Why America Needs More Geriatricians
Their numbers are dwindling; here's the money and care case for them
Editor's note: This article is part of a year-long project about aging well, planning for the changes that aging brings and shaping how society thinks about aging.
One would think that an aging population would need and welcome geriatricians. But that is not the case. Just when they are needed most, geriatricians are a dying breed. Neither physicians nor nurse practitioners are attracted to this specialty.
Making a convincing business case for geriatrics requires lingual felicity. You have to be able to speak out of both sides of your mouth. Basically, there are two markets: health care organizations (hospitals and their dominions) and health plans (including Medicare), each with different, even conflicting, interests.
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Making the Arguments
For hospitals, the argument runs that geriatrics can both increase revenue and save money. It increases revenue by attracting people who use a lot of hospital services (i.e., sick old people). The trick is not to attract the really sick ones because they use too many resources.
Since hospitals are typically paid on a fixed price per stay basis, geriatrics saves money for them by avoiding complications once older patients are hospitalized. Iatrogenic problems (ones caused by medical examination or treatment) like delirium and overmedication can add days to hospital stays.
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By improving post-hospital care, geriatrics may also help prevent re-hospitalizations, for which Medicare penalizes hospitals.
Meanwhile, the pitch to health plans (and some hospitals if they become Accountable Care Organizations — health care providers who coordinate care) is that geriatrics saves money by delivering better chronic disease care (relying on the same skills needed for post-hospital care above).
People with chronic diseases, especially those with multiple diseases, use a disproportionate share of resources. Geriatricians are experts in managing complex chronic disease. The goal of such management is catastrophe avoidance, preventing complications that lead to emergency department visits and hospital admissions.
Viewing Geriatrics As An Investment
The challenge then is how to fit such useful and lofty goals into the payment operating system. Most physicians are still paid on the basis of direct patient contact. To generate income, doctors need high volume; even if they are not paid on a fee-for-service basis, they are judged by the number of encounters they provide. But geriatrics is slow and time consuming. You have to explore lots of problems from many vantage points and create complex, coordinated interventions.
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Ideally, one would view geriatrics, indeed all chronic care management, as an investment. Payment would be predicated in part on what the clinicians did, but in large measure on what they accomplished. Keeping older persons, especially frail older persons, functioning and out of hospitals is no small task.
Essentially, geriatricians should be rewarded in ways similar to those used for the financial market analysts: modest but comfortable base pay with bonuses for achieving good results. We don’t yet have a Dow Jones for geriatrics, but maybe we need one.