More Geriatricians Will Not Solve the Geriatric Care Crisis

About every 6 months another article will come out crying out for the need for more geriatricians to address the "the Silver Tsunami" or deluge of more elderly and oldest of the elderly. The following borrowed from The Music Man can be used as a guide to write your own media piece, or perhaps you can use it to see why media efforts often paralyze the needed response in ways that can prevent the restoration of basic access to care.


Trouble in River City Due to Too Few Geriatricians and Lack of Geriatric Training

A good opening for such an article (Few Young Doctors NPR) is to get quotes from small town people about their needs. Soon there is a Statement of Need indicating that there are only a few geriatricians in the state - a state with great and growing needs for geriatricians, nurses and therapists. There is often an implication that the need is for those who know how to care for this population, but there are many holes in the arguments:
  • Geriatricians are the most poorly distributed primary care providers. About 75% are found concentrated in Super Center or Major Center zip codes where 33% of the population is found and 30% of the elderly are found. These are among the highest cost of living and cost of health care areas in the US - areas largely suitable for the elderly due to high cost of living and highest cost of housing. Internal medicine and pediatric primary care choice results in 70% concentrated in Super or Major Centers with family medicine at only 30 - 35% inside of physician concentrations. (Physician Distribution By Concentration Studies)
  • Only family medicine matches up with the distribution of the elderly or the general population. Family practice positions filled by MD, DO, NP, and PA distribute equitably and regardless of concentrations of income, physicians, housing costs, etc. This is why family physicians are three times more likely to be seen by an elderly patient. This was recorded by Ferrer in national studies.  Family docs are 36% found where 40% of the US population is found in 2621 counties lowest in concentration. FM increases in importance in the places where other specialties shrink away.
  • Geriatrics fails most in distribution to the elderly for reasons most important to understand. The main reason is that Medicare and Medicaid payment plans pay too little for office, cognitive, basic services. The second reasons is that geriatric care is most complex and time consuming because of the patient population. This means that geriatrics often has to have outside supplementation from a facility, academic setting, grant, or other source. Supplementation is not going to come from lowest paid facilities where care is needed. The new Medicare regulations will make this even worse. 
  • Geriatric practice requires supplementation for survival. Those who run fellowships need the fellows to help with services. Students of all types (pharmacy, nursing, social work, mental health) help prop up geriatric training and geriatric care. The bigger and academic hospitals support efforts when these are important to getting patients out of the hospital sooner.
  • Nurses and therapists follow the distribution of facilities - facilities being closed by current health policy. Therapist numbers also are set in place by payment policies. Regulations and payments have restricted the number and distributions of therapists.

About the Boys Band Solution with More Geriatricians Trained in More Geriatric Fellowships

There Is Often the Assertion that the Current Workforce Is Inadequately Prepared for Geriatrics and the Silver Tsunami
  • Surveys of residents often reveal that they feel inadequate in one or more areas. This is also perpetrated by the institution and faculty, especially those who have not been outside institutions. If I want to justify training, all I have to do is ask residents - which is what family medicine did to attempt to justify a 4th year of training. Fortunately the reality of an additional year and more debt for no more payment or income took hold. Procedural training may well require academic return for updates. Cognitive services have different requirements involving experience, continuity, and learning outside of the walls of the practice.
  • Experienced physicians in practice who have had time outside to reflect about learning after formal training often have a different response. A major myth of training is that it takes years of academic training or a fellowship to prepare for a career in a certain specialty. What may be true for highly technical areas may not be true for the generalist areas. 
  • Geriatric training that is optimal requires that the clinician be the one to make the clinical decisions plus the care of elderly patients. The optimal training also prepares trainees on the same or similar patients as you will have in practice. Also training should be specific to the team you will have in practice and the resources in your practice community. In other words, training really begins when you begin practice. On your own working with a team in a practice, you can learn specific to the practice and patients and community. Nurses noted the difference in residents after a few months of a rural rotation. They left as residents and came back as physicians. 
  • Preparation and training is about complex encounters with the elderly over decades of time - not a few months or a year or two of training. Osler knew the value of the experienced practitioner when he established (or got credit for) formal graduate medical education one hundred years ago. The experts have long forgotten this.
  • Training can facilitate preparation, but complex care demands experience. Training in an academic center does not necessarily prepare graduates for the complexity of the care at sites where the elderly are concentrated and are most in need of care. 

Growing old gracefully is noted to be all about being able to adapt to changing life and health situations. Growing as a physician requires life-long learning applying what you learn to the changing life and health situations of patients.

Retention in Primary Care, Where Needed, and in Continuity Requires Payment Power

One of the best interventions for geriatric care is to keep the physician supported and active in local practice. The design must work to retain continuity providers who understand their elderly patients as well as their families and local resources.

This requires much better support and much better reimbursement than the Medicare and Medicaid payment designs 1980 to 2020. To illustrate how bad the thinking was, Young Physicians were paid less by the new Reagan Design of 1983, the one that also brought us DRGs. Nurse practitioners and physician assistants paid less has also been a bad idea, especially for primary care and care where needed. Inadequate payment leads to higher turnover between primary care practices and away from primary care. This is best seen in the twice as high turnover rates of NP and PA compared to primary care docs although there is little reason to think that primary care physicians are immune to this with the changes of the last few years.

The Specialties Most in Demand Are Defeated By Payment

The rapid growth of the elderly and of the oldest of the elderly generates the most demand by 2030 - 2040 in the areas of primary care, mental health, general medical specialties, and general surgical specialties. These specialties are all stagnant due to payment design that sends trainees to more fellowships and lesser distribution - and to locations away from the elderly.

The Council on Graduate Medical Education in the COGME 21st Report has noted the changing demographics and the lack of workforce response, issuing a priority need for the nation in the specialties of Family medicine, Geriatrics, General internal medicine, General surgery, High priority pediatric subspecialties, and Psychiatry. These are also specialties providing the services that are increasing the most in demand from the Silver Tsunami. The current payment design prevents training from resolving these deficits of workforce.

  • Payment design prevents the choice of FM - stuck at 3000 graduates a year since 1980. FM has long set the mark in retention within a specialty after training, but is eroding as ER, urgent care, and hospitalist careers have captured 20% of family physicians so far and increasing. More likely is that FM loses 25% to inactive or part time and 25% to careers not in family medicine. 
  • Internal medicine training  has totally failed for the purpose of more general internal medicine as less than 15% find their way to adult and elderly care. 
  • Geriatrics predominantly depends upon IM and FM graduates and requires the costly additional year or two. Since this does not result services with higher payment and it results in more complex care, geriatric expansions are prevented. Students with higher and growing debt have much better choices.
  • General surgery and the other general surgical specialties are also prevented by payments much higher for those completing one or more fellowships, fellowships which also reward their institutions nicely. The facilities and counties in need of general specialties are prevented from such workforce by payment plus training designs. General surgical specialties are important in trauma response, which is defeated across the nation by payment plus training design.
  • Psychiatry is also most complex and least paid and requires 4 years of training for a career of poor support by payment design.

Pediatric subspecialties have also had problems arising from long training and very little increased reward.

Turning to the Experts to Play the Music Using Quotes

But remember, sometimes the experts do not know how to play the tune that is a fit for the people in need of geriatric care. There are ways to do geriatric training that can make a difference.

Methods of Community Based Geriatric Training 

Real training in any area such as geriatrics requires that trainees be in charge of the patient and follow them in continuity settings over time learning from them. They must learn about patient care involves the local team and local health resources.

  • Best training involves a Project Echo type linkage (New Mexico telehealth) to bring expertise to the patient and their clinician in the broad range of special areas. 
  • Also a roving geriatric consultant that comes out where care is needed can facilitate care but these Area Health Education Center AHEC-based approaches were killed along with other outreach programs.
  • Ideally the combination would work for a state or region. The combination of in person and telehealth can combine advantages and minimize disadvantages.

Longing for the Way Things Should Be Anecdotal Closing

As we close with the Barbershop Quartet we can consider what once was with a great longing for times past. 

At one time Medicare and Medicaid was helping. From 1965 to 1980 the gains in primary care and basic services and small hospitals resulted in improved health access for the elderly and for tens of millions of Americans behind by design. The gains were specific to the areas where poor and elderly patients were concentrated - allowing small hospitals and small practices to care for those covered and those not covered by insurance.

From 1980 to 2020 the M & M design (CMS, Medicare and Medicaid) the M and M funds have found other channels and the original access focus has been lost. This set in motion a process of shrinking access through closures of small practices and small hospitals with worsening access for elderly, poor, veterans, fixed income, working poor, rural, underserved, and other populations concentrated where care is needed - where payment design pays the least or supports local practice the least. 

An author can utilize numerous anecdotal stories to punctuate the need or to praise a geriatrician. Some local people can be quoted that they would not know what to do without one - the few that can drive an hour and a half for care. But the problems of older patients and care for the poor remains.

Local people where care is needed should worry more about closure of the local ER or a primary care office or two or three. The combination of lowest payments for cognitive services by government and by insurance, cuts in payments (Medicaid), closures of practices and facilities, poor ratings of local practices because of the patients that they care for, and rapidly higher cost of delivery due to regulation is likely to have many adverse effects specific to his needs and the needs of his family.

Also their town is being taken down by policies that have driven off local pharmacies (mail order), hospitals (one per month closed), and practices. Least payments for basic services result in declining economic impact for areas where basic services are predominant. This insures lesser economics, jobs, situations, and social determinants - the real drivers of health outcomes. 

Meanwhile towns not like their town are getting 36 million dollars to train geriatric workforce that will never be able to serve them - because of payment design.

The main problem for River City, is that the design prevents the cash for the merchandise services needed to deliver complex local care.

Purcell also goes on to note how taking no prisoners negotiations have been breaking the bank of small practices, primary care, mental health...

If your rebuild payment and prevent increased costs of delivery due to regulation, you just might be able to rebuild primary care, mental health, geriatric care, and basic services. Without rebuilding payment, there is nothing that training or anything else can do. This does not mean that more billions will go for more training that will fail to do anything other than what the current payment design allows, minus the cost and consequence of more regulation.

Recent Posts and References 

Rallying One Hundred for Health Access Not MACRA


The Ultimate Government Health Care Paradox - Government must facilitate better EHRs and better health access, not prevent them.
Talk About Unpaid Stressed and Abused For Decades - a journalist wakes to health care abuses, but then there is primary care. 
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Population Health from Above or Below  - population health must not be another new crop to harvest for consultants, associations, and institutions. In must remain about the health of the population, not the wallets of those already doing best.
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric





Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Comments


  1. International Journal of Internal Medicine and Geriatrics is an online, open access, peer-reviewed journal deals with care of older persons, specialists in geriatric medicine, geriatric psychiatrists, and members of other health disciplines with a focus on gerontology.Journal of Internal Medicine and Geriatrics

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