Inpatient hospital care accounted for over 25 percent (PDF) of the $572 billion in Medicare spending in 2011. The Hospital Insurance trust fund, which pays for inpatient services, is running a deficit and is projected to be exhausted by 2024 (PDF).
Testing potential approaches to control health care costs while maintaining or improving the quality of care is the focus of many healthcare reform and innovation efforts. One approach might be to increase the number of geriatricians taking care of hospitalized elders. Geriatricians are physicians who are specially trained to take care of elderly patients.
A recent study (PDF) by RAND and the University of Pittsburgh assessed whether geriatricians are more efficient and effective in managing elderly patients in the hospital than other primary care physician specialties. Even though patients managed by geriatricians were older and sicker than those managed by non-geriatricians, there were no differences in mortality rates in the hospital or within 30 days of being discharged from the hospital. Nor were there any differences in having to be readmitted within 30 days of being discharged from the hospital.
The hospital stays for the geriatricians' patients were about a day shorter on average than the stays for non-geriatrician's patients, which resulted in a roughly $900 difference in the cost of hospital stays. Whether these savings are captured by the hospital, Medicare program, or private insurer depends on how the hospital is paid.
While these results suggest greater use of geriatricians in the hospital setting could save money without jeopardizing patient outcomes, there is a shortage of geriatricians in the United States, with fewer than four certified geriatricians in the United States per 10,000 individuals 75 years of age or older. Less than 1 percent (PDF) of graduates from United States medical schools choose geriatrics as a career.
The shortage reflects in part the declining number of providers going into primary care specialties such as internal medicine and family medicine, which are the source of many of the physicians who enter geriatric fellowship programs. Despite this shortage, the median salary for geriatricians in private practice is lower (PDF) than that for other primary care specialties. Furthermore, even though they have additional training through their fellowship, geriatricians' salaries are on average significantly lower than other physician specialties that require fellowship training. This is in part the result of Medicare payments being lower than many commercial insurance rates for the same types of services. Even among Medicare beneficiaries, geriatricians tend to care for patients that require more time and resources than the average Medicare beneficiary, yet reimbursement is not correspondingly increased.
It remains to be seen whether new models of health care delivery and payment structures—such as patient-centered medical homes, bundled payments for episodes of care, and accountable care organizations—will adequately address disincentives for physicians to enter geriatric medicine and mitigate current shortages. Addressing such disincentives could result in elderly patients receiving equally good care at lower cost.
Melony Sorbero is a policy researcher at the non-profit, nonpartisan RAND Corporation.
Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.