Readying for the senior surge

The first of the nation's 78 million baby boomers are going to reach Medicare eligibility in just three years. By 2030, the number of adults 65 and older will have reached more than 75 million -- almost double the 2005 figure. Unfortunately, the health care work force is woefully unprepared to meet the challenges this population presents.

That's the conclusion of a new Institute of Medicine report looking at the problem and exploring the solutions. The document, a wake-up call of sorts, echoes the American Medical Association's concern that the health care community is not ready.

The sheer number of patients who will need geriatric care is daunting. Already, there is a shortage of 12,000 geriatricians. By the time the last of the boomers hit 65 in 2030, the nation will need 36,000 geriatricians, but there will be only about 8,000, the report notes.

The baby boomers will be unlike the generations of elderly patients before them. Not only are there many more of them, they also have a greater life expectancy than their predecessors. And along with longer life comes not only the perils commonly associated with aging -- malnutrition and falls -- but an epidemic of chronic conditions. About 80% of older adults have one chronic condition, and about 20% have five or more.

These complex health needs necessitate a physician work force able to handle them. But the AMA and IOM agree that it will be virtually impossible to train enough geriatricians in time. So all doctors who treat elderly patients will need to become proficient in meeting their special needs.

Changes will have to start in medical school, where geriatric training has improved but often is still inadequate, according to the IOM. Educational curricula and training programs need to be enhanced.

To that end, the AMA joined the Assn. of American Medical Colleges and other stakeholders to identify specific medical student competencies in geriatrics. This set of 26 skills represents the first consensus on the geriatric basics all students need to know.

The IOM also recommends that medical residencies be changed to give interns exposure to sites of care other than hospitals, such as nursing homes and patients' homes -- a move the AMA supports.

Training should not stop there. Given the shortage of geriatricians, all practicing physicians who treat elderly patients will need to have the skills to handle their complex needs. The Association offers many resources, including physician guides on older driver safety, dementia and home care patients. These tools are available on the AMA's geriatric health Web site (link).

But no amount of educational encouragement will prevent the predicted shortage of geriatric-trained physicians without Medicare pay reform.

Geriatricians are paid primarily by Medicare and Medicaid, both of which pay too little. So geriatricians typically earn less than primary care counterparts. The looming Medicare cuts -- starting with a 10.6% reduction in July --would make the field even less appealing and financially feasible.

If Congress allows the cuts to go through, it will hurt seniors' access to doctors across specialties. In an AMA survey of physicians, 60% of respondents said cuts of this magnitude would force them to limit the number of new Medicare patients they treat.

The Association supports a bill by Sen. Debbie Stabenow (D, Mich.) that would prevent the cuts for the next 18 months and increase Medicare physician payment by 1.8% next year.

Change shouldn't just focus on the professional health care work force. Informal caregivers -- typically family and friends -- far outnumber them. As the baby boomers age, these caregivers will need education so that they can become integrated into the health care team.

Informal caregivers also have unique health care needs that spring from the physical, emotional and sometimes financial strain of tending to an ailing loved one. To help doctors care for these patients, the AMA has created a caregiver self-assessment tool that they can administer. It also is available on the Association's geriatric health Web site.

The IOM report has myriad other recommendations on everything from developing new, more integrated models of health care to improving training and pay for direct-care workers, such as nursing home aides.

Indeed, preparing the entire health care work force for the aging of the baby boomer generation is a massive challenge. But, as the IOM report shows, the solutions are out there -- and the work must be done.