Dr. Levine is a nationally recognized expert in wound care and pressure ulceration. and has published and spoken widely on this topic. He is a Board Member of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Levine's Pocket Guide to Pressure Ulcers co-authored by Elizabeth Ayello RN and published by the New Jersey Hospital Association is in its 4th printing and has sold over 30,000 copies.

photo by Jeffrey M Levine MD geriatrician

The Patient Protection and Affordable Care Act (HR 3590) purports to contain provisions that will provide for better care for America’s seniors and add stimulus to growth of the field of Geriatrics.  One wonders, however, whether this historic bill will have true impact in stemming the flow of medical doctors away from caring for the elderly.  In fact, some basic flaws in our healthcare system remain untouched.

There is a geriatric education and training provision in Section 5305 that will result in enhancement of teaching, development of curricula and best practices, and expand training for nurses, social workers, pharmacists, and psychologists.  These changes are welcome, particularly if they enhance the funding of academic geriatrics and assist in education of subspecialists regarding care of the elderly.  However, I see limited impact upon practice patterns without more substantial incentives to limit access to expensive, hi-tech modalities that may not improve outcomes. 

Section 5501 was designed to enhance reimbursement for primary care practitioners using a bonus system.  Certain Medicare reimbursement codes submitted by primary care practitioners who furnish 60% of their services using these codes receive a 10% bonus.  It is doubtful, however, that this 10% bonus will even begin to rectify the payment gap that exists between physicians who practice geriatrics and other subspecialists.  The reality is that today’s medical students choose their career path using primarily financial and life-style considerations – something that will not change with health care reform. 

Section 5203, the Health Care Workforce Loan Repayment Program speaks volumes with regard to financial priorities of the President’s Health Care Reform Act.  This section provides loan repayment for pediatrics specialists at a rate five times more than that allotted to appropriations to enhance the geriatrics health professions. 

Some aspects of the Act designed to study where healthcare resources should go are unnecessary when applied to geriatrics.  For example Section 5101 establishes a National Health Care Workforce Commission with will study current and future needs for America’s healthcare workers.  Section 5103 establishes a National Center for Health Care Workforce Analysis.  In fact, previous studies already commissioned and completed have established without question the need for workers in the field of geriatrics, and strategies to address these gaps have already been suggested.

There are indeed aspects of the Patient Protection and Affordable Care Act that will have positive impact on geriatrics.  However there is nothing to curb overuse of technology, and little to level a playing field that devalues care of the elderly in favor of subspecialists.  The new Health Care Reform Act will maintain of the status quo of today’s medical structure in favor of unlimited access to high-technology medicine and the vast disparity in pay between primary care practitioners and subspecialists.   

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Related posts:   

Retooling for an Aging America: The Thud that Should Have Been a Bang
Geriatric Patients are Different

Shakespeare, the Diversity of Aging, and the Need for Geriatrics




  • Christopher Langston
    04/08/2010, 10:01 am  Reply

    Thanks for the ping-back on the Glass Half Empty post at HealthAGEnda

    I agree with you about the issue of needing to limit the over use of expensive high tech interventions that don’t have benefits to patients. I would even go further to say that we should limit (or at least slow) access to expensive interventions whose benefits are very small over lower cost alternatives until lower cost approaches have been tried.

    However, many of the limitations of the current system make these arguments very tough for the public to accept. Without a strong proactive care system, the notion of watchful waiting or slowly stepping up intensity (and expense of care) is greeted with justifiable skepticism. In most care systems depending upon the organization or the providers to be organized enough, to give time for a trial of an old generic drug before switching to an expensive new one, would be foolish. They won’t call you back to see how it is working, so why should a patient want to go through the extra hoops of starting with anything less than the best, newest, and of course most expensive.

    The same logic applies across the entire spectrum of services. If patients can’t trust the health care system to monitor and follow-up on their conditions why would they want to collaborate on limiting spending? In fact anything that mentions “limiting” access to anything is perceived by the public as a fundamental conflict of interest, as in cases where physicians get financial rewards for limiting expenditures.

    Of course providers are even more conflicted on the other side – those expensive interventions are income for someone – but the real risks of unnecessary care are simply not well understood.

    It will take a lot of work to (re) establish the trust needed to make “limits” an acceptable word.

    • 04/08/2010, 5:11 pm

      Thank you Christopher for your thoughts. I agree that there are many inherent barriers in our system of care to embrace cost control through sensible decision-making. Kudos to you for your fine work with the Hartford Foundation and the pro-geriatric content of your blog.

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.