• Kenton J Johnston, Hefei Wen, and Karen E Joynt Maddox.
• Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St Louis, Missouri.
• J Am Geriatr Soc. 2020 Feb 1; 68 (2): 297-304.

ObjectivesMedicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures.DesignA retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors.SettingEight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey.ParticipantsMedicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data.MeasurementsOutcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression.ResultsGeriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrent-year risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00).ConclusionMedicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.© 2019 The American Geriatrics Society.

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