If we want more doctors to become geriatricians, raising the incomes and improving the working conditions of primary-care doctors is only a first step.
The statistic is repeated over and over: Chronic diseases generate three-quarters of U.S. health costs. What’s less commonly considered is how many of the patients who have those chronic conditions are 65 or older. Medicare patients have a dramatically higher incidence of diseases such as diabetes, hypertension, COPD, arthritis and heart failure than younger people do. Moreover, patients with five or more chronic conditions account for 76 percent of Medicare expenditures.
The situation will grow worse as the baby boomers age. According to Thomas Bodenheimer of the University of California San Francisco and two of his associates, “The population over age eighty-five, the group with the highest proportion of people with multiple chronic conditions, is projected to grow from five million in 2005 to twenty-one million in 2050, ensuring a major increase in the number of very-high-cost patients."
Studies show that patients have worse outcomes when they get most of their care from specialists and don’t have a primary-care doctor coordinating their care. But the primary-care workforce is shrinking in relation to the population, while the specialist workforce is increasing - a direct result of the two-to-one income advantage that specialists have over primary-care physicians.
What has been less remarked upon is the dearth of geriatricians, who are specially trained to care for older patients with chronic conditions. In one four-county area centered around Sacramento, Calif., for example, there are only 15 geriatricians; in contrast, there are 350 pediatricians in that area. The number of geriatricians in the U.S. has actually dropped by a quarter in the past decade to just 7,600. By 2030, the American Geriatrics Society estimates, the country will need 36,000 geriatricians.
Family physicians and general internists, of course, are trained to provide primary care to the elderly. But they are dealing with other age groups, as well, and in the current practice environment, they don’t have enough time to provide all of the recommended care to everyone - let alone focus on the unique needs of seniors. Geriatricians, in contrast, concentrate on key elements of care that other physicians may miss, such as how to prevent falls at home, how to get blood pressure taken after meals, and the number of medications a patient is on. Overmedication is itself a chronic problem for many Medicare patients.
The idea that a geriatrician can serve as a corrective to the uncoordinated, overly aggressive care of multiple physicians may come as a surprise: Since when do we need a specialist to prevent other specialists from harming patients? But in fact, that’s exactly what hospitalists are supposed to do on the inpatient side. Their core functions are to make sure the patient has a medical home in the hospital, that specialists are appropriately called in for consults, and that someone knows what everyone else is doing for the patient.
So how do we account for the disparity between the rapid growth in hospitalists, who now number 30,000, and the diminution in the ranks of geriatricians? Follow the money. Hospitalists help hospitals decrease length of stay, increase throughput, improve scores on Medicare’s core measures, and reduce readmissions. So, although they don’t bill enough to justify their salaries, which are on the high end for primary care, hospitals are willing to subsidize them.
In contrast, geriatricians, who are usually family doctors or internists with advanced training, help elderly patients manage their conditions or recover from hospitalizations. By working for a financially at-risk organization such as Kaiser Permanente or Geisinger Health, geriatricians help improve the bottom line. But in private practice, all they do is attract patients who demand more physician time that is inadequately reimbursed.
So if we want more doctors to become geriatricians, raising the incomes and improving the working conditions of primary-care doctors is only a first step. We need to transform the entire care delivery system into a model that rewards physicians for managing chronic conditions, both in and outside of the office. When that happens, physicians will flock to geriatrics, and a big part of our cost conundrum will be solved.