WASHINGTON — The U.S. health workforce, including physicians, is “woefully unprepared” to deal with the coming onslaught of aging Americans, according to an Institute of Medicine panel that cited poor training and perverse payment incentives in geriatrics as among the chief problems.
Headed by Dr. John Rowe, a geriatrician and professor of health policy and management at Columbia University, New York, the interdisciplinary panel declared even the current workforce “not prepared to deliver the best possible care to older patients.” The panel said in its statement accompanying the report, “All health professional schools and health care training programs should expand course work and training in the treatment of older individuals.” Furthermore, “virtually all” health care workers are or will be treating an elderly population and so should be required to demonstrate competence in that area as a criterion of licensure and certification, the group asserted.
Dr. Harvey Fineberg, head of the Institute of Medicine, said the government-advisory body created the 15-member panel in January 2007 to address the “major demographic shift” looming in this country. He added, “Too few health professionals are well prepared, especially to handle the multiple medical problems that are seen in old age, including such geriatric concerns as dementia and falls and incontinence.”
The work force shortage in geriatric care is especially dire because of remarkably high turnover among nurses' aides (71% annually) and other workers, the panel concluded after more than a year of study. Among physicians, Medicare's low reimbursement rates are mainly to blame for low incomes for doctors choosing elder care: “Medicare should increase its reimbursement rates for services delivered by geriatric specialists,” the report urged. In fact, the panel declared that Medicare currently “hinders the provision of quality of care to older adults” not only with low payment rates, but also with its focus on acute illness and its lack of coverage for preventive services and care coordination.
In a press conference, Dr. Rowe said that ironically, physicians with extra training in geriatrics actually reduce their private-practice incomes. Geriatricians and specialists in nursing and other fields should be offered incentives in the form of increased incomes, loan forgiveness, scholarships, and other awards, according to the report. Nonphysician providers and caregivers face both the disincentives of poor funding from Medicare and Medicaid and “the fact that these workers have not been recognized as the pivotal health care workers that they are,” said panel member Carol Raphael, president and chief executive officer of the Visiting Nurse Service of New York. The panel called specifically for states to boost Medicaid payments that cover these workers' services and benefits.
Warning, as others have, that the health care system isn't close to being prepared for the 78 million aging baby boomers, the panel called for “new models” of long-term and geriatric care that include increased delegation of responsibilities within the health workforce hierarchy, the greater use of interdisciplinary teams, and increased involvement of patients and their families in elders' care. Many good models have been developed, said the panel, but too often have been put on the shelf for lack of funds for implementation.
Members of Congress have turned their attention to the geriatric care workforce. On April 16, the Senate Special Committee on Aging held a hearing on the subject, focusing on the new report. Dr. Rowe testified, and committee members echoed many of his panel's concerns. For instance, Committee Chairman Sen. Herb Kohl (D-Wis.) said, “We know that few nursing programs require coursework in geriatrics and that in medical schools, comprehensive geriatric training is a rarity.”
Sen. Kohl announced plans to introduce a bill later this spring to “expand, train, and support all sectors of the long-term care workforce,” including physicians.
Too few health professionals are well prepared to handle the multiple medical problems seen in old age. DR. FINEBERG