1. National Commission for Quality Long Term Care Testimony of George Taler, MD Director, Long Term Care Washington Hospital Center Washington, DC Past President, American Academy of Home Care Physicians

2. Summary Primary Care & Geriatric Medicine A different approach to the health care challenges of an aging population Restructuring health care delivery and health care financing

3. Woo B. N Engl J Med 2006;355:864-866 Median Compensation for Selected Medical Specialties Bodenheimer T. N Engl J Med 2006;355:861-864

4. Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates

5. Bodenheimer T. N Engl J Med 2006;355:861-864 Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists

6. National Medical Association Gallup Poll of Membership, 2003

7. Maryland Academy of Family Physicians 2005 Practice and Income Survey 663 Active Members (private practice: 66%) Median annual income: $103,400 –37% no change since 2001 –41% decrease since 2001 In response: –16% have increased hours or # of patients/wk –44% have decreased hours in clinical practice –35% plan to retire, relocate or change careers

8. Geriatricians Have Greatest Career Satisfaction

9. Changes in Medicare Payments to Physicians 1999-2012

10. Concentration of Total Annual Medicare Expenditures Among Beneficiaries, 2001 Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services. Percent

11. High-Cost Medicare Beneficiary Spending Medicare Spending % of Total Mean Top Quartile 85%$24,800 Second Quartile 11%$3,290 Bottom Half 4%$550 Total100%$7,310 Medicare Spending % of Total Mean Top 5 %43.1%$63,030 Top 6-10 %18.4%$26,900 Top 11-25%23.5%$11,430 Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services. Note: Spending reported in 2005 dollars

12. Yes, but… Just because you have a bad year, does your bad luck persist and for how long?

13. Expenditure History of the Top 25% of Medicare Beneficiaries, 1997 Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

14. Distribution of High-Cost Months, 1997-2001 Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

15. Concentration of Total Cumulative Medicare Expenditures Among Beneficiaries, 1997-2001

16. Targeting the High-Cost User Diagnostic characteristics Functional characteristics Resource utilization history

17. Prevalence of Chronic Conditions Beneficiary Group (Spending pattern) AllLow Cost High Cost (Non-persistent) (Persistent) Coronary Artery Disease28.2%19.1%50.0%53.7% COPD19.6%13.9%28.9%37.5% Congestive Heart Failure18.5%10.1%33.0%44.3% Diabetes16.7%12.6%23.5%29.5% Cognitive Impariment8.8%5.7%13.9%18.7% Asthma3.9%2.9%4.5%7.3% ESRD2.3%0.7%4.2%7.9% Mean number of conditions1.00.71.62.0 Notes: COPD=Chronic Obstructive Pulmonary Disease, ESRD=End Stage Renal Disease. Data from a 5 percent random sample of fee-for-service (FFS) beneficiaries between 1989 and 1997. Source: CBO preliminary analysis.

18. Number of Chronic Conditions Predicts High-Cost Status Notes: The 7 conditions considered were: CHF, CAD, COPD, ESRD, Asthma, Diabetes, and Cognitive impairment. Source: CBO preliminary analysis. Beneficiary Group (Spending pattern) Low CostHigh Cost (Non-persistent) (Persistent) 0 of the 7 conditions89.5%4.4%6.1% 1 condition71.5%11.1%17.3% 2 conditions53.3%15.0%31.7% 3 conditions34.5%16.1%49.4% 4 conditions20.2%13.8%66.0% 5 conditions10.8%9.9%79.3% 6 conditions5.4%6.0%88.7% 7 conditions0.0% 100.0%

19. Spending for People with Chronic Illnesses and Activity Limitations Sources: Partnership For Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” December 2002; MEPS, 1998.

20. Service Organization Structure & Process Criteria Make the HOME the center of health care delivery and social supports Re-establish the Doctor-Patient relationship Continuity of care across all settings and over the natural history of illness Coordinate Medical, Social and Housing services Match patient goals and processes of care

21. Life Care Coordination Fees Layered fee for non-covered services –Comprehensive Geriatric Assessment –Team meetings –Care coordination –Enhanced urgent care services –On-call services –Gap-filling fund Renewable contingent on performance –Adherence to evidence-based guideline targets –Patient and caregiver satisfaction targets –Reduced costs

22. “Whose Ox Gets Gored?” Sponsoring Hospitals –Cover “margin” expectations –Rate incentives for supporting innovation SNF/ICF –Escalated payments for greater complexity –Decreased payments for custodial care –Incentives for community-based referrals

23. The “Ask”: How You Can Help Advocacy for a focused, population-based health care delivery system transformation Development of population target criteria Development of new financing mechanisms Special interdisciplinary training programs Development of a public-private partnership towards common goals and incentives

24. “You can judge a civilization by the care it takes of its old and sick people. I want America to pass this test well.” Rep Claude D. Pepper