The History of Geriatric Medicine
In 1900, there were 3.1 million Americans age 65 and older. Today, that number is close to 40 million. By 2030, twenty percent of all Americans will be over the age of 65. People age 85 and older are the fastest growing segment of the entire population, with expected growth from 4 million people today to 19 million by 2050.
This group constitutes the heaviest consumers of health care. The "demographic imperative" of our aging population has far reaching ramifications to our society.
At the turn of the twentieth century, pediatrics as we know it today did not exist. A few enterprising pediatricians hung out their shingles, and a growing nation started to take their children to pediatricians. A century later, an aging population should be calling for the similar development of geriatrics. However, various factors have made this almost impossible to achieve.
The term "geriatrics" was coined in 1909 by Ignatz L. Nascher. The American Geriatric Society ("AGS") was founded in 1942. The development of geriatrics as a specialty has been more advanced in England, which probably reflects a historically greater population of older persons. With the aging of the U.S. population, one might have expected a greater development of geriatric medicine.
By age 75 the average older adult has between 2 to 3 chronic medical conditions and some have 10 or 12 conditions. The elderly most often see general internists and family physicians. However, the vast majority of physicians and health care practitioners have not been trained in geriatrics or the special needs of the elderly. As a result, practitioners may treat an 85-year-old patient the same way they would a 45-year-old. There has been a significant lack of clinical data in regard to standard treatment methodologies in the elderly. One example of the potential impact of this is the treatment of atrial fibrillation, an irregular heart rhythm. In younger individuals, the appropriate treatment is electric cardioversion and medications to maintain a normal rhythm. The AFFIRM study showed that in the elderly, this approach leads to worse outcomes, and a more conservative approach is indicated. Prior to the results of the AFFIRM study, I had to grapple with the poor quality of life that my patients had while being treated with powerful medications by the cardiologists. This is not a unique situation. Specialists tend to treat older patients in the same fashion as they treat younger individuals despite having little or no data to support their approach.
Prior to 1965, when physicians did an internship and residency, they received room and board. In return for support from the American Medical Association ("AMA") for the Medicare program, the government began subsidizing medical education. Today, this subsidization is several billion dollars a year. This was supposed to assure an adequate supply of physicians for the Medicare program, but many physicians today do not accept new Medicare patients. Government financing of graduate medical education has made it easier for young physicians to advance into subspecialty programs. Previously, many physicians went into primary care practice prior to deciding whether to subspecialize. An unintended consequence of governmental support of medical education is that it has limited the free market development of geriatrics and primary care in general, while actually encouraging physicians to go into higher paying subspecialties. At the present time, there are over 22,000 physicians board certified in cardiology and less than 5,000 board certified in geriatric medicine. Furthermore, the number of geriatricians is decreasing annually!
In the early 1990's, the government decided to try to rein in increasing health care expenditures. They chose to use the AMA's codes for physician services and a process by which they would determine how physicians would be reimbursed. The committee that makes this determination (the RUC) is composed of 29 members. The RUC essentially determines how physicians are paid to care for Medicare beneficiaries. However, there are no regular members of the committee that are geriatricians! In fact, the committee is made up almost exclusively of specialists. Furthermore, the government pays the AMA over 70 million dollars a year for the privilege of using their coding system. It should not be surprising that reimbursement has been heavily weighted towards procedures and specialists. Only recently has there been a move towards recognizing the value of the primary care office codes. This move may be too little and too late. Furthermore, there has yet to be adequate recognition of the importance and value of work performed in nursing facilities. While gains were made in 2006 in reimbursement for caring for seniors in assisted living facilities and in their homes, the payment for those codes were reduced in 2007. It is a small wonder that fewer physicians are going into primary care or geriatrics.
The future of Medicare, and of our rapidly aging population, is clearly in the hands of our federal legislature.