The Dominance of Medicare Reimbursement
One of the most significant factors impacting geriatrician pay is the patient population they serve. A geriatrician's practice consists almost exclusively of patients aged 65 and older who are enrolled in Medicare, the federal health insurance program. The reimbursement rates offered by Medicare are notably lower than those from private insurers, which often cover younger, healthier patients seen by other specialists. This lower payment structure directly translates to reduced revenue for geriatric practices.
The disconnect between cost and payment
While caring for older adults requires significant time and extensive care coordination due to multiple chronic conditions (multimorbidity) and social factors, the traditional fee-for-service model often fails to compensate adequately for this complexity. Geriatricians often see fewer patients per day to accommodate longer, more detailed visits, but this is not proportionally rewarded under payment systems that prioritize volume over time and complexity. The financial constraints this creates can limit a practice's profitability and impact physician salaries.
The Procedural vs. Cognitive Pay Gap
Physician compensation in the U.S. is heavily skewed toward procedural-based specialties, which perform high-volume, high-reimbursing interventions. Specialties like neurosurgery, orthopedic surgery, and cardiology consistently top salary rankings due to the high value placed on procedures in the current healthcare system.
Valuing time and thought over procedures
In contrast, geriatric medicine is a cognitive-heavy specialty. Geriatricians spend their time performing comprehensive assessments, managing complex medication regimens (polypharmacy), addressing mental and emotional health concerns, and coordinating care with multiple other providers. The billing codes for these time-intensive, non-procedural services generate far less revenue than a single surgical procedure, contributing significantly to why geriatricians are paid less. This disparity creates a powerful financial disincentive for medical students considering the specialty, despite the growing demand for their expertise.
Administrative Burden and Financial Strain
The nature of geriatric care also introduces substantial administrative burdens that affect financial outcomes. Managing a patient with multiple chronic conditions involves extensive documentation, constant communication with families and caregivers, and navigating a complex web of services. This heavy workload often leads to increased practice overhead and potential burnout, without a corresponding increase in reimbursement.
Challenges in geriatric practice management
- Complex Billing: Practices must navigate complex Medicare billing and coding rules, which are constantly changing, to ensure proper reimbursement.
- Care Coordination: Organizing a patient's care involves liaising with specialists, physical therapists, social workers, and home health agencies, which is time-consuming and often uncompensated.
- High Practice Costs: To provide comprehensive care, geriatric practices may require more support staff, technology, and facility resources than a typical primary care office, further straining budgets.
Comparison of Physician Compensation Factors
To illustrate the disparity, consider a comparison between a geriatrician and a procedural specialist like an orthopedic surgeon. While both undertake extensive training, the compensation structures and patient loads differ dramatically.
| Factor | Geriatrician | Orthopedic Surgeon |
|---|---|---|
| Primary Patient Demographics | Medicare beneficiaries (65+) | Mixed, with more private and commercial insurance |
| Reimbursement Rates | Heavily reliant on lower Medicare rates | Higher rates from private insurers for many procedures |
| Focus of Practice | Cognitive, consultative care; disease management, polypharmacy, and psychosocial needs | High-reimbursing procedures; surgeries and interventions |
| RVU Earning Potential | Lower, based on time-intensive, cognitive services | Higher, based on a high volume of procedural services |
| Time per Patient | Often longer, more complex visits | Typically shorter, focused on a specific procedure or issue |
| Training Length | Residency + 1-year fellowship | Residency + surgical fellowship(s) |
The Looming Workforce Shortage
Lower compensation, coupled with the emotional demands of caring for an aging and often very sick population, contributes to a critical workforce shortage. The number of board-certified geriatricians has remained stubbornly low, even as the elderly population in the U.S. continues to grow rapidly. This shortage places an increasing burden on the few geriatricians currently practicing and leaves many older adults without the specialized care they need. Addressing the compensation issues is a key part of solving this public health crisis. https://www.americangeriatrics.org/where-we-stand/healthcare-workforce
Conclusion
In summary, the question of why are geriatricians paid less is a multifaceted one rooted in the economic realities of the U.S. healthcare system. The combination of lower Medicare reimbursement rates, the inherent complexity and time-intensive nature of geriatric care, and a reimbursement system that prioritizes procedural volume over cognitive expertise all contribute to the financial disparity. As the elderly population expands, policymakers and health systems must find ways to value and compensate cognitive specialties appropriately to attract more physicians to this crucial field and ensure high-quality care for older adults. New payment models, such as value-based care, are being explored as potential solutions to better align compensation with the patient-centric, holistic approach that defines geriatric medicine.
