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

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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. 60
Table 6.4 Sources of Financial Support for Clinical and Academic Training for Geriatric Medicine and Geriatric Psychiatry Fellows and Junior Faculty Geriatric Medicine Medicare VHA NIH BHPr Foundations Training Year Clinical Year 1 GME Funding VHA Geriatric Training for Physicians, Fellowship Dentists, and Behavioral Mental Health Professionals Program Year 2 GME 1 Funding VHA Special Training for Physicians, Hartford/AFAR Fellowship Dentists, and Behavioral Academic Mental Health Fellowships Professionals Program RWJ Clinical Scholars Hartford Centers Years 3 to 6 VHA Special K08 Award Geriatric Academic Hartford/AFAR Fellowship Career Award Fellowships RCD Awards K23 Award RWJ Clinical Scholars HSR&D Awards T 32 NRSA Award Pfizer/AGS Health Outcomes RR&D Awards F32 NRSA Award AFAR Research Grants ARCD Awards Pepper Centers AFAR/Pfizer GRECC Nathan Shock Immunology Centers Merck/AFAR Clinical Alzheimer’s Centers Pharmacology Brookdale Fellowship Beeson Faculty Scholars Hartford Centers Reynolds Centers Years 7 CDEA Awards K24 Award Beeson Faculty Scholars and beyond GRECC K02 Award Hartford Centers Pepper Centers Nathan Shock Centers Alzheimer’s Centers Source: IHPHSR ADGAP Database Project, 2002 Abbreviations and Key AFAR American Federation for Aging Research AGS American Geriatrics Society ARCD Advanced Research Career Development BHPr Bureau of Health Professions CDEA Career Development Enhancement Award F32 Postdoctoral Individual Award GME 1 Graduate Medical Education (Use for Year 2 is controversial, see text) GRECC Geriatric Research Education and Clinical Center HSR&D Health Services Research and Development K02 Independent Scientist Award K08 Mentored Clinical Scientist Development Award K23 Mentored Patient-Oriented Research Career K24 Mid-career Investigator Award in Patient-Oriented Research Development Award NIH National Institutes of Health NRSA National Research Service Award RCD Research Career Development RR&D Rehabilitation Research and Development RWJ Robert Wood Johnson Foundation T32 Institutional Research Training Grant VHA Veterans Health Administration Additional support for fellowship training as reported by the program directors has also included: Clinical Revenue Medical School Revenue Other State or Federal Revenue Other Foundation or Private Support The John Hartford Foundation of New York City is supporting advanced training in geriatrics for medical sub-specialists through the Association of Subspecialty Professors (T. Franklin Williams awards program), and training for surgical specialists through the American Geriatrics Society (Dennis Jahnigen awards program). The Bureau of Health Professions (BHPr) initiated funding for geriatric medicine and dentistry faculty training programs in 1988. This program provides two years of stipend for fellows and one year salary support for faculty retraining. Initially this program accepted trainees who had completed family practice, internal medicine, and general dentistry residency programs. Geriatric psychiatry was added to the training program in 1992. Since its inception, the Training for Physicians, Dentists, and Behavioral/Mental Health Professionals Program has funded 55 programs and trained 324 fellows and faculty. Eighty five more fellows and faculty are projected to be trained from the most recent funding cycle (Personal communication, Kathleen Bond, BHPr, May 24, 2002). Other sources of support for first-year fellows include clinical revenue, medical school revenue, other state or federal revenue, foundation or private support. 61
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The Association of Directors of Ger
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The Association of Directors of Ger
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National Oversight Panel M. Brownel
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The American Geriatrics Society . .
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List of Tables and Figures Chapter
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Page 29 and 30: participants. Geriatricians have be
Page 31 and 32: Table 4.8 Medicaid Recipients and P
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Page 35 and 36: Figure 4.3 Geriatric Caseload for P
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Page 41 and 42: 5 Academic Geriatrics Programs in U
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Page 47 and 48: Figure 5.1 Number of Years as Acade
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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
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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
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Page 77 and 78: General Internal Medicine The 1999
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Page 83 and 84: Geriatric Education Retreats (GERs)
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Page 87 and 88: chapter. The goals of these student
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Page 91 and 92: Conclusion This report summarizes r
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Page 103 and 104: Appendix F. Geriatric Medicine and
Page 109 and 110: Helen Hoenig, M.D., M.P.H., Duke Un
Page 111 and 112: 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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