The state needs more professionals to focus on geriatric care while also addressing other ways to meet the increasingly complex care needs of older residents, says the American Geriatric Society (AGS).
In Connecticut, only 134 certified geriatricians are currently practicing—caring for a 65-plus population that topped 577,000 in 2015, according to the AGS. And that population will continue to grow, the AGS says, with an elderly population of 956,000 expected by 2030. That’s a 40 percent increase, and will require an estimated 340 geriatric specialists to meet that treatment need.
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In Connecticut, there are only 134 certified geriatricians practicing.
“We need to increase the number of trainees going into careers in geriatrics,” said Nancy Lundebjerg, chief executive officer of the American Geriatrics Society and a Connecticut native. “Aging is an area where there will be tremendous opportunities for those with specific training in care of older adults, especially as we boomers enter our golden years.”
But Dr. Mary Elizabeth Tinetti, chief of geriatrics at Yale University School of Medicine, said a way to remedy the shortage is to train all practitioners in the fundamentals of elder care.
Tinetti, who directs the Yale Program on Aging, said most older adults don’t necessarily need a geriatric specialist. Rather, they need physicians—including family medicine, cardiologists, endocrinologists, pulmonologists, surgeons and advance practice nurses (APRNs) who are trained in geriatric principles and who can provide geriatric skills.
There are multiple reasons why it’s so difficult to recruit and train geriatricians, according to Dr. Gail Sullivan, director of the geriatric medicine fellowship at the University of Connecticut School of Medicine. Primary care is very unpopular due to its comparatively lower pay combined with what she calls the “hassle factors”—too much paperwork, confusing government information technology requirements, keeping abreast of the myriad medications for multiple chronic conditions like diabetes, heart disease, dementia, arthritis and high blood pressure.
“If you realize that you’re going to work really hard and be pretty miserable and also not get paid for it, it’s a potent combination, especially when coupled with our youth-obsessed society,” Sullivan said. At UConn, only two weeks are devoted to geriatric care in the medical curriculum. And in many years, Sullivan said she has trouble filling the few available geriatric residency slots.
Overwhelmed And Underpaid
Many students go into medicine because they want to cure disease, but that’s often not possible in a geriatric population, said Dr. Bruce Koeppen, dean of the School of Medicine at Quinnipiac University. “What geriatrics is all about is the management of chronic disease. For a good portion of students and young physicians, that doesn’t excite them.”
The scope of geriatric practice is also daunting, Koeppen pointed out. They have to know a vast amount of information, something about every single aspect of the body, including psychiatry. It can be overwhelming for many students.
He thinks medical schools need to demystify what geriatric practice is really like. At Quinnipiac, students spend time embedded with primary care physicians in the community. This allows them to actually deal with geriatric patients. An elective in geriatric medicine, which encompasses hospice and palliative care, is offered to fourth-year students.
Tinetti said, “Most older adults, even if they have multiple conditions, can still be taken care of by a well-trained and skilled generalist—an APRN or physician. It’s only a small group of people who are beyond the capabilities of general practitioners and that’s when there needs to be a referral to a geriatric specialist.”
One way to maximize the scarcity of available specialists is to co-manage care, an increasingly common process where doctors, physician assistants and APRNs work together to provide optimal care for the patient.
It’s About the Money
Loan forgiveness may tilt the scales toward geriatrics for some prospective physicians. Most medical students face upwards of $200,000 in loan payments after graduation. Loan forgiveness is already an option for some graduates working in underserved communities, according to Tinetti. So perhaps physicians who agree to take care of vulnerable older adults could get part of their student loans forgiven.
Another part of the solution, she said, is changing our cultural perceptions of aging and paying those who care for the elderly more. “We live in a country that doesn’t want to accept growing older or death,” she said. “If you paid some of the other specialists less and paid geriatricians more, it would change things overnight. It’s about the money.”
The current reimbursement system rewards procedures, rather than patient management. If you sit down, talk to a patient and manage their medicines, but don’t do a procedure, reimbursement rates are drastically lower than if you spent the same time doing a procedure, Koeppen explained. “There’s a lot of talk about reforming the reimbursement system, but the problem I see is that it will become very divisive, because I don’t see the pie getting any bigger.”
More doctors is one solution, but Nora Duncan, the director of Connecticut AARP, wonders what can be done to keeps costs down, help people gain access to the services they need and continue to allow them to stay home and age in place. The solution may lie in technology.
AARP supports funding more remote care services for qualified patients. Medicare, the federally financed health program for older adults, already pays for some virtual services. The legislature just approved a bill requiring the state-funded Medicaid program, which covers some low-income seniors, to do the same. Supporters are optimistic that the governor will sign the bill, which would take effect July 1.
“By extending Medicaid for telemonitoring, it holds the promise of helping people stay home instead of going to a nursing home,” Duncan said. This approach means care providers can monitor patients and maximize limited resources without always requiring an in-person visit. It will also help solve access issues for those in rural areas or who lack transportation.
