Care for the elderly may become more financially viable

Michael Wasserman, MD, a geriatrician in Aurora, Colo., believes, like many in his specialty who attended the American Geriatrics Society's 2009 annual scientific meeting in Chicago, that incomes earned by caring for the elderly are about to become much more stable.

"The momentum is growing to recognize the value of primary care and geriatrics," said Dr. Wasserman, who also consults on setting up geriatric practices. "We may finally be in the right place at the right time."

Dr. Wasserman was among those who discussed practice management issues at the April 29-May 2 meeting. Among the topics: why senior care could become more financially viable and tips on how doctors can set up sustainable practices even under current reimbursement levels.

For example, payment increases have been mentioned in U.S. Senate Finance Committee health reform discussions as a possible solution to the shortage of primary care physicians -- something that could make primary geriatric care more attractive.

There also is a growing need for geriatric medical care. According to projections from the U.S. Census Bureau, the population ages 65 to 84 is expected to grow 114% from 30.8 million in 2000 to 65.8 million in 2050. The number of those older than 85 will grow even faster, jumping 389% from 4.3 million in 2000 to 20.9 million in 2050.

"There are challenges, but there are really opportunities," said Jay P. Slotkin, MD, MPH, moderator of one of the panels at the meeting. He runs a solo geriatric practice in Southold, N.Y. "We all know the need is there, and the environment is changing."

But while many in attendance said financially viable geriatric practices were about to become more possible outside of academic settings, they also said certain strategies made them so now, even at current payment levels.

The profit margins of Senior Care of Colorado, the company Dr. Wasserman set up with his partner, geriatrician Donald Murphy, MD, to provide services exclusively for those older than 65 covered by Medicare, are narrow, but the company is expanding. Senior Care started in January 2001 with six physicians and annual revenues of approximately $2.5 million. It has since grown to 25 physicians and nearly $14 million in yearly revenues.

"You have to not just see the patients. You have to capture that work and learn how to appropriately bill for it," Dr. Slotkin said.

Experts advised reducing work that cannot be reimbursed. They also stressed that documentation should be as complete as possible.

"If you spend a lot of time educating your patient or coordinating care, document what you do," Dr. Wasserman said. "This is critical to the viability of geriatric practices. The mistake many clinicians make is they don't know how to bill for their time. I have clinicians who work 12 hours a day and code for four hours. They have not done a good job of valuing their time. That will kill the practice."

Those who primarily care for the elderly should self-identify as geriatricians to the Centers for Medicare & Medicaid Services. Doing so means being compared with other geriatricians rather than other physician specialties that may have very different patient populations. This can reduce the risk of an audit, experts said.

"Make sure you use the geriatrician code," said Edward Ratner, MD, a geriatrician in Minneapolis. "This will make you less of an outlier."

Telephone care that is not reimbursed should be avoided, and the patient asked to come in or a home visit arranged. Physicians also need to be clear about why certain services are being provided. Medicare requires that they be medically necessary but does not define that term. Physicians, however, must.

"You cannot just demonstrate medical necessity from a lab value," said Michael Lewensohn, director of medical reimbursement services for ODMD Medical Management LLC in Harrison, N.Y. "You want to say what was going on, and why the doctor needed to do what they did. Be very clear. Give a reason for billing and being with the patient."

Those who work in the area also stressed that audits, while stressful, should not be feared.

"Medicare has a rule book. ... Follow the rule book, and you will be fine," said Dr. Wasserman, whose business has survived several audits as well as scrutiny from the U.S. Dept. of Health and Human Services' Office of Inspector General. "As long as you document, you'll be fine. These guys do not want to go to trial. If you testify about the little old lady with 12 problems, and you say you have to spend an hour and a half with her, a jury is going to believe you."

Rejections also should be monitored to look for patterns and identify services that are not routinely reimbursed or paid for at all, and goals for the business should be realistic. Growth is important, but growing too fast can create cash-flow problems. There can be a time lag between new physicians starting and getting them set up so Medicare covers their services.

Experts also suggested establishing systems that work for the particular practice. For example, some physicians avoid long visits and using prolonged service codes. Others said they were crucial. Some care only for those in nursing homes, but others prefer to provide elder care in a wide variety of settings.