Why do we need UGS?

I want to thank you all for joining us today. I appreciate your interest in improving the care of our elderly patients and the promotion of Geriatrics.

First of all I want to thank our outgoing president Mimi Beattie and her unselfish efforts in making possible our productive last two years.

As incoming President, it is my responsibility to lay out our Society’s goal and direction. Last year, I remember during my speech that I mentioned that we are now in a crossroads. On one hand, we are finally aware of the financial unsustainability of our so-called entitlement programs, Medicare, Medicaid and Social Security. On the other hand, we are witnessing an explosion of that portion of our population we call the elderly. Herein lies our challenge. As Geriatricians, we can either sit by or watch Medicare fail and with it, the only working health care system for our elderly since Lyndon Johnson passed the Medicare Act in 1965. Or, as healthcare providers in the frontline where we can see for ourselves during the course of our day to day encounters with our patients the unique problems in their care. We can come up with solutions to the present crisis.

Now, you may ask what influence can we have in shaping our present health care system? But then I ask you, do you feel that you are content with what is being done at present to right the dilemma than Medicare has found itself in. Are you aware of the things that are being done right now to save our Health Care System?

I attended the AGS meeting in Orlando last May after last having attended it 15 years ago. I found it to be more relevant. In addition to Geriatric Medical updates a lot of time was spent on things like business systems, Marketing of Geriatrics, Innovative Practice Models and National Policy Changes that affect the care of our patients.

The preconference Association of Directors of Geriatric Academic Programs leadership meeting was about payment transformation and opportunities for innovative geriatric programs with focus on bundled payments, accountable care organizations and capitated programs for dual eligibles. They discussed the trend towards risk shifts from government to providers, from fee for service to fee for value.

On the session entitled the ABC’s of ACO’s , the presenters gave a description of three Pioneer ACO programs in Montefiore in the Bronx, The University of Michigan and Physician health Partners in Denver.

114 ACO’s generated savings to the Medicare Trust Fund of 128 million dollars
There were 60 ACO’s not generating savings
29 generated savings of 129 million dollars
25 ACO’s had less spending than the target benchmark but without shared savings.

Spending targets are determined by CMS. If actual spending is lower than target savings, the savings are shared if quality targets are also achieved.

There are 33 quality measures across 4 equally weighted domains including
patient caregiver experience
care coordination and patient safety
preventive health
At risk populations

ACO’s must achieve at least the 30th percentile or 70% of measures in each domain to avoid placement in a correction action plan.

Some markets are easier than others. To achieve cost savings, the rate of cost growth in a prospectively aligned population should be lower than the rate of cost growth of a national comparison group. Cost baseline is calculated for each PACO from that site’s historical cost perspective.

Are anyone of you involved in an ACO, planning to start one or know of anyone who is involved? To me, communicating with Medicare is like trying to communicate with God. Right now, it seems like the only way that Medicare is allowing cooperation or coordination with us geriatricians working in the trenches is through innovative programs like ACO’s

It was interesting to see some people whose names I have only come across in books and journals like Joseph Ouslander. Mary Tinetti and David Reuben discussed recent policy changes in the care of older adults with multiple and chronic health needs.
Included among the things they discussed was the Annual Wellness Visit, Geriatric Quality Measures like the Physician Quality Reporting System, CMS Complex Chronic Care Management Services is a new G code for Procedures and Professional Services for nonMD services and is part of the effort to reimburse for MD/ staff time (also care transitions and home care supervision) The UGS was instrumental in bringing this about. They mentioned the transition to ICD 10, the Medicare Choices Model which is an option to receive palliative care services from certain hospice providers while concurrently receiving services provided by their curative care providers. Mary Tinetti and David Reuben have been working on Goal Oriented Patient Care, which is care focused on patient-determined outcomes over traditional measures like survival, biomarkers, disease specific signs and symptoms of function.

Mary Tinetti emphasized the need for Geriatrics to come up with a standardized set of quality measures to present to Medicare.

I attended the session ran by Dr. Louise Aaronson of the University of California San Francisco Division of Geriatrics on Rebranding Geriatrics. She is part of the AGS National Rebranding Geriatrics Workgroup. It was an interactive group session with exercised on Geriatric Messaging trying to answer the question, “What is Geriatrics?”

I attended a session on awardees on Innovative Geriatric Models like GEDI-WISE which stands for Geriatric Emergency Department Innovations in Care thru Workforce Informatics and Structural Enhancements. It is a unique model of ED care for older adults—one that employs geriatric-specific assessments, multidisciplinary care coordination, and geriatrics-trained ED personnel to reduce preventable admissions for older adults by assessing and meeting their geriatric-specific, non-acute care needs in the ED

Finally, I attended the Council of State Affiliated Representatives or COSAR. This is a forum by which affiliate representatives can exchange ideas, discuss public policy issues and communicate and collaborate with the American Geriatrics Society. During the last COSAR meeting there was a guest from the Voices for Better Health Program from Community Catalyst a program currently operating in Ohio, Michigan New York, Rhode Island and Washington focused on Improving the care of older adults who are dually eligible for Medicare and Medicaid by building partnerships between geriatric care providers and consumers. They had a guest from the National Partnership to Improve Dementia Care in Nursing Homes, a private-public collaboration working in every state to reduce the use of antipsychotics in nursing homes as well as implement non-pharmacological interventions and person centered dementia care.

It is apparent that a lot of things are happening related to geriatric health care in the country and it will only be a matter of time until we here in Salt Lake City feel its effects. Now the question is can we afford to be passive or should we be proactive in dealing with these changes.

In the May 2012 article of the Annals of Internal Medicine, I came across the article “Is Geriatric Medicine Terminally Ill?” I found it interesting that I should see an article such as this in the Annals of Internal Medicine and not in JAGS. In its conclusion it said, and I quote ” Unless major Changes Occur that promote equitable compensation, professional recognition and measurable improvement in health outcomes for elderly patients, the subspecialty of geriatrics may be headed towards extinction”

I considered that statement a challenge and not a death sentence to get up off our butts and do something and we have so much opportunity to do something.

The Affordable Care Act is one step being taken to avert a possible collapse of our present medical safety net for the elderly. The premise is by developing innovations in the system of care, we can recreate a more efficient and cost effective health care delivery system.
Why is our present Geriatric health care system inefficient? 
There is a disconnect between what we want to achieve and how the behavior associated with what we want to achieve is being rewarded. We incentivize the wrong behavior. One example is the fee for service system. It incentivizes more procedures more hospitalizations, more admissions to nursing homes. We do not give proper incentive to prevention of falls, prevention of adverse drug reactions, prevention of fractures, treating delirium, diagnosing dementia, preventing constipation, etc.
There is no ownership. No one person responsible for a patient's overall care through different levels of transition from home to hospital to nursing home to outpatient clinic.
There is no uniform standard way of measuring quality of care.
The medical system is fragmented.

Also, the problem with Geriatrics is that unlike other fields such as Cardiology or Gastroenterology, I feel it is finding a hard time in defining or distinguishing itself. Perhaps some of the problem is in marketing. Because it does not have a distinct business niche and therefore no competitive advantage, it reflects on its relatively low financial compensation. In fact it is the only Internal Medicine Subspecialty where it is possible to have a smaller salary than primary care Internal Medicine. Supply follows Demand and not the other way around. The fact that there are so few geriatricians implies that the demand is not there. The problem perhaps is not in the supply of geriatricians but rather in the demand for geriatricians. Think about this last sentence carefully. Unless we can satisfy our patients’ and our nation’s needs in a way that is perceivably better than anyone else then our jobs may truly be headed towards extinction.
If we do not tackle these important problems, who will?
I do not have the answer to these problems. But I was hoping that through more individuals networking and involvement in the UGS and the AGS, perhaps we can find some answers. I believe in the group brain. I would like to see increased involvement from physicians and geriatric care providers in our community. The problem I think is that we doctors are busy and cannot find the time to physically attend meetings. That is why I feel that improving our UGS website is important.
The website can be a virtual meeting ground where ideas can be heard, improve involvement and engagement. I was thinking of perhaps using the website as a blog site where we can discuss these issues. I am also thinking along the lines of a regular web/newsletter. Perhaps we can have regular case conferences where we can discuss interesting cases over dinner.  On these dinners I am hoping to develop relationships that will enable us to solve these problems that I have discussed.
I have looked into the Pennsylvania Geriatrics Society Western Division, which seems to be the model AGS Affiliate.  It has about 133 members and hosts two conferences that invite renowned speakers and invites participation not only in the state but nationwide. Its financial status is excellent. They have been able to sponsor attendance to the UGS Meetings to worthwhile awardees. Obviously we cannot even nearly be as accomplished as the Western Pennsylvania Geriatrics Society. They started in 1990. It would take several steps, and each step should be taken before the next one. One of the first steps is member involvement, then, generating revenue. Worthwhile goals like being able to sponsor education of worthwhile students would be in the future. Right now, we should focus our efforts and resources only to the most worthwhile causes aimed at growing our organization.
I was in the U of U Geriatric Fellowship Program from 1997 to 2000 under Gerry Rothstein. After fellowship, I realized that I needed to keep myself up to date on Geriatrics and to maintain my edge. We all need to aspire toward excellence in Geriatrics. So about 2 or 3 years ago, I started attending Geriatric Grand Rounds And now I have attended the annual AGS meeting. The UGS can be a medium by which we all can hone our Geriatric skills as community providers without necessarily becoming part of the University Geriatrics Division. We as Geriatricians should be able to offer a value proposition.

In January, the UGS board will be having a strategic planning meeting to set specific goals for the coming year. We would also like to ask for nominations for the position of president elect. Nomination forms are available if you do not have them yet.

I am also trying to improve our website. It is very basic right now but we would like you to visit it to check on news, the calendar of events, and perhaps we can develop a blog through which you can give your opinions and communicate with us.

We do need your participation and involvement. This is a very important task that will affect all of our patients and us. Obviously the more we are, working together, the more chances we have to succeed.

Florentino Abueg
UGS Incoming President
( Copy of Speech during UGS Leadership Meeting November 13, 2014 )