Acknowledgements100520038Paragraph100520039This letter was written while I was the attending in a geriatric psychiatry clinic at the University of Chicago Hospital. But like the colleague I mention at the beginning of this letter, I have also decided to leave outpatient geriatric practice. In June 2007 I moved to the Jesse Brown VA and no longer rely on Medicare reimbursement to support my activities.
A couple of years ago, one of the best geriatric psychiatrists I know, the one to whom I sent my father-in-law when he began to show cognitive changes, gave up her practice to become a hospitalist. As she put it, “I was tired of supporting my clinical practice by giving lectures for drug companies.” Her decision is not an unusual one. Data from the ADGAP suggest that only 56% of psychiatrists certified in geriatrics recertify after 10 years. On average in medical specialties the recertification rate is 88%. There are currently about 2,300 Board Certified geriatric psychiatrists. If we use the current recertification rate, it would suggest that over the next 10 years more than one thousand will not recertify. Restated on an annual basis, that is a loss of over 100 geriatric psychiatrists. Yet on average only about 80 per year are newly certified (1). Furthermore, there are diminishing numbers of psychiatrists pursuing a fellowship in geriatric psychiatry. In the last six academic years (2000–2001 through 2006–2007), the number of geriatric psychiatry fellows has decreased more than 10% (107–93) while all other subspecialties have seen an increase (Addiction, 49–64; Child and Adolescent, 702–757, Forensics, 44–75) (2).
I would not be the first to point out that the prestige, payments, and research dollars in our medical system are highly skewed toward high-tech diagnostic and interventional techniques, while palliative and rehabilitative approaches that involve primarily the physician’s cognitive activities are far less well rewarded. Unfortunately, this is dramatically played out in the case of geriatric psychiatry. We have no high tech procedures for which we can bill. This is not to say that we do not make use of EEG, CT MRI or SPECT. But when we do, other specialists are reimbursed. All we sell is our time and this is not well reimbursed. In the clinic in which I practice and train residents, a complete psychiatric evaluation or a 45 minute psychotherapy session is reimbursed by Medicare at less than $100 and, unlike other branches of medicine, the patients co-pay is not 20% but can be 50%.
All this must influence one’s response to trainees who express an interest in practicing geriatrics. According to the AMA for those graduating medical school in 2006 the average amount of debt is over $130,000 (3). How will the newly minted geriatric psychiatrist sustain an office practice? Will she leave geriatrics or move her practice to a nursing home where high volume can compensate for low Medicare rates? If so, who will provide the community-based services that we believe helps maximize function? Need does not translate into care unless there are commensurate resources. In other sectors of health care, such as the pharmaceutical or insurance industries, high profits and high salaries are justified as necessary inducements. But more lectures on geriatric psychiatry or more federal support for geriatric fellowships will not pay off student loans.
What will help attract and keep psychiatrists in geriatrics? I have no sure answer, but other countries have dealt with similar issues. When I visited England in the 1980s to learn about their system, one of the factors that helped make geriatric psychiatry attractive was that the NHS paid a significant premium for psychiatrists to make home visits to geriatric patients. Seeing a patient in their home can provide so much more clinical information than an office visit. It also makes psychiatrists available to otherwise difficult to reach patients. Here reimbursements were being aligned with clinical need.
At my university hospital, geriatric medicine has partially dealt with the reimbursement problem by creating free-standing geriatric clinics. It is within the context of such a multidisciplinary clinic that I practice. This maneuver allows the hospital to charge Medicare a “facility fee” that is usually larger than my professional fee. Could something comparable be done to support community based geriatric psychiatrists? True, a solo psychiatrist may not be able to hire the nurses, social workers and other health care workers that such a fee helps offset. But even a reduced fee that compensated the practitioner for office overhead and the additional time required to interface with family, other physicians, non-mental health workers, and community agencies might make a significant difference.
This letter was written while I was the attending in a geriatric psychiatry clinic at the University of Chicago Hospital. But like the colleague I mention at the beginning of this letter, I have also decided to leave outpatient geriatric practice. In June 2007 I moved to the Jesse Brown VA and no longer rely on Medicare reimbursement to support my activities.