Healthcare professionals are generally trained in isolation and continue their practice in much the same way. Geriatrics has historically embraced an interdisciplinary team approach to training and practice. The importance of a well-balanced interdisciplinary team has been shown to be beneficial in the care of the elderly; however, payers and government regulators are attempting to lower one aspect of healthcare cost by making decisions that will directly affect the balance of the care team. Our current geriatric care system is under increasing pressure to find efficient and effective systems of care, so building the right team for our aging population is crucial. Intelligent regulations and appropriate incentives are a critical part of this.
One important component of a geriatric care team is the nurse practitioner (NP). NPs are advanced practice nurses, a field that was born in 1965 at the University of Colorado. Today, there are more than 115,000 practicing NPs, with an additional 6000 added annually as a result of programs at over 300 academic centers. NPs are able to reach patients in a unique manner by blending nursing and medical care.
This unique care, combined with the increased availability of NPs, has not been lost on the Governor of Pennsylvania, Ed Rendell, who believes strongly in the value of NPs. The governor stated that, “We should employ nurse practitioners in the delivery of health care services far more than we do.” A major reason for this support is an estimate by academics that an NP can perform approximately 70% of the functions that a primary care physician can—often at 50% or less of the costs. The Pennsylvania plan calls for expanding the scope of NPs through unlocking of regulations that restrict their scope of practice.
Federal legislators are also attempting to expand the scope of NPs with an aim toward long-term care involvement, as current law requires that all care in a skilled nursing facility be provided under the direct supervision of a physician. The Long-term Care Quality and Modernization Act of 2006 would amend this to include, “at the option of a State, under the supervision of a nurse practitioner, clinical nurse specialist, or physician assistant who is working in collaboration with a physician.” This would expand the role and responsibilities of NPs in skilled nursing facilities. In addition, this legislation would amend current law that does not permit nonphysician practitioners to be employed by the skilled nursing facility. This would enable NPs to be employed by a skilled nursing facility and supervise resident care.
Unfortunately, many of these moves to advance the role of NPs are being questioned by organized medical associations that fear that the increased scope of practice of nonphysician professionals will decrease the role of the physician. As geriatric care providers, we need to work together to support each other’s efforts, with the goal of improving patient care.
The American Geriatrics Society (AGS) describes geriatricians as physicians who are initially board-certified in Family Practice or Internal Medicine and who, since 1994, have been required to complete fellowship training in geriatrics beyond their residencies. This makes them uniquely qualified to provide expertise within a care team, especially in dealing with advanced medical treatments.
The last several years have seen a decline in the number of physicians trained in geriatrics each year to less than 350, which does not even keep up with the number of geriatricians retiring from active practice.1 This trend was worsened by Congress eliminating in fiscal year 2006 funding under Title VII for Geriatrics Health Professions Programs, which supports geriatric education. Fortunately this funding was reinstated, thanks in large part to the efforts of the AGS.
As a result of limited Medicare reimbursement and shrinking resources allocated to geriatrics, fewer than 4500 of the 100,000 general Internal Medicine physicians are currently certified in geriatrics.2 At the current time, there are just 7600 certified geriatricians in the United States, as com pared with an estimated need of 21,000. In 2005, there was only one geriatrician for every 5000 Americans age 65 years and older—a ratio that is likely to worsen. This is in sharp contrast to the United Kingdom, where every medical school has a geriatrics department, resulting in geriatrics as the third most popular specialty.
Further decreases in the number of geriatricians will likely result from decisions such as the one by California Governor Arnold Schwarzenegger to tax all physicians in the state 2% on their gross practice revenue. The revenue from this tax is planned to be used to provide coverage for the uninsured within the state, a move unlikely to positively impact geriatricians, since nearly all of their patients are covered under Medicare.
State and federal legislation and reimbursement strategies need to support the role of geriatricians as a critical component of the geriatric care team, rather than as an opportunity for cost savings—which may be short-sighted because it has been shown that focusing on primary care results in improved health outcomes, as well as financial savings.
The pharmacist has long been recognized as a key member of the geriatric care team. The role of the pharmacist has been increasing in importance due to the growing problem of polypharmacy. The importance of medication therapy management (MTM) was included in the Medicare Modernization Act, which requires all Medicare Part D plans to provide MTM to targeted Medicare beneficiaries by qualified providers. Unfortunately, the terms used to describe targeted beneficiary and qualified providers are left to each individual plan. A targeted beneficiary is defined by the Centers for Medicare & Medicaid Services simply as a beneficiary having all three of the following characteristics: taking multiple Part D medications, having comorbid conditions, and having prescription expenditures that will likely exceed $4000 annually. The exact definition of comorbid conditions and multiple medications is left to the plan to decide, oftentimes leaving Medicare beneficiaries who would benefit from MTM out of reach. In addition, the definition of qualified providers is also left to each prescription plan. Pharmacists who should play a lead role in all MTM services are unfortunately often replaced by plans with less experienced providers.
There are several summaries created by the American Pharmacists Association (APhA) of the most respected scientific and clinical literature establishing the documented human and financial cost of drug therapy misadventures, the need for improved pharmaceutical care services, and the documented clinical and economic impact of pharmacists who have taken on the job of providing pharmaceutical care.3 Despite the recognition of the value of pharmacists, a legislative push to get pharmacists recognized as providers (thus having the ability to bill Medicare directly under Medicare Part B) has not gone far; instead, pharmacists are forced to work through prescription plans to gain a place on the geriatric care team with regard to MTM for targeted beneficiaries.
The Complete Team
Of course, the complete geriatric care team requires a complement of providers from different disciplines, as complex geriatric care can be accomplished only through a team effort. Each member of the team needs to maintain focus on improving the quality of care through teamwork. The team must work to get all key stakeholders to realize each member’s value and to support the expansion of their reach for the benefit of the older adults served.
The AGS and its affiliates, as professional organizations, reach beyond one discipline and have advocated policymakers to move in the direction needed to produce strong geriatric care teams that include a balance of needed disciplines. AGS provides leadership to healthcare professionals, policymakers, and the public by implementing and advocating for programs in patient care, research, professional and public education, and public policy. With a mission and vision to improve the health, independence, and quality of life for all older people, having the right interdisciplinary team is critical so that every older American will receive high-quality patient-centered care. As the AGS this year will have a clinical pharmacist as its leader, perhaps we can help other groups find the right medicine for building the right team.
Dr. Stefanacci served as a Centers for Medicare & Medicaid Services (CMS) Health Policy Scholar for 2003-2004. He is Founding Executive Director, Health Policy Institute, University of the Sciences, Philadelphia, PA. Dr. Spivack is Associate Physician Editor of Clinical Geriatrics.
1. Torrible SJ, Diachun LL, Rolfson DB, et al. J Am Geriatr Soc 2006; 54:1453-1462.
2. American Board of Internal Medicine. Candidates certified—All candidates. Available at: www.abim.org/resources/dnum.shtm. Accessed February 27, 2007.
3. American Pharmacists Association. Evidence of the value of pharmacists. Available at: www.aphanet.org/AM/Template.cfm?Section=Pharmacy_Practice_Resources&Template=/CM/HTMLDisplay.cfm&ContentID=2907. Accessed February 27, 2007.
Please send any questions or experiences about Medicare Part D you would like to share with readers to: BSpivack@Waveny.org