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AAGP Statement on Caring for Our Seniors: How Can We Support Those on the Frontlines?

United States Senate Special Committee on Aging

4/16/2008

Statement for the Record Submitted by the American Association for Geriatric Psychiatry to the Special Committee on Aging, United States Senate, Hearing on Caring for Our Seniors: How Can We Support Those on the Frontlines?

The American Association for Geriatric Psychiatry (AAGP) appreciates the opportunity to offer its comments for the record of the Committee’s recent hearing on “Caring for Our Seniors: How Can We Support Those on the Frontlines?”

The recent report of the Institute of Medicine, Retooling for an Aging America: Building the Health Care Workforce, concludes that, without changes at the national level, older Americans will lack access to affordable, quality health care – including mental health care. AAGP has long been concerned about the workforce in the area of late-life mental health care, particularly the declining numbers of doctors entering the field of geriatric psychiatry – those pursuing a research career, becoming clinician-educators, and entering clinical practice. The diminishing workforce in these areas will inevitably lead to inadequate access to quality mental health care for the aging Baby Boomers generation. There is a need for cadre of specialty-trained subspecialists to do research, teach and train others in graduate medical education and institutional and community based continuing education efforts, and to serve as clinical resources for consultation, community education, and tertiary care in communities. These needs require a robust pipeline of geriatric psychiatry fellows who will pursue various career paths in geriatric psychiatry and systematic efforts to assure that they are willing and able to continue their work in the field.

The IOM’s report is the product of a project to examine the optimal health care workforce for older Americans in an aging society. The aim of the study was to determine the health care needs of Americans over 65 years of age, and address those needs through a thorough analysis of the forces that shape the health care workforce, including education, training, modes of practice, and financing of public and private programs. A committee of 15 experts, including AAGP’s President-elect Charles F. Reynolds, III, MD, met over a period of 15 months to study the best use of the workforce, how the workforce (both generalist and specialist) should be educated, the most effective organization of health care delivery, and needed improvements of public programs such as Medicare and Medicaid.

AAGP lauds the IOM’s comprehensive approach to meeting the workforce needs for an aging population in the United States, and for recognizing that this is an emerging public health crisis. The committee’s leadership and expertise should ensure that the report will be received with the serious consideration the topic deserves.

However, we believe that additional time and attention is required to address the special workforce and clinical-service needs for older adults requiring mental health services. Often medical-psychiatric-environmental factors conspire to diminish the quality of life for older adults, especially those with primary mental health conditions like depression, dementia and substance abuse disorders. A targeted report on these issues could greatly influence future policy and resource allocation decisions that will need to be made as the baby-boom generation marches through time.

Geriatric Mental Health Needs

The prevalence of mental illness among older adults and the compounding effects of mental illness plus other illnesses argue for legislative and regulatory changes to increase access to care. With 1 in 10 Americans over age 65 and nearly half of those over 85 suffering from Alzheimer’s disease, one-third of people age 71 and older having some cognitive impairment, and upwards of 5 percent of the elderly in the community and 13 percent of those in home health care living with depression, greater investments into a quality mental health care system are sorely needed.

Today there are just 3.9 geriatric psychiatrists for every 10,000 Americans age 85 and older and just 1.1 for every 10,000 over 75 years of age, according to the Association of Directors of Geriatric Academic Programs (ADGAP). It is estimated the country needs 5,000 geriatric psychiatrists, and yet last year there were fewer than 1,600 board-certified geriatric psychiatrists in the United States, a number that has declined significantly since 1999, when there were 2,425. The data are clear, however, that most geriatric psychiatric services that are provided in this country are not from board certified geriatric psychiatrists, but are delivered by general psychiatrists in the community. It is also clear that the medical education pipeline in this country will never train sufficient board certified geriatric psychiatrists or geriatricians to meet the need or demand for geriatric mental health services. According to ADGAP, however, general psychiatrists are not prepared to meet the complex needs of older patients. Because these providers, of necessity, make a significant contribution, it is essential that policy makers and legislative bodies implement policies that promote enhanced geriatric expertise among general psychiatrists.

Deficiencies in the workforce of geriatric mental health practitioners already constitute a problem for consumer access to services, stretching across disciplines, and trends demonstrate that it is getting worse even as the baby boomer generation approaches late life. It is important to note that the problem extends to other specialists in mental health and aging. In social work, only about 1,115 (3.6 percent) of master’s level social worker students specialize in aging and only about 5percent of practitioners at any level identify aging as their primary area of practice, even though the National Institute on Aging projected that 2020, 60,000-70,000 gerontological social workers will be needed. Among psychologists, only about 3 percent view geriatrics as their primary area of practice and only 28 percent of all graduate psychologists have some graduate training in geriatrics.

The fact that other mental health disciplines are similarly deficient in geriatric specialists indicates that, as it is already difficult for older adults to obtain competent, appropriate treatment for mental illnesses, the problem will be greatly exacerbated in the next decade with the aging of the baby boom generation.

The precipitous drop in the numbers of geriatric psychiatrists clearly threatens to decimate the field of geriatric psychiatry. A larger issue than having board certified geriatric psychiatrists for treating individual patients is the possibility of losing the specialization entirely – which will mean that, in addition to treatment, both teaching and research will suffer. Physicians who treat, teach, and study in the area of geriatric psychiatry will be approaching the issues with less focus, through general psychiatry, or tangentially, through other disciplines (neurology, gerontology, geriatric medicine). Older adults with even mild to moderate mental illness diagnoses tend to have high rates of other illnesses. If these disorders are not properly treated, they can escalate into more serious mental conditions, complicate the treatment of physical health conditions, compromise patient outcomes, and increase the cost of care. Geriatric psychiatrists have the expertise that no other discipline has for addressing this complicated set of circumstances.

Disincentives for Geriatric Mental Health Practice

The IOM report acknowledges that “the costs associated with extra years of geriatric training do not translate into additional income, and geriatric specialists tend to earn significantly less income than other specialists or even generalists in their own disciplines.” The problem is in many ways even more pronounced in the field of geriatric mental health. An important consideration for psychiatrists who are considering geriatric specialty training or for those already in practice who hope to continue to be able to see geriatric patients are numerous reimbursement disincentives to practice in the field. These barriers are myriad, but include out-of-date payment policies of government and private insurance that reflect obsolete models of practice not relevant to modern geriatric mental health services and that perpetuate long-held stigma and outdated ideas of treatment efficacy. The reimbursement issues for geriatric mental health are most blatantly apparent in Medicare’s 50 percent coinsurance requirement for outpatient psychiatric services, a requirement that is a matter not of policy but of statute, dating to the inception of Medicare in 1965. Although efforts to repeal this inequity – all other Medicare outpatient doctors’ visits are reimbursed at 80 percent – have recently made great strides with the passage of legislation in the U. S. House of Representatives and renewed interest in the issue in the Senate, there is still an uphill battle to win enactment.

Beyond insurance parity, more direct reimbursement problems disproportionately affect geriatric psychiatrists. For instance, in 2006, Medicare significantly increased reimbursement for evaluation and management (E&M) services performed by physicians. This increase was long sought and urgently needed by all geriatric practitioners whose practices involve complex office evaluations as opposed to the long established biases in the Medicare system favoring more procedure-based specialties. But for psychiatry, 2007 also brought a 9 percent reduction in reimbursement for psychiatric services as a result of a five-year review of relative value units (RVUs). While geriatric psychiatrists are in some instances able to offset the loss of the latter by greater use of E&M codes, for geriatric practitioners in other disciplines, such as psychology and social work, this option is not available. While an across-the-board reduction in the physician fee schedule of a similar magnitude has been staved off by Congress year-by-year as it has searched for the means to finance a permanent correction, the additional reduction for mental health practitioners must also be addressed.

The coinsurance inequity and the reduction in psychiatric services reimbursement are just two examples of the disincentives for entering geriatric mental health field that compound the difficulties that generally face other geriatric specialties. At a time when the government ought to use Medicare policy to stimulate the growth in the numbers of geriatric mental health providers, current efforts to control healthcare spending may adversely affect geriatric mental health providers disproportionately more than other healthcare providers, producing the opposite effect.

Recommendations

AAGP recommends a number of legislative initiatives that would help to remedy the clear need for a stronger geriatric mental health workforce:

· Follow-up Study on Mental Health
AAGP believes that the broad scope of the IOM’s, while meeting a crucial need for information on the many issues regarding the health workforce for older adults, precluded the in-depth consideration of the workforce needed for treating mental illness. The study just completed should be followed by a complementary study focused on the specific challenges in the geriatric mental health field. This study should follow up the general IOM study in two specific ways: 1) It should examine the access and workforce barriers unique to geriatric mental healthcare services; 2) In discussing possible alternative models of geriatric service delivery (medical homes, PACE programs, collaborative care models, etc.) it should articulate the importance of integrating geriatric mental health services as intrinsic components.

· Loan Forgiveness Legislation
AAGP strongly supports legislation to provide loan forgiveness for health care professionals who enter geriatric specialties. AAGP supports S. 2708, the Caring for an Aging America Act, which would create a new program for loan repayment for specialists across disciplines who enter geriatric specialties. AAGP also supports H. R. 2502, the Geriatricians Loan Forgiveness Act, which allow fellows in geriatric medicine and geriatric psychiatry to include fellowship training as part of their obligated service under the National Health Corps Loan Repayment Program.

· Title VII Geriatric Health Professions Program
The geriatric health professions program, which has been administered by the Health Resources and Services Administration (HRSA) under Title VII of the Public Health Service Act, has supported three important initiatives: the Geriatric Faculty Fellowship has trained faculty in geriatric medicine, dentistry, and psychiatry; the Geriatric Academic Career Award program has encouraged newly trained geriatric specialists to move into academic medicine; and the Geriatric Education Center (GEC) program has provided grants to support collaborative arrangements that provide training in the diagnosis, treatment, and prevention of disease. Weakening or even elimination of these programs, as occurred for one year in FY 2006, would have a disastrous impact on physician workforce development over the next decade, with dangerous consequences for the growing population of older adults who will not have access to appropriate specialized care. AAGP strongly urges reauthorization and increased funding for these programs.

· Medicare Reimbursement Issues
AAGP strongly supports efforts to enact a long-term correction of the Medicare physician payment formula and to address other aspects of the Medicare payment system that discourage entry into geriatric mental health specialties, particularly the 50 percent copayment requirement for outpatient psychiatric treatment and the unacceptably low reimbursement rates for psychiatric services.

Summary

The small numbers of specialists in geriatric mental health care, including geriatric psychiatry, combined with increases in life expectancy and the growing population of those age 65 and over, estimated to be 20 percent of the U.S. population in 2030 (up from 12 percent in 2006), foretells a crisis in health care that will impact older adults and their families nationwide. Unless changes are made now, older Americans will face long waits, decreased choice, and suboptimal care. Consequently, AAGP urges Congress, the regulatory agencies, and leaders in health care policy to act upon the IOM’s report and make the necessary changes to recruit and retain a skilled workforce in geriatrics and geriatric mental health care, and to adopt an efficient and effective organization of geriatric medical and mental health care services.

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