I am a geriatrician, which is a physician who specializes in caring for older adults. I tell my patients, “If you want a doctor who will prescribe lots of medications, order lots of tests, send you to lots of specialists and put you in the hospital at the drop of a hat, I’m not your guy.” I’ve practiced a high touch, low tech brand of medicine for the past 25 years. My patients and their families appreciate my approach to care and there is data that shows it to be quite cost effective. So, how come there are so few doctors like me and how come the Medicare program has such astronomical costs?
Prior to 1965 when physicians graduated from medical school and proceeded on to an internship or residency program, they were fortunate to get room and board. It was a struggle, but a necessary one. Many physicians went into what was then considered “General Practice” in order to save enough money to obtain further training in a specialty of interest.
As the Johnson administration developed the Medicare program, it was decided that the government would subsidize graduate medical education, believing that would assure an adequate workforce to care for our aging population in the years to come. Taxpayer dollars subsidize young doctors through their training. With geriatricians amongst the lowest paid of all physicians, most young doctors choose to take advantage of these subsidies and continue on to train in high paying specialties. Fewer than 7,000 physicians are now board certified in geriatric medicine, and that number is going down every year!
Today, the Medicare Trust Fund spends over $10 billion a year on graduate medical education. Remarkably, very little of this money is dedicated to teaching doctors how to care for older adults. There is no accountability to the seniors and their families who pay Medicare taxes. A recent report couldn’t even determine what $3 billion a year of these funds was actually spent on.
At a time when congress is calling for value based purchasing and evidence based medicine, what value are we getting for the $10 billion a year spent by the Medicare Trust Fund? Indeed, many of the expensive procedures and medications used by specialists caring for older adults have not been studied in people over the age of eighty. Geriatricians and Geriatric Interdisciplinary teams, on the other hand, tend to take a high touch, low tech approach to care that patients and their families appreciate and has been shown to provide quality and cost effective care.
Geriatricians like myself have known for years the differences in treating older adults. There are a number of good examples. In older adults, the use of expensive medications in trying to prevent the abnormal heart rhythm of atrial fibrillation has been shown to have worse outcomes than in younger patients. The aggressive treatment of elderly men for prostate cancer can be more harmful than conservative treatment. The treatment of fractured vertebrate with an expensive procedure known as vertebroplasty has not been shown to be appreciably better than a doing nothing! Most people are intuitively aware of the increased complications that older people face during hospitalization.
A multibillion dollar industry of antipsychotic medication has recently been called into question by the Office of Inspector General. These very powerful and dangerous medications are typically used off label as a chemical restraint in the management of demented older adults. The lack of adequate education of health care professionals as it relates to the treatment and management of dementia, and in particular, Alzheimer’s Disease, is incomprehensible for a program spending $10 billion a year to support the training of physicians.
The cost of Medicare keeps rising every year. Congress has a huge opportunity to impact the quality and cost of care without spending an extra dime. They can require that the money spent on graduate medical education be used primarily for the education of physicians, nurse practitioners, physician assistants, nurses, pharmacists, social workers, psychologists, physical, occupational and speech therapists in the core competencies of caring for seniors. We can no longer afford subsidize the development of expensive, procedurally based care with dollars that were meant to develop the workforce necessary to care for our seniors.
Healthcare reform was made up of over a thousand pages of workarounds for a broken health care system. If Congress is serious about value and accountability, they’d start by reforming how our Medicare tax dollars are spent on educating our healthcare workforce. If they don’t, then how can we believe they’re serious about actually trying to fix a broken system?