How HRSA, CMS could help grow the geriatrician workforce

The future of the U.S. healthcare system is already being shaped by the growing population of older adults. But providers with expertise caring for them are dwindling — and the federal government’s work to grow the field is hitting a wall.

Older adults tend to have more complex health conditions, are disproportionately impacted by chronic disease and disabilities, and are more likely to be affected by problems such as injuries from falls, according to the National Council on Aging. Those complexities result in billions of dollars in care each year, largely financed by Medicare and Medicaid.

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But federal initiatives to increase the number of geriatric specialists aren't luring enough medical students to keep up with the rising need.

American Medical Association President-elect Dr. Bobby Mukkamala described geriatricians as navigators of senior care who are capable of making nuanced assessments of what patients need and coordinating with other specialists. That's critical to promoting value-based care care, said Mukkamala, an otolaryngologist in Flint, Michigan.

But according to the American Board of Medical Specialties, the number of board-certified geriatricians is on the decline: it fell from 10,270 in 2000 to 7,413 in 2022. That's because specialists in care for older patients are retiring and not being replaced, said Dr. Ecler Jaqua, associate professor of family medicine at the Loma Linda University School of Medicine.

Physicians without specialist training may be seeing more older patients, but that's not enough, said Dr. Jerry Gurwitz, chief of geriatric medicine at the University of Massachusetts Chan Medical School.

“There’s this naive belief that just being among old people provides you with expertise. It would be like saying that in pediatrics, just hanging around a playground with kids running around made you an expert in the care of children,” Gurwitz said. “It’s a dumbing down of the expertise needed to run these programs, to develop these programs.”

Ample warning

The number of people aged 65 and older is expected to rise from about 57 million to about 71 million between 2022 and 2030, according to the most recent projections from the U.S. Census Bureau. Their share of the population is expected to grow from 17% to 21% during those years.

Forecasts like those have proliferated for decades and the aging of the baby boom generation is a surprise to no one. For instance, the National Academies of Sciences, Engineering, and Medicine used Census data in 1996 to predict that people 65 and older would make up more than one-fifth of the population by 2050.

The federal government has long understood the stakes. Agencies such as the Health Resources and Services Administration and the Centers for Medicare and Medicaid Services have doled out a lot of money to boost the geriatric care workforce.

For example, HRSA distributed $206 million in July to 42 medical schools to fund the geriatrics training after Congress and President Joe Biden boosted funding. In 2020, lawmakers and Biden reauthorized the Geriatric Workforce Education Program for five years and reinstated the Geriatrics Academic Career Awards program, which is designed to increase the number of geriatrics-focused educators.

Agencies such as CMS and the Administration for Community Living are taking steps of their own to improve care for older patients. The final rule setting Medicare payments for inpatient hospital services next year ties reimbursements to age-focused quality measures, for instance, a CMS spokesperson said. And HHS released a national aging policy framework in May, which includes goals such as establishing geriatric emergency departments and geriatric surgery accreditations.

A tough job

Yet only 174 of 419 geriatric medicine positions at medical schools were accepted this year, according to the National Resident Matching Program. The trend is worsening: In 2022, 210 positions of 411 were filled; last year, 177 of 411 were.

The number of programs filling up each year is also on the decline, even as the number of fellowships continues to grow. There were 148 geriatrics fellowship programs in 2020, there are 154 now and the percentage that went unfilled increased from 70% to 75%.

Still, more than 500,000 people have participated in geriatrics-related continuing education courses via the HRSA Geriatric Workforce Education Program, according to HHS.

These interventions do more to help doctors already in the field than to persuade medical students to pursue geriatrics, however, Gurwitz said. And fluctuating funding over the years has made the Geriatric Workforce Education Program an imperfect solution, he said.

Part of the problem is that it isn’t financially worth it for students to pursue a career in geriatrics, Jaqua said.

Students must add an extra year of fellowship learning onto an already extensive, expensive academic career, Jaqua said. And once they join the workforce, they make less money than other specialists, she said.

The geriatrician shortage itself also makes the specialty less appealing, Jaqua said. Geriatricians carry heavy caseloads of people with numerous comorbidities, sometimes treating up to a dozen complex patients a day, she said.

The Medicare Payment Advisory Commission has recommended policies such as establishing a new payment code for comprehensive geriatric assessments, creating a scholarship and loan program for geriatric specialty clinicians including nurse practitioners and physician assistants, and requiring hospitals that receive graduate medical education payments to provide geriatrics training.