For Dr. Cheryl E. Woodson, geriatric medicine is a passion that doesn’t pay the bills.
“I love this. I just love this,” she said one recent afternoon in her office in Chicago Heights, Ill. Dr. Woodson had just diagnosed early-stage dementia in a 73-year-old patient, recommending a hip replacement while the woman is still cognitively capable of rehabilitation, and then had consoled the woman’s weeping daughter.
But Dr. Woodson can no longer afford to run her solo practice as she once did. She has stopped taking new patients over the age of 65, when Medicare kicks in, since reimbursement for their care is now “40 cents on the dollar,” she said, not enough to staff her office and pay the rent.
“If I take new Medicare patients, I can’t keep the door open,” Dr. Woodson said. With Medicare paying less now then it did in 2001, she added, “you can serve seniors or feed your children.” Not both.
Dr. Woodson’s dilemma is shared by many internists and family practitioners, endangered specialists in a health care system that pays for procedures and tests but not for the time-consuming management of chronic conditions. “We get paid to do things to people, not for people,” Dr. Woodson is fond of saying.
This is especially true for the elderly, who are generally not good candidates for we-can-fix-it medicine. Instead, as they lose mobility, cognition and thus independence, they require lengthy office visits, close monitoring and supportive services. These days, it is difficult to find a new doctor for anyone over the age of 65, because they are so expensive to treat.
Dr. Woodson’s solution to the cash crunch is to keep her existing elderly patients and to turn away new ones. At the same time, however, she has begun providing geriatric consultations, much like a cardiologist or orthopedist might. Each Wednesday afternoon, she does three such consultations, each at least an hour long, which produce what she calls a “level-of-care prescription” that the primary-care physician and family can implement on their own.
The goal of the assessment is to determine what’s wrong with the elderly patient, whether it can be fixed and how to manage things if it can’t be, which is often the case. Each appraisal details the patient’s overall health status and involves a review of current medications, level of independence, mobility, behavior and memory.
From that assessment comes a recommendation of what services are needed, who can deliver them and where that is best accomplished: at home, in a retirement facility or in a nursing home. That determination is not based soley on a patient’s condition, but also on how much hands-on care family members are willing and able to provide and how much hired help they can afford. Often the evaluation is followed by a family meeting, with Dr. Woodson as referee.
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http://newoldage.blogs.nytimes.com/2008/10/16/when-medicare-falls-short/
