TRAFFIC DANGEROUS DRUGS ARE OFTEN FOUND IN FATALLY INJURED OLDER MALE DRIVERS

To the Editor: Hurray for the American Geriatrics Society, the American Board of Family Practice, the American Board of Internal Medicine and all those (Hazzard et al.) who have fought the battle to reduce the length of geriatric fellowships. This effort allows those residency graduates whose main interest is private practice to perform only 1 additional year while reserving 2 years for those graduates interested in research or teaching. We hope that this effort will increase the number of filled fellowship slots and subsequently increase the number of practicing geriatricians. We also give credit to other professionals (Steel et al.) and organizations that have been promoting home visits as a way to provide more personal, less costly care to those older people who are homebound. Last, but not least, we must remember the American Geriatrics Society’s successful lobbying of Congress last year to discourage eliminating geriatrics from the “five year rule,” or being the only exception to the rule that Medicare reimburse for only 3 full years the direct and indirect teaching costs of healthcare institutions that sponsor postgraduate primary care training. This successful effort has allowed both additional years of clinical geriatric fellowship training to be reimbursed as well. Despite these impressive accomplishments, however, we have encountered another formidable hurdle. An old Medicare law (IL372) that governs this reimbursement for clinical care in teaching institutions has recently been enforced to cover possible fraud involving large monetary penalties to healthcare institutions that fail to comply. Because geriatric fellowships are the only ones eligible for this full reimbursement, they have come under tremendous scrutiny as it relates to proper documentation by faculty physicians in teaching programs. Alhough the IL372 law refers primarily to resident physicians, clinical fellows are also included in the ruling. Basically, all visits by resident and clinical fellows eligible for Medicare billing must be followed by appropriate documentation in the progress note by the supervising physician. The documentation must include pertinent signs and symptoms, physical exam findings, laboratory and radiological findings, diagnosis, and treatment plan. In principle, the law does not affect clinical geriatric fellows any differently than it does other clinical fellows. The issue is the scope of the problem for clinical geriatric fellows because the overwhelming majority of their patient population, compared with that of other fellowships, involves the Medicare population. Ironically, the issue has resulted in a greater need for one-on-one geriatric faculty supervision of fellows. All Medicare visits must also be billed by the respective supervising faculty or, as it is referred to, the “teaching” physician. This requirement tends to restrict the autonomy and identity of fellows in training. The only situations that allow the direct billing of Medicare services by a clinical fellow include: (1) those in which fellows are not in approved programs (i.e., primarily research training); ( 2 ) moonlighting arrangements; (3) those of fellows in nonprovider settings (independent outpatient center, private physician’s office, clinic, or health maintenance organization in such cases, there is no written affiliation agreement with the hospital, and the hospital does not count the time spent by the fellow for direct graduate medical education payment purposes), As it relates to fellows, however, there is no specific documentation regarding nursing home visits. Adding insult to injury, the rule states that the “teaching physician” must be in the building at the time of the visit, with the exception of home care visits in which the “teaching physician” must accompany the fellow in order to bill Medicare. Let’s face facts: many residency graduates are skeptical about performing another year or two because of the amount of money they owe in loans for their graduate education; geriatrics is also not the most glamorous specialty by any means; and then there’s the issue of being reimbursed at nearly the lowest level of any specialty. This is a call for help from the American Geriatrics Society to lobby to amend these rules before further serious damage is done to the credibility of the field.