Wanted: More Doctors for Old People
One of the most glaring paradoxes in the U.S. health-care system is the persistent shortage of geriatricians. You've got a group of patients that is growing, and for whom the federal government guarantees health-care coverage. Yet slots in geriatrics programs go begging while people crowd into surgical specialties. Why?
Part of this is social: Geriatrics is viewed as depressing. Your patients are nearing the end of their lives, so you're basically managing decline, rather than restoring someone to health. Of course, oncology is also depressing, but it doesn't seem to have a recruiting problem, possibly because 1) some of the patients do recover and 2) statistically, cancer is nowhere near as inevitable as aging.
But part of it is also a pay problem. Good geriatricians do intensive case management for patients with multiple problems; that is expensive. Or it would be, if Medicare reimbursed for this sort of intensive case management, which it mostly doesn't.
That, however, may be changing. Starting in January, according to the New York Times, Medicare will pay extra for managing patients with two or more chronic problems:
Doctors will draft and help carry out a comprehensive plan of care for each patient who signs up for one. Under federal rules, these patients will have access to doctors or other health care providers on a doctor's staff 24 hours a day and seven days a week to deal with "urgent chronic care needs."
... As part of the new service, doctors will assess patients' medical, psychological and social needs; check whether they are taking medications as prescribed; monitor the care provided by other doctors; and make arrangements to ensure a smooth transition when patients move from a hospital to their home or to a nursing home.
Doctors can expect to receive about $42 a month for managing the care of a Medicare patient. Care management services can be provided only if patients agree in writing. Patients will pay about 20 percent of the $42 fee, the same proportion as for many other doctor services.
Is $42 enough? That's not clear to me. Staff availability on a 24/7 basis is a pretty big commitment, depending on how it's implemented, and doctors may decide that the extra reimbursement doesn't cover the cost of providing the extra services. But at least it's a start.
On the one hand, it's salutary to see the government finally addressing such a glaring gap in its biggest health-care program. On the other hand, that it took this long is kind of shocking. We've known about the geriatrician problem for a long time -- I wrote about it for the Atlantic in 2007, and it was already an old chestnut in aging research.
The lack of geriatricians matters, because old patients can be a festival of different problems, and often the medication to treat one problem can make other problems worse. Blood pressure medication, for example, may raise the risk of falls in the elderly, which is a big problem if you have osteoporosis. A specialist in the problems of the elderly needs to evaluate those relative risks and decide which risks to take; that's time-consuming, and therefore expensive. And yet it took us forever to fix the funding gap -- if indeed we have fixed it.
Keep this in mind whenever you hear that we need the government to step in because the private health-care market isn't adequately funding some pressing need -- and especially when someone tells you that we need government to deliver the magic price-reducing benefits of monopsony buying power, the way governments do in Europe. The government is basically the sole buyer of geriatric services; what its monopsony power produced was not fantastic access at a low price point, but a chronic shortage. Identifying a problem that the government could theoretically solve is a very long way from actually solving that problem effectively.
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