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

panel felt were most important for measuring quality of care provided
to medically vulnerable older persons.
The full set of quality indicators for these conditions were
published in the fall of 2001 (Wenger, Shekelle, Davidoff et al., 2001).
This publication also reviews the evidence supporting the selected
quality indicators for half of the conditions: dementia, end-of-lifecare,
falls and mobility, heart failure, medication management,
osteoarthritis, osteoporosis, pain management, pressure ulcers,
pneumonia, and urinary incontinence. Papers describing the evidence
related to quality indicators for the other eleven conditions are
available on the American College of Physicians-American Society
of Internal Medicine website (www.acponline.org/sci-policy/).
The ACOVE project team developed instruments to test the quality
indicators in actual clinical practice, utilizing data abstracted from the
medical record, the patient (or a proxy), and administrative data.
Preliminary results suggest that physicians perform well when
addressing common internal medicine topics, but do not attain the
quality indicators for the selected geriatric syndromes. The next phase
of the ACOVE project will test an intervention to improve physician
performance in three geriatric syndrome areas; cognitive
impairment/dementia, falls, and urinary incontinence.
Reynolds Geriatric Education Centers
Several of the ten Reynolds Education Centers funded in July 2001
have educational components directed to practicing physicians. (See
Table 5.9 in chapter 5 for a list of funded centers.)
Geriatric Interdisciplinary Teams in
Practice Initiative
In 2000 and 2001, the John A. Hartford Foundation awarded four
grants to support the development and evaluation of diverse
approaches to using teams in the clinical care of older adults. These
projects are located at the Rush-Presbyterian-St. Luke’s Medical
Center, Chicago, Illinois, Project Director, Steven K. Rothschild;
PeaceHealth Oregon Region, Center for Senior Health, Eugene, Oregon,
Project Director, Ronold D. Stock; University of Colorado Health
Sciences Center, Denver, Colorado, Project Director, Eric Coleman; and
the Group Health Cooperative of Puget Sound, Seattle, Washington,
Project Director, Edward Wagner (Regenstreif, Robbins, Langston et
al., 2001).
Implications
The aging of the U.S. population will have a major impact on the
practice of medicine and future health care costs. Current cost
containment strategies are inadequate to address this demographic
trend. The principles of geriatric medicine practice that have
developed over the past 50 years, if widely applied to the care of older
Americans, provide an opportunity to deliver quality, cost-effective
care for the well elderly and for older adults with chronic illness. In
addition, investment in research that leads to substantial advances
in the prevention and treatment of the diseases that result in the
greatest functional loss among the old is essential.
Medicare reimbursement is the single most influential force
shaping medical practice in the U.S., accounting for 26.7% of
physician income in 2000 (AMA, Socioeconomic Monitoring Survey of
Physicians, 2002). Medicare, in large part, remains a traditional
indemnity payer, with incentives skewed toward conducting
procedures and providing technical care associated with hospital
practice. Disproportionately large co-pays for psychiatric services
and limited compensation for outpatient evaluation and management
services create a disincentive for physicians to provide primary care
or comprehensive assessment services to older adults. This results
in the common phenomenon of older patients seeking care from
several medical or surgical sub-specialists and receiving limited care
coordination from their primary care physicians. Geriatricians limit
their practice to older adults, and thus receive the majority of their
compensation from Medicare. Many of the time-intensive services
geriatricians provide to older adults and their families are inadequately
reimbursed. The growing gap between Medicare reimbursement and
the actual costs of delivering quality medical service seriously affects
the health care currently provided to our elders and certainly in the
future will discourage young physicians from considering a career in
geriatric medicine.
Applying the principles of managed care to Medicare is an
experiment in progress directed at reversing these disincentives to
coordinated care. For geriatricians, managed care offers the promise
of realigning incentives toward preventive care, providing increased
support to the frail elderly, and integrating acute and long-term care.
Geriatricians are also in high demand as physician leaders of many
managed Medicare insurance plans, but existing economic forces in
most communities are making managed Medicare programs difficult
to sustain. Future Medicare reform, driven by the need to contain
federal expenditures, will critically affect the practice of geriatric
medicine and psychiatry and the medical care that frail older adults
will receive in the future.
The ABIM, ABFP, and ABPN’s decision to certify geriatric medicine
training was predicated on academic geriatricians’ needs. Credibility
and the potential for academic program growth required a training
pathway leading to recognition of faculty clinicians’ specialized clinical
skills. A temporary practice pathway is a standard approach utilized
by specialty boards to phase in new training requirements and
associated examinations. For physicians practicing in the community,
the new geriatric medicine CAQs represented a potential threat to
physicians’ ability to continue providing care to older adults. Many
physicians chose to sit for the CAQ examination even though they
were uncertain about the relevance of certification to them. For
practicing physicians without primary board certification, the CAQ
door was never open. The AMDA medical director certification process
and AGS recognition award, described above, were, to some degree,
responsive to the needs of practicing physicians without board
certification who were searching for a geriatric medicine credential.
Preliminary data from the ABFP/ABIM surveys suggests that
many of the early diplomates are not returning for re-certification.
One explanation may be that over the past ten years practitioners in
community practice have not found the CAQ to significantly influence
their practice activities, job availability, or salaries. Surprisingly, the
ABIM also documented that only 60% of geriatric fellowship-trained
IM diplomates from the 1988 and 1990 cohorts have returned for
re-certification. For these reasons, it is likely that the number of
certified geriatric medicine and psychiatry physicians will decline
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