Older adults use more health care services than any other age group. Americans over age 65 today are only 13 percent of the population, but account for half of physicians’ visits and half of all hospital stays. The percentage of Americans over 65 will increase to 20 percent by 2020. According to a 2002 study at Johns Hopkins University, 20 percent of those 65 and older have at least five chronic conditions.
At the same time only a small proportion of practicing health care providers have had any formal training in geriatrics and the situation is only to get worse. Within the next 10 years, the number of physicians retiring will outstrip the 25,000 new doctors graduating each year. The percentage of physicians nationally over 55 years of age is 31%, for those over 65 it is 17%. (With a trend toward early retirement, this is a troubling trend.)
In 2005, there was one geriatrician for every 5,000 Americans 65 and older, a ratio that experts say is sure to worsen. Of 145 medical schools in the United States, only nine have departments of geriatrics. Few schools require geriatric courses. And teaching hospitals graduate internists with as little as six hours of geriatric training.
The mismatch between supply and demand is a troubling issue for us. The aging population will increase the demand for physicians per thousand population from 2.8 in 2000 to 3.1 in 2020. The geriatric population is often the most complicated, not only medically but also socially and psychologically. Caring for frail older people is about managing, not curing, a collection of overlapping chronic conditions, like osteoporosis, diabetes and dementia. It is about balancing the risks and benefits of multiple medications, which often cause more problems than they solve. And it is about trying non-medical solutions, like timed trips to the bathroom to improve bladder control.
Demand for full-time registered nurses per thousand population will increase too. There are almost 100,000 vacant positions for nurses plus a turnover rate greater than 50 percent. This is despite 185,000 new nurses added to health care payrolls between 2001 and 2004. The majority of these were foreign born. Many of the remaining group were nurses over the age of 50 who were returning to the workforce. Obviously this indicates a short-term patch to a long term problem.
The U.S. needs to train 3,000 to 10,000 more physicians a year – up from the current 25,000 – to meet the growing medical needs of an aging, wealthy nation. It is estimated the U.S. will have a shortage of 85,000 to 2000,000 doctors in 2020.
But attracting physicians to care for older Americans is a problem. The best-paid doctors are those who do the most procedures; radiologists and orthopedic surgeons top the list with average annual incomes of $400,000. Geriatricians, who do a residency in internal or family medicine and then a fellowship in geriatrics, are near the bottom, at $150,000 a year. Much of what they do — communicating with family members, discouraging unnecessary tests — is time-consuming but not reimbursed.
This is unlike the British health care system where every medical school has a geriatrics department and geriatrics is the third most popular specialty. Part of the reason might be that reimbursement there goes up with the age of each patient, a formula that improves compensation.
In addition to changing reimbursement, another proposed solution to the shortage is for geriatricians to limit their practice to the frailest of the elderly, generally those past 85, along with a subset in the 65-to-85 age bracket who have complicated needs.
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