[Senate Hearing 107-400]
[From the U.S. Government Publishing Office]
S. Hrg. 107-400
PATIENTS IN PERIL: CRITICAL
SHORTAGES IN GERIATRIC CARE
=======================================================================
HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
WASHINGTON, DC
__________
FEBRUARY 27, 2002
__________
Serial No. 107-19
Printed for the use of the Special Committee on Aging
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78-786 WASHINGTON : 2002
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SPECIAL COMMITTEE ON AGING
JOHN B. BREAUX, Louisiana, Chairman
HARRY REID, Nevada LARRY CRAIG, Idaho, Ranking Member
HERB KOHL, Wisconsin CONRAD BURNS, Montana
JAMES M. JEFFORDS, Vermont RICHARD SHELBY, Alabama
RUSSELL D. FEINGOLD, Wisconsin RICK SANTORUM, Pennsylvania
RON WYDEN, Oregon SUSAN COLLINS, Maine
BLANCHE L. LINCOLN, Arkansas MIKE ENZI, Wyoming
EVAN BAYH, Indiana TIM HUTCHINSON, Arkansas
THOMAS R. CARPER, Delaware PETER G. FITZGERALD, Illinois
DEBBIE STABENOW, Michigan JOHN ENSIGN, Nevada
JEAN CARNAHAN, Missouri CHUCK HAGEL, Nebraska
Michelle Easton, Staff Director
Lupe Wissel, Ranking Member Staff Director
(ii)
C O N T E N T S
----------
Page
Opening Statement of Senator John Breaux......................... 1
Prepared Statement of Senator Jean Carnahan...................... 3
Prepared Statement of Senator Debbie Stabenow.................... 4
Statement of Senator Harry Reid.................................. 5
Statement of Senator Tim Hutchinson.............................. 6
Statement of Senator Larry E. Craig.............................. 21
Statement of Senator Blanche Lincoln............................. 158
Panel I
Stephen Bizdok, Las Vegas, NV.................................... 8
Daniel Perry, Executive Director of the Alliance for Aging
Research, Washington, DC....................................... 9
Panel II
Dr. Charles Cefalu, Board Member of the American Geriatrics
Society, Professor and Director for Geriatric Program
Development, Louisiana State University, New Orleans, LA....... 22
Claudia Beverly, Ph.D., R.N., Associate Director of the Donald W.
Reynolds Center on Aging, Little Rock, AR...................... 42
Michael Martin, Executive Director of the Commission for
Certification in Geriatric Pharmacy, Alexandria, VA............ 145
APPENDIX
Testimony submitted by Association of Professors of Medicine..... 167
Statement submitted by the American Association for Geriatric
Psychiatry..................................................... 172
Statement from the American Psychiatric Association.............. 179
Statement from the American Psychological Association............ 187
Testimony of Robert Butler, International Longevity Center....... 194
Testimony submitted by Council on Social Work Education.......... 199
Statement of the American Occupational Therapy Association....... 205
Statement of the Association of American Medical Colleges........ 242
Statement of the American Association of Colleges of Osteopathic
Medicine....................................................... 253
(iii)
PATIENTS IN PERIL: CRITICAL SHORTAGES IN GERIATRIC CARE
----------
WEDNESDAY, FEBRUARY 27, 2002
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The committee met, pursuant to notice, at 9:04 a.m., in
room 628, Dirksen Senate Office Building, Hon. John Breaux
(chairman of the committee) presiding.
Present: Senators Breaux, Reid, Lincoln, Craig, and
Hutchinson.
OPENING STATEMENT OF SENATOR JOHN BREAUX
The Chairman. The committee will please come to order. Good
morning, everyone. Thank you for being with us. I appreciate
our colleague, Senator Harry Reid, taking time to be with us
this morning as a member of our committee and thank him for his
attendance.
I want to thank everyone for being with us. I want to
particularly welcome Mr. Steve Bizdok, who traveled all the way
from Las Vegas, NV in order to share a really incredible story
with us today.
This morning's hearing is entitled ``Patients in Peril:
Critical Shortages in Geriatric Care.'' This marks the seventh
in a series of long-term care hearings that our committee has
held during this Congress. The shortage of health care
professionals with specific training in geriatric care takes us
to the core of what I mean when I say that we must ensure that
all Americans have the opportunity to not only live longer but
also to live better lives.
We will hear today from a patient whose life was literally
in jeopardy because well-meaning health care professionals
lacked the real training to diagnose his illness. He is not
alone. The senior population is living increasingly longer and
more and more people will experience the effects of chronic
conditions. In the United States we train our future doctors at
125 prestigious medical schools around the country. While each
of these schools has a pediatrics department, only three in the
entire country have geriatric departments and only 14 require
even a course in geriatrics.
As the population of people 85 years of age and older
continues to grow at the fastest rate in the nation, we are
experiencing an unprecedented shortage of nurses and less than
1 percent of those who remain are certified in geriatrics.
As we move across the health care spectrum the outlook is
increasingly bleak. Social workers, dentists, nutritionists,
nurse assistants, therapists and psychologists will all play an
increasingly important role as the baby boom generation
continues to age, yet none of these disciplines is adequately
prepared in the workforce to handle the illnesses and the
conditions specific to geriatric patients. Pharmacists, who
often play an intermediary role between the doctor and the
patient, are just as unprepared. A recent report stated that
each year nearly 1 million seniors are prescribed medicines
which people their age should never take. Other studies
indicate that 35 percent of all Americans over the age of 65
experience adverse drug reactions, at a cost of $20 billion a
year for treatment. Clearly we must do better than that and we
can do better than that.
I applaud the Veterans Administration for their efforts to
train geriatricians through their fellowship program and I also
recognize the work done by private foundations, such as the
Hartford Foundation, the Brookdale Foundation, and the Reynolds
Foundation, who have done much with little Federal funding.
Thirty-five geriatric education centers across the Nation
should also be recognized for training hundreds of thousands of
interdisciplinary health care professionals to better serve
older Americans.
In addition, I am happy to note that I have worked with Dr.
Greg Folse, a geriatric dentist from Louisiana, to improve the
oral health care provisions of the nursing home survey and
oversight efforts over at CMS.
While all of these efforts are commendable, they are simply
not enough. I believe it is important to note that this issue
should not be taking us by surprise. For many years now
organizations such as the American Geriatric Society, the
International Longevity Center, and the Alliance for Aging
Research have come to Capitol Hill to urge Congress to address
this looming issue. During the spring of 1998 the Special
Committee on Aging held a forum to highlight and discuss the
shortage of geriatricians. During that same time I was also
serving as chairman of the National Bipartisan Commission on
the Future of Medicare and learned that by the year 2030 more
than half of the nation's medical expenditures would be
accounted for by older Americans. It is obvious that this
shortage of geriatric-trained health care workers is not only a
threat to an increasing number of elderly Americans but also to
the economic health of our nation.
I certainly look forward to learning more about this issue
from our distinguished panels and would like to recognize our
distinguished leader, Senator Harry Reid, if he would have any
comments.
[The prepared statement of Senator John Breaux follows
along with prepared statements of Senator Jean Carnahan and
Senator Debbie Stabenow:]
Prepared Statement of Senator Breaux
Good morning and thank you all for being here today. I
especially want to welcome Mr. Steve Bizdok who traveled from
Las Vegas in order to share his incredible story with us today.
I also want to welcome the Committee's Ranking Member Larry
Craig and my other colleagues, a number of whom I know have a
specific legislative interest in today's topic.
This morning's hearing, ``Patients in Peril: Critical
Shortages in Geriatric Care'' marks the seventh in a series of
long-term care hearings that the Committee has held during the
107th Congress. The shortage of health care professionals with
specific training in geriatric care takes us to the core of
what I mean when I say that we must ensure that Americans not
only live longer, but live better. We will hear today from a
patient whose life was literally in jeopardy because well-
meaning health care professionals lacked the training to
diagnose his illness. He is not alone. While the senior
population is living increasingly longer, more and more people
will experience the effects of chronic conditions.
In the United States we train our future doctors at 125
prestigious medical schools. While each of these schools has a
pediatrics department, only three have geriatric departments
and only 14 require a course in geriatrics. As the population
of people 85 years and older continues to grow at the fastest
rate in the nation, we are experiencing an unprecedented
shortage of nurses; and, less than one percent of those who
remain are certified in geriatrics. As we move across the
health care spectrum the outlook is increasingly bleak. Social
workers, dentists, nutritionists, nurse assistants, therapists,
and psychologists will all play an increasingly important role
as the baby boom generation continues to age, yet none of these
disciplines is adequately preparing its workforce to handle the
illnesses and conditions specific to geriatric patients.
Pharmacists, who often play an intermediary role between the
doctors and patients, are just as unprepared. A recent report
stated that each year nearly one million seniors are prescribed
medicines which people their age should never take. Other
studies indicate that 35 percent of Americans over the age of
65 experience adverse drug reactions at a cost of $20 billion
annually for treatment. Clearly we must do better.
I applaud the Veterans Administration for their efforts to
train geriatricians through their fellowship program and I also
recognize the work done by private foundations such as the
Hartford Foundation, the Brookdale Foundation, and the Reynolds
Foundation who have done much with little federal funding. The
35 Geriatric Education Centers across the nation should also be
recognized for training hundreds of thousands of inter-
disciplinary health care professionals to better serve older
Americans. In addition, I am happy to note that I've worked
with Dr. Greg Folse, a geriatric dentist from Louisiana, to
improve the oral care provision of CMS's nursing home survey
and oversight efforts. While all of these efforts are
commendable, they are simply not enough.
I believe it is important to note that this issue should
not be taking us by surprise. For many years now organizations
such as the American Geriatrics Society, the International
Longevity Center, and the Alliance for Aging Research have come
to Capitol Hill to urge Congress to address this looming issue.
During the spring of 1998, the Special Committee on Aging held
a forum to highlight and discuss the shortage of geriatricians.
During that same time I was also serving as the Chairman of the
National Bipartisan Commission on the Future of Medicare, and
learned that by the year 2030 more than half of the nation's
medical expenditures would be accounted for by older Americans.
It is obvious that this shortage of geriatric-trained health
care workers is not only a threat to an increasing number of
elderly Americans, but also to the economic health of our
nation.
I look forward to learning more about this issue from my
fellow Senators and from our distinguished panels. I also look
forward to hearing recommendations about what can be done to
ensure that America's seniors continue to live not only longer
lives, but better lives as well.
------
Prepared Statement of Senator Jean Carnahan
Thank you, Mr. Chairman, for holding this hearing. I
believe that the testimony of the witnesses will provide
valuable insight to the importance of specialized training in
geriatric care for health professionals.
In Missouri and across the country, the ``baby boomers''
are aging. In the next several years, the number of American
citizens over the age of 65 will increase dramatically. By the
year 2030, 70 million Americans will be 65 and older. As the
population ages, they will have different healthcare needs.
These needs will not be met unless we address the current
shortage in geriatric healthcare providers.
Patients want to receive the best possible healthcare from
those most qualified to treat them. When women seek prenatal
care, they turn to providers specifically trained in the care
of pregnant women. When parents seek care for their children,
they turn to providers specially trained in pediatric residency
programs. When adults seek healthcare for specific cardiac,
pulmonary, gastrointestinal, or psychiatric issues, they make
appointments with cardiologists, pulmonologists,
gastroenterologists, or psychiatrists. Patients realize the
importance of the provider's specialized training in finding
the best possible solution to their problem. For seniors, the
desire is the same. They want to be cared for by those most
qualified to provide their healthcare.
Today, there are fewer than 9,000 geriatricians in the
United States. Unfortunately, most of these doctors will retire
as the baby boomer generation attains Medicare eligibility. Of
the approximately 98,000 medical residency and fellowship
positions supported by Medicare in 1998, only 324 were in
geriatric medicine and geriatric psychiatry. At the same time,
the number of physicians needed to provide medical care for
older persons is expected to triple in the next 30 years.
Further complicating the issue is the limited number of
academic geriatricians. A large portion of their time is spent
with patients, leaving little time to mentor or train the next
generation of geriatricians. In addition, they have little time
to conduct vital research regarding the care of the elderly.
There must be incentives in place to encourage young
physicians and other healthcare providers to pursue a career in
geriatrics. That is why I am supporting a bill, the Geriatric
Care Act. The Geriatric Care Act would remove some of the
disincentives that have cause the geriatrician shortage. First,
the bill would authorize Medicare coverage of geriatric
assessment and care coordination for seniors with complex
health and social needs. Second, the bill would provide
hospitals additional slots in their geriatric residency
training programs. The current cap on the number of residents
per hospital has caused many hospitals to reduce or eliminate
their geriatric training programs.
Thank you, again, Mr. Chairman, for holding this hearing. I
look forward to working with my Senate colleagues to address
this situation.
------
Prepared Statement of Senator Debbie Stabenow
Mr. Chairman, thank you for convening today's hearing on
this critical issue. As we all know, our aging population will
dramatically change the way health care is administered in our
country. The statistics are staggering: today in America, well
over 35 million people are over the age of 65--and that number
is growing at a fast pace.
Although America has the best caregivers in the world, not
nearly enough are specially trained nor certified to provide
geriatric care. Currently, we are experiencing shortages in
geriatric care at every level. Only 1.3 percent of physicians
in America are geriatricians. Less than one percent of nurses
are certified in geriatrics. Less than one-half of one percent
of pharmacists have geriatric pharmacology certifications.
Even more challenging is the lack of resources to train
geriatricians. Only a handful of our medical and nursing
schools offer sufficient training in geriatrics. More must be
done to help schools train students and to attract young
healthcare professionals to the field of geriatrics to meet the
rapidly growing demand. Two bills have been introduced in the
Senate--The Advancement of Geriatric Education Act and the
Geriatric Care Act--both offer solutions to this healthcare
crisis. I am currently reviewing these bills and am eager to
work with the committee and my colleagues in the Senate to
begin to address the enormous need for geriatric care in our
country.
There are some success stories that merit more attention
because they have demonstrated very positive results for
seniors. The Program of All-inclusive Care for the Elderly
(PACE) program is a wonderful way to help elderly patients
retain their independence while receiving the specific kind of
care that they need. These Medicare and Medicaid funded
programs provide a ``one-stop shopping'' area for seniors,
where senior participants have access to a full range of
support and health care.
In Michigan, we are very lucky to have one PACE program,
the Center for Senior Independence. Of the many constituents I
work with, one woman's story shines as an example of how
helpful PACE can be. This woman is 67 and a resident of
Detroit. She is a two-time stroke victim, has use of only one
arm, is diabetic, and has a large ulcer on one leg and has had
to have her other leg amputated. For many years, she lived with
her daughter who took care of all her needs. However, she was
determined to be independent and sought services to help. She
now is a patient at the PACE program happily living at home.
Every morning a driver picks her up and takes her to the
Center. There she can get all her prescriptions, see her
doctor, or they will take her to offsite medical appointments.
The Center also provide her with dietary assistance even does
her laundry! She and her family have been extremely pleased
with the Center. We need to make this wonderful program
available for more of our aging population.
Aging advocates are also working in Michigan to help reduce
the shortage of geriatric care in rural areas. For example,
Northern Michigan University is working to establish a
gerontology minor program. Additionally, the University has
been working to attain sufficient funding to establish the
Northern Michigan University Center for Gerontological Studies.
This Center will fill the gap and provide exactly the kind of
specialized training that is currently lacking and will
continue the important research that must be conducted on the
process of aging. I am very interested in helping this program
succeed and in helping to bolster the programs in the other
medical and nursing schools in my state.
Finally, I want to highlight the importance of geriatric
pharmacists. Because the average senior citizen takes 18
prescription medications per year, it is vital that pharmacists
who specialize in the unique needs of seniors are available.
According to some studies 35 percent of Americans over age 65
experience adverse drug reactions. Often, seniors have
different health risks that younger people may not have. It is
very important that we have enough specially trained geriatric
pharmacists to monitor and to take these risks into account
when filling prescriptions. As I work with my colleagues to
develop meaningful Medicare prescription drug benefit, we must
also be mindful of this shortage of pharmacists and the role it
plays in providing truly adequate care for our seniors.
In conclusion, I am looking forward to hearing from our
witnesses and also look forward to working with the committee
on this critical issue.
STATEMENT OF SENATOR HARRY REID
Senator Reid. Thank you very much, Chairman Breaux, and
thank you very much for your leadership in this most important
committee. I have enjoyed my service on this committee. I
served on the Aging Committee in the House and I must say your
stewardship is certainly in keeping with the pattern that was
set by Senator Pepper, who was so good when I first joined the
committee in the House.
I would like to welcome Mr. Steven Bizdok to the Senate
from Nevada. Mr. Bizdok has been a resident of Las Vegas for
more than 40 years. His story is compelling. His story
illustrates the value of geriatric care and why we must take
measures to increase the number of doctors, nurses, pharmacists
and mental health professionals who are trained in geriatrics.
Too often problems in older persons are misdiagnosed,
overlooked or dismissed as normal conditions of aging because
doctors and other health care professionals simply are not
trained to recognize how diseases and impairments might appear
differently in the elderly. As a result, patients like Mr.
Bizdok suffer needlessly and Medicare costs rise because of the
avoidable hospitalizations and nursing home admissions.
It is no secret that our nation is growing older. Every day
this year approximately 6,000 people will celebrate their 65th
birthday. The number of old Americans will more than double
from 35 million to 70 million by the year 2030. The vast
majority of our health care providers, however, are not yet
prepared to meet the challenges associated with caring for the
elderly. Increasing the number of certified geriatricians and
improving access to geriatric care simply will not be easy.
Geriatrics is the lowest paid medical specialty because the
extra time required for effective treatment of the elderly is
barely reimbursed by Medicare and other insurers.
To encourage more doctors to become certified in geriatrics
I am reintroducing the Geriatricians Loan Forgiveness Act. This
is legislation that would forgive $20,000 of education debt
incurred by medical students for each year of advanced training
required to obtain a certificate of added qualifications in
geriatric medicine or psychiatry. I would say, Chairman Breaux,
in that you are one of the senior members of the Finance
Committee, I think this would be something to really take a
look at.
Another barrier to increasing access to geriatric care is a
provision in the Balanced Budget Act of 1997 that established a
hospital-specific cap on the number of residents based on the
level in 1996. Because a lower number of geriatric residents
existed prior to December 31, 1996, these programs are
underrepresented in the cap baseline. The implementation of
this cap is resulting in the reduction of and, in some cases,
the elimination of geriatric training programs, despite the
fact that they are needed now more than ever.
I am pleased to join Senator Lincoln in reintroducing the
Geriatric Care Act, legislation that would allow hospitals to
exceed this cap and expand their geriatric fellowship programs.
Another important provision of this legislation would give our
frail elderly access to geriatric care coordination by making
this benefit reimbursable under the Medicare program.
Geriatric care helps seniors live independent, productive
lives. By postponing physical dependency, our nation could save
as much as $5 billion each month in health care and custodial
costs. Simply put, increasing the number of health care workers
trained in geriatrics is good medicine and good economics.
I look forward, Mr. Chairman, to working with you on this
most important issue dealing with geriatric care and I would
ask that you excuse me about 25 after because the Senate opens
at 9:30 and I have to be there.
The Chairman. Other duties call. Thank you very much for
your comments and your suggestion on the legislation, which I
think is really very positive.
Next I recognize Senator Hutchinson from Arkansas, who has
some geriatric facilities there that are doing good work.
STATEMENT OF SENATOR TIM HUTCHINSON
Senator Hutchinson. Thank you, Senator Breaux. I want to
thank you particularly for holding this hearing today. I am
especially pleased that we have an Arkansas on our second
witness panel, Claudia Beverly, who is the associate of the
Donald Reynolds Center on Aging in Little Rock.
Senator Reid. Would the senator yield just for a second?
Senator Hutchinson. Yes.
Senator Reid. Donald Reynolds was a Nevadan.
Senator Hutchinson. Indeed he was.
Senator Reid. He came from Arkansas, though.
Senator Hutchinson. He almost bought Arkansas. But the
Donald Reynolds Foundation----
Senator Reid. He would have but he spent most of it on
buying Nevada.
Senator Hutchinson. I know that the Donald Reynolds
Foundation has probably meant as much to Nevada and Arkansas
both in their charitable giving and the many projects that they
have supported and this is very appropriate, the commitment
they have made to this geriatric center in Little Rock and we
are very pleased to have it. Claudia is well known in Arkansas,
as well as across the Nation for her expertise in geriatric
nursing.
Mr. Chairman, last June Senator Mikulski and I held a
hearing on the need for greater focus on geriatrics in the
Subcommittee on Aging and I subsequently introduced
legislation, along with my colleague and ranking member of the
Special Committee on Aging, Larry Craig. Our bill is called the
Age Act and it does four very important things.
First, the bill provides an exception to the 1997 residency
cap to allow hospitals to have up to five additional geriatric
residents. Second, the Age Act authorizes the Centers for
Medicare and Medicaid Services to provide graduate medical
education support for the second year of a geriatric
fellowship, which is critical to developing a cadre of academic
geriatricians. Senator Craig and I sent a letter to CMS
Administrator Tom Skully just this week asking CMS to do this
administratively. Third, the Age Act asks the Secretary of
Health and Human Services to report to Congress on ways to
better educate and disseminate information on geriatrics to
Medicare providers. Then fourth and finally, the Age Act
increases the authorization amounts for geriatric programs
under Title VII of the Public Health Service Act, such as the
Geriatric Academic Career Award Program and Geriatric Education
Centers, which focus on generating geriatric scholars and
providing geriatric training to all health care professionals.
Now Mr. Chairman, you and our majority whip Senator Reid
have both emphasized and I think explained very clearly how the
explosion among the aging is occurring demographically in our
society. Just to put it in perspective, one in five Americans
will be over the age of 65 in the year 2030 and that is
dramatic. At the same time, only 9,000 of our nation's 650,000
doctors have received any specialized training in the area of
geriatrics. I think those two sets of statistics make a very
compelling case for what we face. Of 125 medical schools only
three, including I am glad to say the University of Arkansas
for Medical Sciences, have formal departments of geriatrics. In
only 14 medical schools is geriatrics a required course of
study. Everywhere else it is optional. By contrast, every
medical school in the Nation has a pediatrics department and
every medical school in England has a geriatrics department.
Just as children have unique medical needs, so do older
Americans. Aging individuals often exhibit different symptoms
than younger people with the same illness. Similarly, elder
people often exhibit different responses to medications than
younger people. Many seniors also take multiple drugs ordered
by multiple physicians, which can lead to adverse drug
reactions.
As was evidenced in the hearing the Aging Subcommittee held
last June, our nation is in dire need of more geriatricians and
health care professionals with geriatrics training. About
20,000 geriatricians are currently needed for the current aging
population and we only have 9,000. So we have a great challenge
ahead of us.
Mr. Chairman, the kind of legislation that Senator Reid
speaks of, that you have led the way in, Senator Mikulski and
myself, I know that is the way we can find consensus on these
various proposals to meet what all of us see as the great
geriatrics need of the future and I would ask that my full
statement be included in the record. I am anxious to hear our
panel and I thank the chair.
The Chairman. Thank you very much, Senator Hutchinson and
Senator Reid, for your comments.
You have heard from us. Now it is time to hear from the
real people that we have come to hear from, and that is Mr.
Steve Bizdok and Mr. Dan Perry. Mr. Bizdok, as I indicated
earlier, is from Las Vegas. You have an incredible story. You
look like the picture of health but that was not the story
before. Dan Perry, of course, is the Executive Director of the
Alliance for Aging Research. We have worked together with his
organization for a number of years. This is a good piece of
material that you all have put out; very interesting and very
timely.
We will hear from Mr. Bizdok. We would love to hear from
you.
STATEMENT OF STEPHEN BIZDOK, LAS VEGAS, NV
Mr. Bizdok. Thank you. Good morning, Chairman Breaux,
Ranking Member Craig, Senator Reid, members of the committee
and distinguished guests. It is an honor to be here this
morning and I hope that my testimony will be helpful.
My name is Stephen Bizdok and I have been a resident of Las
Vegas, NV for over 40 years. When I was younger I was not
really concerned about what kind of doctor I saw but as I grew
older and became ill, I realized that I had to have someone who
could understand what my mind and body were going through. That
was when I discovered the importance of geriatric medicine.
My health started deteriorating in the summer of 1999 when
I started to have seizures. They started out small and I would
have about one per week. Then they started to snowball until I
was having a seizure every day. Then they started multiplying
so that I had cluster seizures. I started to panic because I
did not trust myself to drive and I was all alone in my home
when I was having these seizures. Each one would last up to 15
or 20 minutes and I could not even drive to the doctor.
During my well periods I asked my friends to drive me. By
that point I would go to a quick care center to get medical
attention and was constantly shifted from doctor to doctor to
doctor. My primary care physician did not have a clue what was
happening to me. They assumed it was a brain problem.
In October 1999 I had a very large seizure while I was at
home alone and I laid on the living room floor for 4 days. A
friend of mine who had not heard from me for 4 days sent some
friends who had a key to my place to come check on me. They
found me on the floor in a fetal position and called an
ambulance. I spent 2\1/2\ months in intensive care hooked up to
life support. The doctors at the hospital got a court order to
take me off of life support. All of my organs had started to
shut down and the doctors put me on a death watch for 4 days.
On hearing of my impending death, they gave away my car, my
clothes and all of my personal belongings. My friends and
family came to the hospital to say goodbye.
I finally woke up on my own in the hospital room
around February 25, 2000, 4\1/2\ months after my friends found
me on my living room floor. I had slept through the entire
millennium. Doctors still did not know what happened to me.
When I went into the coma I weighed 220 pounds. When I woke
up from the coma I weighed 123 pounds and I did not have the
use of my legs. The doctors in the hospital started me on
physical therapy so I could walk again. I was discharged from
the hospital on April 6, 2000 when I was strong enough to use a
walker. I went from the hospital to a care home. From that
point on, the people who owned the care home suggested that I
enroll in supplemental insurance and I enrolled in a Medicare
Social HMO in Las Vegas. That is when I was introduced to
geriatric medicine.
I was assigned to a geriatrician and I will never forget my
first visit because it lasted over one hour. He gave me a very
thorough physical and asked many questions. I started seeing
him on a regular basis and had a standing appointment once
every 3 months.
One year later I had two seizures. My geriatrician
diagnosed my condition as a heart murmur or irregular
heartbeat. My geriatrician put me in the hospital immediately
when I told him I was having a pain in my back that traveled
under my right arm and to the right side of my chest. That is
when he called in the heart specialist. Within 2 days I had a
pacemaker put in. I was finally receiving the treatment for my
condition. It took a geriatrician to diagnose the problem.
My health problems started to turn around after I received
geriatric care. Since receiving the pacemaker, my health has
improved tenfold. It is unbelievable. First, I am not having
seizures any more and I am able to live on my own. I can take
care of all of my own medication and can live an active life
again. I used to take 14 pills every morning and now I am down
to just six.
There is nothing my geriatrician, Dr. Muyat, can do about
my getting older but he can help me from becoming old.
Thank you for your time today. Please feel free to ask me
any questions.
The Chairman. Mr. Bizdok, thank you very much. That is
probably the most incredible story that I have heard since I
have served on this Committee. It is an unbelievable story and
I think it makes the point very well and we thank you so much
for being with us.
We are going to let Mr. Perry give his statement; then we
will have some questions. Dan.
STATEMENT OF DANIEL PERRY, EXECUTIVE DIRECTOR, ALLIANCE FOR
AGING RESEARCH, WASHINGTON, DC
Mr. Perry. Thank you very much, Mr. Chairman, Senator
Hutchinson. Let me say before I begin what a pleasure it has
been to work with this committee and its professional staff,
both majority and minority. It has been very gratifying and I
thank you for that.
With these hearings, Mr. Chairman, you are helping many of
the health organizations that are represented here today to
bring forth an important reality, and that is that our health
care system continues to give short shrift to professional
education in geriatric health care and that practice is on a
collision course with the aging of the baby boom.
What you have just heard from Mr. Bizdok is a story that is
familiar to many older Americans and to their families. So this
morning the Alliance for Aging Research releases a new report
titled ``Medical Never-Never Land: Ten Reasons Why America is
not Ready for the Coming Age Boom.'' Despite the well known
graying of America's patient population, most of our health
care providers, as you have heard, still have little or no
specific education in geriatrics or aging-related health that
is optimal for older people.
With your leadership and with bipartisan support, our
nation is now moving to ensure that Medicare will be fiscally
sound in the decades ahead yet we have given far less attention
to the quality of the health care that we are buying. We have
done far too little to ensure that health care providers have
the formal training they need to provide the highest quality of
care for their older patients.
It is no secret that older people utilize a
disproportionately larger share of health care services. While
people over the age of 65 represent now just 13 percent of the
population, this group consumes one-third of all the health
care spending and occupies one-half of all physician time.
In less than 10 years the baby boom generation begins its
transformation into the biggest Medicare generation in history.
Think of it this way. Today some 6,000 Americans celebrate
their 65th birthday. In 2011 it will be 10,000 a day cruising
past the age of 65 and swelling the Medicare rolls. The number
and proportion of people over the age of 85, which are those
most likely to require health care services, will nearly
quadruple by mid-century. Meanwhile, as you have all said, the
formal training of America's health care professionals is
seriously out of step with this great demographic challenge.
As Senator Hutchinson has pointed out, out of 650,000
physicians in the U.S., only 9,000, which is about 1.5 percent,
have certification in geriatric medicine and the number is now
shrinking. We expect to lose as many as a third of those in the
next 2 years because of retirements.
In the nursing profession less than 1 percent of the total
have geriatric certification. Out of 200,000 pharmacists in the
U.S., less than one-half of 1 percent have certification in
geriatric pharmacology. As with the other professions, this
lack of formal geriatrics training among pharmacists has real
consequences. A study in the Journal of the American Medical
Association just in December found that 20 percent of older
Americans are routinely prescribed drugs that experts in
geriatric pharmacology say should almost never be used by older
people because of serious health risks.
Mr. Chairman, in this report we have borrowed from the
imagination of Walt Disney and from the words of Dr. Robert N.
Butler, the founding director of the National Institute on
Aging. It was more than 20 years ago that Dr. Butler
characterized age denial in American health care by calling it
``Peter Pan medicine.''
As adults grow older there are complications and changes
that require specialized training to provide the best possible
care and to produce the most desirable health outcomes.
Unfortunately, very few professionals in this country have been
exposed to the techniques and knowledge of geriatric health
care as part of their professional training. This dangerous
disconnect creates a medical Never-Never Land in which patients
keep getting older and the health care providers are less and
less likely to have the specific training in the needs of older
patients.
With this report, you have our list of 10 reasons why
America remains mired in medical Never-Never Land. Suffice it
to say that at present, the health care system is too quick to
write off the complaints of older patients. We undervalue the
importance of keeping older people healthy and independent. We
do far too little to attract young people into geriatric health
care and we do not have sufficient numbers of specialized
faculty to incorporate the style and instincts of geriatric
health practice into the training of all our health providers.
The American public understands that the lack of geriatric
training for health providers can have devastating
consequences. According to a survey that we commissioned just
this month, 74 percent of all Americans feel it is very
important that their health care providers have specific aging-
related training to effectively treat the elderly. Surely this
is a matter that deserves the same bipartisan attention that
mobilized Congress to protect the solvency of programs such as
Medicare.
In closing, Mr. Chairman, I want to point out that
obviously we are not just talking about statistics and programs
and budgets; we are talking about people, real people as you
have heard this morning. For every Mr. Bizdok there are tens of
thousands, millions of families that have similar stories to
tell.
We are not here this morning to cast blame on anyone but to
state the obvious, that it is a critical problem that too many
health care professionals come to their older patients with no
formal education in geriatric health care. As you have said,
America can and should do better. Thank you.
[The prepared statement of Mr. Perry follows:]
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The Chairman. Thank you, Mr. Bizdok and Mr. Perry, for your
testimony.
I think this is an area where the American medical
profession is missing the boat. I mean the fastest growing
segment of our population are seniors. We are going to have 77
million baby boomers starting to become senior citizens in the
very near future. If you have the fastest growing segment of
our population that are living longer than ever before and we
only have three medical schools in this entire country that are
formally teaching geriatrics, the American medical profession
is missing the boat.
I do not know why. Maybe they think that is not an area
they should be in in, that people ultimately will pass on. We
all know that but people are going to be around a lot longer
than they used to be and we will have a lot more of them.
We are going to explore this a lot further but if I was
running a medical school, the first thing I would do would be
to ensure that we have an adequate geriatric department that
formally teaches people how to deal with particular problems.
It is not sufficient just to tell people well, what is the
matter with him? Well, he is old. We know that but it is
probably a problem associated that is causing the particular
medical deficiency that the person is suffering from, like Mr.
Bizdok.
Your story is just truly incredible and we are sorry that
you had to experience what you had to experience but hopefully
your story can be used to tell the medical profession that they
have to do a much better job in this particular area.
I really do not know what to ask you. I am sort of at a
loss for words. Your story is so powerful in and of itself, it
does not have to be elaborated on. I guess the bottom line,
Senator Hutchinson, is that had he had a geriatrically trained
doctor, they would have caught this particular problem that you
were having, which is similar to what a lot of other seniors
may experience.
Mr. Bizdok. Correct.
The Chairman. You almost left us.
Mr. Bizdok. Yes, real close. I really kind of feel blessed
that I did find my Dr. Muyat and he has just been great. He
watches me carefully, watches my diet, the whole ball of wax.
He says to me, ``Aren't we putting on a little weight?'' I say,
``Thank you for noticing.''
The Chairman. Well, that is the problem. There just are not
enough medical professionals, as Dan said, in all of these
areas, in pharmaceuticals and dentistry and all of the other
health care arenas. I mean treating a 20-year-old is quite
different from treating a 70-year-old or an 80-year-old or now
people in their 90's and above. I mean there are different
things to look for and if you have not had that particular type
of training, you are likely to miss it.
Dan, what do we do? You pass a law in Congress saying thou
shalt have more geriatric professionals? Because we had this
problem before. We had an overabundance of specialists and a
shortage of general practitioners and I think that is getting
back into proper balance now because of things Congress
actually did to encourage more general practitioners because we
were having an overload of specialists and not enough family
practitioners and general practitioners to solve the needs of
the society.
What do we do? What is your suggestion as to how we correct
the imbalance and the lack of professional geriatricians?
Mr. Perry. Thank you for the question, Mr. Chairman. In our
report we lay out some very specific recommendations. Before I
get to that, let me respond to your remarks earlier asking what
is wrong with American medical and health education, why are
not the health professions taking more of a lead?
Indeed, many of the health professions have been creating
certification programs within their own fields in this area--
family practice, internal medicine, psychiatry, psychology,
nurses. They are offering certification but there are
structural problems related to reimbursement that keeps people
out of the field. There are structural problems in the way
Medicare, as was mentioned, puts caps on the number of faculty
slots so that we do not have enough professors of geriatrics in
the medical schools, in the nursing schools, in the schools of
pharmacy to teach the students.
So we have a complex problem that is going to require a
real partnership between the Federal Government, the medical
schools, the health professions. We provide funding for
training of health professions in the Bureau of Health
Professions at HRSA but it is far too inadequate. Geriatrics is
lumped together with many other good purposes so it does not
have the visibility and perhaps we should think of a new bureau
of geriatric resources. Given that it is the most obvious
factor of our aging population and our health care problem, we
need to have more focus on this issue and your help in the
Federal Government can play a major role in that.
The Chairman. Well, that is a helpful suggestion. My final
question to you, Dan, is how do we stack up and compare with
other countries in this area? Do other countries have the same
shortfall in geriatric professionals as we do or are some
countries doing better? Are there any comparisons out there we
can learn from?
Mr. Perry. Virtually every nation in the world is
experiencing this explosion of older people, people surviving
longer, and that is what we would all hope for, but many other
industrialized nations are more systematically incorporating
training in geriatrics and gerontology into their health
professions far better than we are. I think it was pointed out
earlier that in the United Kingdom--I think it was Senator
Hutchinson--virtually every school in that country has a full
department of geriatrics and we have three. In Japan it is
about half. In Canada and elsewhere it is more directly
integrated into health care training across all of the health
professions. I want to emphasize the importance of that and you
will hear more this morning from nursing and pharmacy.
The Chairman. Well, thank you very much.
Mr. Bizdok, we have poster children for everything and I
would like to make you the poster citizen for better geriatric
training. Your story is just right to the point.
Mr. Hutchinson, any questions?
Senator Hutchinson. On that point, Mr. Bizdok, welcome
back.
Mr. Bizdok. Yes, yes.
Senator Hutchinson. It was a very inspiring story and I
will tell you what went through my mind is how many did not
wake up or how many did not get eventually a geriatrics doctor
who we may have lost not ever knowing and who may have--I mean
your obvious robust love for life, this is something we need to
have the kind of geriatrics physicians, diagnosis of what is
causing--you said you were taking 12 pills a day.
Mr. Bizdok. Actually from the beginning, 16.
Senator Hutchinson. Sixteen.
Mr. Bizdok. It took all morning.
Senator Hutchinson. Without the right kind of geriatrician,
the combination of those and how they affect an older patient
and how that varies from one person to another, to me, that
underscores again the need of this whole focus that we are
trying to have in the hearing today.
By the way, before all of this happened had you ever heard
of geriatrician?
Mr. Bizdok. No, not at all.
Senator Hutchinson. So that is one of the questions in my
mind--how do the American people and the aging population in
this country even know about the specialty of geriatrics and
how much that can contribute to their lives? That is going to
be a challenge that we face, as well.
Mr. Perry, I appreciated your testimony very much and you
talked about, on the question of why we are in this situation,
why we have three medical schools. I understand there are
approximately 500 geriatric fellows in the whole country; among
all the medical students, 500 choosing to specialize in
geriatrics.
You mentioned visibility and focus. Are there any other
reasons why medical schools in your opinion are not making
geriatrics a required course? Are there incentives that we are
failing--obviously I have introduced legislation to address
this but do you have any thoughts on beyond visibility and
focus on the issue, why we are seeing so few choose geriatrics?
Mr. Perry. I think because geriatrics is essentially
primary care, it is not high-tech. What happened with Mr.
Bizdok is that his appropriately trained physician recognized
the problem that was not being addressed earlier, managed to
get him to specialists in cardiology and address the right
problem. But it is too often covered by the complexity of older
people with many chronic health problems co-existing at the
same time, and are therefore taking many different medications
at the same time. Too often the person that is providing for
them does not have that instinct, that sixth sense that comes
with geriatric training to look into issues of memory loss or
incontinence or frequent falls. Those are sort of the hallmarks
of the things you look for in geriatric care and without that
training, we tend to miss those and many of them end up quite
tragically.
I think that the approach to this is really three different
ways. We need to provide incentives, as Senator Reid is
proposing to do, for students to go into the field. We need to
create educational leaders, faculty that are trained to set up
the programs, to create the curriculum, to do the teaching, and
that is where the Bureau of Health Professions and HRSA can
help and in your legislation, Mr. Hutchinson. You are aiming at
the training.
The third is those that are in the field, those that are
practicing this important primary care, they need to have
incentives in terms of reimbursement from Medicare to be able
to stay in this field. Otherwise we are going to continue to
create barriers. Who wants to go into a practice of medicine
where they are not even going to be able to pay off their
medical loans at the end of the day?
Senator Hutchinson. Good observations. You mentioned in
your comments there that among the problems are falls and that
has been something that I have been very interested in and we
have introduced something legislation regarding elderly falls.
In your excellent report you talk about the hospitalizations
for hip fractures in people aged 65 and older rising from
230,000 in 1988 to 340,000 in 1996 and that almost all
geriatric hip fractures are fall-related, which is stunning and
the impact that has on the quality of life and even the
survivability after one year. You also talk about the rise in
elderly illnesses.
How has all of this affected health care delivery in
hospitals and other providers in the day-to-day delivery?
Mr. Perry. Health care delivery in the United States and in
other industrialized countries is becoming geriatric health
care but the irony is that the techniques to deliver the best
care most cost-effectively, which comes with adequate training,
is not part of our program.
Let me emphasize we are not saying----
Senator Hutchinson. So it is geriatric needs without
geriatric specialization.
Mr. Perry. Exactly. But I want to emphasize an important
point. We are not saying that every person over the age of 65
needs to be seen by a geriatric specialist. We do not have the
resources and we do not have the time to create that kind of a
large practice specialty.
We do need to have more geriatric specialists to teach, to
create the educational programs so that no health professional
in the United States will graduate--this would be our hope--
without some exposure in the course of their training, be they
a nurse, a pharmacist, an occupational therapist or a physical
therapist--no one should graduate without some exposure to the
techniques of geriatric.
Senator Hutchinson. So in other words, we not only need
more specialists; we need mandatory training for all health
care professionals to be able to diagnose and refer where
needed.
Mr. Perry. Exactly, and we need to have the faculty that is
in place to be able to do the training, and we need to then be
able to reimburse and make the field more attractive overall.
As you said, Senator, we need to raise the visibility of this.
Older Americans need to know that their providers may not have
the training that they need and bring the power of that message
to bear.
Senator Hutchinson. Thank you. Thank you for your
testimony.
The Chairman. Our poster citizen here will be able to raise
the awareness of the problem.
Your dialog with Senator Hutchinson was absolutely correct.
You do not have to have a geriatric specialist to see every
person over a certain age but when a general practitioner is
unable to make a diagnosis of an elderly patient's problem,
they ought to know that there is a geriatric specialist that
could be brought in to look at it, to look for particular
things that are unique to an aging person's health problems and
they need to know where to go. That is why the schools have to
make that information available.
Mr. Bizdok, can I ask you what type of work did you do
before?
Mr. Bizdok. I was an entertainer. That is how I ended up in
Vegas.
The Chairman. You made a very important contribution to us
and thank you very, very much.
Mr. Bizdok. All those lovely ladies that I had to escort--
somebody had to do it.
The Chairman. That is the rest of the story. Thank you very
much, Mr. Bizdok. We appreciate it. We will stay in touch with
you.
This panel is excused and we would like to welcome up our
second panel, which consists of Dr. Charlie Cefalu, who is a
board member of the American Geriatric Society and Professor
and Director for geriatric program development down in
Louisiana at Louisiana State University. We are very pleased to
have him.
Senator Hutchinson, would you like to introduce the next
two? I think they are both from Arkansas.
Senator Hutchinson. I would be more than delighted to. We
are so pleased today to have Dr. Charles Cefalu, board member
of the American Geriatrics Society, professor and director for
geriatric program development at LSU, as you have said.
Claudia Beverly. Dr. Beverly is a registered nurse and
associate professor in the College of Nursing at the University
of Arkansas for Medical Sciences. Dr. Beverly also serves as
Associate Director for the Reynolds Center on Aging and
director for the Arkansas Aging Initiative and she brings great
experience and expertise, so we are very fortunate to have her
with us today.
I thought I only had one Arkansan.
The Chairman. Michael Martin is the Executive Director of
the Commission for Certification in Geriatric Pharmacy in
Alexandria, right here in the DC. area, and we are delighted to
have all three of our panelists.
Dr. Cefalu, we are pleased to have you up here. Thank you
so much for being with us.
I would like to acknowledge also that we are joined by our
ranking member, Senator Larry Craig. Senator Craig, do you have
any thoughts for the good of the committee at this point?
STATEMENT OF SENATOR LARRY CRAIG
Senator Craig. Thank you very much, Mr. Chairman. I am
pleased that you are obviously pursuing the building of
information in this extremely important area.
I think when we look at the reality of you and me and our
dear friend from Arkansas, there is a time and place out there
in the not too distant future when we are going to have to look
at the kind of care that our parents are looking at today. We
are of that baby-boomer crowd and it is a crowd that is
knocking at the door of critical care and geriatric care and
the shortages and the realities of caring for that crowd are
inevitable. Building the record today, preparing for it today
is the right course and I thank you for pursuing this.
The Chairman. Thank you, Senator Craig.
Dr. Cefalu.
STATEMENT OF DR. CHARLES CEFALU, BOARD MEMBER OF THE AMERICAN
GERIATRIC SOCIETY, PROFESSOR AND DIRECTOR FOR GERIATRIC
PROGRAM DEVELOPMENT, LOUISIANA STATE UNIVERSITY, NEW ORLEANS,
LA
Dr. Cefalu. Thank you. Mr. Chairman and members of the
committee, I would like to thank you for convening this hearing
and allowing me to testify today on the shortage of
geriatricians in the United States. I also want to thank the
many members of this committee for their leadership on this
important issue.
I am Dr. Charles A. Cefalu, Professor and Director of
geriatric program development at the Louisiana State University
Health Sciences Center in New Orleans, LA. After a short tenure
in rural private practice in Southeast Louisiana, I received my
formal geriatric medicine training in North Carolina at Wake
Forest. At that time geriatrics training as unavailable in
Louisiana and it still is today.
I am here today on behalf of the American Geriatric
Society, an organization of over 6,000 geriatrics and other
health care professionals, and the Louisiana Geriatric Society,
a new organization of 100 plus geriatric health care
professionals.
Geriatricians are primary care-oriented physicians who are
initially trained in family medicine or internal medicine and
complete at least one additional year of fellowship training in
geriatrics. Following their training, a geriatrician must pass
a certifying examination.
Geriatric medicine emphasizes care management and
prevention, helping frail, elderly patients to maintain
functional independence and to improve their overall quality of
life. With an interdisciplinary approach to medicine,
geriatricians commonly work with a coordinated team of
nonphysician providers. For these patients, geriatricians are
able to manage their care in the least resource-intensive
settings, such as in a patient's home, obviating the need for
more costly hospitalizations and nursing home placements.
A sufficiently large core of geriatricians will be needed
to provide care for the roughly 10 percent of the elderly who
are the oldest and most frail. Geriatricians also will need to
train other health care professionals who treat large numbers
of elderly patients. However, the shortage of geriatricians
does indeed exist. Of the approximately 98,000 medical
residency and fellowship positions supported by Medicare in
1998, only 324 were in geriatric medicine. If we are going to
cope effectively with the aging of our population, we must
resolve the national shortage of both academic and clinical
geriatricians.
Louisiana has one of the most critical shortages of
geriatricians in the nation. In the year 2000 only about 44
physicians in Louisiana held certification in geriatric
medicine. Furthermore, neither the LSU School of Medicine in
New Orleans or Shreveport has an established, accredited
geriatric medicine fellowship program. Physicians interested in
seeking formal training must leave the State for their training
and very often never return because of the tremendous numbers
of opportunities elsewhere.
A major obstacle to the development of a Louisiana training
program is the Medicare GME cap imposed on hospitals for
purposes of training slots. I might remind you both at LSU and
Tulane chief residents both entered the Johns Hopkins program
this year because they were not able to enter a program in
Louisiana.
The other most significant reason for the lack of physician
interest in a geriatrics career in Louisiana and nationally is
Medicare reimbursement. Physicians are almost entirely
dependent on Medicare revenues, given their patient caseload.
However, Medicare does not adequately cover geriatric-oriented
services or reimburse for time-intensive complex geriatric
care. Indeed, a recent MedPAC report identified low Medicare
reimbursement levels as a major reason for inadequate
recruitment into geriatrics.
First, the physician payment system does not provide
coverage for the cornerstone of geriatric care--assessment and
the coordination and management of care--except in limited
circumstances and does not support an interdisciplinary team.
Second, the Medicare reimbursement system bases payment
levels on the time and effort required to see an average
patient and assumes that a physician's patient caseload will
average out with patients who require longer to be seen and
patients who require shorter times. However, the caseload of a
geriatrician, seeing frail, elderly patients, will never
average out.
Further exacerbating inadequate payments is the 2002
Medicare fee decrease of 5.4 percent on all Medicare providers.
Increasingly, geriatricians are leaving private practice
because of the inability to run a self-sustaining practice.
If enacted, the following recommendations would help
resolve the geriatrician shortage and associated problems.
First, Congress should revise the current Medicare payment
system to cover geriatric assessment and care management
services provided by an interdisciplinary team. Senate Bill
775, the Geriatric Care Act introduced by Senator Lincoln and
Reid, would authorize Medicare to cover these services.
Second, Congress should revise the Medicare fee schedule to
better compensate for high-cost, complex Medicare patients.
Senate Bill 1589 introduced by Senator Rockefeller includes
such a payment schedule update.
Third, Congress should provide for an exception to the
overall GME cap for geriatricians mentioned previously. Senate
Bill 775, as well as the Advancement in Geriatrician Education
Act, Senate Bill 1362 introduced by Senator Hutchinson and
Senator Craig, ranking minority member, would provide for a
limited exception from the cap.
Finally, Congress should provide adequate funding for
geriatric health care professions programs, particularly the
Geriatric Academic Development Awards, which help to develop
geriatric academicians. Senate Bill 1362 would expand the
number of such awards.
Finally, we would like to work with the committee and the
Congress to legislate these important changes. Failure to act
in this area is likely to result in diminishing quality care
for frail, older persons and potentially the decline of the
geriatrics profession. I thank you for the opportunity to be
here today.
[The prepared statement of Dr. Cefalu follows:]
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The Chairman. Thank you, Dr. Cefalu. We appreciate your
testimony.
Ms. Beverly.
STATEMENT OF CLAUDIA BEVERLY, PH.D., R.N., ASSOCIATE
DIRECTOR OF THE DONALD W. REYNOLDS CENTER ON AGING, LITTLE
ROCK, AR
Ms. Beverly. Good morning, Mr. Chairman, members of the
committee, Senator Hutchinson, Senator Lincoln from Arkansas,
and ranking member Senator Craig. Thank you so much for this
opportunity to talk about geriatric-trained health care
professionals. I feel like I am in a state that is probably one
of the leaders in the country in terms of what we are doing in
geriatric education and geriatric practice and I want to share
a little bit of that with you today.
I am Associate Director of the Reynolds Center on Aging. At
the same time, on the national level I am on the National
Advisory Council for Nursing Education and Practice to HRSA, to
the Division on Nursing. So I have a very good first-hand view
of what is going on nationally, as well as at the state.
In addition, I am a vice chair for programs in one of the
three departments of geriatrics in the country and was a part
of developing that department of geriatrics and the mandatory
course that the junior med students have so that all of our
physicians, when they graduate, now have had a 4-week course in
geriatrics. At the same time, I was part of the College of
Nursing when 12 years ago we developed a stand-alone course in
geriatrics, in clinical, to go with that.
So I think in those two disciplines in particular and also
pharmacy, I have had a good relationship with the PharmD
program where most of the students in that program do have a
geriatric rotation. So we feel like we are doing and beginning
to do quite a bit.
I also want to take this time to thank the senators,
particularly Senator Hutchinson as being one of the major
authors of the Nurse Reinvestment Act because I think the Nurse
Reinvestment Act, at least on the Senate side, is a very good
beginning. It is a strong act. I just hope that very soon the
conference committee is appointed because without that, we are
just sitting and waiting. However, there are parts of that
Reinvestment Act that I think are extremely important to
nursing and in particular to geriatric nursing so that we can
better educate our certified nursing assistants in long-term
care, as well as associate degree and baccalaureate nurses and
also geriatric nurse-practitioners.
One of the things about nursing care of older adults is
that we are in a variety of settings. There is a continuum of
settings in which older adults receive care. It includes
nursing homes, home, the hospital, ambulatory care.
The nursing home, I want to just spend a little bit of time
on that because I think nursing homes are an embarrassment to
this society. I think that until we really address how do we
want to care for our older adults and what is exciting to me is
our baby boom generation are taking care of their older adults
and they are not liking what they see. So I hope that we will
begin to really look at what kind of staff do we need in
nursing homes? We know the staff mix is not right. We know when
we have adequate staff--we have studies to show that--that
outcomes of our older adults in nursing homes changes.
One of the most poignant things to me is that a certified
nursing assistant has to have only 75 hours of training and
that two-thirds of the States require no more than this.
However, in the State of Arkansas we require 1,000 hours to be
a dog groomer, so I think there is a very big disparity on how
we train people to take care of our older adults.
I also want to speak on behalf of nurse-practitioners. We
have a collaborative practice out of our Department of
Geriatrics and Center on Aging where we have a physician who is
a medical director and a nurse-practitioner who are in 10
different nursing homes. We have seen a positive outcome in
patients where we have this collaborative practice arrangement
and yet the nurse-practitioner in particular is affected by
reimbursement and the rules and regulations and I think we
could address some of those, such as when a patient enters a
nursing home in particular, a Medicare patient most of them
have been in the hospital. They go to a transitional care unit.
The nurse-practitioner by rule is not allowed to do the history
and physical on admission, even though a physician had just
seen that patient within 24 hours of discharge from the
hospital. I think we need to address that. We need to address
expanding the role of the nurse-practitioner.
I think in terms of hospitals, one of the things that we
see with the shortage of nurses is units are closing, beds are
closing. We have a difficult time getting our patients into the
hospital because of the lack of beds. It goes to the lack of
nurses in general.
Let me add that while I think the University of Arkansas
for Medical Science College of Nursing is doing a good job with
educating our nurses at the baccalaureate, at the masters, as
well as at the doctoral level, for the most part in this
country less than 23 percent of our baccalaureate programs
offer a stand-alone course in geriatrics and it is even much
less than that when you look at medicine.
Just a little bit about geriatric gerontology education.
One of the things that is sorely missing and I was glad to hear
Mr. Perry talk about is the focus or content on cognitive
impairment. When we look at our aging society, about 12 percent
65 and older are cognitively impaired. That increases to 50
percent about age 80 to 85. So we have a huge need to how are
we going to take care of our older adults? How are we going to
train people? That is a major disconnect in what we are doing.
I want to briefly highlight and I was glad to hear the
foundations that were mentioned earlier that have made a
commitment to aging, the Donald W. Reynolds Foundation being
one and yes, we are very happy that we have that relationship
with them. Another is the John A. Hartford Foundation and for a
long time they have trained physicians, provided monies to do
that, and most recently have started social work but, more
recently than that, nursing. I am happy to say that Arkansas is
one of five centers of excellence in geriatric nursing funded
by the Hartford Center and we are the only one in the South, so
we are trying to help all the states in the South to increase
geriatric education.
Last about interdisciplinary education, I have seen and
been a part for almost 25 years where we do not focus in our
curricula on interdisciplinary training. We expect when people
graduate to know how to work with each other. While there has
been money put into that and the VA does the very best with
that, we do not have adequate resources to keep that training
going.
One of the other foundations that I want to add to this is
the Schmieding Foundation in Northwest Arkansas. When you talk
about geriatricians, we have seven in Northwest Arkansas. We
have 22 in Central Arkansas. We have one in South Arkansas. So
we're doing something right about getting geriatricians. The
Schmieding Foundation, through Lawrence Schmieding, was very,
very supportive and has donated over $15 million over a 20-year
period to create our first of seven satellite centers on aging
in the State of Arkansas, all of which will have a primary care
clinic, all of which will have a heavy education focus. Thank
you.
[The prepared statement of Ms. Beverly follows:]
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The Chairman. Thank you very much, Ms. Beverly.
Mr. Martin.
STATEMENT OF MICHAEL MARTIN, EXECUTIVE DIRECTOR OF THE
COMMISSION FOR CERTIFICATION IN GERIATRIC PHARMACY, ALEXANDRIA,
VA
Mr. Martin. Good morning, Mr. Chairman, Senator Craig,
Senator Hutchinson, Senator Lincoln. My name is Michael Martin
and I am the Executive Director of the Commission for
Certification in Geriatric Pharmacy or CCGP.
I would first like to commend the members of this committee
for their support and work on legislation to assist seniors
gain access to improved care under Medicare, to receive
coverage for prescription drugs, and to improve the quality of
care in nursing facilities. In addition, I would like to
commend the members' current interest in enacting Federal
standards in assisted living facilities to improve quality of
care.
CCGP was invited by the Alliance for Aging Research to join
the efforts to unite the health professions in addressing the
critical lack of geriatric-trained health care professionals.
CCGP is proud to state that it has been proactive and in the
forefront of identifying the need for pharmacists who are
specially trained to provide pharmaceutical services to the
nation's elderly population. In fact, we were created in 1997
principally to identify this need, document the scope of
practice, and administer a post-licensure certification process
to recognize those pharmacists with the unique requisite skills
to provide comprehensive care to the elderly.
Effectively caring for the elderly requires a cooperative
effort among the entire health care team. I am here today to
discuss the role of pharmacists in the interdisciplinary health
care team and specifically how certified geriatric pharmacists
or GCPs can improve the medication and therapy management of
seniors. I will also address areas in which congressional
action can help to increase seniors' access to the expertise of
pharmacists.
The CGP designation can help ensure consumers that the
pharmacist has special knowledge regarding the needs of the
senior population. CGPs can be effective in any setting to
manage seniors' medication regimens, including hospitals, the
community, and long-term care.
Currently the CGP designation is the only designation that
recognizes the clinical expertise of these senior care
pharmacists. This designation has been recognized in the
pharmacy practice acts of Arizona, North Carolina and Ohio. The
CGP credential also has been recognized by the Department of
Veterans Affairs and is recognized in Australia and Canada. Yet
only 720 out of nearly 200,000 pharmacists in the United States
have received the CGP designation. The reasons for this include
the following.
Lack of Federal recognition of pharmacists under the Social
Security Act makes the pharmacist unable to bill Medicare and
Medicaid for the clinical services that they provide to manage
patient medication therapy.
Most pharmacists who currently specialize in senior care
have acquired their skills on the job because until recently,
the clinical literature lacked data regarding the effects of
medications on seniors, particularly the old old, those aged 85
and older, the fastest-growing segment of our population.
The lack of formal training in geriatric pharmacy.
Currently schools of pharmacy often lack the availability of
curriculum in geriatric care. As the members of this committee
are aware, a shortage of pharmacists currently exists in the
United States.
There are a number of reasons why geriatrics has not been a
popular specialty for health care providers. These include the
complexity of care for older patients, an unfortunate lack of
interest in individuals approaching the end of their lives and
most significantly, a lack of payment mechanisms that address
the unique medical approach required to effectively manage
older patients.
This lack of emphasis on the special medication needs of
seniors must end. Currently, medication-related problems cost
the United States health care system more than $200 billion per
year and are the fifth leading cause of death in the United
States. These medication-related problems, including adverse
drug reactions, improper dosing, either over- or
underprescribing, multiple medications for the same indication,
and drug-induced hospitalizations, are often preventable. In
fact, a 1997 study published in the Archives of Internal
Medicine found that in nursing facilities, interventions by
consultant pharmacists reduced the number of patients who
experienced a medication-related problem by almost 50 percent
and saved $3.6 billion per year in these settings.
To assist pharmacy and the geriatric population to gain
access to the types of services necessary to ensure the highest
quality of care, I urge the committee and your colleagues in
Congress to take the following steps.
Pass a Medicare prescription drug benefit that includes
pharmacy for pharmacist medication therapy management services.
This legislation should recognize the CGP designation for
pharmacists who participate in medication therapy management.
Pass legislation to recognize pharmacists under the Social
Security Act to allow pharmacists to be paid directly for the
clinical services they provide.
Pass legislation to provide funding for additional
pharmacists to relieve the shortage and to provide incentives
to bolster geriatric curriculum in schools of pharmacy.
Provide funding for pharmacist residency programs in
geriatric care. Schools of pharmacy need to develop curriculum
to teach students and incentives need to be provided for
students to complete rotations at hospitals, nursing facilities
and other long-term care facilities and in the community to
provide for the special needs of seniors.
Sponsor and support legislation to require additional
pharmaceutical research regarding the effects of medication on
the elderly.
Preserve the Federal Nursing Facility Standards and the
requirement that consultant pharmacists provide drug regimen
review to reduce medication-related problems.
The Chairman. Mr. Martin, excuse me. I am going to have to
ask you, if you could, to summarize because we just had a vote
that has just begun.
Mr. Martin. Yes, sir.
We must reform the way our nation approaches medical care
for seniors. Effective health care for seniors requires a
coordinated assessment and case management provided by an
interdisciplinary team focussed on the patient's overall well-
being. Public and private health care systems simply do not pay
for that kind of care. Instead, they pay for extensive tests
and treatment but not for the kind of care needed to identify
the at-risk elderly and protect them from potentially life-
threatening medical problems.
Again thank you very much for this opportunity to appear
before you to address this important national issue and we look
forward to working with you on this issue in the future.
[The prepared statement of Mr. Martin follows:]
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The Chairman. Thank you, Mr. Martin, and I thank all the
panel members.
Dr. Cefalu, thank you for being with us. You have some
disturbing statistics. We only have, I think, 44 physicians in
the entire State of Louisiana that have a certificate of
certification in geriatric medicine, which is really
astounding.
You made about eight different recommendations as to things
that can be done. It is interesting that almost every one of
them involves money. The question that I need to explore, is
there not money in treating older people? I mean all doctors
are being reimbursed basically the same way, I take it. Or is
there discrimination against the way people treating older
people in geriatrics are being paid that is different from the
way physicians and other specialties are being reimbursed?
Dr. Cefalu. Well, there are several factors, as we have
said. There is the 5.4 percent cut, which has further
complicated the issue but the issue is, as has already been
explained----
The Chairman. But that cut is not just for geriatrics. That
is across the board.
Dr. Cefalu. Across the board. The main issue is--I mean
that is the last blow but the main issue has already been
discussed today, the issue that it takes an extreme amount of
time for physicians in private practice to see older patients
and get the same reimbursement that they would for treating a
20-, 30-, 40-year-old patient.
Now when you are talking about 10 and 12 medications and
seven or eight chronic conditions, the age factor, it does not
take 5 to 7 minutes to see an older patient.
The Chairman. Do the reimbursement rate--and maybe you do
not know this because I do not know it--are the reimbursement
rates under Medicare not taking into consideration the time
that a doctor spends with the patient? He gets reimbursed the
same amount if he spends 5 minutes or an hour?
Dr. Cefalu. Absolutely. That is basically the issue. The
current system does not factor in the time and complexity of
the visit and that is the whole point that we are coming at the
Health Care Financing Administration, is to correct that visit
for the time and complexity that it takes to see that patient.
For instance, Senator, when you see an older patient with
confusion, polypharmacy, that is not a 7- or 10- or 15-minute
visit. For the healthy Medicare HMO patient that has maybe one
illness and is on one medication for hypertension, fine, but
not for the minority elderly, the underprivileged elderly, the
majority of the elderly. I mean you are talking about a
Medicare HMO population that may make up 3 to 5 percent of the
elderly but the majority of the patients require time-intensive
visits.
We are talking about a population that is the most rapidly
growing segment of the elderly and that is the 85 plus, the
frail elderly, where this is particularly an acute situation,
where they require more time than any other segment of the
elderly, much more than the middle old or the young old.
The Chairman. Thank you. You mentioned providing an
exception for the overall graduate medical education cap for
geriatricians.
Dr. Cefalu. Yes, sir.
The Chairman. How would that work? Universities are,
through the Medicare program, reimbursed for training
physicians but if you just remove the cap, that does not
encourage anybody to go into geriatrics. I mean you just have
more people studying to be doctors but it does not say that
more people have to study to be geriatricians.
Dr. Cefalu. No, it does not. The Medicare cap specifically
relates to Louisiana by the way in which, as I said in my
testimony, neither LSU school has a fellowship. So that is a
disincentive for any facility in Louisiana to encourage the
development of geriatric programs. It is money out of their
back pockets. It is a money issue but there is no reimbursement
for it at all. So there is no incentive for teaching, for the
teaching component, the Medicare component itself.
Regarding the cap, though, that is one issue. The other
issue is, as I said, the time and complexity of a visit. That
is a major issue here. But if there is a cap--let me say again
if there is a cap that was instituted in 1997, then there is no
incentive to expand the fellowship programs across the United
States. Again in Louisiana this is critical that that cap be
removed or we are not going to be able to do anything in the
State.
The Chairman. Is there a natural or maybe abnormal
reluctance on the part of physicians to want to treat older
people?
Dr. Cefalu. There is. It is not a glamorous specialty.
There is also the reluctance related to the medical
training issue, and that is just as in pediatrics, older
patients have unique illnesses, such as confusion, such as
incontinence, such as falls, which are not direct so they do
not meet the eye, as is a 20- or 40-year-old patient. They
require training to learn how to evaluate confusion and falls.
Falls are not simply related to arthritis. There are many
different causes for falls--medications, a drop in blood
pressure. They are numerous.
So the atypical presentation of disease in the elderly
makes it implicit that medical students at all 4 years of
training and residents and fellows receive training in
geriatric medicine. You just cannot assume that the medicine is
the same as treating a 20- or 40-year-old.
It is like pediatrics. Pediatric patients have their own
illnesses, their own atypical presentation of disease, their
own limitations in dosages. Well, the same applies to the
elderly and you just cannot assume that a 75- or 80-year-old
patient is going to be treated the same way as a 20- or 40-
year-old because the processes are different. The aging process
has with it certain changes that may be associated with certain
systems that you may not be aware of. There are certain disease
states that present very atypically and if that physician is
not trained, he is going to miss the boat and the problem here
is not only excess cost in the hospital but delayed diagnosis
and excess mortality for these patients.
We are coming back to the training issue, that physicians
are not trained and if they are not trained, they do not feel
comfortable and they avoid these patients.
The Chairman. Well, you have made some very good points.
The fastest growing segment of our population are seniors. The
baby boomers, again with 77 million getting ready to enter into
this category, we will have a larger number of people in this
category who live for a lot longer than they used to. I think
it has become very clear that we are inadequately situated to
treat these people from a medical standpoint. We simply do not
have the medical professionals that we need to treat the
fastest growing segment of our population, which have unique
problems and unique medical disabilities, as you have said,
that a 20-year-old does not have.
We are going to have to work together--the medical
profession, as well as the Congress, as well as the public at
large--to try to correct this. This is a real challenge that we
have to face.
We have a vote, as I indicated. Senator Blanche Lincoln is
going to be coming back and if I could, because I know she has
some questions, I am going to go vote and she is on her way
back. As soon as she gets back she will continue this and we
should wrap it up very shortly. In the meantime, the committee
will take a short recess.
[Recess.]
STATEMENT OF SENATOR BLANCHE LINCOLN
Senator Lincoln. If I could have everyone's attention, I
think we will call the committee back to order.
I would like to begin first by thanking the chairman for
holding this very important hearing today. I have been
extremely interested and involved in the issues of geriatrics
and geriatric training, the care of our elderly in this
country, and I think that interest comes from being of the
``club sandwich'' generation. I have not only my aging parents
and my young children that depend on my husband and I but my
husband's grandmother is 104, so we have three generations on
either side of us and it is a very, very important issue to us
personally, as well as to our nation.
Shortages in geriatric care have indeed placed our nation's
seniors in peril, a situation that will only worsen with the
coming ``Aging of America'' and our demographic crisis.
I would certainly like to thank the chairman both for his
interest and his enthusiasm on this issue in providing us a
forum to discuss some of the potential solutions to the looming
crisis that our country has.
We can accomplish the goal of improving our geriatric
health care in the United States by boosting the number of
certified geriatricians and other geriatric providers in our
country and by improving access to geriatric care. As has been
mentioned, I have sponsored the Geriatric Care Act with Senator
Reid. I have depended on many of you for input and certainly
the professional aspect on what we need to do in improving the
care of our aging population in this country.
It is worth remembering that we are not just struggling
with the shortage of geriatric physicians; we are also
struggling with the shortage of nurses--and I compliment my
colleagues here on the committee for their introduction of the
Nurse Reinvestment Act--social workers, psychologists,
nutritionists and pharmacists who work with geriatricians to
provide a web of comprehensive care for our most frail,
vulnerable seniors.
We had a wonderful forum in Arkansas several months ago on
the continuum of care. We filled up one auditorium and two
overflow rooms at the medical school with numbers of providers
from all different areas of care for our seniors. They were
very interested in what we are trying to do in Washington.
Their input is vital as we come up with the right solutions
because we do not have the time to make any wrong turns.
I know that my colleagues share that commitment and that is
why I applaud Senator Breaux, as chairman. His excitement about
this issue, both on the Aging Committee and on the Finance
Committee will give us a great opportunity to be able to focus
on many of these issues.
I have so many things that I could say and I know that I do
not need to take up too much time but I would like to just say
that when Senator Harry Reid and I introduced the Geriatric
Care Act we were excited to be able to put forth a bill to
increase the number of geriatricians in our nation through
training incentives and Medicare reimbursement for geriatric
care. We have fine-tuned some of the aspects of our bill and we
will be reintroducing it soon.
It was amazing to me to find out that out of 125 or so
medical schools in this country, only three offer programs in
geriatrics. UAMS and the Don Reynolds Center is right at the
heart of that, and in Arkansas we are extremely proud of that.
But as a mother of small children, realizing that every one of
those 125 medical schools provides a school of pediatrics, with
the ever-increasing number of aging in our population in our
nation, it just astounds me that only three of those medical
schools are focussed on geriatrics. So I am delighted we have
the opportunity today to focus in on that.
The care of our senior citizens in this country is
extremely broad. Certainly the training of geriatricians but
there are many other issues that we are looking at at this
point from on the Federal level in keeping all healthcare
providers financially solvent.
I was just visiting with a community from our home State of
Arkansas earlier this morning where four of the cardiologists
in their community, they will lose two of them by the end of
this month or next month because of their reimbursement cuts.
Of course, 75 percent basically of their clientele are the
elderly in that community.
So there are a lot of different aspects of providing health
care to our elderly in this country and we have to focus on
many of them here in the time that we have to be able to do
something.
The Geriatric Care Act also removes the disincentive caused
by the Graduate Medical Education cap established by the
Balanced Budget Act of 1997. As a result of this cap, many of
our hospitals have eliminated or reduced their geriatric
training programs. There are many things, as I have just
mentioned, that were a result of the 1997 Balanced Budget Act
that we need to readdress for our providers and that is
hopefully something we can do in the Finance Committee in the
coming months.
I am very proud of the work that is being done at the Don
Reynolds Center on Aging and the Department of Geriatrics at
the University of Arkansas for Medical Sciences. Thanks to Dr.
David Lipschitz and especially to Dr. Claudia Beverly who is
here with us today, I feel like Dr. Beverly and I have really
traveled some miles together. She has taught me a great deal
and I think certainly my family's experiences and willingness
to share it with the Reynolds Center has hopefully in some ways
benefited them, as well.
One of the other things that we are extremely proud of is
that Arkansas has more geriatricians per capita than any other
State in the nation, with a total of 35. That may be why our
elderly population is increasing, as well, as a percentage of
our population, because we do provide the care and the focus
there, but we want to definitely translate that to the rest of
the Nation and I will certainly be at the center stage in
trying to promote that with my colleagues.
As Dr. Beverly discussed some in her testimony, nurses are
an essential part of the care in all health care environments,
whether they be hospitals, nursing homes, home health or
hospice, and I am certainly a strong supporter of the Nurse
Reinvestment Act that the Senate passed last year and really
appreciate the leadership of my colleagues, particularly
Senator Mikulski and Senator Hutchinson from Arkansas, in
addressing the national nursing shortage.
We should also recognize that in addition to encouraging
people to enter the nursing profession, we must offer them
opportunities to train in geriatrics, and I was pleased that
Dr. Beverly mentioned some of those aspects.
In closing, I would just like to say that all of us here
today could share stories about the challenges that we face by
our parents, our grandparents, our family and our friends, as
they contend with passing years.
Just to touch on what Mr. Martin mentioned in terms of the
pharmacy, my grandmother lived with us the last 2 years of her
life and coming from a small community, we knew of that
comprehensive care provided by pharmacists because we only had
a couple of doctors, a couple of pharmacists, and several
others in the community. But whenever she was sick she said,
``Don't worry the doctor is with me. I'll just call the
pharmacist.'' She said, ``The doctor's busy; the line is backed
up.'' Instead she would call Mr. Kelly and he would say, ``Miss
Adney, you know, you can stop taking your blue pill but keep on
your yellow pill and make sure that you take it with a biscuit
or some milk because it needs to go down with something.''
It is amazing. It is a continuum of care and it is a
collaborative effort in our aging years. Consequently, my
grandmother had a very peaceful time.
So I think it is so important that everyone is at the table
and that we discuss what everyone has to bring to this
discussion. As we look at our loved ones and those that are
dealing with the aging process, I hope that each and every one
of us will remember these are the people who have raised us.
They are the ones who have loved us, who have worked for us,
who have fought for us. It is our turn now to work for them, to
fight for them, to come up with a solution to what we are faced
with in the next 10 to 15 years, and this is where we must
start.
So again I applaud my chairman. I am pleased that he has
seen this as an important issue, he has brought it up, and he
has given us the opportunity to talk about it and discuss it
and come up with some solutions. I know that he and others will
join me as we work in the Finance Committee, as well, to look
at how we can bring some of these issues up.
So we thank you all for being here. I have a couple of
questions, if I may.
Dr. Cefalu, you talked a lot about how geriatricians who
understand the health needs of older patients could cut down on
inappropriate hospitalizations, multiple visits to specialists,
and needless nursing home admissions. I believe that although
Medicare reimbursement for geriatric care may be expensive, it
would save significant amounts of money in multiple areas in
the long run. Could you elaborate on that or how it might
happen?
Dr. Cefalu. Yes, it is all about bringing health care back
to the holistic approach, if I could use that term, or the
whole patient. We have a society, which to a certain extent in
good, in that there is a lot of subspecialization related to
research, and that is all great. But to some extent we have
missed the boat in that there is not enough primary care, there
is not enough gatekeeping, there is not enough coordination.
Geriatric health care, because of the huge number of
patient problems from confusion, the polypharmacy, as I
mentioned, the falls, all issues that are outside a typical
office visit and a primary care physician's typical medical
school training require an extensive amount of time and
training for evaluation. They involve a gatekeeper but also not
only the physician component but the expertise of the geriatric
nurse, the expertise of the geriatric pharmacist or the pharm-
D, the medical social worker because psycho-social problems are
so critical. Psycho-social disposition. Where is this patient
going to go? Can he go back home? They're a frequent faller;
no, they cannot go home. Maybe they need to go to a nursing
home. Maybe they can go to adult day care. Rehab, which is
something out of the expertise and training of a typical family
physician or internist.
So all of these issues require a team and physicians, and I
know this myself because in a rural Kentwood private practice I
was just stymied by the older patient who came in who was on 9
or 10 medicines and all of these problems. I did not even have
the training at that time before my fellowship to know how to
even evaluate confusion and that possibly it might be related
to depression or medications. Mistakenly maybe I did mislabel
somebody as dementia when they were not and hopefully that did
not happen, but I was enlightened after my fellowship.
But I also realized at that time that it was not me. It was
not just my inadequate training. It was the fact that I needed
enough time to evaluate that patient to where it would pay me
to stay in private practice and at least break even instead of
closing my office, like so many physicians have done and said,
``I can't deal with older patients because I can't make a
living.''
But it is also having the social worker, the nurse, the
pharmacist and the rehab, that team there and to have those
resources to be able to evaluate that person fully because all
those resources are necessary. The only place that is being
currently done is in academic settings where that type of
assistance and resources can be subsidized; the physician's
visit is subsidized. But in the private setting you just cannot
make it.
So it is a team approach because all of these people have
expertise that can be provided in a primary care or
consultation visit, whether it is in-patient or out-patient.
Unless the Care Act is implemented that provides for the
physician to be able to see that patient and be reimbursed for
his or her time with the team and the resources, then it is not
going to happen. Until Senator Breaux had to leave but until
that cap is removed, that is going to be a disincentive to
training and we are not talking about general removal of the
cap. We are talking about only, as your bill states, for the
limited number of fellowship programs out there that have to do
with geriatric training.
That was a long answer but it cannot be answered in one or
two sentences. Thank you.
Senator Lincoln. I am aware that you had earlier answered
the question about the difference between a geriatrician's
typical patient and a regular physician, the kind of time that
is involved, the kind of consultation with others, whether it
is the pharmacist, whether it is the social worker or the
psychologist. All of those are so critical and it was made so
blatantly clear to me when I visited the Reynolds Center and
saw how they operated with all of that team together. There is
no way that a physician could make it on that single
reimbursement for the time that they were spending, compared to
the regular patients.
Dr. Beverly, again thank you for coming to Washington. You
know I am president of your fan club. Your experience and
testimony here today but your experience particularly has been
invaluable to me in terms of being able to figure out what
roads we need to take in order to try and solve some of these
problems.
My personal experience with the Reynolds Center on Aging,
with a father who is in the advanced stages of Alzheimer's, and
a mother who is a primary caregiver and also aging, are
critical components in my personal experience.
It was so real to me when the other day I had a call from a
constituent on the other side of the State who had been dealing
with an aging spouse for the last 5 or 6 years. She mentioned
that she had finally found the Reynolds Center. She said it was
amazing. She said, ``I'm not going to 10 different doctor's
appointments I know these doctors are not talking to one
another about the comprehensive health of my husband.'' She
said, ``We got to the Reynolds Center and realized that this
comprehensive approach was so valuable to us as a family and
for him as an individual because there was the interaction and
the communication.'' That certainly makes a difference.
I would like for you, if you could, to just elaborate on
your suggestions to train nurses in geriatrics. What is the
biggest difference in patient care that you see when you
compare regular nurse-practitioners with geriatric nurse-
practitioners?
Ms. Beverly. I think the biggest difference in patient care
is that when you have a nurse at whatever level that has
received knowledge and developed skills in the care of older
adults, we see better outcomes and we see that in whichever
setting we are in.
I think one of the concerns that I have is--and I am going
to start with nursing in general--has been our ability to keep
the pipeline into nursing what it ought to be. When we look at
nursing and we see--and this came out of the 2000 RN Sample
Survey--is that during a 20-year career a nurse will realize a
$6,000 increase in salary and that is a huge problem.
At the same time, having enough faculty prepared in
geriatrics to train or even faculty in general to educate our
nurses when today the reality is that the practice setting
usually pays $15,000 to $20,000 more to faculty, so we see the
drain on faculty not only because faculty are getting older but
we are not seeing younger faculty come into the mainstream.
So we talk about that in general for nursing but specific
to geriatric nursing, it is even more critical. SREB, Southern
Regional Educational Board, just finished a study in
geriatrics. It is on the bottom of the 16 specialty areas in
terms of faculty preparation or it is next to the bottom. I
think that when we see less than 23 percent of our
baccalaureate programs including geriatrics as a stand-alone
course, then we are faced with a major problem of preparing
nurses.
But I would also like to respond a little bit about our
senior health center, which is a hospital-based out-patient
clinic. The Reynolds Center is associated with University
Hospital and it is the hospital that operates it as a hospital-
based out-patient clinic. The value of those type clinics is
that there is a facility fee that is reimbursed by Medicare. We
like to have 80 to 90 percent of our patients being Medicare.
No private physician can afford 80 to 90 percent Medicare
patients.
We also, for all new patients, have one hour with patients
and we have on return, 30 minutes. At the core of this care is
an interdisciplinary team that is a geriatrician, a geriatric
nurse-practitioner, a social worker, but we also have
consultation from pharmacy, neuropsychology, and others.
The beauty of it is that hospitals can choose to do this
and MCSA in El Dorado and Northwest Health Systems in the
northwest part of the State have chosen to develop hospital-
based out-patient clients but the problem is these clinics lose
money but the thing the hospitals like about it is then it does
generate funds for the hospital and most of the time you will
be about break-even in the primary care clinic.
So we are working with hospitals around the State and I
think it is very important to begin looking at that type of
reimbursement and is it really covering what the needs of older
adults need, and so forth?
One last thing with geriatric nurse-practitioners that we
are finding. We graduated eight geriatric nurse-practitioners
from our program in December. Seven of them to date do not have
a position in geriatrics because of funding, because of lack of
a nursing home or lack of a position that would fit with what
their skills are. Part of that is reimbursement. How do they
pay for it? How do you enter into a collaborative practice?
The need is overwhelming and the need is there. We have to
look at how we can make sure that the positions for nurses are
created with that expertise and develop that and we are
beginning to look at that issue.
Senator Lincoln. We do need to if we are graduating
geriatric nurse-practitioners with the skills that are so
needed. I mean that is one of the things the Robert Wood
Johnson Foundation found for us in Arkansas--in terms of senior
needs, there are a lot of underutilized programs and services
out there. We must make sure people are aware of what is there.
Just one quick question, Mr. Martin. It astounds me that
medication-related problems are the fifth leading cause of
death in the United States. That is amazing.
You talked about pharmacist intervention. Maybe you could
just elaborate a little bit on what that entails. How is it
initiated? Under current systems is there a patchwork of ways
that that pharmacist intervention happens? Obviously there are
better ways that we could do it and we are striving toward
those but maybe you have some shortcuts or ideas that would be
best for us.
Mr. Martin. Currently there is a patchwork. One of the
first things I would like to put back on the table, as we have
already heard from Dr. Cefalu and Dr. Beverly, the difficulty
for doctors and nurses to get reimbursement. You can then
imagine the struggle that pharmacy is having when it is not
formally recognized as part of the health care team, by the
fact that they are omitted from the Social Security Act and
other areas like that. So that huge struggle of just being
recognized is one of the first issues that I think we need to
address.
There are practice settings where the pharmacist does do an
excellent job. These would be in nursing facilities, long-term
care settings, where their skills and expertise in medication
management services is recognized, is utilized. Outside of that
arena it is painfully and woefully being neglected or not
getting tended to at all. So there are some practice areas
where pharmacy is able to do its job but outside of those
limited areas, it is really not able to do the work that they
are trained to do.
Senator Lincoln. Well, to all of you all, and I will close
our hearing here shortly, but I think one of the things that is
so amazing to people is when you do talk about the fact that
there is only three out of 125 medical schools that offer a
program in geriatrics. Each one of them has a program in
pediatrics. How can we get the benefits of geriatric out--the
message that it is essential? How do we do that? Because
whenever I say that to people they are just amazed because they
have aging parents or aging grand-parents and they are thinking
about how much of their time and their frustration is caught up
in caring for that aging population and they know that they are
one day going to be there. If we are that ill- prepared now and
the time that it takes to train these individuals and the fact
that we are losing geriatricians and those that are able to
train them.
Is there a way that we can get more of that word out? How
do we do that?
Dr. Cefalu. One of the best ways at the medical school
level and the nursing school level and the pharmacy level is we
have not done a good job in teaching what successful aging is.
Medical students' idea of aging is let us go to the nursing
home and see this bedridden, contracted patient with a pressure
ulcer that has a tube in his stomach and has a catheter coming
out and several other tubes.
The best way to enhance geriatric care is to teach it from
the standpoint of how to prevent the aging process and all the
complications and to prevent unnecessary medication
utilization, that type of thing. So exposing all students and
professionals in training and, for that matter, trying to
provide an optimal environment of healthy aging for the healthy
senior so that they see the positive side of aging and not the
end result is one of the ways to go.
Real quickly I want to thank you for sponsoring these
bills, especially related to the cap. That is critical for our
State. If we do not have the removal of the cap specifically
for geriatric fellowships, and that is all we are talking
about, then that is going to really impede our ability to get a
program going next to our sister state, Arkansas, which has
done a beautiful job. So I want to thank you for that.
Senator Lincoln. Oh, absolutely. I will be looking to you
all to assist in getting that word out because although I am
not as close to the 65 number as some of my colleagues are, I
have to say I am still very concerned about what it is going to
be like when I do get there. My husband is a physician; I have
looked at the time he has spent in his training, his
fellowship. It takes time to train medical professionals and if
we do not start now, even though I am farther away from it than
anyone else in the Senate right now, I am still worried that we
will not have made the kind of preparation time we need to be
prepared, and that is going to be critical.
Ms. Beverly. Can I add? I think that there is a myth out
there in colleges of medicine and nursing and pharmacy when
faculty will say well, we do teach geriatrics; we integrate it
across in several different courses. But geriatrics has a
defined body of knowledge that needs to be pulled out and needs
to be recognized and it needs to be a mandatory stand-alone
rotation, both clinical and theory, so that the student is
exposed in a very positive way to healthy aging, to what
functional assessment is all about, to the continuum of
settings in which individuals receive care. To do that, you
have to have a faculty excited about geriatrics and I think
especially the initiative through the Hartford Foundation
across the country--I do not know where our map went but we are
now beginning to have scholars in geriatric nursing. We are
also having centers of excellence. We are reaching out to
states so that we can, especially in nursing, gain that
enthusiasm.
I might say in terms of medicine, when we first started
teaching the 4-week mandatory rotation for our junior medical
students, we were 10 points below the bottom when students came
back and told us how they liked it. But now, in our fourth
year, we are about in the middle and we keep rising each year
in terms of students liking geriatrics. So we have also seen an
increase in applicants to our fellowship program because they
are beginning to have some positive experience in geriatrics.
We are seeing the same in nursing in terms of if they have a
course in the undergraduate program then we see more entering
or applying for the masters program and we are beginning to see
that increase at the doctoral level in terms of geriatric
nursing.
So I think it starts with exposure but it is costly to do
that. We have to get the colleges across the country in
medicine, in nursing, in pharmacy, really keyed into this
problem and to begin doing something about it.
Senator Lincoln. From Mr. Martin's standpoint it has to
be--as I said, watching both my aging parents and my
grandparents, it is not until you get to that stage, when you
are dependent on four or five or six different prescription
drugs in your daily life, that you realize the importance of
that interaction with physician care and all of the other
things that you are doing.
We need to get people certainly aware of the importance of
that integration into their comprehensive care before they get
to the age where they need all of that.
Mr. Martin. One of the things we need is an expanded
awareness that pharmacists are a part of the health care team,
recognizing them through collaborative practice acts within the
various states, education on a consumer level. It is
interesting that all the polls always come back and say the
consumer trusts the pharmacist the most but I think the
consumer still is unaware of all the services that a pharmacist
can provide.
So outside of settings such as nursing facilities or other
long-term care settings where the pharmacist is indeed a part
of the team, we need to expand that into all of the practice
settings, into the community, into other settings so that the
consumer is indeed aware that this is the person he can turn to
for those types of services.
Again reimbursement is going to be a large issue for all of
this because under the current structure--this is going to
sound a little too noble but pharmacists kind of do it out of
the goodness of their heart. They understand that these
services are needed and they provide them whenever they can and
they often do not get reimbursed for them, so that is probably
one of the first fixes we need to go after.
Senator Lincoln. Right.
Well, I want to thank all of you for joining us today. I do
apologize that I was absent for the first panel. I know that
there was some very moving testimony there and I certainly will
have that relayed to me. But I do want to thank all of you all
and I especially want to thank Senator Breaux, our chairman,
for taking an interest in this issue and moving forward. No
doubt I think you all have gotten the message that I am
extremely interested and will certainly be working on how we
can improve the quality of health care but also the dignity of
life to our aging citizens in this country. Thank you.
The committee is adjourned.
[Whereupon, at 10:55 a.m., the committee was adjourned.]
A P P E N D I X
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