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Geriatric Medicine: A Clinical Imperative for an Aging Population, Part IA Policy Statement from the American Geriatrics Socie
This is the first section of the policy statement. Part II will appear in the April issue and Part III will appear in the May issue of the Journal.
EXECUTIVE SUMMARY
• The nation’s aging population is growing rapidly. The aging population is living longer, with fewer acute care based needs and more chronic care based needs. In general, our health care system meets chronic care needs in a limited and fragmented manner.
• Chronic care services are a hallmark of geriatric care. Geriatricians are physicians who are experts in caring for older persons; these primary care-oriented physicians are initially trained in family practice or internal medicine and complete at least one additional year of fellowship training in geriatrics.
• A subset of the nation’s elderly population requires geriatric care. Approximately 15% of community dwelling Medicare beneficiaries need access to a geriatrician or geriatric services provided by a primary care physician.
• The first category of non-institutionalized Medicare beneficiaries is comprised of seniors with multiple, complex chronic conditions. In addition, residents of nursing homes and other congregate care facilities need access to quality, geriatric care.
• Over the past ten years, peer reviewed literature has strongly supported geriatric care models. These innovative care delivery systems include the use of geriatric assessment, ongoing care coordination, a physician-directed multidisciplinary team and a holistic approach to patient care that involves clinical, psychosocial and environmental follow-up.
• Despite the benefits of geriatric care, a shortage in the geriatric work force persists. Today, there are approximately 7,600 certified geriatricians in the nation, despite an estimated need of approximately 20,000 geriatricians. The lack of geriatricians impedes the delivery of chronic care to needy, elderly individuals.
• Financial disincentives pose the largest barrier to entry into the field. Geriatricians are almost entirely dependent on Medicare revenues. Given their patient caseload, low Medicare reimbursement levels are a major reason for inadequate recruitment into geriatrics.
• The Medicare bill included several new chronic care provisions, including a largescale disease management pilot program. However, the new disease management program will not adequately address the needs of persons with multiple chronic conditions, nor will it address the financial disincentives within Medicare that have limited the supply of geriatricians.
• Different reforms are needed to increase interest in geriatrics, such as changes in the Medicare fee-for-service payment system, changes in the new disease management program, and changes in payment policy for federal training programs.
INTRODUCTION
Our country is aging rapidly. In 1900, there were 3.1 million Americans age 65 and older, and, today, there are roughly 35.6 million aged persons.1 By the end of the next decade, we will see an even more dramatic increase in the growth of the older population, a result of the post World War II “baby boom.” By 2030, it is projected there will be about 71.5 million older persons, more than twice their number in 2000.1 People age 85 and older are the fastest growing segment of the entire population, with expected growth from 4 million people today to 20 million by 2050.1 It is this group—the old, old—who consume the largest amount of Medicare resources. In fact, five percent of the Medicare population consumes 50 percent of the Medicare dollars.1 Many of these “high consumers” are the frail elderly.
The implications of this “demographic imperative” are dramatic. We simply are not prepared for the burdens it will place on our health care and financing systems.
In addition, the nature of illness is changing due to longer life spans among our citizens as a result of public health measures and advances in medicine. Americans are not dying typically from acute diseases as they did in previous generations. Now chronic diseases such as diabetes and heart disease are the major cause of illness, disability, and death in this country, accounting currently for 75 percent of all deaths and 80 percent of all health resources used.2 People live longer with disabling chronic conditions. On average, by age 75, older adults have between two to three chronic medical conditions and some have ten or twelve conditions.3 Individuals with chronic illness have special health care needs, which involve greater care coordination and need for access to non-clinical support services. In addition to the special needs associated with chronic illness, older persons in general have unique characteristics that differentiate them from younger populations. But, the majority of physicians and health care practitioners caring for older patients have not been adequately trained in geriatrics. As a result, many practitioners may treat an 85-year old patient the same way they would a patient of 50 years—despite the remarkable differences between these patient populations. As a comparison, it has long been recognized that children’s health care requires a specialized knowledge base and no physician would treat a five-year old in the same manner as an adult patient.
It is time to give the field of geriatrics the recognition given to pediatrics.
Too often, illnesses in older people are misdiagnosed, overlooked or dismissed as the normal process of aging, simply because health care professionals are not trained to recognize how diseases and drugs affect older patients differently than younger patients. All of these situations potentially could translate into suffering by patients, concern from their caregivers and unnecessary costs to Medicare related to inappropriate hospitalizations, multiple visits to specialists who may order conflicting regimens of treatment and needless nursing home admissions.
Special training is needed to prevent these outcomes. Geriatricians—physicians who specialize in the treatment of the frail elderly—are uniquely positioned to promote evidence-based, best practice for this vulnerable population.
A number of reports have been written on the need for increased geriatric training for physicians and other providers in order to meet the coming baby boom, beginning with the Institute of Medicine (IOM) in 1978.4 Progress has been made, but as the IOM more recently noted, progress remains insufficient.5
The Medicare program has just undergone major reform: the addition of an outpatient prescription drug benefit and new disease management services. These are important changes designed to move this venerable program to the standards of the 21st century. At the same time, these changes do not fully address the needs of the frail elderly as they lack a physician-oriented chronic care delivery program for the frail elderly. This report explores these and related issues at length by discussing:
• The history of geriatric medicine;
• The patients who need geriatric care;
• The benefits of geriatric care;
• Work force shortage issues related to geriatric care;
• The reasons for the geriatric shortage;
• Limitations in current Medicare reforms in this area, such as the difference between disease management and chronic care; and
• Proposed recommendations to improve the geriatric shortage.
WHAT IS GERIATRICS?
Geriatrics is the branch of medicine that deals with the problems and diseases of older adults and aging. It is a relatively new field. Medical science has learned a lot about aging and age-related disease and how to prevent and manage such disease and associated chronic disability. Unfortunately, research and knowledge in geriatric medicine has not been transferred fully to the health care workforce, both because of the shortage of geriatricians, and the newness of the field.
What is a Geriatrician? Geriatricians are physicians who are experts in caring for older persons. They are primary care-oriented physicians who are initially trained in family practice or internal medicine and who are required to complete at least one additional year of fellowship training in geriatrics. Following their training, a geriatrician must pass an exam to be certified and then engage in continuous professional development, including passing a recertifying exam every ten years.
Geriatric medicine training promotes specialized knowledge that focuses on quality care and safety for frail elderly persons. The following key features characterize geriatric care:
• Expertise in managing common conditions that affect older persons including dementia, falls, urinary incontinence, malnutrition, osteoporosis, sensory impairment, and depression;
• Understanding the interaction between aging and other conditions and diseases;
• Recognizing the effects of aging and other conditions on clinical health, physical and mental function and independence;
• Understanding the appropriate use of medications to avoid the potential hazards and unintended consequences of multiple medications;
• Coordinating care among other providers to help patients maintain functional independence and improve their overall quality of life;
• Evaluating and organizing health care and social services to preserve the independence and productivity of older persons; and
• Assisting families and other caregivers as they face decisions about declining capacity, independence, availability of support services, and end-of-life decision-making.
Using an interdisciplinary approach to medicine, geriatricians commonly work with a coordinated team of nurse practitioners, geriatric psychiatrists, medical and surgical specialists, physician assistants, pharmacists, social workers, physical and speech therapists and others. The geriatric team cares for the most complex and frail of the elderly population.
WHO ARE THE PATIENTS THAT NEED GERIATRIC CARE?
Another common question is, “Do all patients need a geriatrician, just as most children regularly see a pediatrician?” The answer is no. Both work force realities and patient needs mean that a small portion of the Medicare population should access a geriatrician. Two discrete categories of beneficiaries need this access.
Approximately 15 percent of community dwelling Medicare beneficiaries need access to a geriatrician or geriatric services provided by a primary care physician.6 In addition, residents of nursing homes and other congregate care facilities need access to quality, geriatric care.
The first category of non-institutionalized Medicare beneficiaries is comprised of seniors with multiple, complex chronic conditions. For these individuals, standard treatment for any one disease is not wholly appropriate given the complexity of interactions between their conditions and the aging process itself. The data suggests that frail elderly patients who are high utilizers of health care services lack adequate access to quality, geriatric care.
Twenty percent of the Medicare population has at least five chronic conditions, accounting for two thirds of total program spending.2 These beneficiaries see on average 14 different/unique physicians in a year, have about thirty-seven office visits, and fill numerous prescriptions.7 Fifty-five percent of these beneficiaries experience an inpatient hospital stay compared to five percent for those with one condition or nine percent for those with two conditions.7 Finally, average annual prescriptions filled increased from 3.7 for all people studied with no chronic conditions to 49.2 for people with five or more chronic conditions.7
Individuals with five or more chronic conditions represent a large portion of a geriatrician’s patient base. Geriatricians provide care coordination services to these patients based on their need for extensive family and patient telephone consultation, heavy pharmacological usage, and high need for transitional care as these patients move from different settings in the health care system.
Per capita spending and inappropriate utilization grows commensurate with a beneficiary’s number of chronic conditions. For instance, beneficiaries with greater numbers of chronic conditions run considerably higher risk of hospitalizations for medical conditions that should have been treated on an outpatient basis before they got to a stage requiring hospitalization.8 Access to quality, geriatric care could decrease inpatient utilization, thus decreasing costs to Medicare and improving beneficiary quality of life—all through the delivery of well coordinated clinical and social support services.
A vignette of a typical geriatric patient is provided below. All too often, these patients fall through the cracks of our health care system.
An 87-year old woman is brought into a geriatrician’s office by her daughter. The daughter is concerned about her mother’s health, ability to drive and to live alone. Since her husband’s death a few months ago, the patient has experienced a decline in her ability to care for herself. She has been behind in her bills, has been skipping meals, and recently had an automobile accident. She has been unsteady on her feet and reports having fallen several times over the last several months. Unwashed laundry in her home smells of urine. She sees several physicians for her arthritis, heart and lung diseases and takes several prescription medications from each physician. The daughter is unsure about whether her mother is actually filling the prescriptions or taking the medications. The daughter senses that, through better-coordinated care, her mother may be able to stay in her home and improve her physical health.
The second category of geriatric patients is residents of long-term care facilities. These patients already receive some assessment and care coordination services, as mandated by federal law. While these services could be enhanced, in comparison to the outpatient setting these patients do benefit from the availability of assessment and care coordination services.
THE BENEFITS OF GERIATRIC CARE
Another important question for policy makers relates to the model of geriatric care. Are there proven benefits of geriatric care?
Over the past ten years, peer reviewed literature has strongly supported geriatric care systems. Some of these innovative care delivery models include: the use of geriatric assessment, ongoing care coordination, the use of a physician-directed multidisciplinary team and a holistic approach to patient care that involves clinical, psycho-social and environmental follow-up.9,10
Peer reviewed studies have demonstrated the following benefits of geriatric care:
• Preservation of physical function or slowing of decline;
• Dramatically increased patient and family satisfaction;
• Decreased time spent in an inpatient setting such as a hospital or nursing home;
• Improved social functioning in the community;
• Decreased rates of depression;
• Increased access to social support services; and
• Reduced disability.
These benefits are significant when delivered to the most complex and frail of the elderly population. Geriatric medicine promotes wellness and preventive care, with emphasis on care management and coordination that helps patients maintain functional independence in performing daily activities and improves their overall quality of life. As our nation ages and the baby boom population demands greater health care services, these benefits will be critical to maintaining productivity and an independent lifestyle.
Acknowledgments
The American Geriatrics Society (AGS) acknowledges those who assisted in the preparation of this report. We thank Ms. Jane Horvath, an independent consultant in health care policy, and Ms. Susan Emmer, long-time AGS policy consultant, for their assistance in drafting the report. Several former and current AGS and Association of Directors of Geriatric Academic Programs (ADGAP) Board members reviewed and commented on the report. They include AGS executive committee members: Drs. Richard Besdine, Paul Katz, David Reuben, Meghan Gerety, and Jerry C. Johnson, and ADGAP Board member Dr. John Burton. In addition, Dr. Gregg Warshaw, past AGS and ADGAP President, and Dr. Elizabeth Bragg, co-investigator of the ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine, contributed to this report.
The American Geriatrics Society is a nationwide, not-for-profit association of geriatric health care professionals dedicated to improving the health, independence, and quality of life for all older people. The AGS promotes high quality, comprehensive, and accessible care for America’s older population, including those who are chronically ill and disabled. The organization provides leadership to health care professionals, policy makers, and the public by developing, implementing, and advocating programs in patient care, research, professional and public education, and public policy.
The Association of Directors of Geriatric Academic Programs was formed in the early 1990s to provide a forum for academic geriatric medicine divisions and program directors. Its purpose is to foster the enhancement of patient care, research, and teaching programs in geriatrics medicine within medical schools and their associated clinical programs. ADGAP is affiliated with the American Geriatrics Society in New York City and shares offices and staff with the AGS.
The Empire State Building, 350 Fifth Avenue, Suite 801, New York, New York 10118, (212) 308-1414; www.americangeriatrics.org.
