Geriatric Medicine Training and Practice in the United States at the ...

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Table 4.5 Leading Causes of Death and Numbers of Deaths, Age 65 Years and Over: United States, 1980 and 1999 1 LRD – Lower respiratory disease 2 COPD – Chronic obstructive pulmonary disease 3 Renal Disease – Nephritis, nephrotic syndrome, and nephrosis *Source: Centers for Disease Control and Prevention, National Center for Health Statistics, 1980 **Source: Hoyert, Smith, Arias et al., 2001 Utilization of Services The trends in the number of aged Medicare enrollees and federal Medicare expenditures for the aged over the past 20 years are shown in Tables 4.6 and 4.7. Federal efforts to control the rate of growth of these expenditures has centered on complex formulas that control payments to providers and the less successful application of managed care principles to Medicare. Medicaid payments to older adults have also risen significantly during the past 20 years (Table 4.8). The VHA, charged with caring for the nation’s veterans, is the largest health system in the United States with more than 6 million patients. The median age of veterans is 58.3 years; 36.8% of male veterans are over the age of 65 and 1.5% are over the age of 85 (www.va/opa/vetpopbook). The VHA medical care budget in 2001 was over $22 billion (US Department of Veterans Affairs, 2002). In 1999, 25% of office visits to physicians in the U.S. were made by adults age 65 or over (192.2 million visits). This represented 592 visits per 100 persons age 65 or older, as compared to 283 visits per 100 1980* 1999** Cause of Death Deaths Cause of Death Deaths Diseases of the Heart 595,406 Diseases of the Heart 607,265 Malignant Neoplasms 258,389 Malignant Neoplasms 390,122 Cerebrovascular Diseases 146,417 Cerebrovascular Diseases 148,599 Pneumonia and Influenza 45,512 Chronic LRD 1 108,112 COPD 2 43,587 Pneumonia and Influenza 57,282 Atherosclerosis 28,081 Diabetes mellitus 51,843 Diabetes mellitus 25,216 Alzheimer’s disease 44,020 Unintentional injuries 24,844 Unintentional injuries 32,219 Renal Disease 3 12,968 Renal Disease 3 29,938 Chronic liver disease 9,519 Septicemia 24,636 Table 4.6 Aged Medicare Enrollees: 1980-1999 Year (as of July 1st) Millions of People 1980 25.5 1985 28.2 1990 30.9 1995 33.1 1996 33.4 1997 33.6 1998 33.8 1999 33.9 Source: U.S. Centers for Medicare & Medicaid Services, 2000 persons of all ages (CDC, 2001:281). Forty-six percent of office visits made by older adults were to family physicians or general internists; 54% were made to other medical specialists (CDC, 2001:285). Over the past decade, the trend has been for an increasing percentage of ambulatory office visits to occur in non-primary care specialists’ offices. Table 4.9 lists the percentage of ambulatory visits accounted for by older adults to various specialties in 1999. During 1999, hospitalization rates were 120 hospital discharges per 1000 persons of all ages. As compared to the overall population, the hospitalization rate was 1.9 times higher for adults age 65-74, and 2.7 times higher for adults age 75 and over (CDC, 2001: 291). In 1999, in the U.S., more than 1.9 million nursing home beds were available, and the occupancy rate was 83%. The rates of nursing home utilization varied from 11/1000 people age 65-74 to 183/1000 people age 85 or over (CDC, 2001: 306). During 1998, 1.82 million people utilized some type of home health care service, for an overall rate of 70 patients/10,000 people. This rate increased to 407/10,000 people age 75-84 and 885/10,000 for people age 85 or over (CDC, 2001:289). Tables 4.10 and 4.11 show trends in skilled nursing facility utilization and the growth of nursing homes. Table 4.12 lists the number of proprietary, voluntary non-profit, and government owned nursing homes. The majority of nursing home beds are occupied by older adults (Table 4.13). Among older adults in nursing homes, one-half are age 85 or older, 75% are women, and 88% are white. In 1997, Medicare and Medicaid combined were the source of payment for 68% of institutional care (US Center for Health Statistics, 2000). In addition, the VHA operates 137 nursing homes and in 2001 provided treatment to 87,000 nursing home patients (www.va.gov). During the past decade there has been a nationwide rapid growth of assisted living facilities. While definitions of assisted living vary across states, it was estimated in 1998 that 600,000 residents were living in 25,000-30,000 assisted living facilities. The typical assisted living resident is an 83-year-old female requiring assistance with 3 Table 4.7 Medicare Disbursements for the Aged: 1980-2000 Year Hospital Insurance – Part A 1 Medical Insurance – Part B 1 (ending Sept. 30th) (millions of dollars) (millions of dollars) 1980 20,951 8,497 1990 58,503 36,837 1995 100,107 54,830 1996 109,379 57,807 1997 120,239 60,989 1998 118,467 65,118 1999 113,321 67,996 2000 110,142 76,507 1 Beginning in 1998, home health agency transfers were shifted from Part B to Part A. Source: U.S. Centers for Medicare & Medicaid Services, unpublished data, 2001 28
Table 4.8 Medicaid Recipients and Payments to Adults Age 65 or Over: 1990-1998 Year Recipients Payments ($) 1990 3,202,000 21,508,000 1995 4,119,000 36,527,000 1996 4,285,000 36,947,000 1997 3,955,000 37,721,000 1998 3,964,000 40,602,000 Source: U.S. Centers for Medicare & Medicaid Services, 2001 Table 4.9 Ambulatory Visits to Physicians By Specialty, Patients 65 Years and Older Practice Percent Ophthalmology 55.8 Cardiovascular diseases 53.9 Urology 46.2 General Internal Medicine 38.9 General surgery 32.9 Neurology 26.6 Dermatology 25.8 Otolaryngology 24.8 Orthopedic surgery 22.5 General /family practice 20.7 Psychiatry 10.2 OB/GYN 6.6 Source: CDC, NAMCS, 1999 Table 4.10 Skilled Nursing Facilities, 1 1980-1999 Beds/1,000 Year Number Beds Medicare Part A (1,000s) Enrollees 1980 5,155 448 16.0 1990 9,008 512 15.2 1995 13,281 657 17.7 1996 14,177 672 17.8 1997 14,860 685 18.0 1998 15,037 723 18.8 1999 14,913 837 21.6 1 Facilities and beds certified under Medicare. Source: U.S. HCFA, 2001 and U.S. Census Bureau, 2001 Table 4.11 Nursing Homes and Related Care Facilities, 1 Selected Characteristics, 1985-1999 Year Number Number of Beds/NH Occupancy of Homes Beds (1,000s) Rate 1 1985 19,100 1,624 85 91.8 1995 16,700 1,771 106 87.4 1997 17,000 1,821 107 88.4 1999 18,000 1,965 109 82.8 1 Nursing and related care homes with 3 or more beds and routinely provided nursing and personal care services. Excludes places providing only room and board and places serving specific health problems. Source: U.S. NCHS, National Nursing Home Survey, 1999 ADLs (Citro & Hermanson, 1999). The extent of physician visits to and the supervision of assisted living residents has not been documented. The use of home health services by older adults and the enrollment of aged patients in hospices continue to grow, as shown in Table 4.14. The VHA operates 73 comprehensive home-care programs (U.S. Department of Veterans Affairs, 2002). Physician Workforce Trends The most recent estimates of the number of geriatricians and geriatric psychiatrists required to provide medical care to older Americans were developed in the early 1990s (Reuben, Zwanziger Bradley et al., 1993). Their study considered demographic and economic factors as well as the need for all non-surgical physicians. They projected that primary care physicians would provide 62-69% of all care to older adults, with the remaining care provided by geriatricians and medical specialists. Geriatricians spent about 43% of their time in direct clinical care (remaining effort includes administration, research, and teaching). Reuben’s model took into consideration that the need for geriatricians would be closely related to U.S. economic growth, with fewer geriatricians required in a “slow-growth economy” situation. “Geriatricians are perceived as a luxury item. That is, in times of Table 4.12 Ownership of Nursing Homes 1999 Type Number Number of Beds of Homes (thousands) Proprietary 12,000 1,291 Voluntary Non-Profit 4,800 523 Government and other 1,200 151 Source: U.S. NCHS, National Nursing Home Survey, 1999 Table 4.13 Nursing and Related Care Homes, 1 Residents 65 Years and Older, Selected Characteristics, 1997 Total Patients: 1,465,000 Characteristic Percent Age: 65-74 years 13.5 75-84 years 36.1 85 years and over 50.4 Sex: Male 25.4 Female 74.6 Race: White 88.4 Black 9.4 Hispanic 2.2 Type of Nursing Care: Skilled care 47.8 Intermediate care 47.8 Residential care 3.6 Source of Payment: Medicaid 38.2 Medicare 29.7 Private Sources 28.2 Other 3.8 1 Nursing and related care homes with 3 or more beds and routinely provided nursing and personal care services. Excludes places providing only room and board and places serving specific health problems. Source: U.S. CHS, Advance Data, 2000 29
Page 1 and 2: The Association of Directors of Ger
Page 3 and 4: The Association of Directors of Ger
Page 5 and 6: National Oversight Panel M. Brownel
Page 7 and 8: The American Geriatrics Society . .
Page 9 and 10: List of Tables and Figures Chapter
Page 11 and 12: Figure 7.4 Figure 7.5 Figure 7.6 Fi
Page 13 and 14: the fastest acceleration in 12 year
Page 15 and 16: esidency review committee provide a
Page 17 and 18: Project Methodology National Oversi
Page 19 and 20: Table 2.2 Secondary Data and their
Page 21 and 22: 3 Historical Development of Geriatr
Page 23 and 24: $195.9 million NIA extramural suppo
Page 25 and 26: important political decision by the
Page 27 and 28: 4 The Practice Of Geriatric Medicin
Page 29: participants. Geriatricians have be
Page 33 and 34: Figure 4.1 Distribution of Certifie
Page 35 and 36: Figure 4.3 Geriatric Caseload for P
Page 37 and 38: Table 4.19 Total Annual Compensatio
Page 39 and 40: panel felt were most important for
Page 41 and 42: 5 Academic Geriatrics Programs in U
Page 43 and 44: Table 5.1 Academic Geriatric Progra
Page 45 and 46: Table 5.1 Academic Geriatric Progra
Page 47 and 48: Figure 5.1 Number of Years as Acade
Page 49 and 50: Table 5.4 Women and Minority Facult
Page 51 and 52: Figure 5.6 Physician Faculty Vacanc
Page 53 and 54: Table 5.7 Sources of Geriatric Prog
Page 55 and 56: Table 5.9 Allopathic Medical School
Page 57 and 58: Table 5.11 Allocation of Faculty an
Page 59 and 60: Table 5.12 Allocation of Faculty an
Page 61 and 62: Table 6.1 Geriatric Medicine and Ge
Page 63 and 64: Table 6.4 Sources of Financial Supp
Page 65 and 66: investigators receive $60,000 of su
Page 67 and 68: Table 6.7 Program Directors Reporte
Page 69 and 70: Table 6.10 Program Directors Report
Page 71 and 72: Fellowship Training Activities for
Page 73 and 74: Table 6.16 Fellowship-Trained Geria
Page 75 and 76: 7 Preparing All Physicians To Care
Page 77 and 78: General Internal Medicine The 1999
Page 79 and 80: Trends in GIM Residency Programs Re
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Nursing homes and home care experie
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Geriatric Education Retreats (GERs)
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and GIM programs a mean of 2.8 avai
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chapter. The goals of these student
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This program awarded 20 two-year, $
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Conclusion This report summarizes r
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Bureau of Health Professions, HRSA,
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U.S. Centers for Medicare & Medicai
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APPENDIX A. Research Focus of Curre
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APPENDIX C. RESEARCH FOCUS OF NATIO
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APPENDIX E. SELECTED GERIATRIC MEDI
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Appendix F. Geriatric Medicine and
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Page 107 and 108:
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Helen Hoenig, M.D., M.P.H., Duke Un
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APPENDIX H. RESIDENCY REVIEW COMMIT
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Appendix H. Residency Review Commit
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Association of Directors of Geriatr
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