Thy Name Is Frailty

For a number of years, I was the medical director of a residential facility/nursing home (now "closed") for elderly professional women. There, I encountered many whom I classified as frail based on a combination of age, weakness, memory loss, inability to walk securely, limited vision, deficient hearing, problems performing daily living, a host of illnesses and a certain sadness, often associated with family inattention. It was not only these issues that used to worry me about these patients, it was that the functional deficiencies were coupled with serious illnesses requiring powerful medications which had significant side-effects.

So, I read with interest Medicare Risk Adjustment for the Frail Elderly* which describes CMS' interest in incorporating risk adjustment methodology into payment for "Medicare Advantage and other Medicare private organizations." CMS works with a frailty definition which focuses on functional impairment and difficulty in performance of activities of daily living ("ADL"). CMS' interest is provoked primarily by its role as a payer, rather than any clear pursuit of improvement in the quality of care and outcome benefit. And like most bureaucratic organizations, CMS adopts measurement tools which are based on paper (or in these days, perhaps electronic) records rather than field evaluation of a sample population using the eyes, ears, hands and minds of skilled evaluators.

In the past, as its resources have been limited, CMS reduced capitation payments for patients with high ADL scores, citing its models and actuarial studies. My experience as a physician was that patients would minimize or deny their limitations, and only when confronted by persons familiar with their daily capabilities, finally acknowledge their incapacities. In short, a paper/electronic record approach would seriously underestimate the magnitude of the problem.

Perhaps CMS should require its theorists to incorporate a requirement for actual independent field evaluation of the frailty of its clientele and use that adjuster to enhance its bureaucratic mission. That would be fair to those affected and served by the private Medicare companies, including Medicare Advantage plans.

*Health Care Financing Review/Winter 2008-2009, pp. 83-93.