  We know that responding requires a big time commitment.  We know that some of you may feel that we won’t take your feedback seriously or that your feedback may not be truly anonymous.  But I assure you that we do take it very seriously and it is anonymous.  This survey will include some special questions about our annual grant evaluation process as well as the standard CEP set that allows us to benchmark ourselves against other foundations.  We hope that honest and useful feedback about our weaknesses and errors will help us improve.

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(l to r): Michael Bleich, Linda Cronenwett, M. Elaine Tagliareni, Terry Fulmer, Marla Salmon

Last year, the  Robert Wood Johnson Foundation commissioned an Institute of Medicine (IOM) initiative on The Future of Nursing. The goal of this initiative is to define a clear agenda and blueprint for action that identifies vital roles for nurses in implementing a more effective and efficient health care system. To do so, the IOM has hosted three forums on the future of nursing in November, December, and last Monday, February 22, 2010.  From these meetings, a report will be released in October 2010. This third and final hearing focused on nursing education. Discussions centered on “What We Should Teach,” “How We Should Teach,” and “Where We Should Teach.”

Gerontological nursing advocates Elaine Taglierini, EdD, RN, president of the National League for Nursing, and Terry Fulmer, PhD, RN, dean of the New York University College of Nursing, spoke in the first discussion, “What We Should Teach.” They presented compelling testimony about the importance of educating nurses to care for older adults  and set the tone for the meeting, which featured themes of aging and interdisciplinary collaboration throughout all the panels.  As a representative of a funder focused on aging and health, I found this incredibly rewarding.

Donna Shalala, PhD

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Twitter. Facebook. YouTube. Blogs.

Last year, the foundation took a deep breath and dove into the tantalizing yet murky waters of social media with the launch of this blog. We followed up with the obvious next steps in the social media playbook: creating a Facebook page (the John A. Hartford Foundation)  and a Twitter account (JHartfound). We urge any of you active on those platforms to follow us there, so we can share blog updates, important news relevant to health and aging, and pictures and videos from health and aging-related events. We have some great video up now, including Chad Boult and Diane Meier speaking at January’s Brookings forum, as well as Vin Sahney addressing the 2010 ADGAP meeting.

You may be wondering what we hope to accomplish by spending time twittering, blogging, and facebooking. (It’s remarkable how quickly those nouns developed verb forms.) We see engaging in social media as just another way of accomplishing our mission: improving health care for older Americans. Despite the time and dollars we and other foundations have dedicated to improving training for medical professionals, care for older adults is not improving quickly enough. If we want geriatric social work, nursing, and medicine to be an important part of the conversation surrounding health care reform, we have to talk about them as much as possible, in as many venues as possible.

Additionally, the secondary (or perhaps the primary) purpose of stepping up our communications efforts is to be more transparent about our intentions and perspective. I see blog posts such as Why We (Fight) Write, Declaration of Innovation, and Growing Leaders, our 2008 Annual Report series, as providing a window into our collective foundation mind.

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However, I know David best for the leadership he has provided over many years for the Foundation-funded Geriatrics-for-Specialists Initiative.  The Foundation has come to believe, educated by David and many others, that all physicians need to be knowledgeable about the special considerations in caring for their older patients.  In fields that participate in the surgical care of older adults, stretching from emergency medicine at the front of the hospital, to anesthesia, to rehabilitation at the other end, there is a particular need for internalized expertise.  Older adults are major if not dominant users of many surgically related services and yet there is still limited appreciation for their special care needs pre and post operatively.

Just out this January is a paper in the Journal of the American Geriatrics Society based on remarks David made to the May 2009 annual meeting of the Section for Enhancing Geriatric Understanding and Expertise among Surgical and Medical Specialists (SEGUE), as it is now called, entitled Introduction to the Geriatrics-for-Specialists Initiative:  Geriatrics Specialty Care at the Tipping Point. In his comments David reviews this 16 year old effort, including such milestones as the development of the Jahnigen career development awards for junior faculty in the specialties, the research agenda development process highlighting important gaps in essential geriatric knowledge, and most of all, the development of a sound and respectful partnership among the specialty disciplines and geriatrics.

I think his reflections upon his personal health concerns and their relation to these issues is particularly inspiring.  Dr. Solomon is not only a teacher and researcher in geriatrics but he is also a “customer.”  He concludes, Read the rest of this entry »

When I was a boy, I saved box tops for a secret decoder ring.   
Recently I had occasion to think about the health care analog to secret codes and decoders — the CPT codes (current procedural terminology) used to describe and bill for health care services and the associated Medicare payments that shape health care for older Americans.

On this particular occasion I was at a meeting at AARP, part of our grant, Professional Partners Supporting Family Caregivers, and the discussion turned to how to pay physicians for the time we wanted them to spend educating and counseling family caregivers. (Helping family caregivers take better care of their loved ones and themselves is a key issue to helping older adults stay at home as long as possible while maintaining quality of life for everyone.)

As in so many complex, yet low tech, services that older adults need (e.g., care coordination, geriatric assessment, or end-of-life planning) the issue boils down to one of dollars and time. It is very hard for physicians to allocate enough time to these services or even hire other staff to do so, if the services don’t have a direct, additional fee-for-service payment attached to them.

Medicare is not a very good payer for outpatient primary care services in general — simple bread and butter things like diagnosing changes in chronic conditions and modifying medications or other treatments. But most physicians can do those things quite quickly and so they can afford to have a reasonable percentage of Medicare beneficiaries in their practices.  Unfortunately,  the more complex and time consuming services are also billed using the same Evaluation and Management (E&M) codes that cover most other primary care services in the office.

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In our efforts to improve the health of older adults, we often feel quite alone, even isolated. While we are fortunate to work with and provide support to many, many committed grantees in the health professions and service delivery, many other stakeholders seem to view the Foundation’s work with mixtures of incomprehension, incredulity, and even hostility.

Even though Americans are becoming increasingly aware of the need to improve care for people with chronic disease, the fact that chronic disease, and particularly multiple chronic disease, is disproportionately a problem of older adults seems lost on most people and even many health care professionals.

Certainly our primary strategy of increasing the amount of geriatrics training future health professionals receive seems to puzzle most observers. I think this stems in part from our American assurance that we already have the best health care in the world. If you believe this, then it follows that our professionals must already have all the skills they need.

Unfortunately, as this assumption is UNtrue, the conclusion does NOT follow.  The US ranked 37th internationally in terms of overall health system performance in a 2000 WHO report, and it would probably rank even worse if the measures used included more things relevant to care of older adults. For example, a 2007 Commonwealth Fund report ranked the US last in comparison to five other European and Pacific nations.  Certainly we know that the quality of care for older adults looks quite a bit worse than that for younger adults–particularly when measuring the proportion of appropriate to inadequate care offered, as well as rates of hospital readmissions from the community and nursing homes.

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The following events took place over a year ago, in the summer and fall of 2008, but I have contemporaneous notes and e-mails to refresh my memory. I would love to get feedback before I forward it to the new story archive of The Campaign for Better Care, the consumer and family based effort to improve care for the chronically ill funded by The Atlantic Philanthropies.  Please let me know what you think.

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My parents and my aunt represent two ends of the aging spectrum.  My parents fall into the category of “healthy,” independently living older Americans.  That is, while they have fairly serious multiple chronic illnesses and increasing impairment (arthritis, blindness, hypertension), they are moving through their seventies still coping pretty successfully.  My aunt, on the other hand, represented an increasingly uncommon demographic: an early death in her sixties from an untreatable acute illness. 

The author's father (left) and Uncle Hubert (right)

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Health Care Reform Bogged Down

Since health reform seems mired in the mud as a potential vehicle for implementing any of the recommendations of the Institute of Medicine’s report, Retooling the Healthcare Workforce for an Aging America, we are back on track for the long-haul effort we had originally assumed would be necessary.  

As part of our original strategy of maintaining an active “conversation” around the report, we co-funded the 16th annual Princeton Conference organized by the Council on Health Care Economics and Policy.  The meeting, led by Stuart Altman of Brandeis (a co-chair of the IOM committee), reconvened many of Retooling’s participants a little more than a year after the April 2008 release of their report.  Presentations from the session and a monograph are now available at http://council.brandeis.edu/.

Coincidentally, as I was reading this follow-up report, I saw a paper by Robert Wachter, one of the parents of hospitalism, in a recent issue of Health Affairs.  The paper, “Patient Safety at Ten” is a national report card on health care quality and patient safety 10 years after the Crossing the Quality Chasm  report by the IOM.  He gives our national response an overall grade of B-, up from C+ at 5 years post report, assessed back in 2004.  Given the enormous resources that the Robert Wood Johnson Foundation has poured into safety, the vibrant safety movement that grew out of the Chasm report, and the strong echoing resonance it has had for a decade, this mediocre grade gives me pause. 

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