September/October 2009

The Future of Eldercare
By John W. Rowe, MD
Aging Well
Vol. 2 No. 4 P. 34

Who will provide medical care for tomorrow’s older adults? The healthcare reform debate brings daily reminders of the soaring costs of the Medicare program and the need to bend the curve of healthcare costs, especially as we struggle to expand coverage to all Americans. The problem of costs is certainly an elephant in the room, but it is not the only elephant in the room.

We face a staggering shortage of qualified care providers for older adults, a deficiency that runs through the entire spectrum, from physicians, nurses, and social workers to direct care workers. What will we have accomplished if we find a way to pay for the care but don’t have qualified providers to deliver it?

An informative report from the Institute of Medicine (IOM), “Retooling for an Aging America: Building the Health Care Workforce,” documents the impending workforce problems and recommends solutions that, if adopted now, can help forestall a major deficiency in care for older adults.

While everyone agrees that the demand for sophisticated geriatric care will increase dramatically as the baby boomers age, if current trends continue, the number of board-certified geriatricians, currently numbering slightly more than 7,000, will still be under 8,000 in 2030 when the predicted need will reach 36,000. The situation is even worse in geriatric psychiatry, where we currently have fewer than 2,000 practitioners with little prospect for any increases in the near future. And don’t look for help from other professions. Only 1% of nurses are certified in geriatrics, and only 4% of social workers and 1% of physician assistants identify themselves as specializing in this field.

While the failure of American healthcare professionals to be attracted to caring for older adults has many causes, the paucity of exposure to geriatrics in professional schools, inadequate training requirements, and financial factors are significant contributors. Despite recent notable improvements, many medical and nursing schools continue to have limited exposure to geriatrics in their curricula, with as many as one half of graduating medical students finding their exposure to be insufficient. The most striking deficiency may lie in providers such as personal care attendants. In some states, training requirements in geriatrics for such direct care workers are lower than the number of hours of training required to become a school crossing guard or a cosmetologist.

The impact of a career choice in geriatrics on a physician’s income is especially interesting. If board-certified internists choose to extend their training to take one- or two-year fellowships in geriatrics rather than entering practice, their postfellowship income will actually be lower than if they had not taken the fellowship.

The math here is simple: All geriatricians’ patients are on Medicare, whereas general internists treat patient populations that include Medicare, as well as private health insurance, which pays better than Medicare.

But not all is lost. If we act now, we can reverse these negative trends and be prepared to serve our future elders. The IOM devised a three-part strategy to avoid disaster:

1. Enhancing the competence of all providers in the care of common medical problems of old age. This can be accomplished through increases in trainees’ exposure to geriatrics and by strengthening the training standards and requirements for licensure and certification.

2. Increasing the recruitment and retention of geriatric specialists in all relevant health professions. Options here include approaches to provide financial enhancements, increase payment for services provided by geriatric specialists, debt forgiveness, and more scholarships.

3. Redesigning our models of care so that we deploy the limited healthcare providers in more effective and efficient manners. Many innovative approaches, such as interdisciplinary teams, have proven successful in managing the needs of sick elders, but the funding has often been unavailable to support wide implementation of the effort after the initial research. Such models deserve support, and more research should be done to develop additional new approaches.

And the really good news is that help may be on the way. Already some states, including California, have begun to pass legislation aimed at strengthening the geriatric workforce. And the recent healthcare reform bill that came out of Sen Edward M. Kennedy’s HELP (Health, Education, Labor & Pensions) Committee includes several excellent provisions based on the IOM report.

Whatever form healthcare reform takes, it must attack the workforce issue or the rest really will not matter much as far as our future elders are concerned.

— John W. Rowe, MD, is a professor of health policy and management at the Columbia University Mailman School of Public Health in New York City. He served as chairman of the Institute of Medicine committee that authored the healthcare workforce report.