Geriatric Emergency Rooms Also a Mismatch

Another innovation in the early stages is the geriatric emergency room or section of an ER. This will remain a great marketing tool, particularly where hospitals compete for the high end seniors and their dollars, but...

Geriatric ERs will be Where Seniors Are Not

The recent post about the mismatch between geriatricians and the locations of seniors should give a clue of what is to come. Emergency rooms are just as out of position for the elderly as we see for geriatricians. A geriatric ER would need the same supplementation to survive as is required for geriatric care - and because the care involves Medicare or Medicare plus Medicaid payments too low.

The elderly with lower or fixed incomes tend to avoid high cost of living/high cost of housing areas where emergency rooms are found or were found. The real story regarding emergency rooms and elderly is that many EMs are closing because of concentrations of elderly, poor, Medicaid, Medicare, and other low paying plan patients. Paying more for EM and hospitalist workforce has tipped the margins of smaller facilities below acceptable – as has payment design sending too few dollars via CMS and insurance payers. The ACA also took away sources of payment for ERs and hospitals that see substantial numbers of seniors. 

The arguments against ACA and CMS implementations of ACA are not just political; they are practical. Expansions of insurance plans with payments at or below margin only worsen access for seniors and also those who are poor and without insurance, etc.

Too little paid for highest complexity patients will do that as seen with the failure of the geriatric physician model due to demographics, distribution, and payment design. Not surprisingly the closures of ERs as well as small and rural hospitals continue to be where seniors are concentrated. After rebuilding health access 1965 to 1980 in ways specific to the needs of the elderly via Medicare and Medicaid (seniors tend to be elderly and poor), the US has been tearing access down 1983 to the present. The hospital demise proceeds at a pace of 1 hospital a month. The ER closure rate may be slightly higher as ER can be a loss leader.

Matters would be worse if not for family physicians increasing to about 12% of workforce found in emergency room settings - and doing full scale ER as seen in Graham Center reports. The only workforce increasing rapidly in rural areas is emergency medicine workforce, and it is increasing at a lower rate than in urban areas. FM has made up some of the gap. In the Masterfile the hospital based family physicians have a higher rate of rural location - over 26% in rural locations compared to 20% for office based. This is actually higher than the 18 - 20% of the population found in rural areas. This suggests that family physicians are even more important for rural emergency care due to specific hospital employment as well as due to coverage of the ER for office based FM.

Where hospitals are closed or never existed, small practice family medicine is even more important - if it can survive MACRA. Other specialties have just not made a difference on these front line areas. Also the population found in a county without a hospital is one of the most rapidly growing populations in the nation as the hospitals being closed are in counties with much higher populations than the hundreds closing in the 1980s.

Why Do We See Calls for Geriatric ERs?

There is always the argument that what is good for academic centers is good for the USA, but this is not necessarily true. There will always be academics hoping to make their mark with some new creation. Sometimes a Geriatric ER may be a good idea. Some do have seniors nearby and even influential seniors. Marketing this special service may also pull higher paying seniors from other facilities. In general however, academic settings are in entirely different locations. They tend to be in the 1100 zip codes with top concentrations of physicians. These Super Centers are quite different with 45% of physicians packed in 1% of the land area where only 10% of the population is found (and shrinking). As a reminder, the hospitalist design was not a good fit where care was needed. The additional costs of ER and hospitalist doctors did not work out well except for academic centers and the academic centers were also able to address faculty shortages via ER and hospitalist positions.

More Quiet and More Support for Seniors in ER Settings

Seniors do need a quieter ER, but so do other patients. The environmental changes suggested for EM settings are important for all ages - particularly those that spend far more time in EMs serving as team members delivering care. Resources are often lacking for all EMs across social work, physical therapy, mental health, and other areas.

How Do We Meet the Acute Care Needs of Seniors?

The first step is to increase cognitive payment. Office payments and basic service payments are too low. Evaluation and management is costly and time consuming - and is being killed off by CMS payment designs sending too little to support the team members to do the work. Rebuilding the primary care and mental health workforce is the first step, particularly the MD, DO, NP, and PA grads found in family practice positions. These are the only population distributed workforce in the United States. If funding is not specific to the support of these positions, then it is not specific to seniors, poor, fixed income, and care where needed.

It would also be a good idea to quit killing off small and solo practices as seen with EHR, MIPS, PQRS, MACRA, and other nightmare additional costs coupled with payment cuts for Medicare and Medicaid. Insurance companies also need to be rallied to higher payment for cognitive services - for their own good also.

Seniors should also be cared for as a group rather than being segmented off. Veteran seniors need local care for many reasons such as transportation, mobility issues, and support of local health care where needed. Segmenting off the various seniors into different coverages helps to hide the sad and worsening situation of seniors, similar to the 1950s and 1960s necessitating Medicare and Medicaid. And yes, the reasons have been changes in Medicare and Medicaid designs that do not work well for seniors.

Mobile Home Nurse Based Evaluations

Specially trained nurses are already working to be available to do assessments at emergency room, urgent care, and other settings. They often work in local mental health clinics. The patients can be prevented from costly ER, inpatient, or psychiatric admission. The patients could be evaluated at homes or at the request of law enforcement or local clinicians.This would be a resource for depression, suicidal ideation, dementia evaluation, and more. Seniors often lack transportation and mobility and health care should match up to their need. Telehealth connections are another option.

Resist the Innovation Bandwagon When It Is a Poor Fit

The Geriatric EM will be promoted by those least representative - academic sites. What may seem to work for locations most favored with the most lines of revenue and the highest reimbursement in each line may not work elsewhere as can be seen in hospitalist and other designs.What works for 1100 zip codes in 1% of the land area with 45% of physicians and well over half of health spending and only 10% of the population is generally a poor idea for most of the US distant and different and disadvantaged by the designs of payment and training.

  • Seniors are where ER's aren't
  • Seniors need more support resources and a quiet ER, but so do almost all ERs
  • Senior needs can be met by other means such as nurse evaluation teams or telehealth
  • Senior needs can be met by increasing cognitive payment such that the nation has the primary care, geriatric care, and mental health workforce to prevent the need for ER and hospital care

Recent Posts and References 

Rallying One Hundred for Health Access Not MACRA

The Ultimate Government Health Care Paradox - Government must facilitate better EHRs and better health access, not prevent them.

Government Compromise of Trauma Response
Talk About Unpaid Stressed and Abused For Decades - a journalist wakes to health care abuses, but then there is primary care. 
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Population Health from Above or Below  - population health must not be another new crop to harvest for consultants, associations, and institutions. In must remain about the health of the population, not the wallets of those already doing best.
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.


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