Specialists Could Play Major Part as PCPs in New Shape of Healthcare

With 10,000 Americans turning 65 daily until there will be more octogenarians than newborns, geriatricians are poised to play a major role in the new medical paradigm, the Patient Centered Medical Home (PCMH).

However, geriatricians weren’t always included in the core group of physicians that were identified as serving in the role of primary care providers (PCPs). Instead, the five major specialties considered PCPs were initially family medicine, internal medicine, pediatrics, obstetrics-gynecology and neurology.

Why weren’t geriatricians initially included?

“The reasons are several,” said Jeanne Wei, MD, PhD, executive director of the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging, the largest standalone geriatrics outpatient clinic in the United States. When its $28 million, four-story expansion project is completed in early 2012, the additional space will enhance the geriatrics education and research programs as well as the one-stop-shop for seniors’ care.

“Future improvements in the care of the aging population will rely upon innovative research,” said Wei, a Johns Hopkins-trained geriatrician and former Harvard professor who was recruited to UAMS nearly a decade ago. Her primary research areas include cardiovascular disease, frailty prevention and memory enhancement. “Geriatricians often fill roles that are two-fold. Some serve more as specialists in their own field, while others serve as subspecialists of internal medicine or family medicine. During the mid-1990s, obstetricians and gynecologists joined forces, as did physicians in family medicine, internists, pediatricians, and neurologists, to each successfully lobby and be considered as PCPs.  Geriatricians weren’t quite as cohesive as these five groups, thus geriatricians were left out of the initial group of PCPs.”

Last November, when the Centers for Medicare and Medicaid Services (CMS) said that those who provide primary care would get a slight increase in their reimbursement, geriatricians began lobbying for the PCP role.

“By that time, family medicine specialists and internists were saying geriatricians were subspecialists,” explained Wei. “So CMS took a look at the Medicare billing and found that more than 60 percent of primary care services for seniors were being provided by geriatricians. Thus, geriatricians are now included as PCPs.”

To be fair, Wei said, geriatricians were latecomers to medical specialization, and the field of geriatrics today is where the field of pediatrics was about 75 years ago.

“In the 1930s, the field of pediatrics wasn’t well established,” she explained. “But since then, it became recognized that pediatrics is a separate specialty with a totally separate body of knowledge. Everyone wants the very best care for their children, so most prefer to have a pediatrician, particularly when specialized expertise is needed. In the same respect, people are starting to also better understand the field of geriatrics, though some might not fully appreciate the differences. It’s a relatively new specialty and there aren’t very many geriatricians yet. With so many baby boomers transitioning into seniors, the number of geriatricians will need to rise quickly. The discrepancy between supply and demand is going to be more severe in the coming years because medical training programs aren’t turning out as many geriatricians as proportional to the growing need.”

States are addressing the need for geriatricians in various ways. In Arkansas, at UAMS, every medical student is required to complete a four-week rotation in geriatrics.

“That ensures no one graduates from UAMS with an MD without being exposed to the nuances of caring for an older person,” said Wei. “That’s very special because some schools have a shorter duration of exposure to geriatrics and may not be as well prepared to care for seniors. Arkansas is also the birthplace of the geriatrics program within the VA system. It was established before the geriatrics specialty was widely appreciated in the non-VA sector.”

Arkansas is one of few states that gave voters a choice about how to use tobacco settlement money. They chose healthcare, specifically improving access. From the grass roots movement emerged the Arkansas Aging Initiative, which birthed the Affiliated Centers on Aging network throughout the state.

“Virtually every senior resides within 60 miles of a geriatrician, no matter how remote their home is located,” said Wei, noting that representatives from other states, particularly rural ones, visit often as they aspire to emulate the Arkansas program.

“PCPs are an essential part of the PCMH, and geriatricians can be valuable as PCPs. Geriatricians specialize in consolidating and coordinating the usually fragmented medical care of a senior; they are often passionate about their work and have a holistic approach toward patient care. Geriatricians work hard to make the correct decisions in the most cost-effective way, which as we know, is extremely important for the future of healthcare.”

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