Luring Health Care Providers into Geriatrics

Supporters of loan forgiveness programs aimed at encouraging health care providers to specialize in geriatrics got a boost from a report issued last month by the Institute of Medicine (IOM). Retooling for an Aging America: Building the Health Care Workforce is based on the findings of an ad hoc committee that looked at the health care needs of the 78 million baby boomers who’ll soon be turning 65. The group estimates that there are currently only about 7,100 doctors certified in geriatrics in the US, one for every 2,500 older Americans, a shortage they attribute to a lack of training programs and low Medicare reimbursement rates for geriatricians compared to other specialists. The report comes just as the government prepares to cut Medicare physician payments this July. The group has called for increased reimbursement rates, loan forgiveness programs, and student scholarships.

I was pleased to see that the report also addressed the need for more direct-care workers, including nurse aides, home health aides, and personal care aides. Unlike geriatricians, who have high job satisfaction rates (the highest, in fact, of any specialty), these hands-on workers are generally dissatisfied and have high rates of turnover due to low pay and working conditions, high rates of on-the-job injury, and few opportunities for advancement. Turnover among nurse aides, for example, averages 71% annually, and 90% of home health aides leave their jobs within the first two years. In response, the committee is calling for more opportunities for career growth, higher pay, and access to fringe benefits. They also recommend that all health care workers be trained in basic geriatric care and treating older patients.

As I've said many times before, we can screen and regulate all we want to prevent worker abuse and neglect, but it’s not going to do much good until we make these jobs tenable and have an adequate pool of workers for seniors to choose from.

At the national level, Senator Boxer’s Caring for an Aging America Act of 2008 (S. 2708) would amend the Public Health Service Act to attract professionals and direct care workers by earmarking $130 million for a loan forgiveness program. Those covered include physicians, physician assistants, advance practice nurses, social workers, and psychologists. The legislation would also create the Health and Long-Term Care Workforce Advisory Panel for an Aging America to advise the Secretary of Health and Human Services, the Secretary of Labor, and Congress on workforce issues related to elder healthcare. The bill has bipartisan support and counts among its supporters the American Geriatrics Society, the National Council on Aging, the Alzheimer's Association, AARP, American Academy of Physician Assistants, American College of Nurse Practitioners, American Psychological Association, Coalition of Geriatric Nursing Organizations, and the National Association of Social Workers.

Here in California, our loan forgiveness program is also making headway. AB 2543, which was developed by the California Senior Legislature under the leadership of Shirley Krohn and introduced by Assembly member Patty Berg, is called the California Geriatric and Gerontology Workforce Expansion Act of 2008. To qualify, loan recipients would have to commit to a minimum of three years of service in geriatric care settings. Covered under the bill are physicians, dentists, psychologists, registered nurses, and social workers.

I thought I’d end with an excerpt from the terrific New Yorker article "The Way We Age Now," by surgeon Atul Gawande, which I cited in a posting last fall (see Geriatricians, Angry and Otherwise):

Several years ago, researchers in St. Paul, Minnesota, identified five hundred and sixty-eight men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric specialists. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, ten per cent of the patients in both groups had died. But the patients who had seen a geriatrics team were a third less likely to become disabled and half as likely to develop depression. They were forty per cent less likely to require home health services.

Little of what the geriatricians had done was high-tech medicine: they didn’t do lung biopsies or back surgery or PET scans. Instead, they simplified medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

How do we reward this kind of work? Chad Boult, who was the lead investigator of the St. Paul study and a geriatrician at the University of Minnesota, can tell you. A few months after he published his study, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.

“The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he is now a professor at the Johns Hopkins Bloomberg School of Public Health. On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a twenty-five-thousand-dollar pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs.

Seems to me that the need for more geriatric training is pretty much a no-brainer.

Geriatricians, Angry and Otherwise

Last week, I had a fascinating conversation with French journalist Dominique Prédali, co-author of On Tue Les Vieux, or Killing Elders, which describes elder abuse in French nursing homes and hospitals. Written for the general public, the book's small initial printing sold out the first day it hit bookstores last year and is now in its third printing. She is currently researching a new book on elder abuse around the world, which will be called Douze Gériatres en Colère or Twelve Angry Geriatricians. The angry geriatricians will talk about the social and economic factors that contribute to elder abuse, including ageism in health care, inadequate pensions, and poverty. She will also be looking at the role of failed health policy, including the introduction of market oriented healthcare reforms, in compromising the poor's access to health services.

Her research on the role of economic forces in elder abuse has been far flung, and includes delving into the sociology and anthropology literature that focuses on the effect of poverty on violent crime in developing countries. Among the experts she's interviewed is Ted Miguel, a medical anthropologist at the University of California, San Francisco, who is looking at witch killings in Meatu villages in Tanzania. Witch killings, which have been reported in Kenya, Ghana, Zimbabwe, the Congo, South Africa, Uganda, and parts of South America and India are typically committed against elderly women, and, according to Miguel and others, are much more likely to occur when food is scarce as a result of drought, floods, and other "income shocks." For more on global issues in elder abuse, see my review of Missing Voices: Views of Older Persons on Elder Abuse, which was jointly produced by the World Health Organization and the International Network for the Prevention of Elder Abuse at Missing Voices.

What should make geriatricians happy is the loan forgiveness program for health care professionals proposed by Shirley Krohn, a member of the California Senior Legislator (CSL). Shirley has pulled together an impressive group of geriatricians and others to help draft legislation to cancel all or part of government student loans to those studying geriatrics. Modeled after the state assembly, CSL's 40 senior senators and 80 assembly members develop proposals, which are then ranked by the full group; the highest ranked are pitched to legislators for sponsorship. CSL boasts a 70% success rate of bills chaptered into law. Shirley is working on several other elder abuse bills that address such critical areas as criminal background checks for home care workers and adding undue influence to California's penal code section on elder abuse.

All the talk about geriatricians got me thinking me about a terrific article that appeared in The New Yorker last April, which I've been meaning to add to the reading list of a course I'm developing. In "The Way We Age Now," Atul Gawande, a surgeon, describes the field of geriatrics, beginning with an achingly graphic description of how the body declines as we age ("the gums tend to become inflamed and pull away from the teeth; when you reach inside an elderly patient during surgery, the aorta and other major vessels often feel crunchy under your fingers").

When he accompanies a geriatrician from his hospital on visits, Gawande is struck by the multiple complaints that his colleague's elderly patients describe (unlike his own patients who typically present with a single major problem) and how he triages them. For example, when they visit a patient with arthritis, back pain, incontinence, and what might be metastatic colon cancer, Gawande hypothesizes that his colleague will zero in on the potentially life-threatening cancer. Instead, he spends most of the visit inspecting her feet inch by inch, having concluded that the greatest threat to her engagement in the world is a fall. It is this emphasis on functional capacity and quality of life that Gawande finds remarkable. The article goes on to describe the dwindling number of geriatric programs across the U.S. It is available online at "The Way We Age Now."

And finally, according to the promotional materials, it's like “having a doctor in your pocket.” The UCI School of Medicine recently released its excellent “Pocket Doc” for social work, legal, and law enforcement professionals who want to talk the talk. Written by Laura Mosqueda, it's a portable, comprehensive guide to common geriatric disorders and medications. To get a copy, click on Pocket Doc.