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

Table 6.3 Growth of Geriatric Medicine and Geriatric Psychiatry Fellowship Programs
Specialty 1996-1997 1997-1998 1998-1999 1999-2000 4-year 4-year Program Fellows
# of # of # of # of # of # of # of # of growth in growth in average average
programs fellows programs fellows programs fellows programs fellows programs fellows growth rate growth rate
per year per year
Family 14 22 17 29 20 37 21 42 50.0% 90.9% 14.7% 21.7%
Practice,
Geriatric
Medicine
Internal 89 220 90 276 92 298 93 326 4.5% 48.2% 1.5% 14.3%
Medicine,
Geriatric
Medicine
Geriatric 44 82 47 84 49 91 55 98 25.0% 19.5% 7.7% 5.9%
Psychiatry
Total 147 324 154 389 161 426 169 466 15.0% 43.8% 4.7% 13.0%
Source: Data from the Graduate Medical Education Database, Copyright 1999, AMA, Chicago, IL. (Used with permission)
geriatric psychiatry programs. During 2000-2001 the IM RRC
recognized 96 geriatric medicine programs, and the FP RRC
recognized 23. A total of 321 fellows were training in these programs.
Table 6.2 displays first-year positions available and filled for these
programs since the 1995-96 academic year. Table 6.3 displays growth
rates in these programs between 1996 and 2000. There were 7
osteopathic fellowship programs, 5 in FP and 2 in IM. During AY 2000-
01, there were 7 fellows training in these programs. (See Appendix F
for list of fellowship programs.)
The AMA and AAMC report that during the past five years
approximately 40% of allopathic geriatric medicine trainees were U.S.
medical school graduates (USMSGs). This percent of positions filled
with USMSGs compares with recent rates for cardiology (56%),
infectious disease (56%), ophthalmology (84%), and general surgery
(82%) (JAMA, 2001). As well as USMSGs, a small number of Canadian
graduates and U.S. osteopathic medical school graduates are training
in these programs. In AY 1991-1992, 134 (68%) allopathic geriatric
medicine fellows were U.S. or Canadian medical school graduates.
This number decreased to 91 (40%) in 1995 (JAMA, 1995),
contributing to the decision to establish one-year fellowships. The
number of allopathic fellows who are U.S. or Canadian medical school
graduates rose in AY 2000-2001 to 134; this remains only 41% of
geriatric fellows (JAMA, 2001).
Financial Support for Geriatric
Fellows and Junior Faculty
Sources of support for geriatric medicine trainees and junior faculty
are diverse. Many fellowships are incorporated into medical school
academic programs that have complex funding sources (see Chapter
5). Table 6.4 lists the sources of support for trainee salaries. The
sources of support are generally different for first-year fellows as
compared to those available for fellows in the second year or beyond.
First-year Fellowship Funding
Support for accredited graduate medical education (GME) training is
provided by Medicare for all clinical disciplines. The Medicare program
is the primary source of funding for GME, providing 74% of funding
(nearly seven billion dollars) in 1998 (Council on Graduate Medical
Education, 15th Report, 2000). This funding includes direct and
indirect medical education payments made directly to hospitals
sponsoring GME programs. Direct medical education payments (DME)
compensate teaching hospitals for overhead costs related to GME, as
well as salaries and fringe benefits for residents, fellows, teaching
physicians and GME administrative staff.
The Indirect Medical Education Adjustment (IME) compensates
teaching hospitals for the higher operating costs associated with
residency programs such as more complicated cases, additional tests
ordered by residents as part of the learning process, and reduced
patient care productivity by staff members. The calculation of both
these DME and IME payments involve complicated formulas,
particularly for the IME portion. The payment amounts are calculated
per trainee, vary historically and regionally, and are related to each
hospital’s census of older adults (higher hospital use by older adults
yields higher payments). The average per-resident amount (APRA) in
federal fiscal year (FFY) 2000 was $73,000, with a range of $60,000
to $120,000 (National Center for Health Workforce Information and
Analysis, 2000). Recent adjustments to lower these payments have
been implemented by Medicare as a cost savings measure, and
further cuts are anticipated.
In addition, the implementation of “caps” on hospital
reimbursable training positions has created competition among
program directors for resident slots. This can result in more
recently-established programs losing out to more established
training activities or disciplines that have a significant clinical
financial impact on the hospital.
The VHA is a critical source of financial support for geriatric
medicine and psychiatry fellows and trainees from many other
disciplines. From 1980-1991, the Office of Academic Affiliations
funded 275 geriatric medicine fellowships. In AY 2000-2001 60%
(197/326) of first-year geriatric medicine and geriatric psychiatry
fellow slots were funded by the VHA, with an average cost per fellow
of $43,500. This compares to 123 slots funded by the VHA in AY
1995-1996 at an average cost of $39,108 per fellow. (Veterans Health
Administration, 2001). Unlike Medicare GME dollars, VHA funding is
clearly earmarked for trainees’ salaries and benefits. The change in
the geriatric medicine fellowship duration from 24 to 12 months in the
late 90’s did not result in a net loss of VHA fellowship stipend support;
instead, support for second-year fellowships was shifted to the
accredited first year.
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