WASHINGTON, May 15 -- The healthcare system and society at large are about to be inundated by what the American Geriatrics Society calls the silver tsunami -- a wave of Americans living into their eighth and ninth decades with few willing or able to care for them.
In the latest of a series of reports over decades on the growing crisis in geriatric medicine, the Institute of Medicine (IOM) cited projected critical shortfalls for the aging frail population in qualified physicians, nurses, nurse's aides, social workers, and even family members prepared to share the load.
The concerns are not new, not at all a surprise, and few disagree with the reality of the situation. But little or nothing has been done for a generation to shore up what appears to be a steadily eroding healthcare edifice from a flood of aged patients.
That alarm was first sounded by IOM in 1978, and the bell has been reverberating ever since. The latest IOM report, issued late last month, was titled "Retooling for an Aging America: Building the Health Care Workforce."
In the intervening 30 years there have been some changes, most notably in 1982 when the creation of the first independent department of geriatrics was created at the Mount Sinai School of Medicine in New York, the establishment of geriatrics as a recognized specialty in 1988, and the initiation of geriatric fellowship programs so that by 2002 more than 10,000 physicians were certified in geriatrics.
Yet, the best estimates of the workforce of certified geriatricians today range from a high of 7,100 down to 5,800, with much of the decline reflecting geriatricians who have neglected to complete the mandatory re-certification process required every six years.
David Reuben, M.D., of UCLA, a former president of the American Geriatrics Society, a member of the committee that wrote the latest IOM report, and a member of the American Board of Internal Medicine, which administers the geriatric certification program, said it was difficult to explain the reluctance to re-certify. But he thought the most likely explanation was the lack of necessity.
Once properly trained and originally certified, a geriatrician would not gain an advantage by re-certifying, although re-certification was key to maintaining the overall quality of geriatric care.
Moreover, re-certification requires time and money. Dr. Reuben said it costs about $1,000 to recertify, but several physicians in the audience at an AGS forum on the workforce report said the cost was closer to $1,900.
And money could be a factor because as a subspecialty, geriatricians suffer from the same problem plaguing all providers of care to the elderly -- low income.
The latest IOM report stated that geriatricians make an average of $163,000 a year, which "sounds like a lot of money to most Americans," said John B. Murphy, M.D., of Rhode Island Hospital in Providence, president of the American Geriatrics Society. But it is about half of what a dermatologist is likely to earn. "So if you are graduating from medical school with $150,000 of debt, would you rather pay it back in five years or 10 years?" asked Dr. Murphy.
Nonetheless, Dr. Murphy thinks it is a mistake to reduce the issue to one of dollars and cents, but during a packed forum at the AGS meeting in Washington, money was a hot topic as one geriatrician after another took to the microphones to offer proposals ranging from paying bonuses to geriatricians who recertify, to plans for medical education loan forgiveness to attract new grads into geriatrics.
The IOM report made the case that poor pay and worse benefits are endemic to the field of geriatric care, and geriatricians don't suffer nearly as much as nurses and nurses aides.
The annual turnover rate among nurses' aides who staff the nation's nursing homes is 71%, and the pay is roughly equivalent to that of a worker in a fast food chain, $9.56 an hour.
"And remember that these aides have a very high risk for injury, usually back injuries," said Dr. Reuben. "If you want a really short conversation, next time you visit a nursing home ask an aide about his or her 401K plan. There are none."
What was absent from the forum was anger. The AGS regularly cites physician satisfaction surveys that find geriatricians among the most satisfied of all physicians, which was evident by the comments from those who spoke at the forum. Among the dozens, all but two or three prefaced their comments with a statement about commitment to patient care and "the need for compassion."
Earlier that day 150 AGS members trekked to Capitol Hill where they visited 54 members of Congress to deliver this message: wake up to the "silver tsunami," the AGS term to describe the age wave that they say is poised to topple the U.S. healthcare system.
Of course, as Dr. Murphy and Dr. Reuben admitted, that's the same message that the AGS has been delivering for decades, which begs the question: why should Congress listen now?
John Rowe, M.D., of the Columbia Mailman School of Public Health, who chaired the IOM committee, said it's all about timing. "This, really, is an idea whose time has finally come," Dr. Rowe said at the AGS forum. As evidence of this, he said that last month when he testified before the Senate Special Committee on Aging on the day the IOM report was released, "the entire committee was present for all of my testimony. They all stayed, that just doesn't happen during Congressional hearings."
The other reason, he said, was that this time its not just geriatricians who are making the case. Rather, it's the John A. Hartford Foundation, Atlantic Philanthropies, Josiah Macy Jr. Foundation, Robert Wood Johnson Foundation, Retirement Research Foundation, California Endowment, Archstone Foundation, AARP, Fan Fox and Leslie R. Samuels Foundation, and Commonwealth Fund, all of which supported and funded the IOM report.
The report, meanwhile, contains this "should-do" list:
- Medicare, Medicaid, and private insurers should offer higher compensation to healthcare providers caring for older adults and cover key services, such as care coordination, that are not now covered.
- Public and private payers should offer a "specific enhancement of reimbursement " for healthcare services to older adults provided by practitioners with a "certification of special expertise in geriatrics."
- Congress should authorize and fund additional training programs for all healthcare professionals to better prepare them to care for older adults.
- State and federal governments should offer loan forgiveness, scholarships and other financing incentives to professionals who specialize in geriatrics.
- Congress and foundations should "significantly increase" support for research and demonstration programs that lead to development of new models of care in prevention, long-term and palliative care, and models of care that promote the effective uses of the workforce.
- Public and private payers should promote and reward new models of care for older adults that are shown to be effective and efficient.
- States and the federal government should increase minimum training standards for all direct care workers.
- Public private and community organizations should provide funding and ensure adequate training for family and other informal caregivers.
- Healthcare professionals and regulators should consider expanding the roles and responsibilities of healthcare providers to better meet the needs of an aging population.
Absent from the report was a plan to pay for the "shoulds," other than the observation that money spent now will save money later.
Figuring out how to pay for the needed changes was not, Dr. Rowe said, part of the charge given to his committee. Instead, the committee was charged to analyze the problem and provide very clinical, evidence-based recommendations delivered not from the point-of-view of a single group of providers (physicians) but rather a big-picture approach that gave equal weight to issues of all groups of providers -- even family members who the IOM report said also need some training in the care of elderly relatives.
The next step, said Dr. Murphy, is a meeting planned for June in Washington. "At that meeting we anticipate that all stake holders will come together to map out a campaign," he said.
Dr. Murphy said out of the June meeting he expected a leadership group would emerge, leadership that will have the task of making the "silver tsunami" a headline issue in this year's presidential election.
But, Dr. Murphy said he did not envision AGS as leading that campaign. "We don't want this to be about physicians, we want it to be about all geriatric caregivers."
If physicians lead the charge, he said, they might find themselves charging alone.
The IOM report can be accessed at http://books.nap.edu/catalog.php?record_id=12089#toc.