Senator Frist and other distinguished members of the subcommittee, it is a distinct honor for me to be here with you this morning as you undertake an extremely important piece of legislation that can improve the quality of lives of countless Americans, young and old. I want to thank you for inviting me to present the views of my colleagues who comprise the National Association of Geriatric Education Centers (NAGEC). We are a grouping of the 43 Geriatric Education Centers (GECs) located in academic health centers throughout the U.S. Before I tell you more about what GECs have and are doing and how we think we can contribute to the type of cross-program consolidation implied in S. 555 that you and Senators Kassenbaum and Kennedy introduced in the previous session, I want to commend you for your leadership in bringing the bill back this session.

I was especially struck with the title or theme of these proceedings, "Realigning to Meet the Future," which, to me, begs the question: " What is the future of today’s 33 million older Americans and the 66 million strong elderly population expected by 2030 when 1 of every 5 Americans will be 65 years of age or older?" What will the future hold for that 76 million cohort of post-war persons born between 1946 and 1964 we call the "baby boomers" who are turning age 50 at the rate of 10,000 per day for the next 10 years? The futures of all these people will be quite different for the computer geniuses working for the Bill Gates of the world than if the accident of birth placed some of them in colonias in the transnational area along the Rio Grande in South Texas where our TCGEC colleagues from University of Texas-Pan American struggle to offer training to the few health care professionals available to treat the aging Mexican Americans who pick the vegetables and fruit that we eat. However, the one thing common to all of us is that we will all grow older. And since, on average, older people need more health care than younger ones, who will take care of them, us? What you and your colleagues do regarding legislation to ensure that we have a national health workforce capable of meeting the varying needs of all Americans has as much to do with the futures of older persons as any allied health professional, dentist, nurse, physician, pharmacist, or social worker who constitute the interdisciplinary geriatrics team. Thus, I suggest that the realignment you propose address that singular issue of where those health professionals receive the additional training they need and how best can they receive what they need.

With the above thought in mind, I want to make three points today:

1. First, there are simply too few health professionals who’ve received the additional training they need to care for America’s burgeoning older population. The DHHS Health Resources and Services Administration’s own 1996 publication, National Agenda for Geriatric Education: White Papers, states that "no single health profession has an adequate number of providers with the requisite training fully capable of taking care of today’s older population." (And, I might add, much less those of tomorrow.) As people age and become ill or frail, their medical and social conditions can become very complex, necessitating the care of an interdisciplinary geriatrics team. According to many reputable sources – The National Institute on Aging, The Institute of Medicine, The American Geriatrics Society, The American Medical Association, The John A. Hartford Foundation, and such nationally recognized experts as Dr. David Reuben and his colleagues at UCLA – the field of medicine, just to cite statistics for one health profession, is way short of meeting the demand for physician geriatricians. The number of full-time equivalent primary care internists and family physicians needed by the year 2000 to provide care for older people is estimated to be as many as 30,000 vs. the 8966 we currently have available, which is a declining number due to retirement. (There are and additional 2,400 geropsychiatrists, bringing the total number of physicians with added qualifications in geriatrics to 11,366.) Since we are producing only around 100 new fellowship-trained geriatricians each year, one can see the drastic imbalance. Projected Year 2030 imbalances will be even more pronounced. Furthermore, nearly every health-care field is also in a state of imbalance between the demand for specially trained providers and the number available to care for our older citizens.
   

2. Second, for 15 years, the network of 43 GECs has made good progress in redressing this national workforce issue, and, as such, constitutes a national resource. (I’ve attached a map showing where these GECs are located and the service areas they cover. Also included are a paper describing the outcomes of GECs through 1994, some examples of GEC programming in the area of ethnogeriatrics, and a NAGEC statement on funding.) Just a few of the highlights of what GECs have accomplished are these: (a) 375,000 practitioners trained in 27 health-related disciplines taught in ambulatory care centers, hospitals, extended care facilities, and senior centers; (b) 7500 academic and clinical faculty trained in 170 health-related schools and 550 affiliated clinical sites; (c) 90% of GECs are consortia of three or more colleges, hospitals, community agencies, and AHECs; (d) 41 community-academic partnerships addressing local needs; and (e) 1000 curricular materials on such topics as adverse drug reactions, dementias, and Alzheimer’s disease, depression, incontinence, congestive heart failure, hearing and vision loss, osteoporosis, elder abuse, ethics, interdisciplinary team care, rural access, teleconferences, Web-based modules, and ethnogeriatrics. Regarding the last five, GECs are especially known for all training being interdisciplinary and for having a rural and underserved focus guided by ethnographic principles to ensure more culturally competent practitioners. (Based on a 25% convenience sample of 41 GECs taken April 21-24, 1997, the mean percentage of enrollees in our programs who constitute underrepresented ethnic minorities is 40%.) Many GECs have online courses and are developing cyberlearning modules as part of their distance education programs. Also, GECs have led the way in developing evaluation protocols. In conjunction with HRSA’s Bureau of Health Professions, our colleague, Dr. Jurgis Karuza of the Western New York GEC , is developing a set of educational performance outcome measures (EPOMs) that all GECs will use to track the cascade of what we do for our trainees, who, in turn, do that have putative benefits for their older patients and clients. Finally, GECs have good linkages with AHECs, Interdisciplinary Rural Training Projects, Allied Health and Public Health Projects, the GRECCs of the Veterans Administration, and such special projects as the Primary Care Residency Training Initiative and Geriatric Interdisciplinary Team Training grants the John A. Hartford Foundation has recently made.

3. Third, if a stable stream of modest federal funding were to cease, we would lose this initiative and, I think, irretrievably lose ground against the rapidly growing older population’s health care needs. The most money appropriated for GECs was around $9 million; currently, HRSA’s budget for the 21 funded GECs is about half that. Since each GEC receives an average of only $145,000 federal dollars per year, a sum that is matched dollar for dollar from other sources, we are a cost-effective provider of high quality geriatrics training that meets the needs of local providers. Within the total amount to be appropriated for "AHECS and Other Education Centers," including GECs, as described in S. 555, if the pre-recision FY ’95 budget figure of $9.092 million were applied to geriatrics education, all 41 of the current GECs could be fully funded with concomitant increases in productivity and desired impact. In my 26 years at Baylor College of Medicine, I’ve been the Principal Investigator of 63 funded grants and contracts approaching the $15 million mark. In all of these, the Texas Consortium of Geriatric Education Centers has been the most cost-effective one, leveraging well over $1 local dollar for every $1 grant dollar, which has led to over 28,000 Texas health providers having professional development opportunities to increase their funds of knowledge in geriatrics.

As you and your colleagues and staff endeavor to craft an integration of the 44 Titles III, VII, and VIII programs, please consider how the integrity of the programs can be maintained as they are consolidated into the proposed six authorities. I would ask that you consider the critical mass of geroeducators assembled by the GECs (and the exponential effect of their training of over 375,000 faculty and community practitioners) as a national resource. Thus, maintaining this assemblage of talent seems warranted in light of the imbalance between their supply and demand previously mentioned. Furthermore, I have discussed with Dr. Harris, the witness representing AHECs, the suggestion that you rename the proposed authority labeled "Area Health Education and Other Education Centers" (frequently referred to as the "Enhanced AHEC Cluster") to simply "Interdisciplinary Education Centers" under which the five current programs listed would be subsumed. This label for a cluster of several programs would be more representative of a concept/practice than for a single program; thus, avoiding the confusion over what is meant by an "Enhanced AHEC Cluster." It has even been suggested that frail, older people – for whom there are simply too few health care professionals with added qualifications in geriatrics to properly render the level of care they require and deserve – could be viewed as an underrepresented group of Americans worthy of consideration in Titles III and VII.

In summary, what you and your colleagues do regarding legislation to ensure that we have a national health workforce capable of meeting the varying needs of all Americans has much to do with improving the futures of older persons. Back in the mid 1970’s I heard Robert Butler, M.D., the eminent geriatrician at Mt. Sinai in New York City who was the founding director of the National Institute on Aging, say something that is as pertinent today as it was then. Dr. Butler said something to this effect: the best way to have a good system of health care for older Americans is for each of us to think of ourselves as someday being a frail, old person and then work hard to make sure that the system we want is in place when it’s our turn to be old. Thus, I would ask each person in this room to find a quiet moment later today, close your eyes and see yourself and your spouses and children and grandchildren as being old; then ask yourself this question: "What can I do to ensure that we will all have a good old age?