AAGP Legislative and Regulatory Agenda 2009-2010

Download the AAGP Legislative and Regulatory Agenda 2009-2010 as a PDF

Table of Contents

Priorities for AAGP: 2009–2010
Health Care Reform
Services
Research
Education and Training/Workforce Issues
IOM Study on Geriatric Mental Health Workforce
Reimbursement

The American Association for Geriatric Psychiatry (AAGP) is a professional membership organization dedicated to promoting the mental health and well-being of older people and improving the care of those with late-life mental disorders. AAGP’s membership consists of approximately 2,000 geriatric psychiatrists, as well as members of other health professions who focus on the mental health problems faced by senior citizens.

Legislative and Regulatory Agenda

The AAGP Board of Directors has adopted a Legislative and Regulatory Agenda to articulate the public policy goals of the organization throughout the 111th Congress (2009–2010). AAGP’s legislative and regulatory goals are comprehensive and encompass access, quality, research, and education. AAGP is committed to ensuring quality mental health services for all, especially the elderly. President Obama’s call for extensive reform of the health care system and renewed efforts in Congress to address it should make possible a new emphasis on integrating mental health care into all aspects of the system. It is also clear that, as the Baby Boom Generation moves into the Medicare system, the nation must ensure that the trend of declining numbers of health care practitioners equipped to serve older adults is reversed and efforts undertaken to increase the numbers substantially. Additional funding for research on mental illness in older adults is essential for meeting the needs of the nation’s aging population, and AAGP believes that this priority must be addressed as the President’s commitment to renewed investment in medical research is implemented.

Priorities for AAGP: 2009–2010

HEALTH CARE REFORM

Health System Reform

• Integration of Care

Mental health must be integrated into overall healthcare in both private and public sectors. For frail older adults, the prevalence of numerous chronic conditions generally requires careful coordination of care in order to assure that their complex health care needs are appropriately met, requirements that are even more important when mental illness is among the conditions. Prevention, treatment, and recovery from many health care conditions require prevention and treatment of mental health disorders, which are proven to exacerbate and complicate many of the most serious physical ailments. One of the most telling and shocking statistics in health care is that Americans with mental health/substance use disorders die, on average, 25 years earlier than other Americans—chiefly because they do not receive appropriate, adequate care for overall health. They have the same physical diseases as others, but their mental disorders complicate physical disorders, which in turn are untreated or undertreated because of the mental illness. The causes of premature morbidity include insufficient clinician training in psychiatry; the stigma surrounding mental disorders which remains pervasive throughout our society, including the health care profession; and the difficulty in maintaining treatment protocols due to the nature of some mental illnesses. These issues are present throughout the lifespan.

• Medical Homes and Other Chronic Care Systems

Systems of care targeted towards persons with chronic illness can be especially helpful. However, such systems must include a full range of health care providers and services that are fully integrated into the system. Separating mental health and substance use treatment into an adjunct system, typically underfunded and more difficult for beneficiaries to access, not only leads to poorer outcomes for exceptionally frail patients but also contributes to the continuing and debilitating mental illness stigma.

Model medical homes or other systems based on chronic illness for the frail elderly should be developed under the direction and coordination of geriatric specialists, including geriatric psychiatrists. Appropriate care of these most vulnerable patients requires knowledge and skills that are intrinsic to geriatric medicine and geriatric psychiatry.

AAGP supports design and promotion of systems of care that encourage and provide reimbursement for staff training by geriatric specialists in residential and other health care delivery sites, such as nursing homes, assisted living, home care, and community health centers.

• Health Information Technology

Carefully structured, Health Information Technology (HIT) development has the potential to raise the overall quality of care provided to patients, inform health professionals of the latest standards of care, and improve efficiency in electronic communication of important health care information. But the potential of health information technology can only be realized if health information privacy, security, and non-discrimination are keystones to such development. Assurance of confidentiality is at the foundation of an effective relationship between doctor and patient, and AAGP urges that privacy and security of individually identifiable health information--particularly with regard to mental health, substance abuse, and other sensitive patient information--be a critical core element on any national HIT system.

Health Coverage for the Uninsured

An estimated 45.7 million Americans, or 15.3 percent of the population, lack health insurance, and the weakening economy—with jobs losses and struggling businesses dropping health insurance for their employees—is expected to cause the situation to worsen. One in four uninsured adult Americans has a mental disorder, substance use disorder, or both. The evidence is clear that lack of insurance has a measurable effect on a person’s health—from preventive measures not taken to undertreated chronic diseases. The evidence is also clear that untreated mental illness adversely affects outcomes for other diseases, including major illnesses like heart disease and diabetes. All Americans should have insurance coverage that provides access to quality health care services they can afford.

SERVICES

Improvement of Accessibility and Quality of Services

Numerous studies in recent years have underscored both the prevalence of mental disorders in older persons and also the evidence that research efforts have yielded effective treatments. Scientifically tested treatments have been proven effective in relieving symptoms, improving function, and enhancing quality of life. However, there is a substantial gap between the emergence of effective treatments and subsequent implementation by health care providers. This gap can be as long as 15 years, an unacceptably long delay in getting up-to-date care to elderly consumers. There is a continuing need for translational and health services research to identify the most cost-efficient interventions. As effective methods for mental health care delivery are found, sustained efforts to assist and encourage institutions and clinicians to change their practices will be required.

• Support Funding for Mental Health and Aging Services at SAMHSA

It is critical that there be adequate funding increases for the mental health initiatives under the jurisdiction of the Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA provides funding to State and local mental health departments, which in turn provide community-based mental health services to Americans of all ages, without regard to the ability to pay. AAGP is pleased that the final budgets since Fiscal Year (FY) 2002 have included approximately $5 million for evidence-based mental health outreach and treatment to the elderly. AAGP urges the Administration and Congress to continue and increase funding for this mental health outreach and treatment program, as it is the only Federally funded services program dedicated specifically to the mental health care of older adults.

Funding for the dissemination and implementation of evidence-based practices in “real world” care settings must be a top priority for Congress. Despite significant advances in research on the causes and treatment of mental disorders in older persons, there is a major gap between these research advances and clinical practice in usual care settings. One of the greatest challenges for the future of mental health care for older Americans is to bridge this gap between scientific knowledge and clinical practice in the community, and to translate research into patient care.

Adequate funding for this geriatric mental health services initiative is essential to disseminate and implement evidence-based practices in routine clinical settings across the states. Consequently, AAGP urges that funding for mental health outreach and treatment for the elderly be increased from $4.8 million to $20 million for FY 2010.

Of that $20 million appropriation, AAGP believes that $10 million should be allocated to a National Evidence-Based Practices Program, which will disseminate and implement evidence-based mental health practices for older persons in usual care settings in the community. This program will be a collaborative effort, actively involving family members, consumers, mental health practitioners, experts, professional organizations, academics, and mental health administrators. With $10 million dedicated to a program to disseminate and implement evidence-based practice in geriatric mental health, there will be an assured focus on facilitating accurate, broad-based sustainable implementation of proven effective treatments, with an emphasis on practice change and consumer outcomes. Such a program should include several development phases including identification of a core set of evidence-based practices, development of evidence-based implementation, and practice improvement toolkits and field-testing of evidence-based implementation. This program will provide the foundation for a longer-term national effort that will have a direct effect on the well-being and mental health of older Americans.

• Positive Aging Act

AAGP supports the “Positive Aging Act,” a bill originally introduced in the 107th Congress and reintroduced with bipartisan support in an expanded version in the 108th and 109th Congresses. This legislation would improve the accessibility and quality of mental health services for the elderly. The bill would provide mental health screenings, appropriate referrals for follow-up care and consultations, and the use of available evidence-based protocols for common mental disorders. In addition, grants for community-based mental health treatment outreach teams would be available to provide services in primary health care facilities where older adults receive medical treatments, as well as adult day care centers, senior centers, assisted living facilities and other settings where older adults reside or receive social services.

In 2006, as part of the reauthorization of the Older Americans Act, Congress included provisions of the Positive Aging Act under which the Administration on Aging will make grants to states for the development and testing of model mental health delivery systems utilizing evidence-based protocols for the identification and treatment of mental disorders in older adults. It also provides for development of multi-disciplinary systems for the delivery of mental health screening and treatment referral services for older adults and allows the Administrator to designate an officer to administer mental health services.

AAGP supports efforts to complete action on the Positive Aging Act by enacting the provisions for grants to be made through by the Substance Abuse and Mental Health Administration (SAMHSA). This action would create an important platform for SAMHSA to address the mental health needs of older adults.

RESEARCH

Federally Funded Scientific Research

Between 2005 and 2030, the number of Americans age 65 and older will almost double in the United States, increasing from nearly 37 million to more than 70 million. Over that time period, those aged 65 and older will increase from 12 percent to 20 percent of the total population. With the graying of the population, mental disorders of aging represent a growing crisis that will require a greater investment in research to develop understanding of age-related brain disorders and to develop new approaches to prevention and treatment.

In 2003, the National Institute of Mental Health’s National Advisory Mental Health Council issued a report, Mental Health for a Lifetime: Research for the Mental Health Needs of Older Americans, which noted that almost 20 percent of adults age 55 and older experience specific mental disorders that are not part of “normal” aging. The Council’s report attested to the importance of a strong research effort to address the needs of those with late-life mental disorders and to gain the benefit of unique opportunities that studies of the aging brain present for scientific research on the developmental aspects of mental illness and mental health.

Investment in research is an investment in the future of this country. The fiscal year 2003 marked the successful conclusion of the five-year, bipartisan effort in Congress to double the budget of the National Institutes of Health (NIH). As commendable as that initiative was, the rescission and/or flat funding of NIH since that time are having a devastating impact on the ability of the National Institute of Mental Health (NIMH), the National Institute on Aging (NIA), and NIH as a whole, to sustain the ongoing, multi-year research grants that are necessary to advance research progress to promote and improve the health of the nation.

In addition into investing into broad-based scientific inquiry, there are several specific areas that are critical to improving the mental health of the aging population.

• Support annual increases of funds for geriatric mental health research at NIH to (1) Identify the causes of age-related brain and mental disorders to prevent mental disorders before they devastate lives; (2) Speed the search for effective treatments and efficient methods of treatment delivery; (3) Improve the quality of life for older adults with mental disorders.

AAGP is concerned that Federal funding for research on mental health and aging, as a percentage of the overall NIH budget, has decreased in recent years at the NIMH. This trend must be immediately reversed to ensure that our next generation of elders is able to access effective treatment for mental illness. Federal funding of research must be broad based and should include basic, translational, clinical, and health services research on mental disorders in late life.

• Scientifically tested treatments have been proven effective in relieving symptoms, improving function, and enhancing quality of life. These interventions reduce the need for costly hospitalizations and delay the need for long-term care without simply shifting the burden to the family.
• Special emphasis is required to promote research on serious but neglected late-life mental disorders. Late-life psychosis, behavioral disorders of Alzheimer's disease and other dementias, anxiety disorders, disturbances of sleep, alcohol dependence and personality disorders have received little or no attention from the research community and the funding agencies, despite the fact that these conditions take a major toll on older patients and their families.
• The prevention of mental illness among persons of all ages, including the elderly, is a major public health priority. Research in genetics and brain development across the lifespan may be key to understanding mental illness--when and how it develops and, most importantly, how it may be prevented or more effectively treated in the future.
• Improving the treatment of late-life mental health problems will benefit not only the elderly, but also their children, whose lives are often profoundly affected. Caregiving itself is an enormous drain on the financial security and health of family members, many of whom become depressed or experience exacerbations of their own medical problems and disabilities.

In addition to supporting research activities at NIMH, funding increases for research related to geriatric mental health at the other institutes of NIH that address issues relevant to mental health and aging, including the National Institute of Aging, the National Institute on Alcohol
Abuse and Alcoholism, the National Institute on Drug Abuse, and the National Institute of Neurological Disorders and Stroke are critical.

• Support increased funding for VA research

Although the Department of Veterans Affairs has made genuine progress in psychiatric research in recent years, the level of research funding remains disproportionately low to the utilization of mental health services by veterans. Despite the fact that veterans with mental illness account for approximately one-third of all veterans receiving treatment within the VA system, VA resources devoted to psychiatric and behavioral health research have lagged far behind those dedicated to research on other medical conditions. In fact, support for psychiatric research dedicated to chronic mental illness, substance abuse, and post-traumatic stress disorder (PTSD) has remained relatively flat for the last 15 years, despite the growing numbers of patients in the VA system receiving treatment for mental illness. As the elderly veteran population expands, and the number with mental illness grows, strengthening the research base in geriatric psychiatry becomes increasingly urgent. VA-sponsored research into mental disorders of aging benefits all Americans, not just our veterans.

One area of research that must be addressed is the potential re-emergence of symptoms of PTSD in World War II, Korean War, and Vietnam War veterans. The VA should undertake studies of this phenomenon, as clinicians are reporting these symptoms in VA hospitals and clinics among their elderly patients. Such re-emergence could become a significant problem, especially when the structure of life of these veterans is disrupted by events such as retirement, excessive unstructured time, and death of the spouse and other family members, which may lead to a decline in the social support network. These factors then lead to emergence of physical and mental health issues, which can exacerbate the re-emergence of PTSD symptoms. This area needs to be studied both from a clinical and from an epidemiological viewpoint, and it has obvious implications for the current generation of returning veterans as well. AAGP proposes that funds be allocated for studies to survey veterans in a clinical epidemiology study.

A vitally important VA program for coordinating mental health research with education and clinical care are the Mental Illness Research, Education, and Clinical Centers (MIRECCs). Since 1996, Congress has authorized the VA to establish eight of these centers dedicated to mental illness research, education and clinical activities. AAGP believes the MIRECCs have successfully demonstrated that coordinated research and education projects can achieve rapid translation of new scientific knowledge into improved models for clinical services for veterans with mental illness. These programs should be continued. MIRECCs focus on problems highly relevant to veterans with schizophrenia, PTSD, and other serious mental illnesses, including those whose treatment is complicated by homelessness, substance abuse, or alcoholism. AAGP wishes to emphasize the value of those MIRECCs that focus on issues related to aging, including dementia, and psychiatric disorders in older veterans with concurrent medical illness and/or substance use disorders.

MIRECCs have encouraged research, increased our fundamental understanding of mental illnesses, and given VA healthcare professionals more and better tools to treat patients with mental disorders. Much more can be done in this area if the program is expanded. The MIRECCs are a tremendous resource for improving the quality of mental health services and improving the outcomes of veterans living with mental illnesses.

In addition, AAGP strongly supports the work of Geriatric Research, Education and Clinical Centers (GRECCs). The GRECCs are centers of geriatric excellence designed for the advancement and integration of research, education, and clinical achievements in geriatrics and gerontology. Mental health has played a central role in the entire GRECC program since its inception in the mid-1970s. GRECCs focus on various aspects in the quality of life and care for the aging veteran and are at the forefront of leading edge research and education. Research results have influenced therapies for diseases affecting older veterans and have also been exported outside the veteran community, and AAGP urges continuation and strengthening of these most important research centers.

• Support and encourage participation of seniors in clinical trials

Federal approval for most new drugs is based on research demonstrating safety and efficacy in young and middle-aged adults. These studies typically exclude people who are old, who have more than one health problem, or who take multiple medications. As the population ages, that is the very profile of many people who seek treatment. Thus, there is little available scientific information on the safety of drugs approved by the Food and Drug Administration (FDA) in substantial numbers of older adults who are likely to take those drugs. Just as the FDA has begun to require inclusion of children in appropriate studies, the agency should work closely with the geriatric research community, health care consumers, pharmaceutical manufacturers, and other stakeholders to develop innovative, fair mechanisms to require the inclusion of older adults in clinical trials. Clinical research must also include elders from diverse ethnic and cultural groups.

With prescription drug coverage now available to Medicare beneficiaries, it is important to ensure that beneficiaries are receiving drug treatments that are efficacious, sufficiently safe, and tolerable. Given the advanced age of most Medicare beneficiaries, comorbidity from concurrent medical conditions and use of multiple concomitant medications are common, making these patients more vulnerable to disease-drug and drug-drug interactions. Unfortunately, the scientific knowledge base regarding safe and effective drug treatment of older adults is inadequate to guide geriatric practice. Furthermore, the lack of data on geriatric treatment response, safety, and tolerability makes it difficult to determine what treatments are most appropriate and cost-efficient for treatment of elderly patients, the largest group of Medicare beneficiaries. Therefore, AAGP urges that Federal funds be made available each year for support of clinical trials involving older adults. These trials are necessary to determine what constitutes appropriate, cost-efficient treatment; and this scientific knowledge is required both to inform clinical practice, and to guide the development of sensible regulations and responsible policies for administering any prescription drug benefit for seniors.

“The Retooling the Health Care Workforce for an Aging America Act,” S. 245, would require the Government Accountability Office (GAO) to conduct a study to examine NIH spending on conditions and illnesses that disproportionately affect the health of older adults. The study would examine the number of older adults included in clinical trials supported by NIH institutes. This study would be an important step in addressing this critical issue, and AAGP strongly supports it.

In addition, as little emphasis has been placed on the development of new treatments for geriatric mental disorders, AAGP would encourage the NIH to promote the development of new medications specifically targeted at brain-based mental disorders of the elderly.

• Development of new investigators

Investments in the development of new investigators who initiated peer-reviewed research ensure that federal taxpayers’ dollars support the growth and progress of basic and clinical neuroscience. Without the entry of new investigators, the progress of our scientific enterprise is threatened. Federal support of programs that provide incentives for young scientists to pursue careers has significantly eroded in the past decade. Funding for K awards and R01 grants has declined to the point where medical and graduate students are actively discouraged from pursuing academic research careers. To recruit and maintain a highly talented scientific investigator workforce, the Federal government must take the lead in providing incentives and support.

• Clarify ethical and legal standards for proxy consent for participation in research

The ethics of research involving adults with impaired decision-making capacity will continue to grow in importance as more research is conducted to address the problems of people suffering from cognitive disorders, especially elderly patients with dementia. Despite a wave of initiatives in the late 1990s to clarify policy, surrogate consent for research continues to be a murky legal area, and there are many unclear aspects of regulatory protection for incapacitated subjects. The lack of clarity in existing standards threatens to compromise not only patient protections but also the viability of scientific research so desperately needed to benefit future generations of geriatric patients. AAGP urges continued efforts by the scientific community, patients and their advocates, and policymakers at all levels to develop a widely acceptable model of proxy consent, and to define clearer standards for research participation of adults with impaired decision-making capacity. This is necessary to ensure the protection of human subjects while avoiding unnecessary barriers to research participation.

EDUCATION AND TRAINING/WORKFORCE ISSUES

In April 2008, the Institute of Medicine issued a report entitled, Retooling for an Aging America: Building the Health Care Workforce, which concludes that, without changes at the national level, older Americans will lack access to affordable, quality health care--including mental health care. The small numbers of specialists in geriatric mental health care, including geriatric psychiatry, combined with increases in life expectancy and the growing population of those age 65 and over, estimated to be 20 percent of the U.S. population in 2030 (up from 12 percent in 2006), foretells a crisis in health care that has already begun to impact older adults and their families nationwide. Unless changes are made now, older Americans will face long waits, decreased choice, and suboptimal care. Consequently, AAGP urges Congress, the regulatory agencies, and leaders in health care policy to act upon the IOM’s report to make the necessary changes to recruit and retain a skilled workforce in geriatrics and geriatric mental health care and to adopt an efficient and effective organization of geriatric medical and mental health care services.

AAGP has long been concerned about the workforce in the area of late-life mental health care, particularly the declining numbers of doctors entering the field of geriatric psychiatry--those pursuing a research career, becoming clinician-educators, or entering clinical practice. The diminishing workforce in these areas will inevitably lead to inadequate access to quality mental health care for the aging Baby Boomers. There is a need for a critical mass of specialty-trained subspecialists to carry out research, to teach and train others in graduate medical education and institutional and community-based continuing education efforts, and to serve as clinical resources for consultation, community education, and tertiary care in communities. These needs require a robust pipeline of geriatric psychiatry fellows who will pursue various career paths in geriatric psychiatry and systematic efforts to assure that they are willing and able to continue their work in the field.

Specific issues that AAGP believes should be addressed include:

IOM Study on Geriatric Mental Health Workforce

AAGP believes that the broad scope of the 2008 IOM study, while meeting a crucial need for information on the many issues regarding the health workforce for older adults, precluded the in-depth consideration of the workforce needed for treating mental illness. The study just completed should be followed by a complementary study focused on the specific challenges in the geriatric mental health field. This study should follow up the general IOM study in two specific ways:

• It should examine the access and workforce barriers unique to geriatric mental health care services.
• In discussing possible alternative models of geriatric service delivery (medical homes, PACE programs, collaborative care models, etc.), it should articulate the importance of integrating geriatric mental health services as intrinsic components.

“The Retooling the Health Care Workforce for an Aging America Act,” S. 245, contains a provision mandating this additional study.

Title VII Geriatric Health Professions Education Programs

The Bureau of Health Professions in the HHS Health Resources and Services Administration (HRSA) administers programs aimed to help to assure adequate numbers of health care practitioners for the nation’s geriatric population, especially in underserved areas. AAGP supports increased funding for those programs under Titles VII and VIII of the Public Health Service Act.

Despite growing evidence of the need for more geriatric specialists to care for the nation’s elderly population, a critical shortage persists. In 2001, there were about 2,600 geriatric psychiatrists. In 2005, that number had been reduced to 2,100, less than half of the 5,000 that are needed to provide adequate care for the current population of older adults. The numbers are similar for geriatricians, with fewer than 7,000 certified, far short of the 20,000 needed to meet current needs.

The geriatric health professions program supports three important initiatives. The Geriatric Faculty Fellowship trains faculty in geriatric medicine, dentistry, and psychiatry. The Geriatric Academic Career Award program encourages newly trained geriatric specialists to move into academic medicine. The Geriatric Education Center (GEC) program provides grants to support collaborative arrangements that provide training in the diagnosis, treatment, and prevention of disease. The shortage of geriatric specialists will soon become a major public crisis if it is not addressed. This program must be continued and expanded.

New legislation, the Retooling the Health Care Workforce for an Aging America Act, would expand education and training opportunities in geriatrics and long-term care for licensed health professionals, direct care workers and family caregivers, including strengthening and expanding Title VII and Title VIII geriatrics programs. Specifically, it would:

• Expand funding for Geriatric Education Centers (GECs) to provide grants to offer short-term intensive courses (mini-fellowships) in geriatrics, chronic care management and long-term care to faculty members of medical schools and other health professions schools, including psychology, nursing, and social work. GECs receiving these grants would also be required to develop and offer training courses benefiting direct care workers and family caregivers. It would also require grantees to incorporate mental health and dementia “best practices” training into their courses where appropriate.
• Expand the reach of the Geriatric Academic Career Awards (GACA) program to include junior faculty in nursing, social work, clinical psychology, and other allied health disciplines approved by the Secretary.
• Authorize a new Geriatric Career Incentive Awards (GCIA) program to provide financial support for Masters level clinical social workers and psychologists who wish to pursue a doctorate or other advanced degree in geriatrics, long-term care or chronic care management.
• Provide full funding for the National Center for Workforce Analysis to analyze current and projected needs for health care professionals and paraprofessionals in the long-term care sector.
• Expand the Nursing Comprehensive Geriatric Education Program to support additional training in geriatrics for nurses and nursing faculty, including development of curricula relating to geriatric nursing care and traineeships for individuals pursuing advanced degrees in geriatric nursing.

AAGP strongly supports these new initiatives to strengthen and expand the current geriatrics programs within the Bureau of Health Professions.

Geriatricians Loan Forgiveness

The complex problems associated with aging require a supply of physicians with special training in geriatrics. Although geriatric psychiatry is a relatively small medical specialty, it is one for which demand is growing rapidly as the population ages and the Baby Boom Generation nears retirement. Currently, issues of aging, including geriatric mental health, are inadequately emphasized at the medical school, internship and residency levels. It is critical that action be taken now to alleviate the serious shortage of physicians and psychiatrists trained to meet the special needs of older people. Such legislation would provide important incentives for medical graduates to enter geriatric specialties.

AAGP strongly supports legislation to provide loan forgiveness for health care professionals who enter geriatric specialties. AAGP supports the “Caring for an Aging America Act,” first introduced in 2008 as S. 2708, which would create a new program for loan repayment for specialists across disciplines who enter geriatric specialties. AAGP also supports, the “Geriatricians Loan Forgiveness Act,” H. R. 2502 in the 110th Congress, which would allow fellows in geriatric medicine and geriatric psychiatry to include fellowship training as part of their obligated service under the National Health Service Corps Loan Repayment Program.

REIMBURSEMENT

Medicare Physician Fee Schedule

Unrealistic levels of physician reimbursement will severely affect Medicare patients’ access to mental health care, a problem that became clear early in 2003 when physicians who treat Medicare patients faced the prospect of a 4.4 percent across-the-board reduction in 2003 fees below 2002 levels, which were themselves reduced 5.4 percent below 2001 levels. These reductions stemmed from problems with a formula for calculating annual Medicare spending targets for physicians’ services that was enacted as a part of the Balanced Budget Act of 1997 (BBA). AAGP concerned that any further decline in availability of psychiatric services for older adults will have disastrous consequences for the many older adults with mental health problems, whose access to mental health care is already seriously limited.

Legislation annually enacted since 2003 has staved off further cuts under this formula. However, these changes are only a temporary reprieve. The prospect of additional fee cuts in future years due to a flawed formula suggests that the entire system should be reworked to provide a more realistic proxy for changes in the volume and intensity of services provided to Medicare beneficiaries. AAGP strongly supports efforts to enact a long-term correction of the Medicare physician payment formula.

Reimbursement for Geriatric Services

Congress and the Centers for Medicare and Medicaid Services (CMS) should act to address aspects of the Medicare payment system that both discourage entry into geriatric mental health specialties and discourage continuation of practice in this area, including the unacceptably low reimbursement rates for psychiatric services combined with inadequate reimbursement for geriatric specialists who generally treat the frailest of Medicare patients. AAGP urges consideration of bonus payments under Medicare to clinicians in geriatric specialties, a recommendation included in the 2008 IOM study on the geriatric workforce.

In addition, innovative funding mechanisms need to be examined that encourage not only the education and training of geriatric psychiatrists, but also geriatric mental health researchers, as both clinicians and researchers are needed to ensure the delivery of quality mental health services to the growing elderly population. AAGP encourages Congress to examine the limitations placed on fellowships and traineeships for medical professionals within the current graduate medical education funding mechanism, and consider models that would promote growth in these shortage areas.

Primary care providers often do not have adequate training in treating frail elderly patients, and both they and their patients benefit from consultations with geriatric specialists. Payment systems for Medicare, in particular, and also for other health systems must facilitate such consultations by ensuring that all professionals involved are appropriately compensated for services that allow for more integrated, community-based models of care, such as providing adequate reimbursement for home visits, family education, and liaison with the medical team.

Psychiatric/Mental Health Services

Claims for psychiatric services are often denied for a beneficiary when a primary or secondary diagnosis of Alzheimer’s disease has been determined. In addition to cognitive deficits for which specific treatment is now available, individuals with Alzheimer’s disease often suffer from psychiatric symptoms such as depression and psychosis and behavioral disturbance, which should be treated by mental health professionals and are covered by Medicare. Congress should prohibit arbitrary denial of covered Medicare benefits based on a diagnosis of Alzheimer’s disease and authorize payments based on commonly accepted clinical practice guidelines for dementia care. In 2001, the Centers for Medicare and Medicaid Services (CMS) issued directive to Medicare carriers prohibiting the use of editing devices that result in the automatic denial of services based solely on the ICD-9 codes for dementia. However, while welcome, this directive does not itself prohibit denials of care on the basis of an Alzheimer’s disease diagnosis.

In 2006, the Office of Inspector General (OIG) found that Medicare carriers across the nation inconsistently apply the limitations on outpatient mental health treatment to such a degree that beneficiary copayments can be more than double for the same mental health services based on the beneficiary’s geographic location. The OIG has called upon CMS to issue new guidance to the carriers to ensure consistent application of the copayment and to require carriers to adjust copayments for the beneficiaries who were overcharged. CMS must act promptly to correct this discrepancy.

In addition, physicians are not reimbursed for the time it takes for a full assessment and diagnosis of Alzheimer’s disease or other dementia conditions and for services provided outside the context of a “face-to-face” encounter between the physician and the patient. Examples include family consultation, caregiver education, and ongoing disease management. In recent years, Medicare has begun to move slowly toward reimbursement for some case management functions with other types of patients. Congress should consider authorizing, at least on a demonstration basis, some form of recognition and reimbursement for the psychiatric and behavioral management services needed by Alzheimer's disease patients and their families.

Medicare Regulatory Fairness

The majority of psychiatrists in private practice are in solo practice or in a small group practice. With Medicare CPT billing codes for most psychiatric services clearly defined by the amount of time spent with patients, time spent working through Medicare’s mountain of paperwork is literally time that is taken away from vital patient care.

Psychiatrists are also subjected to widespread and contradictory variations in Medicare carrier coverage rules, increasing demands for documentation of claims, and presumptions by Medicare that innocent billing errors are evidence of intent to defraud the system. In addition to general billing problems, psychiatrists face growing problems specific to psychiatric practice, including:

• Routine denials of any psychotherapy services for patients diagnosed with Alzheimer’s disease even in the early stages of the disease, when the patient’s cognitive impairment is minimal or mild; and even when the psychotherapy modality is appropriate for moderate to severe dementia, as in the provision of behavior therapy, rather than insight-oriented therapies;
• Denials of the right of psychiatrists to bill for evaluation and management services as physicians, a practice by many carriers that must be ended by Medicare through aggressive nationwide action;
• Widespread variation in carrier coverage of psychiatric pharmacologic management; and
• Targeted intensive carrier reviews of claims for outpatient psychotherapy (e.g., above a de minimus threshold number of visits) despite the fact that Medicare does not impose any visit limit on such treatment.

Please email questions and comments to kmcduffie@aagponline.org.