[Congressional Record Volume 145, Number 125 (Thursday, September 23, 1999)]
[Senate]
[Pages S11365-S11366]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. REID (for himself, Mr. Grassley, Mr. Harkin, and Mr. 
        Cleland):
  S. 1628. 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 Health, Education, Labor, and Pensions.


          medicare physician workforce improvement act of 1999

  S. 1630. 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 Health; 
Education, Labor, and Pensions.


               geriatricians loan forgiveness act of 1999

  Mr. REID. Mr. President, I rise today to introduce two pieces of 
legislation that address our national shortage of geriatricians. I am 
pleased that Senators Grassley, Harkin and Cleland are joining me as 
original cosponsors.
  Our nation is growing older. Today, life expectancy is 79 years for 
women, and 73 years for men. While the population of the United States 
has tripled since 1900, the number of people age 65 or older has 
increased eleven times--to more than 33 million Americans. One-third of 
all health care costs can be attributed to this group. The fastest 
growing part of the Medicare population--those over 85--number more 
than three-and-a-half million. But, according to reports from the 
Institute of Medicine, the National Institute on Aging, and the Council 
on Graduate Medical Education, the number of doctors with special 
training to meet the needs of the oldest and frailest Americans is in 
critically short supply.
  I first became concerned about this problem when I 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 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.
  I first introduced legislation to address the national shortage of 
geriatricians during the 105th Congress. While I am encouraged that 
greater attention has been focused on this issue, little has been 
accomplished to improve the shortage of geriatricians. The two bills I 
am introducing today, the ``Medicare Physician Workforce Improvement 
Act'' and the ``Geriatrician Loan Forgiveness Act of 1999'' aim--in 
modest ways and at very modest cost--to encourage an increase in the 
number of the doctors Medicare clearly needs, those with certified 
training in geriatrics.
  One provision of the ``Medicare Physician Workforce Improvement Act 
of 1999'' will allow the Secretary of Health and Human Services to 
double the payment made to teaching hospitals for geriatric fellows. 
This provision is limited to a maximum of 400 individuals in any 
calender year. This is intended to serve as an incentive to teaching 
hospitals to promote and recruit geriatric fellows.
  Another provision of the Medicare Physician Workforce Improvement Act 
would direct 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, this 
would 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 1999,'' 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.
  While almost all physicians care for Medicare patients, many are not 
familiar with the latest advances in aging research and medical 
management of the elderly. Too often, problems in older persons are 
misdiagnosed, overlooked or dismissed as the normal function of aging 
because doctors are not trained to recognize how diseases and 
impairments might appear differently in the elderly than in younger 
persons. As a result, patients suffer needlessly, and Medicare costs 
rise because of avoidable hospitalizations and nursing home admissions.
  A physician who takes special training in the care of the elderly 
becomes sensitive to the need to evaluate and address the patient's 
behaviors and moods, as well as her physical symptoms. This is 
especially important, as the rates of undiagnosed depression and 
suicide among the elderly are scandalous. 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 geriatric fellowships, my bills will provide a measure of 
incentive for top-notch physicians to pursue fellowship training in 
this vital area.
  Increasing the number of certified geriatricians will not be easy for 
a number of reasons. Geriatrics is the lowest paid medical specialty, 
because the extra time required for effective and compassionate 
treatment of the elderly is barely reimbursed by Medicare and other 
insurers. It takes a special individual to commit himself or herself to 
the work of helping older patients preserve vitality and functional 
abilities over time. Often the goal for a geriatrician is not to cure 
disorders, but to delay the onset of disability--that is, simply to 
help seniors live as well as possible. For these reasons, existing 
slots in geriatrics training programs sometimes go unfilled today. But 
while the work may be difficult and not well compensated, protecting 
quality of life for the elderly is extraordinarily important, and we 
need physicians whose training explicitly recognizes that.
  It is similarly difficult for teaching programs to build and remain 
committed to maintaining fellowship training in geriatric medicine, 
because geriatric faculty are scarce and the type of patients brought 
in by a training program often require extremely complex and high cost 
care. Simply, it is cheaper to train other specialties, and more 
lucrative in terms of graduate medical education payments to the 
hospital. In fact, there are only two departments of geriatrics at 
academic medical centers across the entire country.
  Another barrier to alleviating the shortage of geriatricians is the 
result of an unintended consequence of the Balanced Budget Act of 1997 
(BBA). A provision in this law established a hospital-specific cap on 
the number of residents based on the number of residents in the 
hospital 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 has resulted in the 
reduction of, and in some cases, the elimination of geriatric training 
programs. This is one obstacle that should not be overlooked when 
Congress considers legislation to correct some of the unintended 
consequences of the BBA.
  When it comes to training the doctors we need, Medicare's current 
payment system is part of the problem, not part of the solution. The 
Medicare Payment Advisory Commission's (MEDPAC) August 1999 report to 
Congress entitled ``Rethinking Medicare's Payment Policies for Graduate 
Medical Education and Teaching Hospitals'' examines this very issue. 
According to the MEDPAC report:

       Where Medicare does not pay for services generally 
     associated with a particular specialty, it may discourage 
     training. For example, although several studies have 
     indicated an inadequate supply of geriatricians, the number 
     of geriatric training slots exceeds the number of people who 
     choose to enter the specialty. This may reflect a lack of 
     payment for services such as palliative care and geriatric 
     assessment.

  Clearly, the incentives in Medicare's payment system are poorly 
aligned

[[Page S11366]]

when training doctors specifically to care for the elderly is avoided. 
Again, my bill provides a modest incentive for hospitals to increase 
the number of training slots available.
  Medicare should be providing incentives to community-based programs 
to participate in the education of doctors, especially geriatricians, 
by directing graduate medical education payments appropriately to all 
facilities that incur the additional costs of providing training. My 
bill directs the Secretary to undertake up to five demonstration 
projects that will do just that.
  Many reports have highlighted the shortage of geriatricians we have 
today. The response to the problem needs to be a national one, and it 
would be most unwise to simply hope that the labor market will produce 
the kinds of doctors we will increasingly need. I am especially 
grateful to the American Geriatrics Society for its assistance in 
discussing ways to address the problem. I believe that the Medicare 
Physician Workforce Improvement Act and the Geriatrician Loan 
Forgiveness Acts are steps in the right direction, and I ask my 
colleagues to join me in supporting these bills.
  I ask unanimous consent that letters of support from the American 
Geriatrics Society and the Alliance for Aging Research be printed in 
the Record.
  There being no objection, the letters were ordered to be printed in 
the Record, as follows:

                                  American Geriatrics Society,

                                 New York, NY, September 17, 1999.
     Hon. Harry Reid,
     U.S. Senate, Washington, DC.
       Dear Senator Reid: The American Geriatrics Society (AGS), 
     an organization of over 6,000 geriatricians and other health 
     care professionals who are specially trained in the 
     management of care for frail, chronically ill older patients, 
     offers our strongest support to the Medicare Physician 
     Workforce Improvement Act of 1999 and the Geriatricians Loan 
     Forgiveness Act of 1999.
       The AGS is dedicateed 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 nation's 
     elderly, we are strongly commited 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. In fact, the August 
     1999 MedPAC report noted the shortage in geriatricians, 
     despite the availability of training positions. The MedPAC 
     report noted that the shortage is caused by faulty system 
     incentives, such as inadequate Medicare reimbursement to 
     geratricians. 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 present very 
     positive steps toward reversing that trend.
       The AGS 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,
                                        Joseph G. Ouslander, M.D.,
     President.
                                  ____



                                  Alliance for Aging Research,

                               Washington, DC, September 23, 1999.
     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.''
       The Alliance has worked for many years to bring attention 
     to the critical need for more geriatricians, those physicians 
     who are trained to address the complex needs of older 
     patients. Best estimates suggest that there is a need for at 
     least 20,000 geriatricians at present and nearly 40,000 by 
     the year 2030 to care for the graying baby boomers. Not only 
     are we far short of current needs, with less than 7,000 
     geriatricians in practice, but far too few doctors in 
     training are choosing this field.
       The two bills you are introducing represent 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 and corporate 
     philanthropy if we are to sufficiently provide 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.
                                 ______