Martha (not her real name) was not an overly complex case in my field of geriatric psychology. But the case was complex enough to require multiple approaches and reliable follow up. And in rural Mississippi, follow up can be elusive. Soon it occurred to me that Martha’s case is emblematic of how caring for this vulnerable population often runs up against a huge problem — the Medicare merry-go-round.
A 78-eight-year-old with vascular dementia, Martha came to me for the first time with behavioral disturbance — insomnia, agitation, and hypersexual behavior. I admitted her, ruled out medical etiology and cleaned up her medication regimen. She became stable about ten days into the treatment.
On discharge, I give her a one month of supply of medications. After that, the physician seeing Martha for follow up would normally adjust medications or rewrite the medications I prescribe because they are working. This is where it fell apart — there was simply nowhere for her to follow up psychiatrically, no one in her area doing geriatric psychology outpatient. So she had to follow up with her primary care physician. This physician wasn’t comfortable writing for refills because of the medications. So she went without medications.
Of course, she decompensated. She returned back to my unit far from baseline. I restarted her on the medications that she was on during her last stay. However, even at max dose, the antipsychotic was ineffective this time. It took me close to a month to get her stable on a good regimen. She, however, will never return to baseline. Being psychotic is so hard on the elderly brain. At discharge, the family was even contemplating nursing home placement.
I am a willing outpatient provider, but am unable to serve the population I most love in an outpatient setting. I would love to be able to follow my patients once they get out of the hospital. However, I cannot keep up with the tasks that Medicare has placed upon physicians through MACRA and MIPS and I cannot afford to take the penalty either. This is where the vicious merry-go-round begins for members of this fragile patient population like Martha.
There are no geriatric psychiatrists or general psychiatrists taking Medicare because of the poor reimbursements and strenuous requirements of MACRA/MIPS mentioned above. The patients are referred back to their overwhelmed primary care physicians who often are not comfortable with psychiatric medications in this population and therefore don’t write them.
Thus the patients bounce back to inpatient care, causing a significant rise in healthcare costs. In another scenario, there are the depressed geriatric patients with Medicare. They cannot find an outpatient psychiatrist who takes Medicare. They seek help with their primary care physician, who attempts to refer to outpatient care as well but is unable to find anyone. Inpatient treatment is suggested, but they don’t meet inpatient requirements because they aren’t yet suicidal. Primary care physicians aren’t equipped to provide therapy and may not feel comfortable with psychotropic medication. So the patient essentially must decompensate to a point of suicidality or psychosis to get inpatient treatment.
Once there, they get stabilized but unfortunately won’t be able to find follow up and again the merry-go-round has restarted. This already fragile patient populations deserves better. My patients deserve better. If in fact, the argument for MACRA and MIPS was to increase patient satisfaction then it is proving once again to fail miserably, and my patients want off this ride.
Katherine Gantz Pannel is a psychiatrist.
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