Geriatric Workforce Crisis in the United States
I am pleased to have this opportunity to briefly summarize the key issues involving the geriatric psychiatry workforce crisis in the United States (U.S.). To begin with, a statement of the problem: Only ~55-60 physicians are entering geriatric psychiatry fellowships annually in recent years, compared to a peak of over 90 per year almost a decade ago. Such numbers are insufficient even to replace existing geriatric psychiatrists leaving the field (due to retirement, other career changes, and death), let alone to increase the numbers sufficient to make subspecialty care accessible to the rapidly aging U.S. population.
There are of course many reasons for this pipeline problem. Longstanding ageist attitudes among the general public, policy makers, and health care providers including physicians, have long conspired to make careers in geriatrics (psychiatry, medicine, and other specialties and disciplines) seem to many less important and less appealing than other fields. That geriatric care involves chronic disease management, and has few ‘procedures’ or otherwise dramatic-seeming interventions, further lowers its superficial appeal. Somehow the rather clear data on high job satisfaction for those who do choose the field fail to oppose these other perceptions!
As well, those who do consider pursuing fellowship training face an immediate financial disadvantage. While training stipends do provide a living wage, the educational debt burden faced by most U.S.-educated physicians (averaging over $175,000 nationally) makes the prospect of a full year stipend that is typically only one-third to one-half of what would be earned by going directly into practice difficult or simply unviable for many. Child and adolescent fellowships face the same issue, but unlike geriatric psychiatrists, psychiatrists (a) must do such a fellowship if they want to treat children and younger adolescents, and (b) will be able to earn higher salaries than adult psychiatrists as a benefit of their subspecialty training. Neither holds true for geriatric psychiatrists: salaries are comparable or at most only slightly higher than general psychiatrists, and non-geriatric-trained general psychiatrists can and do treat older patients and work in the geriatric care settings. Therefore, for many it is difficult to justify the financial burden of the fellowship year, despite evidence that subspecialists do provide higher quality care for older adults.
To these longstanding problems, recent years have added the general financial and labor uncertainties facing the nation (and of course much of the world). It remains unclear what the effects will be of U.S. health insurance reform or any further attempts to modify how health care is structured and financed. And yet another cause for uncertainty is the upcoming change in the residency pool. Recognizing the need for more physicians to serve the population, several new medical schools have been created and many existing schools have increased their class size, such that within the next few years the U.S. will graduate about 25% more physicians annually. But the number of residency positions, largely funded through GME (graduate medical education) funds via Medicare, has not been increased. Indeed, recent federal budget proposals threaten to decrease, not increase, GME funding. Unless alternative sources are used to support residency positions, the net result will not be an increase in the number of trained physicians in the U.S., but rather merely the filling of existing residency slots entirely by graduates of U.S. medical schools, i.e., squeezing out the vast majority of IMGs (international medical graduates). This may further devastate the supply of trainees for geriatric psychiatry fellowships, since a substantial proportion of current fellows are IMGs.
Are there any signs of hope amidst these bleak circumstances? I do believe that there are substantial opportunities in the coming years. Growing experiments to change the delivery of health care, including medical homes (i.e., a full range of patient-centered services built around primary care) and accountable care organizations (ACOs, i.e., capitated payments putting the health care organization responsible, and financially at risk, for maintaining the health of its covered population) might prove to be ideal settings for collaborative care models in which the limited supply of geriatric psychiatrists and other mental health professionals might be deployed more efficiently and effectively to the benefit of patients. Unfortunately, thus far few medical homes or ACOs have included mental health (let alone geriatric mental health) in central and substantive ways. But other policy decisions may help the workforce situation. Last year, Medicare for the first time included billing subcodes for select clinical services denoting whether they are provided by geriatric psychiatrists. At present there is no reimbursement differential, but the hope is that ultimately these subcodes will reflect higher payment rates when the care is provided by a subspecialist.
Perhaps the biggest impetus to driving such policy changes is the upcoming Institute of Medicine (IOM) report on the geriatric mental health workforce. This report, championed in part by the American Association for Geriatric Psychiatry (AAGP), is a follow-up to the IOM’s 2008 report on the geriatric health workforce more broadly. IOM reports often have strong influence on policy makers.
Lastly, I believe that the postwar ‘baby boom’ generation now reaching their senior years, by dint of its size and its longstanding sense of entitlement, will demand better access to quality mental health services. I expect that we (as I am part of this generation) will pressure our governmental representatives to design and implement the required policy changes. It remains to be seen what such changes will look like, how they will be funded, and whether they will occur in time to prevent the erosive decimation of our current workforce and collective expertise.
Jeffrey M. Lyness, MD, is Associate Dean for Academic Affairs and Professor of Psychiatry at the University of Rochester Medical Center in Rochester, NY, USA. He is a past president of the American Association for Geriatric Psychiatry (AAGP).