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

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.
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