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Patient Protection and Affordable Care Act: Implications for Geriatrics Practice

By Sunil Goyal, MBBS; Melad Kamel, MD; James A. Ranslow; and Linda Thomas-Hemak, MD

From preventive services and screenings to closing Medicare’s donut hole, the PPACA puts a new spin on the practice of geriatrics.

Some provisions of the Patient Protection and Affordable Care Act (PPACA), passed in December 2009 and signed into law in March 2010, have already been implemented. Multiple sections of the PPACA pertaining to both the aging population and geriatric care attempt to increase the accessibility and affordability of care for elderly patients covered by Medicare. The main focus of these sections provides aging patients the opportunity to seek preventive services and screenings at little or no cost to them. This is designed to reduce the current exponential cost of care accrued from hospital and pharmaceutical bills.

Closing the Donut Hole
The PPACA offers assistance to individuals eligible to receive Medicare Part D and requires the closure of the so-called donut hole coverage gap by 2020. To do so, section 3301 of the act required drug manufacturers to provide a 50% discount to eligible Medicare beneficiaries receiving applicable covered Part D drugs beginning in January 2011. During that year, 3.6 million people covered by Medicare received a 50% discount worth a total of $2.1 billion.

From there, the discount rate increases each year until it reaches a 75% discount by 2020 and each year thereafter. The combination of the discounts and 75% coinsurance results in the beneficiary paying 25% of the cost of brand-name drugs as well as generic drugs in the coverage gap. This represents immense savings to older adults who, in many cases, would otherwise be paying close to 75% of the drug cost. With this enacted requirement, a significant portion of the aging population will no longer have to pick and choose which prescription medications they purchase because of personal financial constraints.

The section also required $250 to be paid directly to any Medicare Part D beneficiary who entered the donut hole in any quarter of 2010. As a result, nearly 4 million people received a $250 check to help with their costs.

The average individual with Medicare will save approximately $4,200 from 2011 to 2021. Beneficiaries who have high prescription drug costs will save much more—close to $16,000 over the same period. In comparison, Medicare beneficiaries with low drug costs will save about $3,000 over this period. According to the latest data released by the Centers for Medicare & Medicaid Services (CMS) in June 2012, the average savings per year per beneficiary is $635.

Preventive Healthcare and Annual Wellness Visits
Section 4103 of the PPACA amends section 1861 of the Social Security Act and requires Medicare Part B to cover personalized prevention plan services and comprehensive health risk assessments for beneficiaries. Starting in January 2011, it included measures in the personalized prevention plan to review and update both medical and family health history and create a five- to 10-year screening schedule, making necessary referrals to specialists as recommended by the US Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices. Measures also include identifying personal health risk factors and conditions and devising strategies to address and prevent the need for future medical services. It encourages practitioners to establish interactive telephone and Web-based systems to provide health risk assessments from a patient’s home or another medical office.

Section 4103 also requires clinicians to create and maintain a list of current providers and medications involved in a patient’s care. Health risk assessments must be made available to beneficiaries. Reviews and referrals for testing, assessments, and treatments pertaining to chronic conditions and cognitive impairments also are covered under Medicare Part B.

Under this section, beneficiaries are eligible to receive annual preventive services as well as an initial preventive physical examination (IPPE) within the first year of enrollment, both of which incur no out-of-pocket cost to the beneficiary. Patients may seek prevention services once per year thereafter so long as they have not received an IPPE or any personalized preventive services within the preceding 12 months.

Section 4103 supports the integration of health information technology with the care and services provided for patients. It greatly encourages the use of electronic medical records and personalized patient technology to promote and develop self-management.

A report issued by the US Department of Health and Human Services (HHS) in 2011 suggests that an estimated 32.5 million Medicare beneficiaries received at least one preventive service with no cost sharing between insurance and patient. Millions of Medicare-eligible Americans already have begun making efforts to transition to preventive healthcare measures. In the long run, not only will these measures create a healthier aging and geriatric population, but it is anticipated that they also will greatly reduce the national expenditures in the healthcare system. The cost of care and seriousness of illness both can be proportionately reduced if preventive measures are used as the primary method of care.

Section 4104 of the PPACA provides for the removal of cost sharing with regard to the preventive services found in section 4103. Section 4104, which became effective on January 1, 2011, amends section 1861 of the Social Security Act and redefines the preventive services Medicare covers. These services include various cancer screenings, the beneficiary’s IPPE, and all services outlined in section 4103.

Further amending section 1867(aa)(3)(A) of the Social Security Act, section 4104 requires that federally qualified health centers receive reimbursement from Medicare for providing covered personal preventive services and IPPEs. Section 4104 also amends section 1833 of the Social Security Act and waives the requirement of beneficiaries to provide coinsurance for most preventive services, the IPPE, and services recommended by the USPSTF and that have been given a grade of A or B as described by the USPSTF’s Grade Definitions After May 2007. This waiver is applicable to personal preventive services and IPPEs so long as such services were not sought in the preceding 12-month period.

It includes a one-time review of a patient’s health as well as education and counseling for preventive measures ranging from smoking cessation counseling to self-management support. Older adults also can receive screenings for conditions such as certain types of cancers, diabetes, depression, sexually transmitted diseases, HIV, and osteoporosis (bone scans) as well as age-appropriate vaccinations without a copay or a deductible fee.

These new benefits help older adults maintain their quality of life while saving Medicare money in the long run.

Safeguarding the Medicare Trust Fund
Before the PPACA was signed into law, Medicare’s future appeared questionable. Experts expressed concerns that the Medicare Trust Fund, a major source of financial backing for Medicare, would dry up. But in August 2010, the Medicare Board of Trustees announced that the fund’s outlook had substantially improved due to new regulations in the healthcare reform legislation.

Because of the legislation’s commitment to reduce waste, abuse, and billing errors within the system, the trustees reported that the fund is projected to remain solvent until 2029, representing a 12-year extension beyond previous estimates.

Commitment to Fight Medicare Fraud
Establishing accountability for the quality of care provided and financial responsibility with regard to the personal preventive services covered under Medicare, section 4105 reserves the right for HHS to modify covered preventive services so long as the modification is consistent with USPSTF recommendations and ratings. Effective January 1, 2010, any service receiving a grade of D or lower from the USPSTF grants HHS the authority to withhold payment for currently covered services.

This additional authority does not apply to diagnostic or treatment services. The creation of such a system of checks and balances creates a health structure of accountability and financial incentives to provide quality care to geriatric patients and the aging population. The PPACA contains a $350 million investment to fight fraud as well as provisions that will attack those who defraud the system.

Eventually, every medical practice will need to record and report all the preventive services it provides.

Medicare Benefits Will Stay the Same
The benefits provided by Medicare will stay the same under the PPACA. The new law cuts down on additional payments from the government to people on Medicare Advantage, which serves only as an extra benefit for insurance companies, saving money for all Medicare participants. Regardless of the cuts, those enrolled in Medicare Advantage will receive the same benefits they currently do.

Linking Payment to Quality Outcome
A value-based purchasing program for hospitals will be initiated in 2013 that will link Medicare payments to quality performance on common and high-cost conditions such as cardiac, surgical, and pneumonia care.

The Physician Quality Reporting System will be extended through 2014, with incentives for physicians to report Medicare quality data. Physicians will receive feedback reports beginning in 2012. Providers may choose to report information to the CMS on individual quality measures regarding their Medicare Part B claims, to a qualified reporting registry, to the CMS via a qualified electronic health record, or to a qualified reporting data submission vendor. Long term care hospitals, inpatient rehabilitation facilities, and hospice providers will participate in value-based purchasing with quality measure reporting starting in 2014, with penalties for nonparticipating providers.

Elder Justice Act
The Elder Justice Act will help prevent and eliminate elder abuse, neglect, and exploitation. The HHS secretary will award grants and carry out activities to protect individuals seeking care in facilities that provide long-term services and will support and provide greater incentives for individuals to train and seek employment at such facilities. Owners, operators, and employees will be required to report suspected crimes committed at a facility.

Additionally, Medicare will reduce the Part B deductible by $22 this year. Dependent coverage age has been extended to 26, allowing individuals to be insured under their parents’ Medicare if they’re not covered by other insurance.

Medicare is projecting a 4% drop in premiums for Medicare Part C or Medicare Advantage, which will ensure that all Americans have access to quality affordable healthcare and will create the transformation within the healthcare system necessary to contain costs.

These regulations not only acknowledge that all patients have the right to be healthy as they enter the aging population but also provide the resources and means to make such a healthy lifestyle a reality.

— Sunil Goyal, MBBS, is a clinical observer at The Wright Center for Graduate Medical Education in Scranton, Pennsylvania.

— Melad Kamel, MD, is an internal medicine resident at The Wright Center.

— James A. Ranslow is a health administration student at the University of Scranton and an intern at The Wright Center.

— Linda Thomas-Hemak, MD, is board certified in internal medicine and pediatrics and is program director for internal medicine at The Wright Center.