Independent Medical Reviews
March 23, 2018
Did you know that more than 10,000 baby boomers reach retirement age every single day? It's a staggering figure, but it makes sense considering the overall size of their generation. Born between 1946 and 1964, they are one of the largest population cohorts in U.S. history, with approximately 74 million members alive through 2016. Their considerable numbers and aging demographics will profoundly influence the direction of the health system in the coming years.
The total number of seniors began to grow rapidly at the start of 2010, just as the earliest baby boomers turned 65. This growth spurred greater healthcare utilization and also increased the share of all emergency room (ER) visits from seniors. A hospital survey by the U.S. Centers for Disease Control and Prevention (CDC) found that the 65-plus population made over 20 million trips to an ER in 2013, up from 16.2 million in 2000.
Given the increased need for ER services by the elderly, the CDC highlighted the importance of recognizing the "age differences in the utilization and provision of ER services" among older patients. At the same time, the unique health-related challenges faced by baby boomers merits new approaches to palliative care, a domain not typically suited to the fast-paced, high-pressure environment of the ER.
Palliative care is intended to boost quality of life for patients with life-limiting illnesses, including terminal diagnoses. It can be administered to individuals of all ages and may be paired with curative therapies. Common ailments targeted by palliative regimens include Alzheimer disease, Parkinson disease, amyotrophic lateral sclerosis, congestive heart failure and many cancers.
In recent years, some providers have looked to offer palliative services within ERs. Emergency medicine physicians can become certified in palliative care, with at least 149 of them being credentialed by 2017, according to National Public Radio. The logic of a palliative-enabled ER stems from the fact that half of patients visit the ER during the last months of life and 50 percent of this subset die there.
Longer life expectancies mean baby boomers will have greater need for services such as orthopedic surgery than their parents as their bones and muscles wear out. Moreover, United Health Foundation predicted that this generation will be less healthy as seniors than previous generations, particularly in rates of obesity and diabetes. Is a revamped approach to palliative care, incorporating the ER, a way to reduce hospitalization and contain costs?
The current outlook is mixed. On the negative side, the ER is not an optimal setting for palliative treatments. Doctors have limited time to evaluate and treat patients there and predictably have few opportunities to get to know them well. Delivering palliative care to virtual strangers in noisy, spare rooms is far from ideal.
There's also the drawback of limited staffing. A task force designated by the American Academy of Hospice and Palliative Medicine estimated a shortage of 18,000 palliative care physicians. There's also the issue of different cultures between emergency and palliative care, embodied in the small numbers of palliative-certified ER physicians. Ultimately, shorthanded teams are not equipped to treat the large volume of baby boomers who will inevitably need some combination of ER and palliative services.
The total number of seniors began to grow rapidly at the start of 2010, spurring an increase in the share of all emergency room (ER) visits from seniors.
There is plenty of potential for ER-integrated palliative care. A study at Mount Sinai Hospital in New York City implemented quality-of-life improvements for cancer patients ranging from consultations with a palliative care team to transition planning and symptom assessment and treatment using the Edmonton System Assessment Scale (ESAS).
The benefits of using real-time palliative consults in the ER, in tandem with medical necessity screening tools and processes, can reduce ICU admissions (which account for one-fifth of hospital costs) as well as the number of individuals prematurely sent home.
In addition to a shortage of licensed and certified palliative providers, many health plans also struggle managing the complexities of baby boomer ER use. It doesn't have to be this way. Independent review organizations (IROs) such as AMR can provide the much-needed expertise to payers through our robust physician network. Whether larger carriers or smaller plans, AMR’s peer review services can help navigate a broad spectrum of challenges related to utilization management or appeals volume, compliance and specialist staffing.
Physician-level review offered by experienced IROs directly addresses the issue of medical necessity at the heart of determining the right level of care for ER patients. Do they need to be admitted to inpatient care? Can they safely go home or to a less acute care setting? Or is a palliative/hospice arrangement a better fit? The stakes for answering these questions are higher than ever due to the rising number of seniors, drawn predominantly from the baby boomer generation. Payers, providers and IROs all have vital roles to play in creating practical models for palliative care both within and without the ER.
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