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

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Figure 4.2 Distribution of Certified Geriatric Psychiatrists in the United States, 2001 1 (0.8) The number of certified geriatric psychiatrists 1 per state. The national mean of geriatric psychiatrists per 10,000 population age >75 2 is 1.4 (state ratio in parentheses). Above national mean Same as national mean Below national mean 46 (1.4) 16 (0.7) 6 (0.9) 4 (0.5) 235 (1.4) 1 (0.2) 1 (0.4) 4 (0.5) 26 (1.4) 21 (0.7) 12 (1.3) 5 (1.0) 3 (0.6) 12 (1.0) 101 (1.1) 36 (1.2) 13 (0.6) 26 (1.4) 48 (1.3) 36 (1.0) 75 (1.0) 15 (0.7) 43 (1.3) 13 (0.7) 35 (1.5) 10 (0.6) 35 (1.0) 22 (0.8) 80 (1.4) 81 (1.1) 46 (1.3) 6 (0.5) 20 (0.9) 59 (1.4) 215 (2.3) 19 (0.8) 48 (1.3) 342 (2.9) 4 (0.9) 8 (2.2) 59 (2.5) 81 (1.5) 80 (2.9) 14 (4.1) 12 (1.4) 24 (3.5) 142 (3.3) 20 (2.5) 9 (1.2) 98 (0.7) 1 American Board of Medical Specialities, 2002 2 Census 2000 as compiled by the Administration on Aging Source: IHPHSR ADGAP Database Project, 2002 despite the continued growth of fellowship training programs. It is estimated that from 1998 through 2004 there will be a 34% reduction (from 9,256 to 6,137) of ABIM/ABFP certified geriatricians in the U.S. (Table 4.17). The number of candidates seeking to become certified has been low, but pass rates have been high (90-95%). The APA Survey of Psychiatric Practice Colenda et al., published a review of the findings relative to geriatric psychiatry from the American Psychiatric Association’s 1996 survey of practicing psychiatrists (Colenda, Pincus, Tanielian et al., 1999). For this mail survey, initiated in the spring of 1996, a random sample of practicing psychiatrists was selected. Nine hundred seventy surveys Table 4.17 Projection: Estimated Certified Geriatricians in the United States, 1998-2004 Internal Medicine (IM) and Family Practice (FP) Description Number Total IM/FP CAQs issued from 1988-1998 9256 Total IM/FP CAQs issued after 1998 through 2001 651 Estimated fellowship graduates/CAQs for 2002, 2003 & 2004 (3 years X 260 fellows/year) 780 Estimated Total IM/FP CAQ issued from 1988-2004 10,687 Number of 1988, 1990,1992 and 1994 cohorts eligible for re-certification 8273 Number who did not re-certify from 1988, 1990, 1992, and 1994 cohorts (Estimated rate of re-certification is 45%) 1 4550 Estimated total active IM/FP certified geriatricians in 2004 6137 Estimated reduction in number of certified geriatricians in the U.S. from 1998 to 2004 34% 1 Estimated rate based on experience of re-certification from 1996-2001 Source: IHPHSR ADGAP Database Project, 2001 32
Figure 4.3 Geriatric Caseload for Psychiatrists by Survey Year, American Psychiatric Association Survey of Psychiatric Practice Psychiatrists, % 80 70 60 50 40 30 20 10 0 31.2 46.7 23 61.6 Modified from: Colenda, Pincus, Tanielian et al., 1999 0 1-20 >20 Geriatric Caseload, % 1982 1988-1989 1996 were analyzed, representing a response rate of 70.5%. Data from the 1996 study were compared to previous national surveys from 1982 and 1988-89. For the sub-analysis of geriatric psychiatry, 893 responders were analyzed. Eighteen percent of psychiatrists in this sub-group were classified as having high geriatric caseloads (HGP). This group of psychiatrists had practices with older patients exceeding 20% of their practice population. Fifty-nine percent of this group was classified as having low geriatric caseloads (LGP). The LGP had practices with older patients constituting 20% or less of their patients. Twenty three percent of LGPs reported they did not provide care for older adults (Figure 4.3). Significant demographic differences between the HGP and LGP groups were found. In the HGP there were fewer women psychiatrists (19% vs. 27%), fewer white/non-Hispanics (69% vs. 77%), fewer US/Canadian medical school graduates (67% vs. 81%), and fewer having medical school appointments (50% vs. 59%). Fifteen percent of the HGP physicians had obtained certification in geriatric psychiatry, as compared to 2% in the LGP group. Over time, the surveys revealed a disproportionate increase in minority and IMG psychiatrists who are HGPs; this trend was most significant when comparing the 1988-89 sample to the 1996 sample. The HGPs in the 1996 sample spent proportionally more time in office-based practices, hospital settings, and nursing homes than the LGPs. Medicare payments accounted for a mean of 29% of income for HGPs as compared to 11% for LGPs. Medicare Fees and Compensation of Practicing Geriatricians Medicare is the primary payer for most clinical services provided by geriatricians. Secondary payers (e.g., Medicaid or private supplemental insurance), if available and/or affordable to the patient, cover co-payments and deductibles not paid by Medicare. Medicare’s fee schedule establishes payment amounts to physicians for clinical 39.8 59.1 7.3 14.5 18.1 services. Physicians who participate in the Medicare program may not collect more for a service than the designated Medicare fees, consisting of Medicare payments and allowable co-payments. The amount Medicare reimburses physicians for an office-based service varies by locale. Medicare’s national average fee for a particular service is referred to as the NAA (National Average Allowance). Medicare fees for selected services commonly performed by geriatricians and geriatric psychiatrists are shown in Table 4.18. In some communities private insurance reimbursement rates are significantly higher than Medicare, and geriatricians are at a relative financial disadvantage compared to physicians caring for younger, insured patients. In other locales, Medicare and private insurance fee schedules are similar. In either case, the officebased primary care practice is challenging with respect to reimbursement, requiring highly efficient office organization and visit rates of six or more patients per hour. In 2002, Medicare reduced the average reimbursement to physicians by 5.4%, with further decreases planned over the next several years. Physician organizations are advocating for a reversal of the 2002 and future funding cuts, arguing that further fee reductions threaten access to quality care for Medicare beneficiaries (Pear, 2002). Medicare reimburses geriatricians’ specialized clinical services at variable rates. There is currently no specific reimbursement amount for geriatric assessment in the hospital or the office. Physicians bill for these assessments utilizing standard evaluation and management codes. Also, Medicare reimbursement for psychiatric services is paid at 50% of the allowable charges as compared to 80% for other medical care. In addition, Medicare Part B has limited or no reimbursement rates for other health profession team members. Until the summer of 2000, some hospital-based outpatient geriatric assessment units utilized cost-based reimbursement to hospitals under Medicare Part A to defray the costs of social workers, nurses, and other team members. In cost-based reimbursement, providers are reimbursed at rates based on facility-specific costs as reported on the facility’s cost reports. Since July 2001, hospitals have been reimbursed under a new ambulatory provider code structure for Part A outpatient services. This provides incentives for a higher emphasis on patient volume and procedures than the cost-based system, and has led to the closing of a number of hospital outpatient geriatric assessment services. During the past five years nursing home and home care service reimbursement has increased relative to office-based care, although the allowed overhead associated with nursing home and home care practice is lower than the 50-60% associated with primary care office practice. The 2001 Medical Group Management Association (MGMA) survey of compensation for physicians in private practice (using 2000 data) included only 17 geriatricians. The median annual total income from clinical practice for geriatricians was $141,679. Comparison data for other selected specialties is listed in Table 4.19 (Medical Group Management Association, 2001). As with academic physicians (see chapter 5), geriatricians’ compensation is competitive with other non-procedural specialists, but lags behind physicians in procedural practices. 33
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 and 30: participants. Geriatricians have be
Page 31 and 32: Table 4.8 Medicaid Recipients and P
Page 33: Figure 4.1 Distribution of Certifie
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
Page 81 and 82: Nursing homes and home care experie
Page 83 and 84: 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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