Medicare GME caps may be hurting geriatrician supply

Physicians worry about access to specialists for baby boomers.

By Markian Hawryluk, amednews staff. May 12, 2003.

Washington -- Charles Cefalu, MD, was like many other residents in geriatrics. With no geriatric program in his home state of Louisiana, he went to study at Wake Forest University in North Carolina in 1990 and taught at Georgetown University in Washington, D.C., for five years. It was for personal, not professional, reasons that he finally returned to New Orleans to practice and teach.

"I'm another example of a physician who goes out of state to train and then, for a while at least, doesn't come back to his home state," Dr. Cefalu said. While family brought him back, he returned with a primary goal of developing the state's first geriatric medicine fellowship.

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That program is now under way at the Louisiana State University School of Medicine, but Dr. Cefalu said many other states are not as lucky. Congressionally imposed caps on the number of residents for which Medicare will provide graduate medical education funding to hospitals is, in part, limiting the number of geriatricians trained in the United States, he and others say.

Dr. Cefalu fears there won't be enough geriatricians to meet demand as the baby boomers age. "The supply is woefully low and not even close to meeting projected need," he said.

Congress imposed the caps as part of the Balanced Budget Act of 1997, which effectively froze at 1996 levels the number of residents for which a hospital could draw GME payments. Lawmakers later softened the limit in rural areas to 130% of the 1996 levels and allowed rural hospitals to start residency programs for new specialties, even if that would exceed their caps. But for urban teaching hospitals, adding a resident in geriatrics means eliminating a residency slot for another specialty.

The funding is not insignificant. Depending on the hospital's ratio of Medicare days to private payment days, direct GME payment can reach tens of thousands of dollars for each resident. Indirect GME payments, a per-procedure add-on to account for higher costs in teaching hospitals, are also based on the number of residents, thereby magnifying the caps' impact.

Adding a geriatrics resident means eliminating a slot for another specialty.

Concerned about the future supply of geriatricians, Congress asked the Medicare Payment Advisory Commission for guidance on whether the caps need to be modified. At their April meeting, MedPAC commissioners concluded that the restrictions were not the problem.

"However worthy the goal of increasing the number of geriatricians or clinicians who have access to some training, however important that might be, the issue here is not the caps," said MedPAC Chair Glenn Hackbarth. "The problem is rooted in other things."

Dr. Cefalu agreed that the caps are not the only reason the supply of geriatricians is low. Certification of geriatrics requires an additional year of residency, after three years training in internal or family medicine. And after four years of residency, geriatricians can expect income at the low end of the physician pay scale and complex cases involving patients with multiple chronic conditions.

Those factors have hindered filling residency slots for hospitals that do offer geriatric training. Fill rates have reached about 70%, up from 50% a decade ago but down from highs of more than 90% in 1999. Fill rates also dropped when the requirement for certification in geriatrics was reduced from two years to one in 2000, and hospitals converted second-year residencies into first-year slots.

"The other problem is the number of [faculty members] who have geriatrics as their designated specialty," said Karen Fischer, associate vice president for health care affairs for the Assn. of American Medical Colleges.

"In schools of medicine, faculty play a very important role as role models in career decision-making," she said. "If you don't have faculty who are doing geriatrics, it's hard for them to convince people to go into geriatric training."

Fisher said the AAMC had partnered with the Hartford Foundation to distribute $4.8 million in grants to 40 medical schools to help enhance their geriatrics curriculums. Initial survey data indicate that graduates of those medical schools have a better awareness of geriatrics, but it is too early to tell whether those graduates will choose residencies in geriatrics at a higher rate, she said.

Fighting the caps

But medical colleges and the Gerontological Society of America believe it might be time for Congress to revisit the resident caps. In 1997, the general belief was that there would be a physician surplus by the year 2000, Fisher said. Now many are predicting an impending physician shortage.

"We do think the resident limits are having a chilling effect on the ability of programs and departments and hospitals to go into new specialties or expand existing programs," Fisher said. "It is a policy that is probably one of the tightest in Medicare with very limited exceptions, related mostly to rural hospitals."

A number of legislative proposals would raise the caps for various specialties, but the AAMC would like to see a broader discussion.

"We think it needs to be looked at in a more global way," Fisher said.

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