Expert Panel Calls Dearth of Clinicians to Treat Elderly ‘Emerging Crisis’

“Most professionals who work with older adults say they like their work, but reimbursement remains a problem,” said Blazer. “It just doesn’t pay as well as, say, child psychiatry, especially under Medicare.”

Professional training connecting mental health and geriatrics is inadequate, the panel’s report emphasized.

The elderly population has specific needs, Miller noted. They present with general medical as well as psychiatrically complicated conditions, yet geriatric fellowships go unfilled.

“So because there are not enough geriatric psychiatrists, we have to think creatively,” Miller told Psychiatric News. “We have to take a population-based, rather than a patient-based approach.”

Yet delivery and reimbursement systems have so far not adjusted to this reality.

For instance, some evidence-based models of depression treatment rely on care managers to coordinate the efforts of primary care physicians, psychiatrists, and social workers. However, Medicare currently does not pay for the care managers’ time, despite their demonstrated value. Nor does the system reimburse a psychiatrist who consults with the care manager or the primary care clinician but does not see the patient directly, said Blazer.

The Centers for Medicare and Medicaid Services is exploring alternative models of care but has not changed its policies yet, he pointed out.

Finally, attempts to expand and improve the workforce to care for older people with mental health or substance use problems are seriously hampered by a dispersal of responsibility across numerous federal government agencies, said the report.

For instance, the Health Resources and Services Administration is supposed to promote health care workforce development, but its geriatric training programs include nothing on mental health or substance abuse conditions, according to the report. Only a small part of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) budget is aimed at the elderly, and the agency has eliminated the Older Adults Targeted Capacity Expansion grants program.

“And it’s very telling that the National Institute on Aging didn’t see mental health and substance abuse issues among the elderly as their area of interest,” Miller said.

The previously authorized National Health Care Workforce Commission could use existing law and serve as a central coordinating body for federal efforts—if it were funded by Congress, said the report. Until then, the secretary of Health and Human Services should designate a responsible entity to do so.

How soon that might happen is unclear, said Blazer. “But we have made the recommendations to get the process started.”

“I’d like to see SAMHSA take the lead and work with other agencies, but such a coordinated federal response seems unlikely to happen soon,” Miller suggested.

“As a geriatric psychiatrist, I strongly support the findings and recommendations of this new IOM report on aging and mental health and substance use disorders,” said Jeste, a professor of psychiatry and neurosciences at the University of California, San Diego, in a recent statement. “The American Psychiatric Association hopes that necessary changes are implemented soon to provide badly needed care for our elderly patients, particularly those with financial needs who are among the most disenfranchised sectors of our society.”