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COMMENTARY |
Robert and Arlene Kogod Program on Aging, Mayo Clinic College of Medicine, Rochester, Minnesota.
Address correspondence to Eric G. Tangalos, MD, Robert and Arlene Kogod Program on Aging, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905. E-mail: tangalos{at}mayo.edu
John Morley (1) has given each of us the opportunity to fill in some of the details on "A Brief History of Geriatrics." I have seized this opportunity while the events of the past 20 years can still be peer-reviewed. Any further delays would leave all of my uncontested assumptions permanently in the record books.
It was shortly after a congressional mandate that nursing homes have the responsibility of hiring physician medical directors in 1974 that the American Medical Directors Association (AMDA) began in 1976. The organization struggled in its first decade of life and had larger state chapters than a national organization up until about 1987. In 1988, the Minnesota Medical Directors Association, which was larger and better organized than AMDA, hosted the national meeting in Minneapolis. Then-Senator Dave Durenberger spoke at the meeting, there was an event at a Minnesota Twins baseball game, and AMDA's growth curve got very steep. Dr. James Pattee's course work to define the field of medical direction helped to establish the concept for the Certified Medical Director (CMD), and later, through his efforts, the CMD curriculum was formally established. His work led to the first training course for medical directors held under the aegis of the University of Minnesota and to AMDA's own core curriculum series. Nursing home chains were consolidating and showed an interest in investing in their physician medical directors.
In the early 1990s, significant growth occurred in all professional medical societies. Particularly pre-Sunbeam, there were tremendous opportunities for organized medicine to increase membership, programs, and revenue. Whether it was the manifest destiny of organizational growth or just a lot of money from big pharma, most professional associations took advantage of the situation. It was also a time when educational programming, guideline development, and leadership training for physicians were in vogue. Journals previously without branding and peer-review by professional medical groups now found new identities. The situation was mutually beneficial as professional organizations were able to work with well-run publishing houses, enjoy some advertising revenue, and let others handle distribution and the headaches of maintaining a mailing list.
These were also the days that implemented the Omnibus Budget Reconciliation Act of 1987, the MDS, and Prospective Payment. The Physician Payment Review Commission had yet to come into being. In December 1990, leadership of the AMDA was able to participate on short notice with the Health Care Financing Administration's payment division in the person of the visionary Bart McCann to review and change physician reimbursement in skilled care facilities. Fee schedules to this day are for the most part historically based. In the name of OBRA '87 and because the Minimum Data Set was brand new, a unique opportunity for defining reimbursement for long-term care services was upon us. With support from consumer groups, particularly the National Citizens' Coalition for Nursing Home Reform, Senator David Pryor agreed to write a groundbreaking and influential letter to HCFA, and a new history for physician reimbursement (at least for skilled care visits) was written. Practicing physicians in long-term care facilities had their work revalued.
One area of particular interest to AMDA members concerned the work relative value units (RVUs), since we felt they reflected neither the amount nor intensity of work involved in caring for today's nursing home residents. In our arguments before the Refinement Panel in May 1992, we were able to point out that nursing visits were more closely aligned to hospital visits rather than outpatient examinations. This had widespread applicability and was irrespective of patient age. Table 1 demonstrates the changes in key nursing facility codes (2).
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The more established AGS took on its own strategic new direction in the late 1990s. First there was a reaching out to the multidisciplinary team with the AGS encouraging nurses, social workers, and other health professionals to be active members. This approach would give the AGS a more public image to go with its academic foundation and provide a greater reach into everyday clinical practice. Soon to follow would be the AGS Foundation for Health in Aging, again a public face for an ever-graying American society. Let us hope the strategic plans for both organizations remain sound and that their nonprofit foundations support a variety of geriatric initiatives. Both the public and all medical practitioners need this support.
Footnotes
Dr. Tangalos is a past president of the American Medical Directors Association and was a chair of its Foundation. He currently serves on the Board of Directors for the American Geriatrics Society and is a member of its Foundation for Health in Aging. 
References
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