Annals of Long Term Care

This is the second section of the policy statement. Part I appeared in the March issue of the Journal. The final section will appear in the May issue.

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.

THE GERIATRIC TRAINING GAP—IS THERE A SHORTAGE?

Today, there are approximately 7,600 certified geriatricians in the nation.1 While estimates of potential needs for geriatricians vary, most experts agree that our nation faces a severe and worsening geriatric shortage, both in the area of clinical and academic geriatrics.

The Alliance for Aging Research estimated that another 14,000 geriatricians are currently needed to adequately care for the elderly population.2 By 2030, they estimate the need to have 36,000 trained geriatricians.2 A 1987 IOM study estimated the need for clinical geriatricians in 2000 to range from 9,000 to 29,000 depending on the mode of geriatric practice and other factors involving the quality of care delivered.3 Based on both of these assumptions, the United States lags far behind in training an adequate supply of clinical geriatricians to care for the nation’s frail elderly.

The supply of academic geriatricians is also insufficient. There are approximately 900 full time equivalent (FTE) academic geriatricians working in U.S.