[Congressional Record Volume 143, Number 69 (Thursday, May 22, 1997)]
[Senate]
[Pages S5002-S5004]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. REID (for himself, Mr. Grassley, and Mr. Glenn):
  S. 779. A bill to amend title XVIII of the Social Security Act to 
increase the number of physicians that complete a fellowship in 
geriatric medicine and geriatric psychiatry, and for other purposes; to 
the Committee on Finance.


              THE MEDICARE PHYSICIAN WORKFORCE ACT OF 1997

  S. 780. A bill to amend title III of the Public Health Service Act to 
include each year of fellowship training in geriatric medicine or 
geriatric psychiatry as a year of obligated service under the National 
Health Corps Loan Repayment Program; to the Committee on Labor and 
Human Resources.


             THE GERIATRICIANS LOAN FORGIVENESS ACT OF 1997

  Mr. REID. Good morning Mr. President. I come to the floor today to 
offer two bills which are written to address the national shortage of 
geriatricians we are experiencing in this country. A problem I am sorry 
to say that is getting worse, not better. I am pleased to have as 
original cosponsors of my bills Senator Grassley, the distinguished 
Chairman of the Senate Special Committee on Aging and Senator Glenn, 
also a member of the Aging Committee, one for whom I have tremendous 
respect and regard.
  Our Nation is growing older. Today, life expectancy for women is 79, 
for men it is 73. While the population of the United States has tripled 
since 1900, the number of people age 65 or older has increased 11 
times, to more than 33 million Americans. By 2030, this group is 
projected to double in size to nearly 70 million.
  Mr. President, I first became concerned about this problem when a 
read a report issued by the Alliance for Aging Research in May of 1996 
entitled, ``Will you Still Treat Me When I'm 65?'' The report concluded 
that there are only 6,784 primary-care physicians certified in 
geriatrics. This number represents less than one percent of the total 
of 684,414 doctors in the United States. The report goes on to state 
that the United States should have at least 20,000 physicians with 
geriatric training to provide appropriate care for the current 
population, and as many as 36,000 geriatricians by the year 2030 when 
there will be close to 70 million older Americans.
  The bills I am introducing today, the Medicare Physician Worforce 
Improvement Act of 1997 and the Geriatricians Loan Forgiveness Act of 
1997, aim--in modest ways and at very modest cost--to encourage an 
increase in the number of trained doctors seniors of today and tomorrow 
will need, those with certified training in geriatrics.
  One provision of the Medicare Physician Workforce Improvement Act of 
1997 will allow the Secretary of Health and Human Services to double 
the payment made to teaching hospitals for geriatric fellows capping 
the double payment to be provided to a maximum of 400 fellows per year. 
This is intended to serve as an incentive to teaching hospitals to 
promote and recruit for geriatric fellows.
  Another provision directs the Secretary of Health and Human Services 
to increase the number of certified geriatricians appropriately trained 
to provide the highest quality care to Medicare beneficiaries in the 
best and most sensible settings by establishing up to five geriatric 
medicine training consortia demonstration projects nationwide. In 
short, allow Medicare to pay for the training of doctors who serve 
geriatric patients in the settings where this care is so often 
delivered. Not only in hospitals, but also ambulatory care facilities, 
skilled nursing facilities, clinics, and day treatment centers.

  The second bill I am offering today, The Geriatricians Loan 
Forgiveness Act of 1997 has but one simple provision. That is to 
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. My bill would count 
their fellowship time as obligated service under the National Health 
Corps Loan Repayment Program.
  Mr. President, the graduating medical school class of physicians in 
1996 reported they had incurred debts of $75,000 on average. My bill 
will offer an incentive to physicians to pursue advanced training in 
geriatrics by forgiving a small portion of their debt.
  Last year Medicare paid out more than $6.5 billion to teaching 
hospitals and academic medical centers toward the costs of clinical 
training and experience needed by physicians after they graduate from 
medical school. It is ironic, only a tiny fraction of those Medicare 
dollars are directed to the training of physicians who focus mainly on 
the needs of the elderly. Of over 100,000 residency and fellowship 
positions that Medicare supports nationwide, only about 250 are in 
geriatric medicine and psychiatry programs. Existing slots in geriatric 
training programs oftentimes go unfilled. With 518 slots available in 
geriatric medicine and psychiatry in 1996, only 261, barely one-half of 
them were filled.
  By allowing doctors who pursue certification in geriatric medicine to 
become eligible for loan forgiveness, and by offering an incentive to 
teaching institutions to promote the availability of fellowships, and 
recruit geriatric fellows, my bills will provide a measure of incentive 
for top-notch physicians to pursue fellowship training in this vital 
area.
  We must do more to ensure quality medicine today for our seniors and 
it is certainly in our best interest to prepare for the future when the 
number of seniors will double. Geriatric medicine requires special and 
focused training. Too often, problems in older persons are 
misdiagnosed, overlooked, or dismissed as the normal result of aging 
because doctors are not trained to recognize how diseases and 
impairments might appear differently in the elderly than in younger 
patients. One need only look at undiagnosed clinical depression in 
seniors or the consequences of adverse reaction to medicines to see how 
vital this specialized training really is. This lack of knowledge comes 
with a cost, in lives lost, and in unnecessary hospitalizations and 
treatments.
  We need trained geriatricians to train new medical students. Of the 
108 medical schools reporting for the 1994 to 1995 academic year, only 
11 had a separate required course in geriatrics, 53 offered geriatrics 
as an elective, 96 included geriatrics as part of another required 
course and one reported not offering geriatrics coursework at all. Mr. 
President, this is simply not good enough.

  In a country where by 2030, 1 in 5 citizens will be over the age of 
65, there are only two departments of geriatrics at academic medical 
centers across the entire country. Yet, every academic medical center 
has a Department of Pediatrics. This just does not seem to make sense 
to me. While certainly no

[[Page S5003]]

one would argue the need for emphasis on pediatrics, there is no less 
of a need for emphasis on geriatrics as well. In England, it is my 
understanding that every academic medical center has a department of 
geriatrics. Do our friends in England know something we do not?
  Mr. President, we have here a perfect case where an ounce of 
prevention will be worth a pound of cure. While not every patient over 
65 will need a geriatrician, in fact most will not, we need 
academicians and researchers to train the medical community about the 
field of geriatrics and we need primary care physicians to have access 
to trained geriatricians when a patient's case warrants it. As our 
oldest old population increases, the population growing the fastest and 
most appropriate for geriatric intervention, we must ensure that access 
to geriatricians becomes a reality.
  I believe the Medicare Physician Workforce Act of 1997 and the 
Geriatricians Loan Forgiveness Act of 1997 are steps in the right 
direction. While they will not solve the total problem, they do make a 
critical first step.
  Mr. President, I am grateful to the American Geriatrics Society for 
their assistance in working with my staff on this bill and I especially 
want to thank my cosponsors, Senators Grassley and Glenn, for their 
support and leadership on this issue.
  Mr. President, I ask unanimous consent that additional material be 
printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:


                              The American Geriatrics Society,

                                       New York, NY, May 20, 1997.
     Hon. Harry Reid,
     U.S. Senate,
     Washington, DC.
       Dear Senator Reid: On behalf of the American Geriatrics 
     Society (AGS), I am writing to offer our strongest support to 
     the ``Medicare Physician Workforce Improvement Act of 1997'' 
     and the ``Geriatricians Loan Forgiveness Act of 1997.''
       With more than 6500 physician and other health care 
     professional members, the AGS is dedicated to improving the 
     health and well being of all older adults. While we provide 
     primary care and supportive services to all patients, the 
     focus of geriatric practice is on the frailest and most 
     vulnerable elderly. The average age of a geriatrician's 
     caseload exceeds 80, and our patients often have multiple 
     chronic illnesses. Given the complexity of medical and social 
     needs among our country's oldest citizens, we are strongly 
     committed to a multi-disciplinary approach to providing 
     compassionate and effective care to our patients.
       As you know, America faces a critical shortage of 
     physicians with special training in geriatrics. Even as the 
     76 million persons of the baby boom generation reach 
     retirement age over the next 15 to 20 years, the number of 
     certified geriatricians is declining. By providing modest 
     incentives--which will encourage teaching hospitals to 
     increase the number of training fellowships in geriatric 
     medicine and psychiatry, provide loan assistance to 
     physicians who pursue such training, and support development 
     of innovative and flexible models for training in 
     geriatrics--your bills represent very positive steps toward 
     reversing that trend.
       The American Geriatrics Society has been pleased to work 
     closely with your office to develop initiatives to preserve 
     and improve the availability of highest quality medical care 
     for our oldest and most vulnerable citizens. We believe that 
     the ``Medicare Physician Workforce Improvement Act'' and the 
     ``Geriatricians Loan Forgiveness Act'' represent a cost-
     effective approach to training the physicians our nation 
     increasingly will need. We commend you for your leadership on 
     an issue of such vital importance to the Medicare program and 
     our elderly citizens.
           Sincerely,
                                              Dennis Jahnigen, MD,
     President.
                                                                    ____



                                  Alliance for Aging Research,

                                     Washington, DC, May 16, 1997.
     Hon. Harry Reid,
     Hart Senate Office Building,
     Washington, DC.
       Dear Senator Reid: As the Executive Director for the 
     Alliance for Aging Research, an independent, not-for-profit 
     organization working to improve the health and independence 
     of older Americans, I am writing in support of the ``Medicare 
     Physician Workforce Improvement Act'' and the ``Geriatricians 
     Loan Forgiveness Act.''
       As you know, on May 14, 1996 the Alliance released a 
     report, ``Will You Still Treat Me When I'm 65?'', addressing 
     the national shortage of geriatricians. Currently, there are 
     only 6,784 primary-care physicians certified in geriatrics, 
     the area of medicine that addresses the complex needs of 
     older patients. That is less than one percent of the total of 
     684,414 doctors in the U.S. We currently need 20,000 
     geriatricians and a total of 36,858 by the year 2030 to care 
     for the graying baby boomers. These two pieces of legislation 
     take the important first steps in solving this problem.
       In addition to increasing the number of physicians trained 
     in geriatrics, we need to develop a strong cadre of academics 
     and researchers within our medical schools to help mainstream 
     geriatrics into both general practice and specialties. 
     Increasing the number of fellowship positions in geriatric 
     medicine will improve the situation.
       We must have this kind of support and commitment from the 
     federal government, along with private philanthropy and 
     business if we are to sufficiently care for our aging 
     population. The Alliance for Aging Research is encouraged by 
     your leadership and support in this area and we look forward 
     to working with you to bring these issues before Congress.
           Best regards,
                                                     Daniel Perry,
                                               Executive Director.

 Mr. GRASSLEY. Mr. President, I am pleased to be an original 
cosponsor of two very important bills being offered by my colleague on 
the Senate Special Committee on Aging, Senator Harry Reid. The 
legislation we are introducing today will encourage more of our 
nation's physicians to specialize in geriatric medicine. As our 
population continues to age and with the impending retirement of the 
baby boomers, the need for trained geriatricians will be great. In my 
home State of Iowa, 15 percent of the population is over 65 with the 
third largest percentage of elderly in the Nation.
  The incentives for residents to choose geriatrics as a specialty are 
limited. The financial rewards are fewer than most other specialties. 
In addition, patients require more time and attention because they 
typically have a multitude of health problems. With the cost of 
education so high, many residents face enormous debt when they complete 
medical school. Institutions have trouble attracting students to 
specialize in geriatric medicine due to the lack of financial 
incentives.
  The Geriatricians Loan Forgiveness Act of 1997 will provide help to 
residents. This bill gives the Secretary of the Department of Health 
and Human Services [DHHS] the authority to forgive up to $20,000 of 
loans under the National Health Service Corps Loan Repayment Program on 
behalf of a resident who completes the required 1 year fellowship to 
become a geriatrician. The maximum amount of residents eligible is 400.
  The other bill I am cosponsoring today is the Medicare Physician 
Workforce Improvement Act of 1997. We spent nearly $7 billion last year 
on graduate medical education under the Medicare Program. Yet, only 200 
of the over 100,000 residency and fellowship positions funded by 
Medicare are in geriatric medicine. This does not make sense. Medicare 
is a program for seniors. Therefore, we should be supporting physicians 
who specialize in geriatrics.
  The Medicare Physician Workforce Improvement Act has two provisions 
to encourage academic medical centers to train physicians in geriatrics 
under the Medicare graduate medical education [GME] program. The first 
provision provides for an adjustment in a hospital's count of primary 
care residents to allow each resident enrolled in an approved medical 
residency or fellowship program in geriatric medicine to be counted as 
two full-time equivalent primary care residents for the 1-year period 
necessary to be certified in geriatric medicine. A limit is placed on 
the number of residents enrolled each year to control the cost. No more 
than 400 fellows nationwide can be eligible in any given year. This 
provision will encourage institutions to train more geriatricians using 
Medicare funds.
  The second provision is budget neutral. It directs the Secretary of 
DHHS to establish five geriatric medicine training consortium 
demonstration projects nationwide. The demonstration will allow current 
Medicare GME funds to be distributed to a consortium consisting of a 
teaching hospital, one or more skilled nursing facilities, and one or 
more ambulatory care or community-based facilities to train residents 
in geriatrics. This provision could be beneficial to rural areas and 
other areas not served by an academic medical center.
  I applaud Senator Reid for his efforts to provide our Nation's 
elderly with qualified trained geriatricians. I ask my colleagues on 
both sides of the aisle to join Senator Reid and me in support of these 
legislative initiatives.

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