Recommendation 4-3: Public and private payers should provide financial incentives to increase the number of geriatric specialists in all health professions.

Specific types of financial incentives will be recommended throughout the rest of this chapter. Medicare and Medicaid policies will be especially important in the implementation of financial incentives due both to their role in the financing of health care services for older adults as well as the influence of their policies on other payers.

The costs associated with extra years of geriatric training do not translate into additional income, and geriatric specialists tend to earn significantly less income than specialists in other areas and often less than the generalists within their own fields. In fact, the additional training needed to become a geriatric specialist has been shown to have a negative effect on future earnings. In 1999 a physician who pursued a 1-year geriatric medicine fellowship stood to lose $7,016 annually, and the completion of a 2-year fellowship translated into a net annual loss of $8,592 (Weeks and Wallace, 2004). In 2005 a geriatrician’s median salary was only 93 percent of the median salary for a general internist (ADGAP, 2007b). Similar disparities exist for other professions. For instance, compared with nurses in hospital settings, full-time RNs who work in nursing homes or other extended-care facilities receive lower annual earnings on average, even though they work more hours per week, incur more hours of overtime, and have a larger percentage of overtime hours that are mandatory (HRSA, 2006b). PAs who specialize in geriatrics have lower salaries than other types of PAs (AAPA, 2007). One survey of recent MSW graduates showed that while 70 percent strongly agreed that geriatric care is an important part of social work, only 36 percent strongly agreed that geriatric social work offered good career opportunities (Cummings et al., 2003).

In part this income disparity is due to the fact that a larger proportion of a geriatric specialist’s reimbursement tends to come from Medicare and Medicaid. Additionally, as the population ages, many non-geriatric specialists will experience similar difficulties. Rates of reimbursement are low for primary care codes in general, especially as compared with the procedural codes typically used by other specialists. Medicare and Medicaid reimbursements do not take into account the fact that the care of frail older adults with complex care needs is very time-consuming, a situation that causes geriatric specialists to have fewer patient encounters and fewer billings (MedPAC, 2003).

Recommendation 4-3a: All payers should include a specific enhancement of reimbursement for clinical services delivered to older adults by practitioners with a certification of special expertise in geriatrics.

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