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What are the current and projected future doctor to patient ratios in geriatrics?
- There are currently 7,128 certified geriatricians in the US -- one geriatrician for every 2,546 Americans 75 or older. Due to the projected increase in the number of older Americans, this ratio is expected to drop to one geriatrician for every 4,254 older Americans in 2030.
- There are far fewer geriatric psychiatrists. Currently there are 1,596 - one for every 11,372 older Americans. That ratio is projected to decrease by 2030 to one geriatric psychiatrist for every 20,195 Americans 75 and older.
- In 2007, 91 residents who graduated from US medical schools (USMDs) entered geriatric medicine fellowship programs (slightly more than 0.5% of all medical students in that graduating class), down from 167 in 2003. In 2007, 24 USMDs entered geriatric psychiatry fellowship programs (less than 0.2 % of all medical students in that graduating class), down from 30 in 2003.
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Why is this issue important?
- By 2030, when the last of the baby boomers reaches the age of 65, the U.S. population aged 65 and older will exceed 70 million - approximately twice the number in 2000.
- As America's 77 million baby boomers age, the need for healthcare professionals trained in geriatrics will be high in demand.
- Unfortunately, doctors and psychiatrists specially trained in the care of older adults are in dangerously short supply.
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What factors are contributing - or are expected to contribute to - the shortage of geriatricians?
- Over the last 5 years, a declining number of US medical school graduates have been choosing careers in internal medicine and family medicine - the two fields that are the source of applicants for geriatric fellowship programs.
- Physicians in internal medicine, family medicine - and geriatrics - earn significantly less and have less predictable work schedules than those in other medical and surgical specialties, especially disciplines such as dermatology, plastic surgery, otolaryngology, radiation oncology, and emergency medicine.
- A career focused on caring for older adults can be particularly financially unattractive for physicians who carry increasingly large medical school loan debts.
- In many parts of the U.S., Medicare payment rates for physicians are lower than commercial insurance rates.
- Medicare reimbursement rates for mental health services are discounted even further than rates for geriatric medical services.
- Medicare reimbursement is the major source of income for most geriatricians and, as a result, community-based geriatricians have lower incomes than most other physician specialists.
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What are potential models and programs that could be implemented to alleviate the shortage of geriatricians?
- Loan Forgiveness and Other Financial Incentives
- Create loan forgiveness programs for fellowship training and practice and/or for GM fellowship programs for two years, which would produce fellows with advanced degrees and leadership skills.
- Create incentive programs that provide financial support to medical students, house officers, fellows who, in return, agree to provide geriatrician services in underserved areas for a couple of years after completion of their training.
- GME bonuses could be given to programs that send residents into geriatrics fellowships. Possibilities include a monetary reward to internal medicine/family medicine residency PD's for directing people into geriatrics training might get their attention, or withholding GME money if no HO's from a program do geriatrics over a 2-3 year period.
- South Carolina has been successful in implementing a loan forgiveness program that works in recruiting geriatricians. There has been quite a bit of discussion about having some of the Medicare funds for graduate medical education more specifically targeted to geriatricians. Recognizing that there are political challenges with this recommendation, it still seems worthy of consideration.
- Incentives for Hospitals/Health Systems
- Wisconsin Model: Create incentives for hospitals/health systems to establish geriatric programs that are based on improving the quality of, and more nuanced, care of older adults, not just volume based clinics. This could be done by launching demonstration projects to develop older adults specific Quality Indicators of hospital care. If the incentive is to establish geriatric programs, then most hospitals will open a clinic and expect geriatricians to have volume based performance outcomes and not focus on quality of care improvements (which would save Medicare money) by avoiding hospitalization through lower readmissions, etc.
- Medicare Reimbursement
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CMS and MedPAC could work with professional non-profits on developing a fuller understanding of the geriatric care model, how geriatricians work and manage populations, how they are currently reimbursed and how the current health financing system does not provide incentives for doctors to more fully improve care of older adults. This would be a multi-step process requiring the re-examination of reimbursement and the current E/M codes and billing practices.
- VA GRECC Positions
- Vacant VA positions in Geriatric Research, Education and Clinical Centers (GRECCs) should be approved for recruitment. Nationwide, vacant positions are not opened for recruitment because of local financial constraints. GRECC staff function as key leaders, fostering research, clinical innovation and training of health care professionals in geriatrics. Mandating that these positions be opened for recruitment will improve geriatric care at the local level and create an incentive for more trained geriatricians, who then could contribute to teaching geriatrics to medical students and house officers at the VA and affiliated University programs.
- Compared to the National Institutes of Health, which offers a generous loan repayment program to physicians who are pursuing research and academic careers, the VA's loan repayments program is small, offers less attractive benefits, but is open to multiple health care disciplines. Since candidates for debt reduction are nominated at the local level, but approved at the national level, conflicts between national priorities such as preparing a suitably equipped academic workforce may be overshadowed by short-term local recruitment pressures. Currently, the NIH has more funding available to offer loan repayment incentives, unfortunately; loan repayment is unavailable to those who are not employees of the NIH. NIH could expand the program to include VA employees which would make these positions more attractive to physicians and make them as widely available as possible. Alternatively, Congress could remodel the VA education debt reduction program to more closely resemble the NIH program but with access for almost all geriatric health care disciplines.
- GP MDs, Nurses, PAs, Pharmacist Training
- Increase training to practitioners, other than geriatricians, currently caring for older adults, such as primary care physicians and mid-level practitioners. The Evercare satisfaction survey research demonstrates the public's satisfaction with care provided by mid-level practitioners. The results reveal that the higher level of communication offered by deploying "physician extenders" is well accepted.
- Increase funding for training of multiple disciplines (geriatric physicians, nurses, ANPs/Pas, Pharmacists) engaged in the care of older adults.
- Successful Interdisciplinary Programs
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