Tuesday, July 5, 2016

The World is FlatCare coordination is one of the most popular solutions to saving Medicare. But, while it may be a useful tool, it has limitations. For example, what if an effective care coordination model taught people that the world is flat? Would that make the world flat? Of course not! Care coordination that is instituted with clinicians who don’t know how to appropriately care for older adults has, and will, struggle to yield effective results. The Medicare Trust Fund presently spends $10 billion a year subsidizing the education of our clinical workforce on how NOT to care for older adults.  Providing better coordination of inappropriate care has not and will not yield significant results. Isn't it time for this to change?

Geriatric medicine is the specialty that focuses on the care of older adults. Geriatricians approach their patients from a person-centered perspective, focusing on function and quality of life. With the “geriatric approach to care” I can say that I have stopped more prescription medications in my career than I have started! How many other physicians can make that same claim? 

I have told my patients for many years that if they want a doctor who will performs lots of tests, prescribe lots of medications and hospitalize them at the drop of a hat, I’m not their guy. Most of my geriatrician colleagues practice in a very similar fashion. I have long thought that if we could have a legion of geriatricians responsible for the care of older adults in this country, we could reduce Medicare expenditures by over 30%. That is a conservative estimate!

Let me share an example.  About ten years ago, one of my 88-year-old patients ended up in the hospital with pneumonia. He had been declining for the previous year while being treated with expensive anti-hormonal therapy for his prostate cancer. This treatment leads to a deficiency in testosterone, which leads to muscle weakness and other problems. I decided to have him stop the treatment and actually placed him on testosterone! His urologist got very upset because I wasn't allowing him to kill the prostate cancer and my patient at the same time. When I promised to consider restarting the treatments if his PSA went above 30 (the level at which prostate cancer spreads to the bones), he agreed with my plan. My patient recently celebrated his 98th birthday, and hasn't been hospitalized in ten years! 

Herein lies the problem. The number of board-certified geriatricians has been steadily declining since the mid-1990’s and now numbers under 7,000. This has occurred while the number of older adults is exploding. Various estimates have suggested that we will need between twenty and thirty thousand geriatricians in the future. In the meantime, we also have the problem that most primary care physicians and specialists do not receive adequate training in the care of older adults. The very fact that we are subsidizing their training with taxpayer dollars from the Medicare Trust Fund amplifies the problem. 

Is there a solution to this? Absolutely! The American Geriatric Society has developed a set of core competencies for physicians who care for older adults. In return for receiving graduate medical education (GME) funds, we should require all training programs that train physicians to care for older adults to assure that their trainees achieve these competencies. We can start this process by having board-certified geriatricians represent a majority of the appointees on the Council on Graduate Medical Education (COGME). Presently, there is not a single one! How can a program that is funded by Medicare in order to develop an educated workforce to care for older adults not be directed by geriatricians? The answer is simple.

We need to train our future workforce to be competent in the care of older adults. We know that the world isn’t flat, and we know that our parents and grandparents should be taken care of by physicians who are adequately trained to be competent in geriatrics. Only then will care coordination be an effective tool in improving the care of older adults.


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