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Decline in geriatric fellows defies pay boost: +10% = -10%

Posted in category Geriatric Medicine, Medical Education, Medicare

23 comments

Normally one of the advantages of expecting the worst is that all one’s surprises are good ones. But this year, I am both surprised and dismayed at the new figures on physician enrollment in geriatric fellowship training reported in the December 5 education issue of the Journal of the American Medical Association.

Somehow, despite all of the hullabaloo surrounding health reform, which has done some very good things for pay and attention given to geriatrics and geriatricians, the number of first-year fellows has fallen again from last year’s precarious situation, discussed in Falling Leaves, Falling Numbers.

While the number of internal medicine-based fellowship programs has risen by one (from 104 to 105), the number of first-year fellows has fallen from last year’s reported 215 down to 195, a drop of nearly 10 percent. Similarly, the number of family medicine-based programs has increased by one and the number of first-year fellows has fallen from 64 to 56.

Just a note: The numbers basically lag one year behind the report. So the numbers reported this month reflect fellowship enrollments as of December 2011. So whereas in December 2010, there were 279 fellows in their first year of geriatrics training, in December 2011, there were 251!

What makes this all the more shocking is that—as announced late in 2010 and implemented in 2011—generalist physicians (including geriatricians) caring for Medicare beneficiaries and billing on outpatient evaluation and management codes got a 10 percent bonus on their reimbursement for their services. The American College of Physicians estimates that for its general internal medicine members, the bonus might amount to an increase in revenue of as much as $8,000 in a year.  Since the usual numbers we cite say that older adults represent ~30 percent of the visits to a general internist, this would imply that a geriatrician should take in three times that much additional revenue, or $24,000 for the year.

Given that these bonuses require no new services or work and, as far as I can tell, little or no additional documentation, geriatricians should have seen an increase in net revenue from billings equivalent to more than 10 percent of the salary compensation of the average geriatrician. And yet the number of people electing to join the roles of geriatricians actually fell. This is not how I had heard supply and demand was supposed to work.

Obviously, there is a lot of noise and lag in the system regarding payments. I am sure that screams and hollers about the repeatedly impending imposition of the sustainable growth rate cut on part B physician payments under Medicare were a lot louder than the cries of gratitude for the pay increases. In fact, a quick search of the American Geriatrics Society/Association of Directors of Geriatric Academic Programs websites show no information about what geriatricians might stand to gain from the bonus program. And certainly not the wall-sized printable giant poster I had imagined showing some famous geriatrician pointing at the viewer and saying “I want you … to become a geriatrician and earn more money!”

Timing also counts. People in first-year geriatric fellowships in December will have made their choices somewhere in the preceding 18 months for all but the most competitive programs and may have made their career trajectory decisions much earlier. That means even fellows in training as of December 2011 may not have had enough advance notice about increasing pay to respond by favoring fellowships in geriatrics. So maybe next year, things will be better. Maybe.

There is some good news. Already things are better for geriatric psychiatry. Whereas the 55 programs in geriatric psychiatry had 39 fellows in first-year training in the 2011 report, this year there were 51. A 20 percent increase! I don’t know what they had for breakfast, but I want some, too. Congratulations to geriatric psychiatry program directors! Now, do it again!

Oh, and by the way, pediatric cardiology, which we used as a comparison case in last year’s discussion of these issues, increased its first-year fellows by almost 5 percent, from 134 to 140.

23 thoughts on “Decline in geriatric fellows defies pay boost: +10% = -10%

  1. Chris: I tend o be relatively pessimistic about geriatric fellow recruitment so I am surprising myself by disagreeing with your pessimism. First, as you note, it is too soon for the 10% bonus to affect career choices. Second, I am not sure that the increase is enough to affect many people’s decisions. What makes me optimistic is that we are seeing an increased interest in geriatrics among our trainees. From what I hear for m our trainees, it seems that it is the health care delivery and reforms more than a 10% bonus, however, that may be driving the increased interest. We have had our strongest recruitment year ever. I have talked with my colleagues elsewhere and have heard the same thing. So have a good holiday and don’t despair yet.

  2. Hi Chris,
    I think there are several things at work that can be summarized as poor communication/understanding on the part of trainees, and that 10% is still too little to be competitive.Many/most prospective applicants will (mis)-interpret the 10% boost as having an equal impact on primary care and geriatrics, ie, “Why should I do a fellowship, I get paid the same as primary care docs without the fellowship” . They will not go the step of saying 3 times the number of medicare patients means that the difference will be more than 10%. Further, the ongoing threat of medicare cuts (whether through SGR or Obamacare or fiscal cliff or congressional compromise) make a career based on medicare payment uncertain.
    Trainees are not sophisticated and (mis)perception alters behavior – I would say locally, the perception is that geriatrics is “risky” from a financial standpoint. With the burden of medical school educational debt, most of our grads chose to become hospitalists or subspecialists, they can make 30- 400% more by choosing one of these options, so 10% looks meager by comparison whether for geriatrics or primary care.
    Sad, but not surprising.

  3. Chris, the 10% pay boost would not result in an increase in geriatric fellows so quickly. Additionally, interpretation of the pay boost would be a leap for most fellow-to-be as well given the complicated nature of the newer developments in healthcare. I am personally excited about healthcare and geriatrics. I think that our contribution to healthcare is appreciated more at this time than it has ever been in the past. Our opinion is sought for quality issues, for reducing hazards of hospitalization, for improving outcomes resulting from multiple transitions of care. I think our challenge now is to make sure that we recognize the forces of change, provide leadership and direction, and make sure that all involved know the value of geriatric training and experience.

  4. We have also seen a pretty large increase in interest from residents who want to pursue a fellowship in geriatrics. This has translated to more high quality applicants than positions in our program.

    I doubt money has anything to do with this though. Any of these applicants can get into other specialty fellowships that end in careers paying a good 100k more. They enter into geriatrics because they are driven by other motivators than money.

  5. Thanks for your comment which highlighted the 10% raise about which I was unaware.
    I think there are several reasons why a theoretical 10% raise would not result in an immediate increase in geriatric fellows:
    1. Decision for fellowship starts in the last year of medical school when people choose not to do a family medicine residency or an internal medicine residency. This would lead to a 3-4 year lag from when a real incentive would make an impact.
    2. It is highly unlikely that a 2nd year resident thinking about specialties would connect the dots between CPT codes (99201-99215 and 99304-99350), a 10% reimbursement bonus in the Affordable Care Act, have some awareness of RVU’s and billings and translate that into a salary increase. Residents don’t have a clue about billing, revenue and salary. Most physicians don’t.
    3. It is unlikely that the theoretical $24,000 salary will get passed on. In an academic setting, I am salaried. That money gets folded into the general revenue of my division. My incentive is based on RVU, not revenue so I wouldn’t see that money. In a self employed setting, the money is obviously more likely to get passed on but some of that $24,000 goes to paying the employer based taxes.
    4. The $24,000 starts to make up for the fact that private insurers pay more than medicare. Since geriatricians take a lot of medicare/medicaid, the initial revenue earned starts lower for the same amount of work.
    5. For primary care, it is not just the low salary but the large amount of work required to get that work. In some studies, increasing reimbursement led to primary care docs working fewer hours or seeing fewer patients per hour resulting in a stable salary. It is not that PCP’s don’t care about salary but the workload is a more critical issue that needs to be fixed first.
    6. $24,000 is not a lot of money. All my close friends from medical school went into anesthesiology, dermatology, ophthalmology, emergency medicine. All make at least $100,000 more than me. $24,000 is not enough.
    7. The incentive is only $16,000 not $24,000 since general internists and family medicine docs would get some bonus too.
    8. When a Moh’s Dermatologist can see 10 patients per day and make $400,000 a year in California, a 5 year blip of $16,000 a year will not persuade anyone really.

    So how would I fix it? If minimizing the financial disincentives is a goal then
    1. Change CPT reimbursement for geriatric specific CPT codes (or create some like advance care planning). For example increase NH billing codes.
    2. Serious loan reimbursement for those doing geriatric fellowships.
    3. Give bonuses if geriatricians provide certain services (like nursing homes services or advance care planning prior to putting in a $50,000 10 year ICD device or palliative care services)

    Just some thoughts.

  6. Thanks for all of your thoughts. I take your points that the impact of the 10% pay increase may take time to filter into decision making. Unfortunately, it is also time limited in the law: available from 2011 to 2015 – so unless it gets extended, it might be gone by the time it has an effect on the pipeline.

    For those who observe that the bump of $24,000 is perhaps not enough to change plans, I had two thoughts. First, we don’t need to be faster than the bear, just faster than the other guys running from the bear. If the added pay makes geriatrics more attractive than hospitalism, we will still have made a gigantic advance, even if we can’t beat the draw of gastroenterology or derm.

    Second, if it isn’t enough, things will only get worse as I don’t see any proposals that are going to as clearly raise take home pay. While the other health reform mechanisms (e.g. Medical Homes, ACOs) might lead to an increase in the financial rewards for expertise in geriatrics, they will also increase the number of people across whom those rewards need to be shared (care managers, coordinators, etc). Only the bonus payment is truly more money for just the same work and same outcomes.

    I also think that geriatrics as a field needs to do a much better job of advertising and interpreting the benefits to the field that are coming.

  7. I think there the rising tide of enthusiasm for geriatrics is just beginning, as we re-think our roles as healthcare leaders rather than just another discipline. Whether it’s about wound care, collaborative care, healthcare policy, delirium prevention, social intervention and networking, to name a few, time is on our side. That enthusiasm will be more effective in recruiting future fellows than the $$, although the $$ can only help.

    • Hi Stefan – I’ve always really liked your line of argument (even if it does smack of making lemonade when given lemons). But to walk this talk, what kind of training should geriatricians get? Should there be a separate certificate in clinical systems management?

      BTW what are you doing in Cleveland? Avoiding hurricanes?

    • Stefan,

      Like Chris, I admire your optimism, but I will note that from my new job smack in the middle of a Section of Hospital Medicine (UChicago), it sure looks to me that hospitalists are making big plays to become experts in these areas, too. If you look at the annual conference schedules of the Society of Hospital Medicine, you will see they are FILLED with sessions and whole tracks dedicated to these areas. As for certification in systems management, maybe Paul Katz at AMDA can tell us if NH med directors have been able to cash in on their various certifications.

      Finally, residents might not be able to connect 4 levels of bureacratic dots, but I’m guessing it doesn’t help with system signaling when high visibility training grant money is flowing out of academic geriatric fellowship programs rather than in…? What is the net system signal received by young physicians in training? Go Derm, young man/woman!

      • Thanks Gavin for your observations. I’m curious, however, what are the “high visibility training grant money” is leaving geriatrics? Do you mean JAHF? I woudn’t have thought that info would have filtered down to residents yet. And for the record, we did just renew the CoE program for another three years.

        • Hi Chris, no, not at that level of specificity per se. I wish it were otherwise, but — Stefan’s, Eric W’s and others’ optimism notwithstanding — I do sense a kind of paralyzing fear among at least some geriatricians that the party is moving on without them, even though the demographics are so obviously in “our” favor. Geriatrics is already somewhat burdened with an inferiority complex to begin with, even though all the surveys say that the actual lives of geriatricians are pretty awesome! Hasn’t made a dent, or maybe it has slowed the decline? How enthusiastic can recruiting pitches be given what you outline above and what fellowship directors around the country know about the funding environment…? I think it is a tough situation for geriatric medicine.

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  12. Just a small update. I was looking at a CMS update on what’s new for 2013 and they report spending $560,000,000 on the 10% primary care bonus in 2011. They also reported that 1.7% of the bonus payments went to geriatricians as opposed to 50% of bonus to internists in general, 38% to FM, and 2.5% and 6.8% to PAs and NPs, respectively. The geriatrician’s share would then be about $9.5 million in total.

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  18. I worked as Geriatrician in Toronto (Ontario, Canada) and now I am working in US ( in academics) so I have first hand experience.
    Government of Ontario actually guarantees pay for every geriatrician because of they understood how important geriatricians are. If you want the actual numbers: in 2012 the guaranteed pay was $375K per year for each geriatrician involved in geriatric services there. Canadian dollar was at par with US dollar in 2012. Does it surprise you that there is no problem in convincing medical residents to select geriatrics in Canada.
    When our government talking about 10% it is totally not surprising that enrollment to geriatric fellowships is not (and will not be) changing and only getting worse. If they want to “save” geriatrics here in US they will need to start paying much much more than 10% ( instead of trying to convince everybody that money are not important).
    Unfortunately, geriatrics is not appreciated in US at all, may be because geriatricians in Canada are consultants and therefore, do not do primary care and perceived as true specialists ( and not like “another primary care doctors” as in US).
    Lastly, US cannot blame everything for poor finances and economy: overall financial situation in Canada was /is not better than in US at all.
    Sorry, just had to tell something…
    Just US government sadly does not see the true value in geriatricians as Canadian government does.

    To make geriatrics attra
    What 10% they are talking about

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