Shortage of Geriatric Health Care Professionals
Special Committee on Aging, United States Senate
Statement for the Record Submitted by the American Association for Geriatric Psychiatry
2/27/2002
The American Association for Geriatric Psychiatry (AAGP) commends the Special Committee on Aging for holding this hearing to focus attention on the shortage of health care professionals with the specialized training necessary to identify and treat the health care problems of older Americans. AAGP is a professional membership organization dedicated to promoting the mental health and well-being of older people and improving the care of those with late-life mental disorders. Our membership consists of over 2000 geriatric psychiatrists as well as other health care professionals who focus on the mental health problems faced by senior citizens.
Geriatric psychiatry is a relatively new sub-specialty of psychiatry. It has developed in response to the uniqueness of mental disorders of late life that, coupled with the distinct characteristics of the late stages of life, result in specialized needs of older adults with mental health problems. The field of geriatric psychiatry is based on a discrete, definable, and rapidly growing body of scientific knowledge that has evolved over the past several decades, through the efforts of an international community of clinicians and researchers.
First recognized by the American Board of Psychiatry and Neurology (ABPN) in 1991, our sub-specialty includes physicians who have completed medical school, four years of post-graduate residency training in psychiatry, and then a fellowship in geriatric psychiatry of one or two years (post-graduate residency years five and six) during which they receive intensive training in the biological and psychological aspects of normal aging, the psychiatric impact of acute and chronic physical illness, and the biological and psycho-social aspects of the pathology of primary psychiatric disturbances of older age. While residency training prepares them for a career in general psychiatry, a fellowship in geriatric psychiatry gives them in-depth experience in the diagnosis and treatment of mental health disorders in older adults. In addition to passing a certification exam in general psychiatry, they must also pass one in geriatric psychiatry.
Geriatric psychiatry is also a relatively small sub-specialty. Statistics kept by ABPN indicate that it issued 83 certificates in geriatric psychiatry in 2000 (compared with 1097 for psychiatry). Between 1991 and the end of calendar year 2000, ABPN issued a total of 2,508 certificates in our sub-specialty – which is a close indicator of the total number of board-certified geriatric psychiatrists nationwide.
As the members of the Committee are well aware, older Americans are becoming a larger and larger proportion of our nation’s population. According to the U.S. Census Bureau, the number of individuals age 65 and older grew by 74 percent between 1970 and 1999 – from 20 million to almost 35 million. The median age of the population has increased significantly from 28 years in 1970 to almost 36 years of age in 1999. These trends will accelerate further as 76 million “baby boomers” attain age 65 between 2010 and 2030. By 2030, older adults will account for 20 percent of the total U.S. population – up from 13 percent in 2000. Within this cohort, persons 85 years and older comprise the most rapidly growing segment of the U.S. population.
As the population ages, the number of older Americans experiencing mental problems will almost certainly increase. Nearly 20 percent of those who are 55 years and older experience mental disorders that are not part of normal aging. The most common conditions, in order of prevalence, are anxiety, severe cognitive impairment (such as that caused by Alzheimer’s disease), and mood disorders (such as depression). In addition, the number of older adults seeking treatment for their mental problems could increase in future years as the stigma associated with mental disorders fades with the passing of earlier generations.
As geriatric psychiatrists are already in short supply, these demographic and social trends portend an intensifying shortage in the future -– even if the number of physicians who train in geriatric psychiatry increases significantly over the next 10 to 20 years. How many geriatric psychiatrists are needed? A somewhat dated study by the Institute on Aging indicated that 400-500 academic geriatric psychiatrists and another 4,000 to 5,000 geriatric psychiatrists active in patient care would be needed by 2010.1 More recent analysis indicates that 1,221 M.D. faculty will be needed to provide adequate training in geriatric psychiatry in the short term (defined as the next 10 years).2
Meeting the mental health needs of older Americans in the future will be challenging in light of these trends. However, as noted in an article recently published in the American Journal of Geriatric Psychiatry3, there are a number of encouraging developments:
o First, the field of geriatric psychiatry has made substantial progress in the development of consensus recommendations and practice guidelines for the diagnosis and treatment of specific conditions, such as late-life depression and Alzheimer’s disease, in older Americans. This has permitted health care professionals in primary care and other specialties, and their patients, to benefit from the specialized knowledge and expertise contributed by geriatric psychiatrists. The recommendations and guidelines also identify the types of cases and the circumstances in which a patient should be referred to a geriatric psychiatrist.
o Second, general psychiatrists are in a position to utilize the scientific and therapeutic advances made by geriatric psychiatry and are seeing a greater proportion of geriatric patients in their practices. In 1996, 18 percent of general psychiatrists had a geriatric caseload in excess of 20 percent, an increase of 148 percent over 1982 levels and of 25 percent over 1989 levels.
o Third, because the Psychiatric Residency Review Committee of the Accreditation Council for Graduate Medical Education has recommended that residency programs in general psychiatry incorporate some training experience with geriatric psychiatry, recently graduated general psychiatrists may be more likely than their predecessors to have some knowledge of the unique aspects of diagnosing and treating geriatric populations.
What can Congress do to improve access to mental health services for older Americans now and in the future? Since Medicare provides health care coverage to the great majority of Americans who have attained age 65, its policies can have a significant impact on access to care for this population -– not only through how much it pays for mental health services and what it does and does not cover, but also through its policies regarding payment for the costs associated with graduate medical education (GME).
Under the Medicare fee schedule for physicians’ services, fees are set based on the amount of physician work and practice expenses that are involved in providing a particular service to the typical adult patient -– not the typical geriatric patient. Because the amount of work effort involved in diagnosing and treating a geriatric patient is often significantly greater than for a non-geriatric adult, this approach results in under-compensation for the amount of work involved. Congress should consider encouraging the Centers for Medicare and Medicaid Services (CMS) to create a coding modifier that would permit those physicians to receive higher payments for treating geriatric patients who require a particularly intense level of physician effort to receive higher payment.
Gaps in the types of services Medicare covers are not only a detriment to geriatric patients, but also create financial disincentives for physicians who are considering entering specialties in which their practice would be limited to treating geriatric patients. Older Americans frequently have chronic and disabling health care conditions that require constant monitoring and a continuing course of treatment. Even when these conditions are primarily physical, they often have a significant impact on the mental health of the individual. Although coordinating the care of such patients often entails significant involvement of family members, other personal care givers and other health professionals, Medicare generally does not cover or pay for care coordination services because they do not involve a “face-to-face” encounter between the physician and the patient, but instead require time-consuming contacts, including telephone communications with other care givers -– including family members and other health care professionals. S. 775, introduced by Senator Blanche Lincoln, would provide Medicare coverage of care coordination services for a subset of Medicare beneficiaries with serious and chronic disabling conditions. Medicare reimbursement for such services will recognize the value of these services and make fields such as geriatric medicine and geriatric psychiatry more attractive to physicians in the future. AAGP commends Senator Lincoln and the co-sponsors of her bill for their efforts to close this gap in coverage, and we urge those on this Committee who have not yet co-sponsored S. 775 to do so.4
Current Medicare policy on graduate medical education (GME) may also discourage training more physicians in geriatric sub-specialties in the future. The Balanced Budget Act of 1997 (BBA) caps the number of full-time equivalent residents and fellows it will recognize (and make payment for) at the number of residents and fellows each teaching hospital had in 1996. While these facility-specific caps permit each hospital to shift the number residents and fellows it has among the different specialties, this is a “zero sum” game that may make it difficult to increase the number of residents and fellows in accredited geriatric programs. S. 775 and a bill introduced by Senators Tim Hutchinson and Larry Craig -- S. 1362 -- would both address this potential problem by allowing teaching hospitals to add a limited number of training positions in geriatric medicine and geriatric psychiatry5 without reducing the number of residents and fellows in other fields. AAGP supports these initiatives and urges other members of the Committee to do so.
Finally, arbitrary and unfair limits on what the Medicare program will pay for outpatient mental health services – which require beneficiaries to bear 50 percent of the cost of these services – create real financial barriers to access to needed care. While AAGP recognizes that elimination of this policy carries a substantial budget price tag, it believes that this change is as important to modernizing Medicare as the addition of a prescription drug benefit. When left untreated, mental disorders are associated with poorer physical health, excess disability, heavier utilization of non-mental health care resources, and increased mortality.
While Medicare clearly plays a major role in determining access to mental health services for older Americans and in shaping the economic incentives for physicians and other health care professionals to specialize in treating geriatric patients, the Federal government can promote the training of more geriatric specialists and the appropriate treatment of geriatric patients in other ways as well.
For example, under section 753 of the Public Health Service Act, the Department of Health and Human Services funds geriatric education centers, geriatric education and training projects, and geriatric academic career awards to promote the development of academic geriatricians. Additional funding for these activities would increase the number of physicians involved in geriatric research and in training future generations of health care professionals to meet the special needs of older Americans. S. 1362 would authorize increased funding under section 753 and raise the maximum geriatric academic career award from $50,000 to $75,000 a year. AAGP supports this initiative, and encourages others on the Committee to do so as well.
Likewise, the Agency for Healthcare Research and Quality (AHRQ) provides funding for the development of practice guidelines that help to educate health care professionals about the appropriate ways to diagnose and treat specific conditions. As noted earlier, guidelines have already been developed on late-life depression and Alzheimer’s disease, and their dissemination has increased the awareness of many health care professionals on these matters. Additional guidelines should be developed for other geriatric mental health, such as anxiety and sleep disorders, as well as late-life alcohol and drug abuse that often accompanies other mental disorders. Existing guidelines will also need to be revised as advances in medical research lead to new knowledge that should be rapidly disseminated and translated into improved clinical care. Congress could play an important role in seeing that this occurs.
In closing, AAGP would like to thank the Committee for holding this important hearing and focusing greater attention on the shortage of health care professionals with the specialized training necessary to identify and treat the health care problems of older Americans. We look forward to working with the members of the Committee to improve access to mental health care for geriatric patients in the future.
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1. National Institute on Aging, Personnel for Health Needs of the Elderly Through the Year 2020 (NIH Publication 87-2950), Washington, D.C., 1987.
2. Reuben, Bradley, Zwanziger, et al., “How Many Physicians Will Be Needed to Provide Medical Care for older persons? Physician Manpower Needs for the Twenty-first Century,” Journal of the American Geriatric Society, 1993; 41: 560-569.
3. Colenda, Pincus, Tanielian, et al., “Update of Geriatric Psychiatry Practices Among American Psychiatrists: Analysis of the 1996 National Survey of Psychiatric Practice,” American Journal of Geriatric Psychiatry, 1999; 7: 270-288.
4. As of February 13, 2002, Senators Bingaman, Corzine, Graham, Landrieu, Mikulski, Murray, Reid, Rockefeller, and Snowe have co-sponsored S. 775.
5. Due to a technical drafting error, S. 775 does not currently include geriatric psychiatry within the scope of its graduate medical education provisions. AAGP understands that it was Senator Lincoln’s intention to do so and that a new version of the bill will be introduced in the near future.
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