fiscal year 2006, it was restored for fiscal year 2007, with $31.5 million for the support of 48 GECs, 88 Geriatric Academic Career Awards (GACAs) for individuals, and 11 Geriatric Training for Physicians, Dentists, and Behavioral/Mental Health Professions Program awards given to institutions to prepare faculty for these professions (ADGAP, 2007c). In 2007 Congress approved a fiscal year 2008 Labor-Education-HHS appropriations bill3 that included continuation of the Title VII geriatrics programs at the same funding level as for fiscal year 2007, but President Bush vetoed the bill on November 13, 2007, and the House of Representatives failed to override the veto on November 15, 2007.

Finally, CMS is the major financial supporter of the residency training of all physicians. In fiscal year 2004 it paid $7.9 billion for graduate medical education (GME) (GAO, 2006). Medicare pays for a portion of the cost of GME for physician residents and fellows through direct and indirect medical-education payments. Direct medical education (DME) payments support hospitals’ direct cost of operating a GME program, especially salary support for residents; indirect medical education (IME) payments cover a portion of the added patient care costs associated with teaching hospital settings (MedPAC, 2003). Through GME, Medicare has specifically supported advanced training in geriatrics by counting geriatric fellows as full-time equivalent (FTE) residents, while all other subspecialty fellows count only as one-half of a full-time equivalent. Thus hospitals that train geriatricians receive more GME funding than hospitals that train other types of subspecialists (MedPAC, 2003). Furthermore, when GME updates were frozen in the 1990s, geriatric programs were exempt.

Sites of Training

The training of medical students and residents tends to occur in discrete episodes of care, within single disciplines, and usually only in the hospital or ambulatory setting, which means that residents generally do not have the opportunity to follow patients longitudinally over time and across settings of care. Thus many students and residents lack exposure to alternative sites of care of importance to the geriatric patient—namely, home-care settings, nursing homes, and assisted-living facilities. Deterrents to increasing student clinical experiences in these sites include the need for an on-site supervisor of the same discipline, the need for collaboration with site staff, a lack of student interest, and a lack of time in already crowded programs (Leipzig et al., 2002; Warshaw et al., 2006).

In one national survey, only 27 percent of graduating family-practice

3

Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008. HR 3043. 110th Congress. July 13, 2007.



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