| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||||||||||
Correspondence: Address correspondence to Mary E. Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine, Public Health and Epidemiology, Yale University School of Medicine, 20 York St., TMP15, New Haven, CT 06504. E-mail: mary.tinetti{at}yale.edu
 |
Abstract |
|---|
Key Words: Falls interventions • Falls prevention • Fall-risk evaluation • Medicare • Preventive approaches
Our objectives are to (a) summarize the evidence revealing the burden of falls and supporting the effectiveness of fall-prevention services for older Americans living in the community; (b) delineate the barriers to promoting fall-prevention services from the perspectives of health care providers and payers in the United States; and (c) present strategies that could be implemented in the near term to improve the delivery and financing of care for community-living older Americans at risk for falls. The key groups of health care providers relevant to fall-risk evaluation and management include physicians, nurses, rehabilitation providers (i.e., physical and occupational therapists), and home care agencies. Our focus is on the fee-for-service component of Medicare, which covered 87% of Medicare beneficiaries in 2002.
|
The Burden of Falls |
|---|
Etiology of Falls
Conditions known to increase the risk of falling among community-living older adults include impairments in balance, gait, cognition, vision, and muscle strength; the use of four or more prescription medications, particularly psychoactive medications; depressive symptoms; postural hypotension; and arthritis (Bergland & Wyller, 2004; Sattin, 1992; Tinetti, Speechley, & Ginter, 1988; Tinetti et al., 1995). Environmental hazards such as stairs and obstacles in the walking path and unsafe behaviors such as rushing further increase the risk of falling and experiencing a serious injury (Studenski et al., 1994). The risk of falling increases as the number of these factors increases, suggesting that falling is a multifactorial health condition that results from the accumulated effects of coexisting conditions and their treatment (Nevitt et al., 1991; Tinetti et al., 1988).
Cost Estimates of Falls and Fall Injuries Among Older Americans
Falls account for approximately 10% of visits to an emergency department and 6% of hospitalizations among Medicare beneficiaries (Englander, Hodson, & Terregrossa, 1996). Rizzo and colleagues (1998) reported that, relative to the cost for community-living older adults of similar health status who had not fallen, the average additional health cost of experiencing a fall-related injury requiring hospitalization was $16,000 ($24,330 in 2002 dollars), after adjustment for age and other comorbidities such as heart disease associated with hospitalization (see also Bishop et al., 2002). This estimate included Medicare-covered hospital, home health care, emergency department, and subsequent nursing home costs. According to data from the National Electronic Injury Surveillance System—All Injury Program (Centers for Disease Control and Prevention [CDC], 2003), in 2002, approximately 388,200 people aged 65 years and older were hospitalized after being treated in emergency departments for fall-related injuries. Multiplying this number by the cost estimate derived by Rizzo and colleagues provides a $9.4 billion estimate in additional fall-related health care costs to the system in that year. The CDC similarly estimated the added health costs at $3,560 for the 1.6 million adults aged 65 years and older who required fall-related care in an emergency department but were not hospitalized (CDC, 2005b), resulting in an additional $5.7 billion in health care costs. This gives a total of $15.1 billion in fall-related health care costs to the system that year. In an economic analysis conducted by the CDC using incidence data and actual medical payments, the direct cost of fatal and nonfatal fall injuries in 2000 was estimated at 19.5 billion dollars (Finkelstein, Chen, Miller, Corso, & Stevens, 2005). The CDC findings extended the earlier estimates by adding outpatient and physician visits to emergency department and hospital treatments. These figures are of necessity based only on those falls that came to medical attention. Furthermore, existing estimates do not include caregiver time, nonmedical expenditures, decreased quality of life, or loss of functional capacity, all of which are potentially avoidable fall-related costs.
|
Effectiveness of Fall-Risk Evaluation and Management as a Preventive Approach |
|---|
Complementing these effectiveness studies, there have been a limited number of cost-effectiveness studies of fall-prevention services (Englander et al., 1996; Gillespie et al., 2003; Miller & Levy, 2000). Although the determination of net savings from fall-prevention services is sensitive to multiple assumptions about the prevalence of risks, effect sizes, and service-related costs, studies have uniformly indicated that such services have net-cost savings for older adults at high risk of falls.
Evidence-based clinical guidelines recommend that community-living older adults who present for medical attention because of a fall, who demonstrate difficulty with balance or walking, or who report recurrent falls in the past year receive fall-risk evaluation and management performed by clinicians with appropriate skills and experience (American Geriatrics Society, British Geriatrics Society, & American Academy of Orthopaedic Surgeons Panel on Falls Prevention, 2001). The guidelines did not specify which groups of health care providers should perform the various components of the fall-risk evaluation or management, although in practice the components are variously under the purview of physicians, advanced practice registered nurses, rehabilitation specialists, and home care providers.
|
The Evidence–Practice Gap |
|---|
|
Barriers to Providers Offering Fall-Risk Evaluation and Management Services |
|---|
|
Knowledge and Skills Deficits
Fall-risk evaluation and management, like all multifactorial geriatric health conditions, involves complex decision making and behavioral interventions. Neither traditional professional education nor practice patterns among the relevant provider groups includes sufficient attention to these geriatric health conditions. Many providers thus lack the necessary knowledge, skills, or experience to care for older adults with these conditions. Knowledge of the types of balance exercises known to improve stability and prevent falls, for instance, has not yet widely permeated clinical practice. Furthermore, when making clinical decisions, many providers who are used to diagnosing and treating individual conditions separately are not accustomed to weighing several competing morbidities simultaneously. Decision making for medications, for example, presently is predicated on attaining disease-specific outcomes rather than on weighing the benefits and harms of medications to reduce fall risk without compromising other health conditions.
Fragmentation and Lack of Coordination
Even when providers are willing and able to perform fall-risk evaluation and management, the fragmentation of care among providers and across settings is a barrier to effective patient care. Fall-risk evaluation and management requires coordination and referral among several providers with complementary skills, including physicians, home care nurses, physical therapists, and occupational therapists. The more components and providers involved, however, the harder it is and the longer it takes for practice changes to diffuse (Bradley et al., 2004). Inadequate awareness of the skills of other provider groups exacerbates the difficulty; the roles of physical therapists and occupational therapists, in particular, are poorly understood by some providers. As a result, for instance, home care nurses may not recognize that some individuals might benefit from rehabilitation, and medical providers may fail to prescribe these services.
The challenge of coordinating patient care among health care providers is compounded by the need to coordinate such care between health care and non-health-care settings. Some components of fall-risk management are within the purview of medical care, such as medication reduction and physical therapy, whereas others, such as environmental safety outside the home, and physical activity or exercise, are not. The straddling of responsibility within and outside the health care setting further compromises coordination and limits accountability.
Reimbursement and Financial Concerns
Whether accurate or not, reimbursement for fall-related clinical activities is perceived by the relevant health care provider groups as inadequate; inadequate reimbursement is considered a disincentive for providing fall-risk evaluation and management (Baker et al., 2005).
In addition to the perceived inadequacy of reimbursement, there is confusion among providers of what is or is not covered. This confusion results, in part, from the fact that Medicare covers treatment but not preventive services. On the one hand, fall-risk evaluation and management could be considered a preventive service for which coverage must be specified by changes in the Medicare statute. These changes would require legislation. On the other hand, although fall prevention per se is not covered, the evaluation and management of contributing conditions and the treatment of individuals who have already fallen are services covered at least to some extent.
Even when the issue of prevention versus treatment is resolved, there are still financial barriers. For instance, most of the physician-provider components of fall evaluation and management (e.g., counseling about medications) are covered by Evaluation and Management (E and M) codes, used for documenting the nonprocedural components of the visit. Criteria for assigning E and M codes are vague; some providers consider documentation cumbersome; and coverage decisions are open to variable interpretation among local health insurance carriers.
Furthermore, Medicare specifically provides no additional payments for coordination among providers as a covered service. Although the components of fall-risk evaluation and management may be allowable under Medicare, there is no incentive for the multiple providers involved in the delivery of these services to coordinate their care. As a consequence, components may be duplicated, omitted, or performed inadequately (see Table 1).
|
Barriers to Fee-for-Service Medicare Coverage for Fall-Risk Evaluation and Management Services |
|---|
Concern About Fraud and Abuse
The CMS has a long-standing concern about fraud and abuse in the evaluation and treatment of conditions that are difficult to define and may be relatively common. Relevant to fall-risk evaluation and management, for instance, is that home care and rehabilitative services, both of which often entail multiple visits in nonmedical settings, have come under careful scrutiny. At least in part to control the potential for abuse, the Balanced Budget Act of 1997 required payment under a prospective payment system for home health care. The act also imposed caps on outpatient rehabilitation services; these caps have recently been reinstated after a period of moratorium. The CMS is also concerned about possible billing for nonevidence-based methods to evaluate falls, such as the use of expensive machines to assess equilibrium. Fall-risk evaluation and management services will have to address concerns about fraud and abuse, perhaps by setting up outcome-driven criteria for eligibility or by limiting the duration of services, such as the existing cap on outpatient rehabilitation services.
Statutory (Legislative) Limitations
The complexity of Medicare payment and coverage policies contributes to the barriers facing not only providers but also the CMS itself in financing fall evaluation and management services. Fall risk is a recurrent problem with predictable and frequent use of services. Medicare, created in 1965, has its historic roots in indemnity insurance. It was developed primarily for unpredictable and infrequent use of acute services and not for frequent use of chronic services (Radovsky, 1968). Legislative barriers, resulting from the limits on what decisions the CMS can make on its own, make it challenging to address chronic conditions and geriatric conditions such as falls. These conditions require ongoing, coordinated approaches across multiple providers, settings, and payment systems.
Complex Financing Structure
Fee-for-service Medicare is more accustomed to the single-provider, single-setting model than to the multiprovider, multisetting approach necessary for optimal fall-risk evaluation and management. Different providers deliver fall-risk evaluation and management services in a variety of settings and bill Medicare Part A or B, depending on the circumstances. Insurers that process Medicare hospital claims, generally under Part A, are called intermediaries, whereas those that process Medicare physician claims, generally under Part B, are called carriers. However, the situation is more complex than that. Home health care, for instance, may be covered under either Part A or B. Hospital-based outpatient rehabilitation services are financed under Part B, although the bills are sent to fiscal intermediaries. Outpatient physician and freestanding outpatient rehabilitation services, in contrast, are paid for under Part B, with the bills sent to carriers. The CMS contracts with private insurers to process claims for Medicare beneficiaries. Adding to the complexity and confusion, different models of payment are used in different settings. This complexity is illustrated by home health payments, which are generally provided under the prospective payment system, rather than fee-for-service reimbursement.
|
Near-Term Strategies That Could Promote Fall-Risk Evaluation and Management |
|---|
|
In explaining coverage and payment, language is important. Medicare does not cover services labeled as preventing or controlling risk but rather covers services labeled as treating symptoms. For instance, Medicare pays to treat balance or gait impairment, but not to prevent falls that are due to balance or gait risk. Thus, a person who has a symptom, such as balance or gait impairment, that predisposes him or her to a fall could receive Medicare-reimbursed services. Many known fall-risk factors can be linked to a symptom-specific diagnostic code or an evaluation and management visit.
Beneficiaries can now get a one-time preventive physical examination, including fall-risk assessment, within 6 months of enrolling in Medicare Part B coverage. Approximately 1 million beneficiaries will be eligible for this benefit each year. Initiating fall-risk evaluations in this select population could influence provider practice patterns for older adults more generally.
Enhance Providers' Clinical Knowledge and Skills
Professional education is beginning to incorporate geriatric principles into the training of physicians, nurses, and rehabilitation specialists. It is hoped that this training will result in increased knowledge of the evaluation and management of geriatric conditions such as falls and in enhanced skills in balancing tradeoffs among competing conditions.
For providers in practice, multiple strategies may improve knowledge of, skills in, and, subsequently, behaviors related to new practices such as fall-risk evaluation and management (Berwick, 2003; Oxman, Thomson, Davis, & Haynes, 1995). Commonly employed strategies include continuing education, outreach visits to providers' practice sites, medical record prompts to encourage performance, enlistment of local opinion leaders, and consumer demand for the services. Local and national efforts are underway that use these strategies (Baker et al., 2005; Fortinsky et al., 2004; Reuben et al., 2003). The effects of these efforts on provider practices are not yet known, although they are usually most effective for those who are ready to change their practices.
Create a New V Code for History of Falls
The CDC and CMS recently developed a new V code for history of falls (V15.88) that was implemented in October 2005. This code could be used to identify individuals at risk, measure quality of care, and justify a provider's decision to order or perform certain services. A V code describes a status rather than a specific condition (CDC, 2005a); the specific conditions and diseases that predispose a person to falling already have diagnostic codes. The V code would denote that the person has the status of having fallen (over a designated time frame, likely to be 1 year), is at risk for recurrent falls so that the status is relevant to current care, and could benefit from fall-risk evaluation and management. Depending on the situation, the code could serve as a justification for further evaluation and management such as referral to rehabilitation or performance of time-intensive activities such as medication review and adjustment. Without this code, there is no existing diagnosis or condition code that conveys such information. With a specific code, reviewers may be willing to accept services such as prolonged counseling time or outpatient rehabilitation gait-and-balance evaluation and management without the need for time-consuming manual review. Medicare contractor medical directors could add the V code to local medical review policies. To be effective, providers must be made aware of the new code and its proper use, through avenues such as the CMS Web site and communications from their professional organizations. A specific fall code might heighten the awareness of providers of the importance of falling as a manageable medical problem. It would also enhance the likelihood that providers would perform fall-risk evaluation and management, understanding that these services would be covered. In addition to a V code, consideration should be given to developing appropriate Current Procedural Terminology (CPT) codes indicating specific fall-related procedures. Current Procedural Terminology codes, developed by the American Medical Association, provide uniform terms and codes to describe medical, surgical, and diagnostic services. These codes are used by insurers, including the CMS, for processing claims.
Enlist Professional Leadership
Professional leadership, particularly through highly respected national provider specialty organizations, is a potent force for creating greater awareness and improved norms of fall-risk evaluation and management and increasing attention to geriatric health conditions in practice. In illustration, the American Board of Internal Medicine (2005) created an evidence-based fall-related practice improvement module for its diplomates.
Implement Public Reporting of and Payment for Quality
Given the multiple competing time demands on providers, fall-risk evaluation and management is best framed within the context of something providers view as important or feel they need to do, such as adhere to performance measures. In January 2006, the CMS launched the Physician Voluntary Reporting Program, which encourages physicians to report data on the quality of care they provide to Medicare beneficiaries. The Physician Voluntary Reporting Program will inform the development of pay-for-performance systems that aim to reward clinicians for better care, rather than simply paying based on the volume of services. Through a set of newly established codes, which are similar to procedural codes, physicians can report on a starter set of 16 performance measures, including falls assessment (CMS, 2006). The CMS will provide feedback to participating physicians on their performance on these measures. In addition, the National Committee on Quality Assurance has developed a Health Plan Employer Data and Information Set measure on falls, based on the fall-related quality indicators developed through the Assessing Care of Vulnerable Elders project (Rubenstein et al., 2004), that will result in public performance reporting, giving health plans an incentive to do well (National Committee on Quality Assurance, 2003). These two efforts should help promote fall-risk evaluation and management among both fee-for-service and Medicare Advantage beneficiaries.
CMS mandates a focus on functional outcomes, monitored through the Outcome and Assessment Information Set (known as OASIS), for home care agencies (CMS, 2005c). Home care agencies' performance on these functional outcomes is listed on the CMS Web site, offering an incentive for agencies to improve the functional outcomes of their clients. Home care agencies can improve their performance by adopting fall-risk evaluation and management strategies. Educational efforts will likely be required to ensure awareness of the connection between fall-prevention efforts and patient function. Furthermore, the Medicare Payment Advisory Commission, an independent federal organization established to advise Congress on issues affecting the Medicare program, is developing measures related to falls as part of the Pay for Performance initiative for home care (Medicare Payment Advisory Commission, 2006). These pay-for-performance measures should also foster interest in implementing fall-prevention programs among home care agencies.
Incorporate Fall-Related Practices Into Accreditation Standards
The accreditation process also encourages providers to adopt new practices. For example, the Joint Commission on the Accreditation of Health Care Organizations (2005), the nation's oldest and largest standards-setting and accrediting body in health care, recently added fall measures to its accreditation process for the ambulatory, home care, and assisted living settings. Providers must now show evidence of fall-prevention programming with measurable outcomes.
Explore Other Medicare Coverage Options
A Medicare demonstration and a new Medicare benefit are two other potential strategies for improving the delivery of fall evaluation and management services. The CMS conducts demonstrations to test and identify methods to improve the delivery, financing, and coverage of health care services. Demonstrations may be mandated through legislation or be initiated by the CMS. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, for example, mandated the phasing in of the Chronic Care Improvement Program, a population-based disease-management program, targeting congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease (CMS, 2005a).
It can take many years, if at all, for demonstrations to have an effect on health care policy and practice. Furthermore, fall-risk evaluation and management requires coordinated and integrated decision making across multiple providers and disease categories that is generally beyond the purview and scope of disease management. Nevertheless, it might be worth it to explore ways to incorporate the evaluation and management of falls within the context of other demonstrations.
Another potential option is to explore the creation of a new benefit, such as a limited number of visits per year per beneficiary, to appropriate providers for components presently not covered or covered inadequately. Examples of such components include repeated physician visits for medication review and reduction; rehabilitation for balance, strength, and gait reevaluations; and progressive training. If these services are defined as treatment, then the CMS could craft the new benefit. If they are defined as prevention, then coverage of these services would require Congressional legislation.
|
Broad-Based Changes in Financing and Clinical Practice Systems |
|---|
Systems-based interventions are needed to handle the complexity, and reduce the time and administrative costs, of the evaluation and management of conditions such as falls that coexist with other health conditions. One example of such interventions is the enhanced use of information technologies that could aggregate the fall-risk evaluation and management information from multiple sources and facilitate referral among providers (see Table 3). Additional systems changes include better coordination across provider groups and a shift in clinical practice from its present single-disease focus toward integrated clinical decision making that weighs all health conditions. From a clinical and financing perspective, the current interest in chronic disease management is a step in the right direction, but the focus must be on integrated care across conditions, not on treatment of separate diseases (Berenson & Horvath, 2003).
|
|
Footnotes |
|---|
1 Departments of Internal Medicine and Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT.
2 Office of the Director, Centers for Disease Control and Prevention, Washington, DC.
3 National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA.
4 Office of Research, Development, and Information, Centers for Medicare and Medicaid Services, Baltimore, MD.
Decision Editor: Linda S. Noelker, PhD
Received for publication January 27, 2006. Accepted for publication June 2, 2006.
|
References |
|---|
This article has been cited by other articles:
 |
|
 |
|
  N. Steel, M. Bachmann, S. Maisey, P. Shekelle, E. Breeze, M. Marmot, and D. Melzer Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England BMJ, August 13, 2008; 337(aug13_2): a957 - a957. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D A Ganz, G E Alkema, and S Wu It takes a village to prevent falls: reconceptualizing fall prevention and management for older adults Inj. Prev., August 1, 2008; 14(4): 266 - 271. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. E. Tinetti, D. I. Baker, M. King, M. Gottschalk, T. E. Murphy, D. Acampora, B. P. Carlin, L. Leo-Summers, and H. G. Allore Effect of Dissemination of Evidence in Reducing Injuries from Falls N. Engl. J. Med., July 17, 2008; 359(3): 252 - 261. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. M. Clough-Gorr, T. Erpen, G. Gillmann, W. von Renteln-Kruse, S. Iliffe, J. C. Beck, and A. E. Stuck Multidimensional Geriatric Assessment: Back to the Future Preclinical Disability as a Risk Factor for Falls in Community-Dwelling Older Adults J. Gerontol. A Biol. Sci. Med. Sci., March 1, 2008; 63(3): 314 - 320. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
TOP
Abstract
The Burden of Falls