[Senate Hearing 107-400]
[From the U.S. Government Printing Office]

                                                        S. Hrg. 107-400
                      PATIENTS IN PERIL: CRITICAL
                      SHORTAGES IN GERIATRIC CARE



                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                             WASHINGTON, DC

                           FEBRUARY 27, 2002

                           Serial No. 107-19

         Printed for the use of the Special Committee on Aging

78-786                       WASHINGTON : 2002
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                       SPECIAL COMMITTEE ON AGING

                  JOHN B. BREAUX, Louisiana, Chairman
HARRY REID, Nevada                   LARRY CRAIG, Idaho, Ranking Member
HERB KOHL, Wisconsin                 CONRAD BURNS, Montana
JAMES M. JEFFORDS, Vermont           RICHARD SHELBY, Alabama
RUSSELL D. FEINGOLD, Wisconsin       RICK SANTORUM, Pennsylvania
RON WYDEN, Oregon                    SUSAN COLLINS, Maine
BLANCHE L. LINCOLN, Arkansas         MIKE ENZI, Wyoming
EVAN BAYH, Indiana                   TIM HUTCHINSON, Arkansas
THOMAS R. CARPER, Delaware           PETER G. FITZGERALD, Illinois
DEBBIE STABENOW, Michigan            JOHN ENSIGN, Nevada
JEAN CARNAHAN, Missouri              CHUCK HAGEL, Nebraska
                    Michelle Easton, Staff Director
               Lupe Wissel, Ranking Member Staff Director



                            C O N T E N T S

Opening Statement of Senator John Breaux.........................     1
Prepared Statement of Senator Jean Carnahan......................     3
Prepared Statement of Senator Debbie Stabenow....................     4
Statement of Senator Harry Reid..................................     5
Statement of Senator Tim Hutchinson..............................     6
Statement of Senator Larry E. Craig..............................    21
Statement of Senator Blanche Lincoln.............................   158

                                Panel I

Stephen Bizdok, Las Vegas, NV....................................     8
Daniel Perry, Executive Director of the Alliance for Aging 
  Research, Washington, DC.......................................     9

                                Panel II

Dr. Charles Cefalu, Board Member of the American Geriatrics 
  Society, Professor and Director for Geriatric Program 
  Development, Louisiana State University, New Orleans, LA.......    22
Claudia Beverly, Ph.D., R.N., Associate Director of the Donald W. 
  Reynolds Center on Aging, Little Rock, AR......................    42
Michael Martin, Executive Director of the Commission for 
  Certification in Geriatric Pharmacy, Alexandria, VA............   145


Testimony submitted by Association of Professors of Medicine.....   167
Statement submitted by the American Association for Geriatric 
  Psychiatry.....................................................   172
Statement from the American Psychiatric Association..............   179
Statement from the American Psychological Association............   187
Testimony of Robert Butler, International Longevity Center.......   194
Testimony submitted by Council on Social Work Education..........   199
Statement of the American Occupational Therapy Association.......   205
Statement of the Association of American Medical Colleges........   242
Statement of the American Association of Colleges of Osteopathic 
  Medicine.......................................................   253





                      WEDNESDAY, FEBRUARY 27, 2002

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:04 a.m., in 
room 628, Dirksen Senate Office Building, Hon. John Breaux 
(chairman of the committee) presiding.
    Present: Senators Breaux, Reid, Lincoln, Craig, and 


    The Chairman. The committee will please come to order. Good 
morning, everyone. Thank you for being with us. I appreciate 
our colleague, Senator Harry Reid, taking time to be with us 
this morning as a member of our committee and thank him for his 
    I want to thank everyone for being with us. I want to 
particularly welcome Mr. Steve Bizdok, who traveled all the way 
from Las Vegas, NV in order to share a really incredible story 
with us today.
    This morning's hearing is entitled ``Patients in Peril: 
Critical Shortages in Geriatric Care.'' This marks the seventh 
in a series of long-term care hearings that our committee has 
held during this Congress. The shortage of health care 
professionals with specific training in geriatric care takes us 
to the core of what I mean when I say that we must ensure that 
all Americans have the opportunity to not only live longer but 
also to live better lives.
    We will hear today from a patient whose life was literally 
in jeopardy because well-meaning health care professionals 
lacked the real training to diagnose his illness. He is not 
alone. The senior population is living increasingly longer and 
more and more people will experience the effects of chronic 
conditions. In the United States we train our future doctors at 
125 prestigious medical schools around the country. While each 
of these schools has a pediatrics department, only three in the 
entire country have geriatric departments and only 14 require 
even a course in geriatrics.
    As the population of people 85 years of age and older 
continues to grow at the fastest rate in the nation, we are 
experiencing an unprecedented shortage of nurses and less than 
1 percent of those who remain are certified in geriatrics.
    As we move across the health care spectrum the outlook is 
increasingly bleak. Social workers, dentists, nutritionists, 
nurse assistants, therapists and psychologists will all play an 
increasingly important role as the baby boom generation 
continues to age, yet none of these disciplines is adequately 
prepared in the workforce to handle the illnesses and the 
conditions specific to geriatric patients. Pharmacists, who 
often play an intermediary role between the doctor and the 
patient, are just as unprepared. A recent report stated that 
each year nearly 1 million seniors are prescribed medicines 
which people their age should never take. Other studies 
indicate that 35 percent of all Americans over the age of 65 
experience adverse drug reactions, at a cost of $20 billion a 
year for treatment. Clearly we must do better than that and we 
can do better than that.
    I applaud the Veterans Administration for their efforts to 
train geriatricians through their fellowship program and I also 
recognize the work done by private foundations, such as the 
Hartford Foundation, the Brookdale Foundation, and the Reynolds 
Foundation, who have done much with little Federal funding. 
Thirty-five geriatric education centers across the Nation 
should also be recognized for training hundreds of thousands of 
interdisciplinary health care professionals to better serve 
older Americans.
    In addition, I am happy to note that I have worked with Dr. 
Greg Folse, a geriatric dentist from Louisiana, to improve the 
oral health care provisions of the nursing home survey and 
oversight efforts over at CMS.
    While all of these efforts are commendable, they are simply 
not enough. I believe it is important to note that this issue 
should not be taking us by surprise. For many years now 
organizations such as the American Geriatric Society, the 
International Longevity Center, and the Alliance for Aging 
Research have come to Capitol Hill to urge Congress to address 
this looming issue. During the spring of 1998 the Special 
Committee on Aging held a forum to highlight and discuss the 
shortage of geriatricians. During that same time I was also 
serving as chairman of the National Bipartisan Commission on 
the Future of Medicare and learned that by the year 2030 more 
than half of the nation's medical expenditures would be 
accounted for by older Americans. It is obvious that this 
shortage of geriatric-trained health care workers is not only a 
threat to an increasing number of elderly Americans but also to 
the economic health of our nation.
    I certainly look forward to learning more about this issue 
from our distinguished panels and would like to recognize our 
distinguished leader, Senator Harry Reid, if he would have any 
    [The prepared statement of Senator John Breaux follows 
along with prepared statements of Senator Jean Carnahan and 
Senator Debbie Stabenow:]

                  Prepared Statement of Senator Breaux

    Good morning and thank you all for being here today. I 
especially want to welcome Mr. Steve Bizdok who traveled from 
Las Vegas in order to share his incredible story with us today. 
I also want to welcome the Committee's Ranking Member Larry 
Craig and my other colleagues, a number of whom I know have a 
specific legislative interest in today's topic.
    This morning's hearing, ``Patients in Peril: Critical 
Shortages in Geriatric Care'' marks the seventh in a series of 
long-term care hearings that the Committee has held during the 
107th Congress. The shortage of health care professionals with 
specific training in geriatric care takes us to the core of 
what I mean when I say that we must ensure that Americans not 
only live longer, but live better. We will hear today from a 
patient whose life was literally in jeopardy because well-
meaning health care professionals lacked the training to 
diagnose his illness. He is not alone. While the senior 
population is living increasingly longer, more and more people 
will experience the effects of chronic conditions.
    In the United States we train our future doctors at 125 
prestigious medical schools. While each of these schools has a 
pediatrics department, only three have geriatric departments 
and only 14 require a course in geriatrics. As the population 
of people 85 years and older continues to grow at the fastest 
rate in the nation, we are experiencing an unprecedented 
shortage of nurses; and, less than one percent of those who 
remain are certified in geriatrics. As we move across the 
health care spectrum the outlook is increasingly bleak. Social 
workers, dentists, nutritionists, nurse assistants, therapists, 
and psychologists will all play an increasingly important role 
as the baby boom generation continues to age, yet none of these 
disciplines is adequately preparing its workforce to handle the 
illnesses and conditions specific to geriatric patients. 
Pharmacists, who often play an intermediary role between the 
doctors and patients, are just as unprepared. A recent report 
stated that each year nearly one million seniors are prescribed 
medicines which people their age should never take. Other 
studies indicate that 35 percent of Americans over the age of 
65 experience adverse drug reactions at a cost of $20 billion 
annually for treatment. Clearly we must do better.
    I applaud the Veterans Administration for their efforts to 
train geriatricians through their fellowship program and I also 
recognize the work done by private foundations such as the 
Hartford Foundation, the Brookdale Foundation, and the Reynolds 
Foundation who have done much with little federal funding. The 
35 Geriatric Education Centers across the nation should also be 
recognized for training hundreds of thousands of inter-
disciplinary health care professionals to better serve older 
Americans. In addition, I am happy to note that I've worked 
with Dr. Greg Folse, a geriatric dentist from Louisiana, to 
improve the oral care provision of CMS's nursing home survey 
and oversight efforts. While all of these efforts are 
commendable, they are simply not enough.
    I believe it is important to note that this issue should 
not be taking us by surprise. For many years now organizations 
such as the American Geriatrics Society, the International 
Longevity Center, and the Alliance for Aging Research have come 
to Capitol Hill to urge Congress to address this looming issue. 
During the spring of 1998, the Special Committee on Aging held 
a forum to highlight and discuss the shortage of geriatricians. 
During that same time I was also serving as the Chairman of the 
National Bipartisan Commission on the Future of Medicare, and 
learned that by the year 2030 more than half of the nation's 
medical expenditures would be accounted for by older Americans. 
It is obvious that this shortage of geriatric-trained health 
care workers is not only a threat to an increasing number of 
elderly Americans, but also to the economic health of our 
    I look forward to learning more about this issue from my 
fellow Senators and from our distinguished panels. I also look 
forward to hearing recommendations about what can be done to 
ensure that America's seniors continue to live not only longer 
lives, but better lives as well.

              Prepared Statement of Senator Jean Carnahan

    Thank you, Mr. Chairman, for holding this hearing. I 
believe that the testimony of the witnesses will provide 
valuable insight to the importance of specialized training in 
geriatric care for health professionals.
    In Missouri and across the country, the ``baby boomers'' 
are aging. In the next several years, the number of American 
citizens over the age of 65 will increase dramatically. By the 
year 2030, 70 million Americans will be 65 and older. As the 
population ages, they will have different healthcare needs. 
These needs will not be met unless we address the current 
shortage in geriatric healthcare providers.
    Patients want to receive the best possible healthcare from 
those most qualified to treat them. When women seek prenatal 
care, they turn to providers specifically trained in the care 
of pregnant women. When parents seek care for their children, 
they turn to providers specially trained in pediatric residency 
programs. When adults seek healthcare for specific cardiac, 
pulmonary, gastrointestinal, or psychiatric issues, they make 
appointments with cardiologists, pulmonologists, 
gastroenterologists, or psychiatrists. Patients realize the 
importance of the provider's specialized training in finding 
the best possible solution to their problem. For seniors, the 
desire is the same. They want to be cared for by those most 
qualified to provide their healthcare.
    Today, there are fewer than 9,000 geriatricians in the 
United States. Unfortunately, most of these doctors will retire 
as the baby boomer generation attains Medicare eligibility. Of 
the approximately 98,000 medical residency and fellowship 
positions supported by Medicare in 1998, only 324 were in 
geriatric medicine and geriatric psychiatry. At the same time, 
the number of physicians needed to provide medical care for 
older persons is expected to triple in the next 30 years. 
Further complicating the issue is the limited number of 
academic geriatricians. A large portion of their time is spent 
with patients, leaving little time to mentor or train the next 
generation of geriatricians. In addition, they have little time 
to conduct vital research regarding the care of the elderly.
    There must be incentives in place to encourage young 
physicians and other healthcare providers to pursue a career in 
geriatrics. That is why I am supporting a bill, the Geriatric 
Care Act. The Geriatric Care Act would remove some of the 
disincentives that have cause the geriatrician shortage. First, 
the bill would authorize Medicare coverage of geriatric 
assessment and care coordination for seniors with complex 
health and social needs. Second, the bill would provide 
hospitals additional slots in their geriatric residency 
training programs. The current cap on the number of residents 
per hospital has caused many hospitals to reduce or eliminate 
their geriatric training programs.
    Thank you, again, Mr. Chairman, for holding this hearing. I 
look forward to working with my Senate colleagues to address 
this situation.

             Prepared Statement of Senator Debbie Stabenow

    Mr. Chairman, thank you for convening today's hearing on 
this critical issue. As we all know, our aging population will 
dramatically change the way health care is administered in our 
country. The statistics are staggering: today in America, well 
over 35 million people are over the age of 65--and that number 
is growing at a fast pace.
    Although America has the best caregivers in the world, not 
nearly enough are specially trained nor certified to provide 
geriatric care. Currently, we are experiencing shortages in 
geriatric care at every level. Only 1.3 percent of physicians 
in America are geriatricians. Less than one percent of nurses 
are certified in geriatrics. Less than one-half of one percent 
of pharmacists have geriatric pharmacology certifications.
    Even more challenging is the lack of resources to train 
geriatricians. Only a handful of our medical and nursing 
schools offer sufficient training in geriatrics. More must be 
done to help schools train students and to attract young 
healthcare professionals to the field of geriatrics to meet the 
rapidly growing demand. Two bills have been introduced in the 
Senate--The Advancement of Geriatric Education Act and the 
Geriatric Care Act--both offer solutions to this healthcare 
crisis. I am currently reviewing these bills and am eager to 
work with the committee and my colleagues in the Senate to 
begin to address the enormous need for geriatric care in our 
    There are some success stories that merit more attention 
because they have demonstrated very positive results for 
seniors. The Program of All-inclusive Care for the Elderly 
(PACE) program is a wonderful way to help elderly patients 
retain their independence while receiving the specific kind of 
care that they need. These Medicare and Medicaid funded 
programs provide a ``one-stop shopping'' area for seniors, 
where senior participants have access to a full range of 
support and health care.
    In Michigan, we are very lucky to have one PACE program, 
the Center for Senior Independence. Of the many constituents I 
work with, one woman's story shines as an example of how 
helpful PACE can be. This woman is 67 and a resident of 
Detroit. She is a two-time stroke victim, has use of only one 
arm, is diabetic, and has a large ulcer on one leg and has had 
to have her other leg amputated. For many years, she lived with 
her daughter who took care of all her needs. However, she was 
determined to be independent and sought services to help. She 
now is a patient at the PACE program happily living at home. 
Every morning a driver picks her up and takes her to the 
Center. There she can get all her prescriptions, see her 
doctor, or they will take her to offsite medical appointments. 
The Center also provide her with dietary assistance even does 
her laundry! She and her family have been extremely pleased 
with the Center. We need to make this wonderful program 
available for more of our aging population.
    Aging advocates are also working in Michigan to help reduce 
the shortage of geriatric care in rural areas. For example, 
Northern Michigan University is working to establish a 
gerontology minor program. Additionally, the University has 
been working to attain sufficient funding to establish the 
Northern Michigan University Center for Gerontological Studies. 
This Center will fill the gap and provide exactly the kind of 
specialized training that is currently lacking and will 
continue the important research that must be conducted on the 
process of aging. I am very interested in helping this program 
succeed and in helping to bolster the programs in the other 
medical and nursing schools in my state.
    Finally, I want to highlight the importance of geriatric 
pharmacists. Because the average senior citizen takes 18 
prescription medications per year, it is vital that pharmacists 
who specialize in the unique needs of seniors are available. 
According to some studies 35 percent of Americans over age 65 
experience adverse drug reactions. Often, seniors have 
different health risks that younger people may not have. It is 
very important that we have enough specially trained geriatric 
pharmacists to monitor and to take these risks into account 
when filling prescriptions. As I work with my colleagues to 
develop meaningful Medicare prescription drug benefit, we must 
also be mindful of this shortage of pharmacists and the role it 
plays in providing truly adequate care for our seniors.
    In conclusion, I am looking forward to hearing from our 
witnesses and also look forward to working with the committee 
on this critical issue.


    Senator Reid. Thank you very much, Chairman Breaux, and 
thank you very much for your leadership in this most important 
committee. I have enjoyed my service on this committee. I 
served on the Aging Committee in the House and I must say your 
stewardship is certainly in keeping with the pattern that was 
set by Senator Pepper, who was so good when I first joined the 
committee in the House.
    I would like to welcome Mr. Steven Bizdok to the Senate 
from Nevada. Mr. Bizdok has been a resident of Las Vegas for 
more than 40 years. His story is compelling. His story 
illustrates the value of geriatric care and why we must take 
measures to increase the number of doctors, nurses, pharmacists 
and mental health professionals who are trained in geriatrics.
    Too often problems in older persons are misdiagnosed, 
overlooked or dismissed as normal conditions of aging because 
doctors and other health care professionals simply are not 
trained to recognize how diseases and impairments might appear 
differently in the elderly. As a result, patients like Mr. 
Bizdok suffer needlessly and Medicare costs rise because of the 
avoidable hospitalizations and nursing home admissions.
    It is no secret that our nation is growing older. Every day 
this year approximately 6,000 people will celebrate their 65th 
birthday. The number of old Americans will more than double 
from 35 million to 70 million by the year 2030. The vast 
majority of our health care providers, however, are not yet 
prepared to meet the challenges associated with caring for the 
elderly. Increasing the number of certified geriatricians and 
improving access to geriatric care simply will not be easy. 
Geriatrics is the lowest paid medical specialty because the 
extra time required for effective treatment of the elderly is 
barely reimbursed by Medicare and other insurers.
    To encourage more doctors to become certified in geriatrics 
I am reintroducing the Geriatricians Loan Forgiveness Act. This 
is legislation that would forgive $20,000 of education debt 
incurred by medical students for each year of advanced training 
required to obtain a certificate of added qualifications in 
geriatric medicine or psychiatry. I would say, Chairman Breaux, 
in that you are one of the senior members of the Finance 
Committee, I think this would be something to really take a 
look at.
    Another barrier to increasing access to geriatric care is a 
provision in the Balanced Budget Act of 1997 that established a 
hospital-specific cap on the number of residents based on the 
level in 1996. Because a lower number of geriatric residents 
existed prior to December 31, 1996, these programs are 
underrepresented in the cap baseline. The implementation of 
this cap is resulting in the reduction of and, in some cases, 
the elimination of geriatric training programs, despite the 
fact that they are needed now more than ever.
    I am pleased to join Senator Lincoln in reintroducing the 
Geriatric Care Act, legislation that would allow hospitals to 
exceed this cap and expand their geriatric fellowship programs. 
Another important provision of this legislation would give our 
frail elderly access to geriatric care coordination by making 
this benefit reimbursable under the Medicare program.
    Geriatric care helps seniors live independent, productive 
lives. By postponing physical dependency, our nation could save 
as much as $5 billion each month in health care and custodial 
costs. Simply put, increasing the number of health care workers 
trained in geriatrics is good medicine and good economics.
    I look forward, Mr. Chairman, to working with you on this 
most important issue dealing with geriatric care and I would 
ask that you excuse me about 25 after because the Senate opens 
at 9:30 and I have to be there.
    The Chairman. Other duties call. Thank you very much for 
your comments and your suggestion on the legislation, which I 
think is really very positive.
    Next I recognize Senator Hutchinson from Arkansas, who has 
some geriatric facilities there that are doing good work.


    Senator Hutchinson. Thank you, Senator Breaux. I want to 
thank you particularly for holding this hearing today. I am 
especially pleased that we have an Arkansas on our second 
witness panel, Claudia Beverly, who is the associate of the 
Donald Reynolds Center on Aging in Little Rock.
    Senator Reid. Would the senator yield just for a second?
    Senator Hutchinson. Yes.
    Senator Reid. Donald Reynolds was a Nevadan.
    Senator Hutchinson. Indeed he was.
    Senator Reid. He came from Arkansas, though.
    Senator Hutchinson. He almost bought Arkansas. But the 
Donald Reynolds Foundation----
    Senator Reid. He would have but he spent most of it on 
buying Nevada.
    Senator Hutchinson. I know that the Donald Reynolds 
Foundation has probably meant as much to Nevada and Arkansas 
both in their charitable giving and the many projects that they 
have supported and this is very appropriate, the commitment 
they have made to this geriatric center in Little Rock and we 
are very pleased to have it. Claudia is well known in Arkansas, 
as well as across the Nation for her expertise in geriatric 
    Mr. Chairman, last June Senator Mikulski and I held a 
hearing on the need for greater focus on geriatrics in the 
Subcommittee on Aging and I subsequently introduced 
legislation, along with my colleague and ranking member of the 
Special Committee on Aging, Larry Craig. Our bill is called the 
Age Act and it does four very important things.
    First, the bill provides an exception to the 1997 residency 
cap to allow hospitals to have up to five additional geriatric 
residents. Second, the Age Act authorizes the Centers for 
Medicare and Medicaid Services to provide graduate medical 
education support for the second year of a geriatric 
fellowship, which is critical to developing a cadre of academic 
geriatricians. Senator Craig and I sent a letter to CMS 
Administrator Tom Skully just this week asking CMS to do this 
administratively. Third, the Age Act asks the Secretary of 
Health and Human Services to report to Congress on ways to 
better educate and disseminate information on geriatrics to 
Medicare providers. Then fourth and finally, the Age Act 
increases the authorization amounts for geriatric programs 
under Title VII of the Public Health Service Act, such as the 
Geriatric Academic Career Award Program and Geriatric Education 
Centers, which focus on generating geriatric scholars and 
providing geriatric training to all health care professionals.
    Now Mr. Chairman, you and our majority whip Senator Reid 
have both emphasized and I think explained very clearly how the 
explosion among the aging is occurring demographically in our 
society. Just to put it in perspective, one in five Americans 
will be over the age of 65 in the year 2030 and that is 
dramatic. At the same time, only 9,000 of our nation's 650,000 
doctors have received any specialized training in the area of 
geriatrics. I think those two sets of statistics make a very 
compelling case for what we face. Of 125 medical schools only 
three, including I am glad to say the University of Arkansas 
for Medical Sciences, have formal departments of geriatrics. In 
only 14 medical schools is geriatrics a required course of 
study. Everywhere else it is optional. By contrast, every 
medical school in the Nation has a pediatrics department and 
every medical school in England has a geriatrics department.
    Just as children have unique medical needs, so do older 
Americans. Aging individuals often exhibit different symptoms 
than younger people with the same illness. Similarly, elder 
people often exhibit different responses to medications than 
younger people. Many seniors also take multiple drugs ordered 
by multiple physicians, which can lead to adverse drug 
    As was evidenced in the hearing the Aging Subcommittee held 
last June, our nation is in dire need of more geriatricians and 
health care professionals with geriatrics training. About 
20,000 geriatricians are currently needed for the current aging 
population and we only have 9,000. So we have a great challenge 
ahead of us.
    Mr. Chairman, the kind of legislation that Senator Reid 
speaks of, that you have led the way in, Senator Mikulski and 
myself, I know that is the way we can find consensus on these 
various proposals to meet what all of us see as the great 
geriatrics need of the future and I would ask that my full 
statement be included in the record. I am anxious to hear our 
panel and I thank the chair.
    The Chairman. Thank you very much, Senator Hutchinson and 
Senator Reid, for your comments.
    You have heard from us. Now it is time to hear from the 
real people that we have come to hear from, and that is Mr. 
Steve Bizdok and Mr. Dan Perry. Mr. Bizdok, as I indicated 
earlier, is from Las Vegas. You have an incredible story. You 
look like the picture of health but that was not the story 
before. Dan Perry, of course, is the Executive Director of the 
Alliance for Aging Research. We have worked together with his 
organization for a number of years. This is a good piece of 
material that you all have put out; very interesting and very 
    We will hear from Mr. Bizdok. We would love to hear from 


    Mr. Bizdok. Thank you. Good morning, Chairman Breaux, 
Ranking Member Craig, Senator Reid, members of the committee 
and distinguished guests. It is an honor to be here this 
morning and I hope that my testimony will be helpful.
    My name is Stephen Bizdok and I have been a resident of Las 
Vegas, NV for over 40 years. When I was younger I was not 
really concerned about what kind of doctor I saw but as I grew 
older and became ill, I realized that I had to have someone who 
could understand what my mind and body were going through. That 
was when I discovered the importance of geriatric medicine.
    My health started deteriorating in the summer of 1999 when 
I started to have seizures. They started out small and I would 
have about one per week. Then they started to snowball until I 
was having a seizure every day. Then they started multiplying 
so that I had cluster seizures. I started to panic because I 
did not trust myself to drive and I was all alone in my home 
when I was having these seizures. Each one would last up to 15 
or 20 minutes and I could not even drive to the doctor.
    During my well periods I asked my friends to drive me. By 
that point I would go to a quick care center to get medical 
attention and was constantly shifted from doctor to doctor to 
doctor. My primary care physician did not have a clue what was 
happening to me. They assumed it was a brain problem.
    In October 1999 I had a very large seizure while I was at 
home alone and I laid on the living room floor for 4 days. A 
friend of mine who had not heard from me for 4 days sent some 
friends who had a key to my place to come check on me. They 
found me on the floor in a fetal position and called an 
ambulance. I spent 2\1/2\ months in intensive care hooked up to 
life support. The doctors at the hospital got a court order to 
take me off of life support. All of my organs had started to 
shut down and the doctors put me on a death watch for 4 days. 
On hearing of my impending death, they gave away my car, my 
clothes and all of my personal belongings. My friends and 
family came to the hospital to say goodbye.
    I finally  woke  up on  my own  in the  hospital  room 
around February 25, 2000, 4\1/2\ months after my friends found 
me on my living room floor. I had slept through the entire 
millennium. Doctors still did not know what happened to me.
    When I went into the coma I weighed 220 pounds. When I woke 
up from the coma I weighed 123 pounds and I did not have the 
use of my legs. The doctors in the hospital started me on 
physical therapy so I could walk again. I was discharged from 
the hospital on April 6, 2000 when I was strong enough to use a 
walker. I went from the hospital to a care home. From that 
point on, the people who owned the care home suggested that I 
enroll in supplemental insurance and I enrolled in a Medicare 
Social HMO in Las Vegas. That is when I was introduced to 
geriatric medicine.
    I was assigned to a geriatrician and I will never forget my 
first visit because it lasted over one hour. He gave me a very 
thorough physical and asked many questions. I started seeing 
him on a regular basis and had a standing appointment once 
every 3 months.
    One year later I had two seizures. My geriatrician 
diagnosed my condition as a heart murmur or irregular 
heartbeat. My geriatrician put me in the hospital immediately 
when I told him I was having a pain in my back that traveled 
under my right arm and to the right side of my chest. That is 
when he called in the heart specialist. Within 2 days I had a 
pacemaker put in. I was finally receiving the treatment for my 
condition. It took a geriatrician to diagnose the problem.
    My health problems started to turn around after I received 
geriatric care. Since receiving the pacemaker, my health has 
improved tenfold. It is unbelievable. First, I am not having 
seizures any more and I am able to live on my own. I can take 
care of all of my own medication and can live an active life 
again. I used to take 14 pills every morning and now I am down 
to just six.
    There is nothing my geriatrician, Dr. Muyat, can do about 
my getting older but he can help me from becoming old.
    Thank you for your time today. Please feel free to ask me 
any questions.
    The Chairman. Mr. Bizdok, thank you very much. That is 
probably the most incredible story that I have heard since I 
have served on this Committee. It is an unbelievable story and 
I think it makes the point very well and we thank you so much 
for being with us.
    We are going to let Mr. Perry give his statement; then we 
will have some questions. Dan.


    Mr. Perry. Thank you very much, Mr. Chairman, Senator 
Hutchinson. Let me say before I begin what a pleasure it has 
been to work with this committee and its professional staff, 
both majority and minority. It has been very gratifying and I 
thank you for that.
    With these hearings, Mr. Chairman, you are helping many of 
the health organizations that are represented here today to 
bring forth an important reality, and that is that our health 
care system continues to give short shrift to professional 
education in geriatric health care and that practice is on a 
collision course with the aging of the baby boom.
    What you have just heard from Mr. Bizdok is a story that is 
familiar to many older Americans and to their families. So this 
morning the Alliance for Aging Research releases a new report 
titled ``Medical Never-Never Land: Ten Reasons Why America is 
not Ready for the Coming Age Boom.'' Despite the well known 
graying of America's patient population, most of our health 
care providers, as you have heard, still have little or no 
specific education in geriatrics or aging-related health that 
is optimal for older people.
    With your leadership and with bipartisan support, our 
nation is now moving to ensure that Medicare will be fiscally 
sound in the decades ahead yet we have given far less attention 
to the quality of the health care that we are buying. We have 
done far too little to ensure that health care providers have 
the formal training they need to provide the highest quality of 
care for their older patients.
    It is no secret that older people utilize a 
disproportionately larger share of health care services. While 
people over the age of 65 represent now just 13 percent of the 
population, this group consumes one-third of all the health 
care spending and occupies one-half of all physician time.
    In less than 10 years the baby boom generation begins its 
transformation into the biggest Medicare generation in history. 
Think of it this way. Today some 6,000 Americans celebrate 
their 65th birthday. In 2011 it will be 10,000 a day cruising 
past the age of 65 and swelling the Medicare rolls. The number 
and proportion of people over the age of 85, which are those 
most likely to require health care services, will nearly 
quadruple by mid-century. Meanwhile, as you have all said, the 
formal training of America's health care professionals is 
seriously out of step with this great demographic challenge.
    As Senator Hutchinson has pointed out, out of 650,000 
physicians in the U.S., only 9,000, which is about 1.5 percent, 
have certification in geriatric medicine and the number is now 
shrinking. We expect to lose as many as a third of those in the 
next 2 years because of retirements.
    In the nursing profession less than 1 percent of the total 
have geriatric certification. Out of 200,000 pharmacists in the 
U.S., less than one-half of 1 percent have certification in 
geriatric pharmacology. As with the other professions, this 
lack of formal geriatrics training among pharmacists has real 
consequences. A study in the Journal of the American Medical 
Association just in December found that 20 percent of older 
Americans are routinely prescribed drugs that experts in 
geriatric pharmacology say should almost never be used by older 
people because of serious health risks.
    Mr. Chairman, in this report we have borrowed from the 
imagination of Walt Disney and from the words of Dr. Robert N. 
Butler, the founding director of the National Institute on 
Aging. It was more than 20 years ago that Dr. Butler 
characterized age denial in American health care by calling it 
``Peter Pan medicine.''
    As adults grow older there are complications and changes 
that require specialized training to provide the best possible 
care and to produce the most desirable health outcomes. 
Unfortunately, very few professionals in this country have been 
exposed to the techniques and knowledge of geriatric health 
care as part of their professional training. This dangerous 
disconnect creates a medical Never-Never Land in which patients 
keep getting older and the health care providers are less and 
less likely to have the specific training in the needs of older 
    With this report, you have our list of 10 reasons why 
America remains mired in medical Never-Never Land. Suffice it 
to say that at present, the health care system is too quick to 
write off the complaints of older patients. We undervalue the 
importance of keeping older people healthy and independent. We 
do far too little to attract young people into geriatric health 
care and we do not have sufficient numbers of specialized 
faculty to incorporate the style and instincts of geriatric 
health practice into the training of all our health providers.
    The American public understands that the lack of geriatric 
training for health providers can have devastating 
consequences. According to a survey that we commissioned just 
this month, 74 percent of all Americans feel it is very 
important that their health care providers have specific aging-
related training to effectively treat the elderly. Surely this 
is a matter that deserves the same bipartisan attention that 
mobilized Congress to protect the solvency of programs such as 
    In closing, Mr. Chairman, I want to point out that 
obviously we are not just talking about statistics and programs 
and budgets; we are talking about people, real people as you 
have heard this morning. For every Mr. Bizdok there are tens of 
thousands, millions of families that have similar stories to 
    We are not here this morning to cast blame on anyone but to 
state the obvious, that it is a critical problem that too many 
health care professionals come to their older patients with no 
formal education in geriatric health care. As you have said, 
America can and should do better. Thank you.
    [The prepared statement of Mr. Perry follows:]
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    The Chairman. Thank you, Mr. Bizdok and Mr. Perry, for your 
    I think this is an area where the American medical 
profession is missing the boat. I mean the fastest growing 
segment of our population are seniors. We are going to have 77 
million baby boomers starting to become senior citizens in the 
very near future. If you have the fastest growing segment of 
our population that are living longer than ever before and we 
only have three medical schools in this entire country that are 
formally teaching geriatrics, the American medical profession 
is missing the boat.
    I do not know why. Maybe they think that is not an area 
they should be in in, that people ultimately will pass on. We 
all know that but people are going to be around a lot longer 
than they used to be and we will have a lot more of them.
    We are going to explore this a lot further but if I was 
running a medical school, the first thing I would do would be 
to ensure that we have an adequate geriatric department that 
formally teaches people how to deal with particular problems. 
It is not sufficient just to tell people well, what is the 
matter with him? Well, he is old. We know that but it is 
probably a problem associated that is causing the particular 
medical deficiency that the person is suffering from, like Mr. 
    Your story is just truly incredible and we are sorry that 
you had to experience what you had to experience but hopefully 
your story can be used to tell the medical profession that they 
have to do a much better job in this particular area.
    I really do not know what to ask you. I am sort of at a 
loss for words. Your story is so powerful in and of itself, it 
does not have to be elaborated on. I guess the bottom line, 
Senator Hutchinson, is that had he had a geriatrically trained 
doctor, they would have caught this particular problem that you 
were having, which is similar to what a lot of other seniors 
may experience.
    Mr. Bizdok. Correct.
    The Chairman. You almost left us.
    Mr. Bizdok. Yes, real close. I really kind of feel blessed 
that I did find my Dr. Muyat and he has just been great. He 
watches me carefully, watches my diet, the whole ball of wax. 
He says to me, ``Aren't we putting on a little weight?'' I say, 
``Thank you for noticing.''
    The Chairman. Well, that is the problem. There just are not 
enough medical professionals, as Dan said, in all of these 
areas, in pharmaceuticals and dentistry and all of the other 
health care arenas. I mean treating a 20-year-old is quite 
different from treating a 70-year-old or an 80-year-old or now 
people in their 90's and above. I mean there are different 
things to look for and if you have not had that particular type 
of training, you are likely to miss it.
    Dan, what do we do? You pass a law in Congress saying thou 
shalt have more geriatric professionals? Because we had this 
problem before. We had an overabundance of specialists and a 
shortage of general practitioners and I think that is getting 
back into proper balance now because of things Congress 
actually did to encourage more general practitioners because we 
were having an overload of specialists and not enough family 
practitioners and general practitioners to solve the needs of 
the society.
    What do we do? What is your suggestion as to how we correct 
the imbalance and the lack of professional geriatricians?
    Mr. Perry. Thank you for the question, Mr. Chairman. In our 
report we lay out some very specific recommendations. Before I 
get to that, let me respond to your remarks earlier asking what 
is wrong with American medical and health education, why are 
not the health professions taking more of a lead?
    Indeed, many of the health professions have been creating 
certification programs within their own fields in this area--
family practice, internal medicine, psychiatry, psychology, 
nurses. They are offering certification but there are 
structural problems related to reimbursement that keeps people 
out of the field. There are structural problems in the way 
Medicare, as was mentioned, puts caps on the number of faculty 
slots so that we do not have enough professors of geriatrics in 
the medical schools, in the nursing schools, in the schools of 
pharmacy to teach the students.
    So we have a complex problem that is going to require a 
real partnership between the Federal Government, the medical 
schools, the health professions. We provide funding for 
training of health professions in the Bureau of Health 
Professions at HRSA but it is far too inadequate. Geriatrics is 
lumped together with many other good purposes so it does not 
have the visibility and perhaps we should think of a new bureau 
of geriatric resources. Given that it is the most obvious 
factor of our aging population and our health care problem, we 
need to have more focus on this issue and your help in the 
Federal Government can play a major role in that.
    The Chairman. Well, that is a helpful suggestion. My final 
question to you, Dan, is how do we stack up and compare with 
other countries in this area? Do other countries have the same 
shortfall in geriatric professionals as we do or are some 
countries doing better? Are there any comparisons out there we 
can learn from?
    Mr. Perry. Virtually every nation in the world is 
experiencing this explosion of older people, people surviving 
longer, and that is what we would all hope for, but many other 
industrialized nations are more systematically incorporating 
training in geriatrics and gerontology into their health 
professions far better than we are. I think it was pointed out 
earlier that in the United Kingdom--I think it was Senator 
Hutchinson--virtually every school in that country has a full 
department of geriatrics and we have three. In Japan it is 
about half. In Canada and elsewhere it is more directly 
integrated into health care training across all of the health 
professions. I want to emphasize the importance of that and you 
will hear more this morning from nursing and pharmacy.
    The Chairman. Well, thank you very much.
    Mr. Bizdok, we have poster children for everything and I 
would like to make you the poster citizen for better geriatric 
training. Your story is just right to the point.
    Mr. Hutchinson, any questions?
    Senator Hutchinson. On that point, Mr. Bizdok, welcome 
    Mr. Bizdok. Yes, yes.
    Senator Hutchinson. It was a very inspiring story and I 
will tell you what went through my mind is how many did not 
wake up or how many did not get eventually a geriatrics doctor 
who we may have lost not ever knowing and who may have--I mean 
your obvious robust love for life, this is something we need to 
have the kind of geriatrics physicians, diagnosis of what is 
causing--you said you were taking 12 pills a day.
    Mr. Bizdok. Actually from the beginning, 16.
    Senator Hutchinson. Sixteen.
    Mr. Bizdok. It took all morning.
    Senator Hutchinson. Without the right kind of geriatrician, 
the combination of those and how they affect an older patient 
and how that varies from one person to another, to me, that 
underscores again the need of this whole focus that we are 
trying to have in the hearing today.
    By the way, before all of this happened had you ever heard 
of geriatrician?
    Mr. Bizdok. No, not at all.
    Senator Hutchinson. So that is one of the questions in my 
mind--how do the American people and the aging population in 
this country even know about the specialty of geriatrics and 
how much that can contribute to their lives? That is going to 
be a challenge that we face, as well.
    Mr. Perry, I appreciated your testimony very much and you 
talked about, on the question of why we are in this situation, 
why we have three medical schools. I understand there are 
approximately 500 geriatric fellows in the whole country; among 
all the medical students, 500 choosing to specialize in 
    You mentioned visibility and focus. Are there any other 
reasons why medical schools in your opinion are not making 
geriatrics a required course? Are there incentives that we are 
failing--obviously I have introduced legislation to address 
this but do you have any thoughts on beyond visibility and 
focus on the issue, why we are seeing so few choose geriatrics?
    Mr. Perry. I think because geriatrics is essentially 
primary care, it is not high-tech. What happened with Mr. 
Bizdok is that his appropriately trained physician recognized 
the problem that was not being addressed earlier, managed to 
get him to specialists in cardiology and address the right 
problem. But it is too often covered by the complexity of older 
people with many chronic health problems co-existing at the 
same time, and are therefore taking many different medications 
at the same time. Too often the person that is providing for 
them does not have that instinct, that sixth sense that comes 
with geriatric training to look into issues of memory loss or 
incontinence or frequent falls. Those are sort of the hallmarks 
of the things you look for in geriatric care and without that 
training, we tend to miss those and many of them end up quite 
    I think that the approach to this is really three different 
ways. We need to provide incentives, as Senator Reid is 
proposing to do, for students to go into the field. We need to 
create educational leaders, faculty that are trained to set up 
the programs, to create the curriculum, to do the teaching, and 
that is where the Bureau of Health Professions and HRSA can 
help and in your legislation, Mr. Hutchinson. You are aiming at 
the training.
    The third is those that are in the field, those that are 
practicing this important primary care, they need to have 
incentives in terms of reimbursement from Medicare to be able 
to stay in this field. Otherwise we are going to continue to 
create barriers. Who wants to go into a practice of medicine 
where they are not even going to be able to pay off their 
medical loans at the end of the day?
    Senator Hutchinson. Good observations. You mentioned in 
your comments there that among the problems are falls and that 
has been something that I have been very interested in and we 
have introduced something legislation regarding elderly falls. 
In your excellent report you talk about the hospitalizations 
for hip fractures in people aged 65 and older rising from 
230,000 in 1988 to 340,000 in 1996 and that almost all 
geriatric hip fractures are fall-related, which is stunning and 
the impact that has on the quality of life and even the 
survivability after one year. You also talk about the rise in 
elderly illnesses.
    How has all of this affected health care delivery in 
hospitals and other providers in the day-to-day delivery?
    Mr. Perry. Health care delivery in the United States and in 
other industrialized countries is becoming geriatric health 
care but the irony is that the techniques to deliver the best 
care most cost-effectively, which comes with adequate training, 
is not part of our program.
    Let me emphasize we are not saying----
    Senator Hutchinson. So it is geriatric needs without 
geriatric specialization.
    Mr. Perry. Exactly. But I want to emphasize an important 
point. We are not saying that every person over the age of 65 
needs to be seen by a geriatric specialist. We do not have the 
resources and we do not have the time to create that kind of a 
large practice specialty.
    We do need to have more geriatric specialists to teach, to 
create the educational programs so that no health professional 
in the United States will graduate--this would be our hope--
without some exposure in the course of their training, be they 
a nurse, a pharmacist, an occupational therapist or a physical 
therapist--no one should graduate without some exposure to the 
techniques of geriatric.
    Senator Hutchinson. So in other words, we not only need 
more specialists; we need mandatory training for all health 
care professionals to be able to diagnose and refer where 
    Mr. Perry. Exactly, and we need to have the faculty that is 
in place to be able to do the training, and we need to then be 
able to reimburse and make the field more attractive overall. 
As you said, Senator, we need to raise the visibility of this. 
Older Americans need to know that their providers may not have 
the training that they need and bring the power of that message 
to bear.
    Senator Hutchinson. Thank you. Thank you for your 
    The Chairman. Our poster citizen here will be able to raise 
the awareness of the problem.
    Your dialog with Senator Hutchinson was absolutely correct. 
You do not have to have a geriatric specialist to see every 
person over a certain age but when a general practitioner is 
unable to make a diagnosis of an elderly patient's problem, 
they ought to know that there is a geriatric specialist that 
could be brought in to look at it, to look for particular 
things that are unique to an aging person's health problems and 
they need to know where to go. That is why the schools have to 
make that information available.
    Mr. Bizdok, can I ask you what type of work did you do 
    Mr. Bizdok. I was an entertainer. That is how I ended up in 
    The Chairman. You made a very important contribution to us 
and thank you very, very much.
    Mr. Bizdok. All those lovely ladies that I had to escort--
somebody had to do it.
    The Chairman. That is the rest of the story. Thank you very 
much, Mr. Bizdok. We appreciate it. We will stay in touch with 
    This panel is excused and we would like to welcome up our 
second panel, which consists of Dr. Charlie Cefalu, who is a 
board member of the American Geriatric Society and Professor 
and Director for geriatric program development down in 
Louisiana at Louisiana State University. We are very pleased to 
have him.
    Senator Hutchinson, would you like to introduce the next 
two? I think they are both from Arkansas.
    Senator Hutchinson. I would be more than delighted to. We 
are so pleased today to have Dr. Charles Cefalu, board member 
of the American Geriatrics Society, professor and director for 
geriatric program development at LSU, as you have said.
    Claudia Beverly. Dr. Beverly is a registered nurse and 
associate professor in the College of Nursing at the University 
of Arkansas for Medical Sciences. Dr. Beverly also serves as 
Associate Director for the Reynolds Center on Aging and 
director for the Arkansas Aging Initiative and she brings great 
experience and expertise, so we are very fortunate to have her 
with us today.
    I thought I only had one Arkansan.
    The Chairman. Michael Martin is the Executive Director of 
the Commission for Certification in Geriatric Pharmacy in 
Alexandria, right here in the DC. area, and we are delighted to 
have all three of our panelists.
    Dr. Cefalu, we are pleased to have you up here. Thank you 
so much for being with us.
    I would like to acknowledge also that we are joined by our 
ranking member, Senator Larry Craig. Senator Craig, do you have 
any thoughts for the good of the committee at this point?


    Senator Craig. Thank you very much, Mr. Chairman. I am 
pleased that you are obviously pursuing the building of 
information in this extremely important area.
    I think when we look at the reality of you and me and our 
dear friend from Arkansas, there is a time and place out there 
in the not too distant future when we are going to have to look 
at the kind of care that our parents are looking at today. We 
are of that baby-boomer crowd and it is a crowd that is 
knocking at the door of critical care and geriatric care and 
the shortages and the realities of caring for that crowd are 
inevitable. Building the record today, preparing for it today 
is the right course and I thank you for pursuing this.
    The Chairman. Thank you, Senator Craig.
    Dr. Cefalu.


    Dr. Cefalu. Thank you. Mr. Chairman and members of the 
committee, I would like to thank you for convening this hearing 
and allowing me to testify today on the shortage of 
geriatricians in the United States. I also want to thank the 
many members of this committee for their leadership on this 
important issue.
    I am Dr. Charles A. Cefalu, Professor and Director of 
geriatric program development at the Louisiana State University 
Health Sciences Center in New Orleans, LA. After a short tenure 
in rural private practice in Southeast Louisiana, I received my 
formal geriatric medicine training in North Carolina at Wake 
Forest. At that time geriatrics training as unavailable in 
Louisiana and it still is today.
    I am here today on behalf of the American Geriatric 
Society, an organization of over 6,000 geriatrics and other 
health care professionals, and the Louisiana Geriatric Society, 
a new organization of 100 plus geriatric health care 
    Geriatricians are primary care-oriented physicians who are 
initially trained in family medicine or internal medicine and 
complete at least one additional year of fellowship training in 
geriatrics. Following their training, a geriatrician must pass 
a certifying examination.
    Geriatric medicine emphasizes care management and 
prevention, helping frail, elderly patients to maintain 
functional independence and to improve their overall quality of 
life. With an interdisciplinary approach to medicine, 
geriatricians commonly work with a coordinated team of 
nonphysician providers. For these patients, geriatricians are 
able to manage their care in the least resource-intensive 
settings, such as in a patient's home, obviating the need for 
more costly hospitalizations and nursing home placements.
    A sufficiently large core of geriatricians will be needed 
to provide care for the roughly 10 percent of the elderly who 
are the oldest and most frail. Geriatricians also will need to 
train other health care professionals who treat large numbers 
of elderly patients. However, the shortage of geriatricians 
does indeed exist. Of the approximately 98,000 medical 
residency and fellowship positions supported by Medicare in 
1998, only 324 were in geriatric medicine. If we are going to 
cope effectively with the aging of our population, we must 
resolve the national shortage of both academic and clinical 
    Louisiana has one of the most critical shortages of 
geriatricians in the nation. In the year 2000 only about 44 
physicians in Louisiana held certification in geriatric 
medicine. Furthermore, neither the LSU School of Medicine in 
New Orleans or Shreveport has an established, accredited 
geriatric medicine fellowship program. Physicians interested in 
seeking formal training must leave the State for their training 
and very often never return because of the tremendous numbers 
of opportunities elsewhere.
    A major obstacle to the development of a Louisiana training 
program is the Medicare GME cap imposed on hospitals for 
purposes of training slots. I might remind you both at LSU and 
Tulane chief residents both entered the Johns Hopkins program 
this year because they were not able to enter a program in 
    The other most significant reason for the lack of physician 
interest in a geriatrics career in Louisiana and nationally is 
Medicare reimbursement. Physicians are almost entirely 
dependent on Medicare revenues, given their patient caseload. 
However, Medicare does not adequately cover geriatric-oriented 
services or reimburse for time-intensive complex geriatric 
care. Indeed, a recent MedPAC report identified low Medicare 
reimbursement levels as a major reason for inadequate 
recruitment into geriatrics.
    First, the physician payment system does not provide 
coverage for the cornerstone of geriatric care--assessment and 
the coordination and management of care--except in limited 
circumstances and does not support an interdisciplinary team.
    Second, the Medicare reimbursement system bases payment 
levels on the time and effort required to see an average 
patient and assumes that a physician's patient caseload will 
average out with patients who require longer to be seen and 
patients who require shorter times. However, the caseload of a 
geriatrician, seeing frail, elderly patients, will never 
average out.
    Further exacerbating inadequate payments is the 2002 
Medicare fee decrease of 5.4 percent on all Medicare providers. 
Increasingly, geriatricians are leaving private practice 
because of the inability to run a self-sustaining practice.
    If enacted, the following recommendations would help 
resolve the geriatrician shortage and associated problems. 
First, Congress should revise the current Medicare payment 
system to cover geriatric assessment and care management 
services provided by an interdisciplinary team. Senate Bill 
775, the Geriatric Care Act introduced by Senator Lincoln and 
Reid, would authorize Medicare to cover these services.
    Second, Congress should revise the Medicare fee schedule to 
better compensate for high-cost, complex Medicare patients. 
Senate Bill 1589 introduced by Senator Rockefeller includes 
such a payment schedule update.
    Third, Congress should provide for an exception to the 
overall GME cap for geriatricians mentioned previously. Senate 
Bill 775, as well as the Advancement in Geriatrician Education 
Act, Senate Bill 1362 introduced by Senator Hutchinson and 
Senator Craig, ranking minority member, would provide for a 
limited exception from the cap.
    Finally, Congress should provide adequate funding for 
geriatric health care professions programs, particularly the 
Geriatric Academic Development Awards, which help to develop 
geriatric academicians. Senate Bill 1362 would expand the 
number of such awards.
    Finally, we would like to work with the committee and the 
Congress to legislate these important changes. Failure to act 
in this area is likely to result in diminishing quality care 
for frail, older persons and potentially the decline of the 
geriatrics profession. I thank you for the opportunity to be 
here today.
    [The prepared statement of Dr. Cefalu follows:]
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    The Chairman. Thank you, Dr. Cefalu. We appreciate your 
    Ms. Beverly.

                            ROCK, AR

    Ms. Beverly. Good morning, Mr. Chairman, members of the 
committee, Senator Hutchinson, Senator Lincoln from Arkansas, 
and ranking member Senator Craig. Thank you so much for this 
opportunity to talk about geriatric-trained health care 
professionals. I feel like I am in a state that is probably one 
of the leaders in the country in terms of what we are doing in 
geriatric education and geriatric practice and I want to share 
a little bit of that with you today.
    I am Associate Director of the Reynolds Center on Aging. At 
the same time, on the national level I am on the National 
Advisory Council for Nursing Education and Practice to HRSA, to 
the Division on Nursing. So I have a very good first-hand view 
of what is going on nationally, as well as at the state.
    In addition, I am a vice chair for programs in one of the 
three departments of geriatrics in the country and was a part 
of developing that department of geriatrics and the mandatory 
course that the junior med students have so that all of our 
physicians, when they graduate, now have had a 4-week course in 
geriatrics. At the same time, I was part of the College of 
Nursing when 12 years ago we developed a stand-alone course in 
geriatrics, in clinical, to go with that.
    So I think in those two disciplines in particular and also 
pharmacy, I have had a good relationship with the PharmD 
program where most of the students in that program do have a 
geriatric rotation. So we feel like we are doing and beginning 
to do quite a bit.
    I also want to take this time to thank the senators, 
particularly Senator Hutchinson as being one of the major 
authors of the Nurse Reinvestment Act because I think the Nurse 
Reinvestment Act, at least on the Senate side, is a very good 
beginning. It is a strong act. I just hope that very soon the 
conference committee is appointed because without that, we are 
just sitting and waiting. However, there are parts of that 
Reinvestment Act that I think are extremely important to 
nursing and in particular to geriatric nursing so that we can 
better educate our certified nursing assistants in long-term 
care, as well as associate degree and baccalaureate nurses and 
also geriatric nurse-practitioners.
    One of the things about nursing care of older adults is 
that we are in a variety of settings. There is a continuum of 
settings in which older adults receive care. It includes 
nursing homes, home, the hospital, ambulatory care.
    The nursing home, I want to just spend a little bit of time 
on that because I think nursing homes are an embarrassment to 
this society. I think that until we really address how do we 
want to care for our older adults and what is exciting to me is 
our baby boom generation are taking care of their older adults 
and they are not liking what they see. So I hope that we will 
begin to really look at what kind of staff do we need in 
nursing homes? We know the staff mix is not right. We know when 
we have adequate staff--we have studies to show that--that 
outcomes of our older adults in nursing homes changes.
    One of the most poignant things to me is that a certified 
nursing assistant has to have only 75 hours of training and 
that two-thirds of the States require no more than this. 
However, in the State of Arkansas we require 1,000 hours to be 
a dog groomer, so I think there is a very big disparity on how 
we train people to take care of our older adults.
    I also want to speak on behalf of nurse-practitioners. We 
have a collaborative practice out of our Department of 
Geriatrics and Center on Aging where we have a physician who is 
a medical director and a nurse-practitioner who are in 10 
different nursing homes. We have seen a positive outcome in 
patients where we have this collaborative practice arrangement 
and yet the nurse-practitioner in particular is affected by 
reimbursement and the rules and regulations and I think we 
could address some of those, such as when a patient enters a 
nursing home in particular, a Medicare patient most of them 
have been in the hospital. They go to a transitional care unit. 
The nurse-practitioner by rule is not allowed to do the history 
and physical on admission, even though a physician had just 
seen that patient within 24 hours of discharge from the 
hospital. I think we need to address that. We need to address 
expanding the role of the nurse-practitioner.
    I think in terms of hospitals, one of the things that we 
see with the shortage of nurses is units are closing, beds are 
closing. We have a difficult time getting our patients into the 
hospital because of the lack of beds. It goes to the lack of 
nurses in general.
    Let me add that while I think the University of Arkansas 
for Medical Science College of Nursing is doing a good job with 
educating our nurses at the baccalaureate, at the masters, as 
well as at the doctoral level, for the most part in this 
country less than 23 percent of our baccalaureate programs 
offer a stand-alone course in geriatrics and it is even much 
less than that when you look at medicine.
    Just a little bit about geriatric gerontology education. 
One of the things that is sorely missing and I was glad to hear 
Mr. Perry talk about is the focus or content on cognitive 
impairment. When we look at our aging society, about 12 percent 
65 and older are cognitively impaired. That increases to 50 
percent about age 80 to 85. So we have a huge need to how are 
we going to take care of our older adults? How are we going to 
train people? That is a major disconnect in what we are doing.
    I want to briefly highlight and I was glad to hear the 
foundations that were mentioned earlier that have made a 
commitment to aging, the Donald W. Reynolds Foundation being 
one and yes, we are very happy that we have that relationship 
with them. Another is the John A. Hartford Foundation and for a 
long time they have trained physicians, provided monies to do 
that, and most recently have started social work but, more 
recently than that, nursing. I am happy to say that Arkansas is 
one of five centers of excellence in geriatric nursing funded 
by the Hartford Center and we are the only one in the South, so 
we are trying to help all the states in the South to increase 
geriatric education.
    Last about interdisciplinary education, I have seen and 
been a part for almost 25 years where we do not focus in our 
curricula on interdisciplinary training. We expect when people 
graduate to know how to work with each other. While there has 
been money put into that and the VA does the very best with 
that, we do not have adequate resources to keep that training 
    One of the other foundations that I want to add to this is 
the Schmieding Foundation in Northwest Arkansas. When you talk 
about geriatricians, we have seven in Northwest Arkansas. We 
have 22 in Central Arkansas. We have one in South Arkansas. So 
we're doing something right about getting geriatricians. The 
Schmieding Foundation, through Lawrence Schmieding, was very, 
very supportive and has donated over $15 million over a 20-year 
period to create our first of seven satellite centers on aging 
in the State of Arkansas, all of which will have a primary care 
clinic, all of which will have a heavy education focus. Thank 
    [The prepared statement of Ms. Beverly follows:]
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    The Chairman. Thank you very much, Ms. Beverly.
    Mr. Martin.


    Mr. Martin. Good morning, Mr. Chairman, Senator Craig, 
Senator Hutchinson, Senator Lincoln. My name is Michael Martin 
and I am the Executive Director of the Commission for 
Certification in Geriatric Pharmacy or CCGP.
    I would first like to commend the members of this committee 
for their support and work on legislation to assist seniors 
gain access to improved care under Medicare, to receive 
coverage for prescription drugs, and to improve the quality of 
care in nursing facilities. In addition, I would like to 
commend the members' current interest in enacting Federal 
standards in assisted living facilities to improve quality of 
    CCGP was invited by the Alliance for Aging Research to join 
the efforts to unite the health professions in addressing the 
critical lack of geriatric-trained health care professionals. 
CCGP is proud to state that it has been proactive and in the 
forefront of identifying the need for pharmacists who are 
specially trained to provide pharmaceutical services to the 
nation's elderly population. In fact, we were created in 1997 
principally to identify this need, document the scope of 
practice, and administer a post-licensure certification process 
to recognize those pharmacists with the unique requisite skills 
to provide comprehensive care to the elderly.
    Effectively caring for the elderly requires a cooperative 
effort among the entire health care team. I am here today to 
discuss the role of pharmacists in the interdisciplinary health 
care team and specifically how certified geriatric pharmacists 
or GCPs can improve the medication and therapy management of 
seniors. I will also address areas in which congressional 
action can help to increase seniors' access to the expertise of 
    The CGP designation can help ensure consumers that the 
pharmacist has special knowledge regarding the needs of the 
senior population. CGPs can be effective in any setting to 
manage seniors' medication regimens, including hospitals, the 
community, and long-term care.
    Currently the CGP designation is the only designation that 
recognizes the clinical expertise of these senior care 
pharmacists. This designation has been recognized in the 
pharmacy practice acts of Arizona, North Carolina and Ohio. The 
CGP credential also has been recognized by the Department of 
Veterans Affairs and is recognized in Australia and Canada. Yet 
only 720 out of nearly 200,000 pharmacists in the United States 
have received the CGP designation. The reasons for this include 
the following.
    Lack of Federal recognition of pharmacists under the Social 
Security Act makes the pharmacist unable to bill Medicare and 
Medicaid for the clinical services that they provide to manage 
patient medication therapy.
    Most pharmacists who currently specialize in senior care 
have acquired their skills on the job because until recently, 
the clinical literature lacked data regarding the effects of 
medications on seniors, particularly the old old, those aged 85 
and older, the fastest-growing segment of our population.
    The lack of formal training in geriatric pharmacy. 
Currently schools of pharmacy often lack the availability of 
curriculum in geriatric care. As the members of this committee 
are aware, a shortage of pharmacists currently exists in the 
United States.
    There are a number of reasons why geriatrics has not been a 
popular specialty for health care providers. These include the 
complexity of care for older patients, an unfortunate lack of 
interest in individuals approaching the end of their lives and 
most significantly, a lack of payment mechanisms that address 
the unique medical approach required to effectively manage 
older patients.
    This lack of emphasis on the special medication needs of 
seniors must end. Currently, medication-related problems cost 
the United States health care system more than $200 billion per 
year and are the fifth leading cause of death in the United 
States. These medication-related problems, including adverse 
drug reactions, improper dosing, either over- or 
underprescribing, multiple medications for the same indication, 
and drug-induced hospitalizations, are often preventable. In 
fact, a 1997 study published in the Archives of Internal 
Medicine found that in nursing facilities, interventions by 
consultant pharmacists reduced the number of patients who 
experienced a medication-related problem by almost 50 percent 
and saved $3.6 billion per year in these settings.
    To assist pharmacy and the geriatric population to gain 
access to the types of services necessary to ensure the highest 
quality of care, I urge the committee and your colleagues in 
Congress to take the following steps.
    Pass a Medicare prescription drug benefit that includes 
pharmacy for pharmacist medication therapy management services. 
This legislation should recognize the CGP designation for 
pharmacists who participate in medication therapy management.
    Pass legislation to recognize pharmacists under the Social 
Security Act to allow pharmacists to be paid directly for the 
clinical services they provide.
    Pass legislation to provide funding for additional 
pharmacists to relieve the shortage and to provide incentives 
to bolster geriatric curriculum in schools of pharmacy.
    Provide funding for pharmacist residency programs in 
geriatric care. Schools of pharmacy need to develop curriculum 
to teach students and incentives need to be provided for 
students to complete rotations at hospitals, nursing facilities 
and other long-term care facilities and in the community to 
provide for the special needs of seniors.
    Sponsor and support legislation to require additional 
pharmaceutical research regarding the effects of medication on 
the elderly.
    Preserve the Federal Nursing Facility Standards and the 
requirement that consultant pharmacists provide drug regimen 
review to reduce medication-related problems.
    The Chairman. Mr. Martin, excuse me. I am going to have to 
ask you, if you could, to summarize because we just had a vote 
that has just begun.
    Mr. Martin. Yes, sir.
    We must reform the way our nation approaches medical care 
for seniors. Effective health care for seniors requires a 
coordinated assessment and case management provided by an 
interdisciplinary team focussed on the patient's overall well-
being. Public and private health care systems simply do not pay 
for that kind of care. Instead, they pay for extensive tests 
and treatment but not for the kind of care needed to identify 
the at-risk elderly and protect them from potentially life-
threatening medical problems.
    Again thank you very much for this opportunity to appear 
before you to address this important national issue and we look 
forward to working with you on this issue in the future.
    [The prepared statement of Mr. Martin follows:]
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    The Chairman. Thank you, Mr. Martin, and I thank all the 
panel members.
    Dr. Cefalu, thank you for being with us. You have some 
disturbing statistics. We only have, I think, 44 physicians in 
the entire State of Louisiana that have a certificate of 
certification in geriatric medicine, which is really 
    You made about eight different recommendations as to things 
that can be done. It is interesting that almost every one of 
them involves money. The question that I need to explore, is 
there not money in treating older people? I mean all doctors 
are being reimbursed basically the same way, I take it. Or is 
there discrimination against the way people treating older 
people in geriatrics are being paid that is different from the 
way physicians and other specialties are being reimbursed?
    Dr. Cefalu. Well, there are several factors, as we have 
said. There is the 5.4 percent cut, which has further 
complicated the issue but the issue is, as has already been 
    The Chairman. But that cut is not just for geriatrics. That 
is across the board.
    Dr. Cefalu. Across the board. The main issue is--I mean 
that is the last blow but the main issue has already been 
discussed today, the issue that it takes an extreme amount of 
time for physicians in private practice to see older patients 
and get the same reimbursement that they would for treating a 
20-, 30-, 40-year-old patient.
    Now when you are talking about 10 and 12 medications and 
seven or eight chronic conditions, the age factor, it does not 
take 5 to 7 minutes to see an older patient.
    The Chairman. Do the reimbursement rate--and maybe you do 
not know this because I do not know it--are the reimbursement 
rates under Medicare not taking into consideration the time 
that a doctor spends with the patient? He gets reimbursed the 
same amount if he spends 5 minutes or an hour?
    Dr. Cefalu. Absolutely. That is basically the issue. The 
current system does not factor in the time and complexity of 
the visit and that is the whole point that we are coming at the 
Health Care Financing Administration, is to correct that visit 
for the time and complexity that it takes to see that patient.
    For instance, Senator, when you see an older patient with 
confusion, polypharmacy, that is not a 7- or 10- or 15-minute 
visit. For the healthy Medicare HMO patient that has maybe one 
illness and is on one medication for hypertension, fine, but 
not for the minority elderly, the underprivileged elderly, the 
majority of the elderly. I mean you are talking about a 
Medicare HMO population that may make up 3 to 5 percent of the 
elderly but the majority of the patients require time-intensive 
    We are talking about a population that is the most rapidly 
growing segment of the elderly and that is the 85 plus, the 
frail elderly, where this is particularly an acute situation, 
where they require more time than any other segment of the 
elderly, much more than the middle old or the young old.
    The Chairman. Thank you. You mentioned providing an 
exception for the overall graduate medical education cap for 
    Dr. Cefalu. Yes, sir.
    The Chairman. How would that work? Universities are, 
through the Medicare program, reimbursed for training 
physicians but if you just remove the cap, that does not 
encourage anybody to go into geriatrics. I mean you just have 
more people studying to be doctors but it does not say that 
more people have to study to be geriatricians.
    Dr. Cefalu. No, it does not. The Medicare cap specifically 
relates to Louisiana by the way in which, as I said in my 
testimony, neither LSU school has a fellowship. So that is a 
disincentive for any facility in Louisiana to encourage the 
development of geriatric programs. It is money out of their 
back pockets. It is a money issue but there is no reimbursement 
for it at all. So there is no incentive for teaching, for the 
teaching component, the Medicare component itself.
    Regarding the cap, though, that is one issue. The other 
issue is, as I said, the time and complexity of a visit. That 
is a major issue here. But if there is a cap--let me say again 
if there is a cap that was instituted in 1997, then there is no 
incentive to expand the fellowship programs across the United 
States. Again in Louisiana this is critical that that cap be 
removed or we are not going to be able to do anything in the 
    The Chairman. Is there a natural or maybe abnormal 
reluctance on the part of physicians to want to treat older 
    Dr. Cefalu. There is. It is not a glamorous specialty.
    There is also the reluctance related to the medical 
training issue, and that is just as in pediatrics, older 
patients have unique illnesses, such as confusion, such as 
incontinence, such as falls, which are not direct so they do 
not meet the eye, as is a 20- or 40-year-old patient. They 
require training to learn how to evaluate confusion and falls. 
Falls are not simply related to arthritis. There are many 
different causes for falls--medications, a drop in blood 
pressure. They are numerous.
    So the atypical presentation of disease in the elderly 
makes it implicit that medical students at all 4 years of 
training and residents and fellows receive training in 
geriatric medicine. You just cannot assume that the medicine is 
the same as treating a 20- or 40-year-old.
    It is like pediatrics. Pediatric patients have their own 
illnesses, their own atypical presentation of disease, their 
own limitations in dosages. Well, the same applies to the 
elderly and you just cannot assume that a 75- or 80-year-old 
patient is going to be treated the same way as a 20- or 40-
year-old because the processes are different. The aging process 
has with it certain changes that may be associated with certain 
systems that you may not be aware of. There are certain disease 
states that present very atypically and if that physician is 
not trained, he is going to miss the boat and the problem here 
is not only excess cost in the hospital but delayed diagnosis 
and excess mortality for these patients.
    We are coming back to the training issue, that physicians 
are not trained and if they are not trained, they do not feel 
comfortable and they avoid these patients.
    The Chairman. Well, you have made some very good points. 
The fastest growing segment of our population are seniors. The 
baby boomers, again with 77 million getting ready to enter into 
this category, we will have a larger number of people in this 
category who live for a lot longer than they used to. I think 
it has become very clear that we are inadequately situated to 
treat these people from a medical standpoint. We simply do not 
have the medical professionals that we need to treat the 
fastest growing segment of our population, which have unique 
problems and unique medical disabilities, as you have said, 
that a 20-year-old does not have.
    We are going to have to work together--the medical 
profession, as well as the Congress, as well as the public at 
large--to try to correct this. This is a real challenge that we 
have to face.
    We have a vote, as I indicated. Senator Blanche Lincoln is 
going to be coming back and if I could, because I know she has 
some questions, I am going to go vote and she is on her way 
back. As soon as she gets back she will continue this and we 
should wrap it up very shortly. In the meantime, the committee 
will take a short recess.


    Senator Lincoln. If I could have everyone's attention, I 
think we will call the committee back to order.
    I would like to begin first by thanking the chairman for 
holding this very important hearing today. I have been 
extremely interested and involved in the issues of geriatrics 
and geriatric training, the care of our elderly in this 
country, and I think that interest comes from being of the 
``club sandwich'' generation. I have not only my aging parents 
and my young children that depend on my husband and I but my 
husband's grandmother is 104, so we have three generations on 
either side of us and it is a very, very important issue to us 
personally, as well as to our nation.
    Shortages in geriatric care have indeed placed our nation's 
seniors in peril, a situation that will only worsen with the 
coming ``Aging of America'' and our demographic crisis.
    I would certainly like to thank the chairman both for his 
interest and his enthusiasm on this issue in providing us a 
forum to discuss some of the potential solutions to the looming 
crisis that our country has.
    We can accomplish the goal of improving our geriatric 
health care in the United States by boosting the number of 
certified geriatricians and other geriatric providers in our 
country and by improving access to geriatric care. As has been 
mentioned, I have sponsored the Geriatric Care Act with Senator 
Reid. I have depended on many of you for input and certainly 
the professional aspect on what we need to do in improving the 
care of our aging population in this country.
    It is worth remembering that we are not just struggling 
with the shortage of geriatric physicians; we are also 
struggling with the shortage of nurses--and I compliment my 
colleagues here on the committee for their introduction of the 
Nurse Reinvestment Act--social workers, psychologists, 
nutritionists and pharmacists who work with geriatricians to 
provide a web of comprehensive care for our most frail, 
vulnerable seniors.
    We had a wonderful forum in Arkansas several months ago on 
the continuum of care. We filled up one auditorium and two 
overflow rooms at the medical school with numbers of providers 
from all different areas of care for our seniors. They were 
very interested in what we are trying to do in Washington. 
Their input is vital as we come up with the right solutions 
because we do not have the time to make any wrong turns.
    I know that my colleagues share that commitment and that is 
why I applaud Senator Breaux, as chairman. His excitement about 
this issue, both on the Aging Committee and on the Finance 
Committee will give us a great opportunity to be able to focus 
on many of these issues.
    I have so many things that I could say and I know that I do 
not need to take up too much time but I would like to just say 
that when Senator Harry Reid and I introduced the Geriatric 
Care Act we were excited to be able to put forth a bill to 
increase the number of geriatricians in our nation through 
training incentives and Medicare reimbursement for geriatric 
care. We have fine-tuned some of the aspects of our bill and we 
will be reintroducing it soon.
    It was amazing to me to find out that out of 125 or so 
medical schools in this country, only three offer programs in 
geriatrics. UAMS and the Don Reynolds Center is right at the 
heart of that, and in Arkansas we are extremely proud of that. 
But as a mother of small children, realizing that every one of 
those 125 medical schools provides a school of pediatrics, with 
the ever-increasing number of aging in our population in our 
nation, it just astounds me that only three of those medical 
schools are focussed on geriatrics. So I am delighted we have 
the opportunity today to focus in on that.
    The care of our senior citizens in this country is 
extremely broad. Certainly the training of geriatricians but 
there are many other issues that we are looking at at this 
point from on the Federal level in keeping all healthcare 
providers financially solvent.
    I was just visiting with a community from our home State of 
Arkansas earlier this morning where four of the cardiologists 
in their community, they will lose two of them by the end of 
this month or next month because of their reimbursement cuts. 
Of course, 75 percent basically of their clientele are the 
elderly in that community.
    So there are a lot of different aspects of providing health 
care to our elderly in this country and we have to focus on 
many of them here in the time that we have to be able to do 
    The Geriatric Care Act also removes the disincentive caused 
by the Graduate Medical Education cap established by the 
Balanced Budget Act of 1997. As a result of this cap, many of 
our hospitals have eliminated or reduced their geriatric 
training programs. There are many things, as I have just 
mentioned, that were a result of the 1997 Balanced Budget Act 
that we need to readdress for our providers and that is 
hopefully something we can do in the Finance Committee in the 
coming months.
    I am very proud of the work that is being done at the Don 
Reynolds Center on Aging and the Department of Geriatrics at 
the University of Arkansas for Medical Sciences. Thanks to Dr. 
David Lipschitz and especially to Dr. Claudia Beverly who is 
here with us today, I feel like Dr. Beverly and I have really 
traveled some miles together. She has taught me a great deal 
and I think certainly my family's experiences and willingness 
to share it with the Reynolds Center has hopefully in some ways 
benefited them, as well.
    One of the other things that we are extremely proud of is 
that Arkansas has more geriatricians per capita than any other 
State in the nation, with a total of 35. That may be why our 
elderly population is increasing, as well, as a percentage of 
our population, because we do provide the care and the focus 
there, but we want to definitely translate that to the rest of 
the Nation and I will certainly be at the center stage in 
trying to promote that with my colleagues.
    As Dr. Beverly discussed some in her testimony, nurses are 
an essential part of the care in all health care environments, 
whether they be hospitals, nursing homes, home health or 
hospice, and I am certainly a strong supporter of the Nurse 
Reinvestment Act that the Senate passed last year and really 
appreciate the leadership of my colleagues, particularly 
Senator Mikulski and Senator Hutchinson from Arkansas, in 
addressing the national nursing shortage.
    We should also recognize that in addition to encouraging 
people to enter the nursing profession, we must offer them 
opportunities to train in geriatrics, and I was pleased that 
Dr. Beverly mentioned some of those aspects.
    In closing, I would just like to say that all of us here 
today could share stories about the challenges that we face by 
our parents, our grandparents, our family and our friends, as 
they contend with passing years.
    Just to touch on what Mr. Martin mentioned in terms of the 
pharmacy, my grandmother lived with us the last 2 years of her 
life and coming from a small community, we knew of that 
comprehensive care provided by pharmacists because we only had 
a couple of doctors, a couple of pharmacists, and several 
others in the community. But whenever she was sick she said, 
``Don't worry the doctor is with me. I'll just call the 
pharmacist.'' She said, ``The doctor's busy; the line is backed 
up.'' Instead she would call Mr. Kelly and he would say, ``Miss 
Adney, you know, you can stop taking your blue pill but keep on 
your yellow pill and make sure that you take it with a biscuit 
or some milk because it needs to go down with something.''
    It is amazing. It is a continuum of care and it is a 
collaborative effort in our aging years. Consequently, my 
grandmother had a very peaceful time.
    So I think it is so important that everyone is at the table 
and that we discuss what everyone has to bring to this 
discussion. As we look at our loved ones and those that are 
dealing with the aging process, I hope that each and every one 
of us will remember these are the people who have raised us. 
They are the ones who have loved us, who have worked for us, 
who have fought for us. It is our turn now to work for them, to 
fight for them, to come up with a solution to what we are faced 
with in the next 10 to 15 years, and this is where we must 
    So again I applaud my chairman. I am pleased that he has 
seen this as an important issue, he has brought it up, and he 
has given us the opportunity to talk about it and discuss it 
and come up with some solutions. I know that he and others will 
join me as we work in the Finance Committee, as well, to look 
at how we can bring some of these issues up.
    So we thank you all for being here. I have a couple of 
questions, if I may.
    Dr. Cefalu, you talked a lot about how geriatricians who 
understand the health needs of older patients could cut down on 
inappropriate hospitalizations, multiple visits to specialists, 
and needless nursing home admissions. I believe that although 
Medicare reimbursement for geriatric care may be expensive, it 
would save significant amounts of money in multiple areas in 
the long run. Could you elaborate on that or how it might 
    Dr. Cefalu. Yes, it is all about bringing health care back 
to the holistic approach, if I could use that term, or the 
whole patient. We have a society, which to a certain extent in 
good, in that there is a lot of subspecialization related to 
research, and that is all great. But to some extent we have 
missed the boat in that there is not enough primary care, there 
is not enough gatekeeping, there is not enough coordination.
    Geriatric health care, because of the huge number of 
patient problems from confusion, the polypharmacy, as I 
mentioned, the falls, all issues that are outside a typical 
office visit and a primary care physician's typical medical 
school training require an extensive amount of time and 
training for evaluation. They involve a gatekeeper but also not 
only the physician component but the expertise of the geriatric 
nurse, the expertise of the geriatric pharmacist or the pharm-
D, the medical social worker because psycho-social problems are 
so critical. Psycho-social disposition. Where is this patient 
going to go? Can he go back home? They're a frequent faller; 
no, they cannot go home. Maybe they need to go to a nursing 
home. Maybe they can go to adult day care. Rehab, which is 
something out of the expertise and training of a typical family 
physician or internist.
    So all of these issues require a team and physicians, and I 
know this myself because in a rural Kentwood private practice I 
was just stymied by the older patient who came in who was on 9 
or 10 medicines and all of these problems. I did not even have 
the training at that time before my fellowship to know how to 
even evaluate confusion and that possibly it might be related 
to depression or medications. Mistakenly maybe I did mislabel 
somebody as dementia when they were not and hopefully that did 
not happen, but I was enlightened after my fellowship.
    But I also realized at that time that it was not me. It was 
not just my inadequate training. It was the fact that I needed 
enough time to evaluate that patient to where it would pay me 
to stay in private practice and at least break even instead of 
closing my office, like so many physicians have done and said, 
``I can't deal with older patients because I can't make a 
    But it is also having the social worker, the nurse, the 
pharmacist and the rehab, that team there and to have those 
resources to be able to evaluate that person fully because all 
those resources are necessary. The only place that is being 
currently done is in academic settings where that type of 
assistance and resources can be subsidized; the physician's 
visit is subsidized. But in the private setting you just cannot 
make it.
    So it is a team approach because all of these people have 
expertise that can be provided in a primary care or 
consultation visit, whether it is in-patient or out-patient. 
Unless the Care Act is implemented that provides for the 
physician to be able to see that patient and be reimbursed for 
his or her time with the team and the resources, then it is not 
going to happen. Until Senator Breaux had to leave but until 
that cap is removed, that is going to be a disincentive to 
training and we are not talking about general removal of the 
cap. We are talking about only, as your bill states, for the 
limited number of fellowship programs out there that have to do 
with geriatric training.
    That was a long answer but it cannot be answered in one or 
two sentences. Thank you.
    Senator Lincoln. I am aware that you had earlier answered 
the question about the difference between a geriatrician's 
typical patient and a regular physician, the kind of time that 
is involved, the kind of consultation with others, whether it 
is the pharmacist, whether it is the social worker or the 
psychologist. All of those are so critical and it was made so 
blatantly clear to me when I visited the Reynolds Center and 
saw how they operated with all of that team together. There is 
no way that a physician could make it on that single 
reimbursement for the time that they were spending, compared to 
the regular patients.
    Dr. Beverly, again thank you for coming to Washington. You 
know I am president of your fan club. Your experience and 
testimony here today but your experience particularly has been 
invaluable to me in terms of being able to figure out what 
roads we need to take in order to try and solve some of these 
    My personal experience with the Reynolds Center on Aging, 
with a father who is in the advanced stages of Alzheimer's, and 
a mother who is a primary caregiver and also aging, are 
critical components in my personal experience.
    It was so real to me when the other day I had a call from a 
constituent on the other side of the State who had been dealing 
with an aging spouse for the last 5 or 6 years. She mentioned 
that she had finally found the Reynolds Center. She said it was 
amazing. She said, ``I'm not going to 10 different doctor's 
appointments I know these doctors are not talking to one 
another about the comprehensive health of my husband.'' She 
said, ``We got to the Reynolds Center and realized that this 
comprehensive approach was so valuable to us as a family and 
for him as an individual because there was the interaction and 
the communication.'' That certainly makes a difference.
    I would like for you, if you could, to just elaborate on 
your suggestions to train nurses in geriatrics. What is the 
biggest difference in patient care that you see when you 
compare regular nurse-practitioners with geriatric nurse-
    Ms. Beverly. I think the biggest difference in patient care 
is that when you have a nurse at whatever level that has 
received knowledge and developed skills in the care of older 
adults, we see better outcomes and we see that in whichever 
setting we are in.
    I think one of the concerns that I have is--and I am going 
to start with nursing in general--has been our ability to keep 
the pipeline into nursing what it ought to be. When we look at 
nursing and we see--and this came out of the 2000 RN Sample 
Survey--is that during a 20-year career a nurse will realize a 
$6,000 increase in salary and that is a huge problem.
    At the same time, having enough faculty prepared in 
geriatrics to train or even faculty in general to educate our 
nurses when today the reality is that the practice setting 
usually pays $15,000 to $20,000 more to faculty, so we see the 
drain on faculty not only because faculty are getting older but 
we are not seeing younger faculty come into the mainstream.
    So we talk about that in general for nursing but specific 
to geriatric nursing, it is even more critical. SREB, Southern 
Regional Educational Board, just finished a study in 
geriatrics. It is on the bottom of the 16 specialty areas in 
terms of faculty preparation or it is next to the bottom. I 
think that when we see less than 23 percent of our 
baccalaureate programs including geriatrics as a stand-alone 
course, then we are faced with a major problem of preparing 
    But I would also like to respond a little bit about our 
senior health center, which is a hospital-based out-patient 
clinic. The Reynolds Center is associated with University 
Hospital and it is the hospital that operates it as a hospital-
based out-patient clinic. The value of those type clinics is 
that there is a facility fee that is reimbursed by Medicare. We 
like to have 80 to 90 percent of our patients being Medicare. 
No private physician can afford 80 to 90 percent Medicare 
    We also, for all new patients, have one hour with patients 
and we have on return, 30 minutes. At the core of this care is 
an interdisciplinary team that is a geriatrician, a geriatric 
nurse-practitioner, a social worker, but we also have 
consultation from pharmacy, neuropsychology, and others.
    The beauty of it is that hospitals can choose to do this 
and MCSA in El Dorado and Northwest Health Systems in the 
northwest part of the State have chosen to develop hospital-
based out-patient clients but the problem is these clinics lose 
money but the thing the hospitals like about it is then it does 
generate funds for the hospital and most of the time you will 
be about break-even in the primary care clinic.
    So we are working with hospitals around the State and I 
think it is very important to begin looking at that type of 
reimbursement and is it really covering what the needs of older 
adults need, and so forth?
    One last thing with geriatric nurse-practitioners that we 
are finding. We graduated eight geriatric nurse-practitioners 
from our program in December. Seven of them to date do not have 
a position in geriatrics because of funding, because of lack of 
a nursing home or lack of a position that would fit with what 
their skills are. Part of that is reimbursement. How do they 
pay for it? How do you enter into a collaborative practice?
    The need is overwhelming and the need is there. We have to 
look at how we can make sure that the positions for nurses are 
created with that expertise and develop that and we are 
beginning to look at that issue.
    Senator Lincoln. We do need to if we are graduating 
geriatric nurse-practitioners with the skills that are so 
needed. I mean that is one of the things the Robert Wood 
Johnson Foundation found for us in Arkansas--in terms of senior 
needs, there are a lot of underutilized programs and services 
out there. We must make sure people are aware of what is there.
    Just one quick question, Mr. Martin. It astounds me that 
medication-related problems are the fifth leading cause of 
death in the United States. That is amazing.
    You talked about pharmacist intervention. Maybe you could 
just elaborate a little bit on what that entails. How is it 
initiated? Under current systems is there a patchwork of ways 
that that pharmacist intervention happens? Obviously there are 
better ways that we could do it and we are striving toward 
those but maybe you have some shortcuts or ideas that would be 
best for us.
    Mr. Martin. Currently there is a patchwork. One of the 
first things I would like to put back on the table, as we have 
already heard from Dr. Cefalu and Dr. Beverly, the difficulty 
for doctors and nurses to get reimbursement. You can then 
imagine the struggle that pharmacy is having when it is not 
formally recognized as part of the health care team, by the 
fact that they are omitted from the Social Security Act and 
other areas like that. So that huge struggle of just being 
recognized is one of the first issues that I think we need to 
    There are practice settings where the pharmacist does do an 
excellent job. These would be in nursing facilities, long-term 
care settings, where their skills and expertise in medication 
management services is recognized, is utilized. Outside of that 
arena it is painfully and woefully being neglected or not 
getting tended to at all. So there are some practice areas 
where pharmacy is able to do its job but outside of those 
limited areas, it is really not able to do the work that they 
are trained to do.
    Senator Lincoln. Well, to all of you all, and I will close 
our hearing here shortly, but I think one of the things that is 
so amazing to people is when you do talk about the fact that 
there is only three out of 125 medical schools that offer a 
program in geriatrics. Each one of them has a program in 
pediatrics. How can we get the benefits of geriatric out--the 
message that it is essential? How do we do that? Because 
whenever I say that to people they are just amazed because they 
have aging parents or aging grand-parents and they are thinking 
about how much of their time and their frustration is caught up 
in caring for that aging population and they know that they are 
one day going to be there. If we are that ill- prepared now and 
the time that it takes to train these individuals and the fact 
that we are losing geriatricians and those that are able to 
train them.
    Is there a way that we can get more of that word out? How 
do we do that?
    Dr. Cefalu. One of the best ways at the medical school 
level and the nursing school level and the pharmacy level is we 
have not done a good job in teaching what successful aging is. 
Medical students' idea of aging is let us go to the nursing 
home and see this bedridden, contracted patient with a pressure 
ulcer that has a tube in his stomach and has a catheter coming 
out and several other tubes.
    The best way to enhance geriatric care is to teach it from 
the standpoint of how to prevent the aging process and all the 
complications and to prevent unnecessary medication 
utilization, that type of thing. So exposing all students and 
professionals in training and, for that matter, trying to 
provide an optimal environment of healthy aging for the healthy 
senior so that they see the positive side of aging and not the 
end result is one of the ways to go.
    Real quickly I want to thank you for sponsoring these 
bills, especially related to the cap. That is critical for our 
State. If we do not have the removal of the cap specifically 
for geriatric fellowships, and that is all we are talking 
about, then that is going to really impede our ability to get a 
program going next to our sister state, Arkansas, which has 
done a beautiful job. So I want to thank you for that.
    Senator Lincoln. Oh, absolutely. I will be looking to you 
all to assist in getting that word out because although I am 
not as close to the 65 number as some of my colleagues are, I 
have to say I am still very concerned about what it is going to 
be like when I do get there. My husband is a physician; I have 
looked at the time he has spent in his training, his 
fellowship. It takes time to train medical professionals and if 
we do not start now, even though I am farther away from it than 
anyone else in the Senate right now, I am still worried that we 
will not have made the kind of preparation time we need to be 
prepared, and that is going to be critical.
    Ms. Beverly. Can I add? I think that there is a myth out 
there in colleges of medicine and nursing and pharmacy when 
faculty will say well, we do teach geriatrics; we integrate it 
across in several different courses. But geriatrics has a 
defined body of knowledge that needs to be pulled out and needs 
to be recognized and it needs to be a mandatory stand-alone 
rotation, both clinical and theory, so that the student is 
exposed in a very positive way to healthy aging, to what 
functional assessment is all about, to the continuum of 
settings in which individuals receive care. To do that, you 
have to have a faculty excited about geriatrics and I think 
especially the initiative through the Hartford Foundation 
across the country--I do not know where our map went but we are 
now beginning to have scholars in geriatric nursing. We are 
also having centers of excellence. We are reaching out to 
states so that we can, especially in nursing, gain that 
    I might say in terms of medicine, when we first started 
teaching the 4-week mandatory rotation for our junior medical 
students, we were 10 points below the bottom when students came 
back and told us how they liked it. But now, in our fourth 
year, we are about in the middle and we keep rising each year 
in terms of students liking geriatrics. So we have also seen an 
increase in applicants to our fellowship program because they 
are beginning to have some positive experience in geriatrics. 
We are seeing the same in nursing in terms of if they have a 
course in the undergraduate program then we see more entering 
or applying for the masters program and we are beginning to see 
that increase at the doctoral level in terms of geriatric 
    So I think it starts with exposure but it is costly to do 
that. We have to get the colleges across the country in 
medicine, in nursing, in pharmacy, really keyed into this 
problem and to begin doing something about it.
    Senator Lincoln. From Mr. Martin's standpoint it has to 
be--as I said, watching both my aging parents and my 
grandparents, it is not until you get to that stage, when you 
are dependent on four or five or six different prescription 
drugs in your daily life, that you realize the importance of 
that interaction with physician care and all of the other 
things that you are doing.
    We need to get people certainly aware of the importance of 
that integration into their comprehensive care before they get 
to the age where they need all of that.
    Mr. Martin. One of the things we need is an expanded 
awareness that pharmacists are a part of the health care team, 
recognizing them through collaborative practice acts within the 
various states, education on a consumer level. It is 
interesting that all the polls always come back and say the 
consumer trusts the pharmacist the most but I think the 
consumer still is unaware of all the services that a pharmacist 
can provide.
    So outside of settings such as nursing facilities or other 
long-term care settings where the pharmacist is indeed a part 
of the team, we need to expand that into all of the practice 
settings, into the community, into other settings so that the 
consumer is indeed aware that this is the person he can turn to 
for those types of services.
    Again reimbursement is going to be a large issue for all of 
this because under the current structure--this is going to 
sound a little too noble but pharmacists kind of do it out of 
the goodness of their heart. They understand that these 
services are needed and they provide them whenever they can and 
they often do not get reimbursed for them, so that is probably 
one of the first fixes we need to go after.
    Senator Lincoln. Right.
    Well, I want to thank all of you for joining us today. I do 
apologize that I was absent for the first panel. I know that 
there was some very moving testimony there and I certainly will 
have that relayed to me. But I do want to thank all of you all 
and I especially want to thank Senator Breaux, our chairman, 
for taking an interest in this issue and moving forward. No 
doubt I think you all have gotten the message that I am 
extremely interested and will certainly be working on how we 
can improve the quality of health care but also the dignity of 
life to our aging citizens in this country. Thank you.
    The committee is adjourned.
    [Whereupon, at 10:55 a.m., the committee was adjourned.]
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