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Life Health > Long-Term Care Planning

The Doctor Doesn’t Do Old

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Older people tend to need more medical care than younger people do, and the average age of a U.S. resident is going up.

But today, because of the way the United States trains and pays its physicians, experts say, there are fewer geriatricians than there were 10 years ago. And those numbers do not look like they are about to reverse themselves any time soon.

Panelists talked about the decrease recently during a panel discussion on “long-term care in an era of shrinking government” that was organized by the Urban Institute, Washington.

Len Fishman, chief executive officer of Hebrew SeniorLife, Boston, a senior services organization, noted that geriatricians are the lowest-paid specialists and are paid even less than pediatricians.

He also noted that the U.S. government sends money to every U.S. medical school and could have a say on medical school operations.

“Why do only 3% of medical schools have a required class in geriatrics?” Fishman asked.

Fishman said medical schools that receive government funding should have to make sure that all of the nurses and doctors they train get at least some training in geriatrics.

The government also could improve the state of geriatric education by requiring that every medical school it helps have an affiliation with a nursing home as well as with a teaching hospital, Fishman said.

One consequence of the current lack of geriatrics training is that doctors often give the oldest patients doses of medications that are too high and, in some cases, cause delirium, Fishman said.

In other cases, he said, frail patients with dementia who would benefit from being in a hospice program are not referred to them. Instead, he said, health care institutions maximize their own revenue by putting feeding tubes in the patients, even though the tubes are uncomfortable and there is no solid evidence that the tubes extend patients’ lives, Fishman said.

Another panelist, Robyn Stone, senior vice president for research at LeadingAge, Washington, a consortium of nonprofit groups with an interest in aging, said managers of any LTC training or care coordination programs should remember that, in the real world, institutions provide only about 20% of the long-term care, and that about 80% of the people who need long-term care are out in the community.

“Who touches the patient?” Stone asked. “It’s the family and the direct care worker, for the most part.

Joshua Wiener, director of the program on aging, disability and long-term care at RTI International, Research Triangle Park, N.C., warned against being too sentimental about the ability of communities to accommodate the doubling of the frail elderly population that seems likely to occur.

Volunteers may help in some cases, but “I just don’t see this as being a truly meaningful way of supplying the kinds of services people need,” Wiener said. “Community is basically going to be what it’s always been, which is the family.”

The panelists expressed skepticism about almost all potential sources of LTC funding, including LTCI.

Wiener reported that even home equity is a question mark right now.

Some older people own their homes outright, but some still have mortgages, and many of the mortgages are under water, he said.

“They’re stuck in their house for awhile,” Wiener said.

Fishman said Congress will have to find a way get the money for LTC by shifting resources away from the Medicare acute care budget.

“Increasing spending for long-term care at all is going to be really hard while acute care is driving us toward an unsustainable growth curve,” Fishman said.

The panelists also talked about the difficulty of cutting LTC costs.

Many states are taking simplistic approaches to turning LTC over to managed care plans, Stone said.

“We don’t have a history of managed care programs dealing very well with the long-term care/chronic care population,” Stone said.

Fishman said he does like the fact that Medicare is supposed be making hospitals with excessive readmission rates pay penalties starting in 2012. The threat of having to pay a penalty is having a stunning effect on hospitals’ level of interest in what to patients after patients leave the hospital, he said.


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