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Geriatric Practice: Challenges for Technology. Peter A. Boling, MD Professor of Medicine Virginia Commonwealth University. Selected Problem Areas. Physician-agency regulatory interface Many providers Many different forms Information sharing across settings Many providers

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geriatric practice challenges for technology

Geriatric Practice:Challenges for Technology

Peter A. Boling, MD

Professor of Medicine

Virginia Commonwealth University

selected problem areas
Selected Problem Areas
  • Physician-agency regulatory interface
    • Many providers
    • Many different forms
  • Information sharing across settings
    • Many providers
    • Many embedded data systems
    • Much cost
  • Formulary chaos
bombarded
Bombarded!

Managed care discounts and carve-outs

Super groups and specialty centers

Compliance

OVERHEAD

Formularies

Credentialing

JCAHO

Standards & guidelines

Pharmacy management services

discontinuous non system
Discontinuous “Non-System”

Medicare

+

Choice

Medicare

Medicaid

LTC Insurance

Medigap

Medicare

Drug Benefit

medicare s prospective payment modalities
Medicare’s Prospective Payment Modalities

Nursing

Home

Home Care

Hospital

DRGs RUGs HHRGs

a physician s nightmare
A Physician’s Nightmare

MSA

Medicare

HMO #2

Drug Plan B

Medicare

HMO #1

Drug Plan C

Physician

Medicaid HMO

LTC Ins.

Drug Plan A

Medigap plan

Medicare

PSO

physicians orders
Physicians’ Orders
  • Home health agency (reimbursed)
    • Form 485, initial & every 60 days, + changes
  • Home medical equipment
    • CMNs (11 types)
    • Special forms: motorized devices (scooters)
  • Handicapped parking tag
  • Do Not Resuscitate order
  • Disability, Work excuse, FMLA
physicians orders1
Physicians’ Orders
  • Supplies (Medicaid and other)
  • Diabetic supplies (Medicare)
  • Pharma discount programs
  • Pharmacy orders
    • Prescriptions (handwritten)
    • FAXes from mail-away companies
    • Controlled substances
post acute care information
Post-acute Care Information
  • Hospital discharge summary
  • Phone call
  • Letter
  • E-mail
  • Intranet data within a health system
  • Patient or family recollection

Provider Dependent

the personal data chip
The Personal Data Chip
  • Is the data correct?
    • Human error
    • Intentional falsification
  • Is the data secure?
    • Gets lost, stolen, etc.
  • Who decides what goes on it?
    • Choice of data types and elements
  • Who decides what format is used?
the central data file
The Central Data File
  • Is the data correct?
    • Human error
  • Is the data secure?
    • Access
  • Who decides what goes in it?
    • Choice of data types and elements
  • Who decides what format is used?
    • Many existing systems ($$ Billions)
informatics problems
Informatics Problems
  • Similar items do not cross walk well
  • Software programs do not interface well
  • Organizations use proprietary systems
  • Data in EMR transfers poorly to paper
  • Data in EMR often limited in readability and information content; designed to satisfy regulators not help clinicians
hipaa
HIPAA
  • Misinterpretation (predictably) widespread
  • Providers & staff fear, resist sharing data
  • Health care is therefore more difficult
  • Lack of information leads to
    • Errors
    • Costly redundancy
  • Corrective action is needed
medicare physician payment
Medicare Physician Payment
  • RBRVS based on Relative Value Units
    • Each service valued based on average total cost
  • Work RVUs
    • Pre-visit work
    • Intra-visit work
    • Post-visit work
  • Practice Expense RVUs
  • Malpractice RVUs
99214 two scenarios
99214 – Two Scenarios

Geriatrician

Generalist

medicare part d drugs the formulary problem
Medicare Part D (Drugs)The Formulary Problem
  • Mr. Smith sees the doc; they talk about condition, make decision, write prescription
  • At pharmacy: “not first tier on your plan”
  • Patient wants lower cost option if possible
  • Pharmacist calls doctor, “need alternate choice”
  • Staff pulls office chart, leaves for doctor later
  • Doctor makes second decision, calls pharmacy
  • Pharmacy calls patient
  • Patient returns, gets medicine
  • Elapsed time: 2 to 4 days
medicare part d pbms which formulary for this patient
Medicare Part D PBMsWhich Formulary for This Patient?

Plan

E

Plan

C

Plan

A

Plan

B

Plan

D

Plan

M

Physician

Office

Plan

F

Plan

N

Plan

L

Plan

G

Plan

H

Plan

O

Plan

J

Plan

K

Plan

I

the systems interface problem
The Systems Interface Problem

HHA #1

HME #3

HME #2

HHA #2

HME # 1

HME #6

HHA #4

HME #4

HME # 5

HHA #3

Physician Office

HHA #5

DM #2

PBM #2

PBM #3

PBM #1

DM #1

Hospital #2

PBM #4

Hospital #1

medicare expenditures 1999 by subgroup
Top 1 percent

Top 5 percent

Top 10 percent

12.8 percent

35.9 percent

53.8 percent

Medicare Expenditures (1999)by Subgroup

Rank among Utilizers

% of Total Medicare Expenses

people with advanced chronic illness
People With Advanced Chronic Illness
  • Roughly 5-10 million people
  • Need advanced primary care case managers
  • Do not need “disease state management”
  • Need mobile medical providers
    • House calls
    • Nursing home and assisted living visits
  • Need integrated health care
  • Use 50% of health care resources
  • Are an underserved, marginalized population
what might help
What Might Help
  • Accurate open formulary database on web
  • Don’t create thousands of software solutions for small portions of this mess
  • If there is a mandatory central clinical database, make it broadly inclusive
  • Educate providers accurately about HIPAA
    • If necessary, pass clarifying legislation
  • Avoid creating walled cities of information
  • Substantial restructuring of Medicare and Medicaid
    • Incentives for providers the engage in chronic care
peter a boling md professor of medicine virginia commonwealth university

Peter A. Boling, MDProfessor of MedicineVirginia Commonwealth University

pboling@hsc.vcu.edu

804-828-5323