IS MANAGED CARE GOOD OR BAD FOR GERIATRIC-MEDICINE

This article uses clinical vignettes to examine the simultaneous dange rs and opportunities that managed care brings to geriatric medicine. W hile the complex multifactorial syndromes prevalent in older adults mi ght at first glance seem poorly handled under capitation, we argue tha t the incentives provided under existing delivery systems can be equal ly perverse. These improper incentives have arisen from (1) the fee-fo r-service payment mechanism itself, which has spawned a subspecialty c ulture ill-equipped to deal with the primary care needs of older adult s and (2) the fragmentation of funding sources for geriatric care into two major payers (Medicare and Medicaid), encouraging providers to fo cus on cost shifting rather than the logical integration of services. The result has been a delivery system that provides little impetus to maximize functional status, the central goal of modern geriatric medic ine. Because physicians may assume financial risk under global capitat ion, and because the cost of caring for a frail older adult is inverse ly related to functional status, managed care offers the potential to align the goals of cost containment with the goals of modern geriatric medicine. Physicians should have a substantive voice in the design an d implementation of these systems.