Will Congress Decide the Future of Geriatric Medicine? (2013)

The Census Bureau estimates that by 2030, the number of adults aged 65 and older living in the United States will exceed 72 million, or almost one in every five Americans. This ratio is currently approximately one in every eight Americans. The older adult population in the United States is increasing in relevance. The demand for geriatric healthcare providers is projected to increase over time because of this population shift. Economic equilibrium would expect that people would enter this area of care to close the gap between this pent-up demand and the short supply of geriatricians. Surprisingly, the number of qualified geriatricians has not increased sufficiently to close this growing gap; the opposite is true. Although the total number of first-year fellows by subspeciality in medicine has increased 26%, from 3,675 in 2001–02 to 4,647 in 2010–11, the number of first-year fellows choosing a career in geriatric medicine has decreased 31%, from 299 to 206 over the same period.1 There must be a reason, outside of pure economics, that justifies the stubborn nature of the supply curve of geriatricians. Normally, increased demand for a particular service would result in higher compensation. This is not the case in geriatric medicine. Unlike other areas of medicine, older adults often rely on Medicare for their health insurance needs. Medicare reimburses physicians at a lower rate than private carriers do. The low rate of Medicare reimbursement rarely allows for a viable business model. Geriatric medicine fellowships have suffered because of this, and the outlook is grim. The current fiscal environment has compounded the problem that geriatricians face. The financial debt of the United States is significant, and the increasing cost of health care is a reality. In the coming months, Washington will be negotiating and voting on how to address this financial mess. The future of geriatric medicine may be on the agenda. Two immediate problems that must be dealt with are Medicare and the so-called “fiscal cliff.” With respect to Medicare, clinical geriatricians face a problem today that will worsen in the years to come. Specifically, practice costs as reflected by the Medicare Economic Index are projected to increase for caring for Medicare-eligible individuals, and Sustainable Growth Rate–based physician Medicare reimbursements are projected to decrease. The American Medical Association estimates that this gap will be as significant as 60%.2 Closing this gap is critical for the long-term viability of having a profitable geriatric practice. The “fiscal cliff” is a concept to help conceptualize the urgency that our country faces at this year's end as a result of the Budget Control Act (BCA) of 2011. Consequences of the fiscal cliff include tax increases, sequestration, cuts in Medicare reimbursement rates, and a possible government shutdown as the federal debt ceiling approaches. Gridlock (inaction) is a real possibility considering the post-November election environment in Congress. Sequestration is a measure that will take place if the BCA Joint Select Committee on Deficit Reduction does not agree on at least $1.2 trillion in budget cuts over 10 years. If these budget cuts are not identified, Congress must distribute the total dollars (less interest savings) evenly over 10 years. The budget cut is then split evenly again between defense and nondefense spending. In short, approximately $55 billion would be cut in defense spending and $55 billion in nondefense spending. According to a joint press release released by leading healthcare associations, the sequestration could result in 766,000 healthcare-related job losses by 2021 and 496,000 job losses in 2013 alone.3 The viability of the academic geriatrician is also likely to suffer with sequestration because of the reliance on grant funding. Considering that the National Institutes of Health (NIH) is the primary funding source, people in academia should be concerned. A projected 8.2% budget cut will be allocated to the NIH if sequestration takes place. The primary institute that geriatricians seek funds from is the National Institute on Aging (NIA). Of the NIH's $30.9 billion in FY2012, $1.1 billion was allocated to the NIA. Geriatricians have a vested interested in the method that Congress chooses to address these issues. Speak now. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors contributed significantly to the research and writing of this paper. Sponsor's Role: None.