Medicare payment cuts threaten more strain on overloaded EDs

Physicians warn that emergency departments will become overwhelmed if declining Medicare payment rates squeeze patient access.

By David Glendinning — Posted June 20, 2005

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Washington -- Emergency department physicians have been dealing with a one-two punch of increasing patient visits and declining resources for years. Now the pending Medicare payment reductions could add a third trauma to that list of troubles.

If Congress does not step in before six consecutive rounds of Medicare cuts start in January, seniors who can't find a doctor will come into EDs in unprecedented numbers when their chronic conditions become unmanageable, said Robert Suter, DO, an emergency physician in Dallas and president of the American College of Emergency Physicians.

"We are the last refuge for those who don't have access to primary care," he said. "Every emergency department in the country is at risk for this problem."

Doctors already are seeing increasing numbers of patients of all ages with emergencies, even as hospital closures are decreasing the numbers of EDs. A recent Centers for Disease Control & Prevention report concluded that the number of emergency department visits went up 26% between 1993 and 2003, while the number of available EDs went down 12.3%

A growing percentage of seniors are making visits to EDs, helping to drive the increase. If declining payment rates force physicians to stop seeing new Medicare patients or drop some of their current ones, the American Medical Association worries that this problem of patient overload could become a full-blown crisis.

"That's a very genuine fear and very likely to happen if the Medicare cuts are not corrected," said J. Edward Hill, MD, AMA president-elect and a family physician from Tupelo, Miss.

The widespread perception is that many patients visiting EDs are uninsured people seeking routine primary care. But recent studies, such as the one by the CDC, reject that notion. Fewer than 15% of all the patients who came into EDs two years ago were uninsured, and only 13% of the visits in 2003 were for situations that were considered nonurgent, according to the CDC report.

The same holds true for seniors, most of whom are insured by Medicare. The primary reason for increased ED visits by those 65 and older is that medical advances have allowed people to live longer with chronic conditions than they did 10 or 20 years ago, Dr. Suter said.

These patients aren't seeking routine treatment in the emergency department for their chronic conditions. Instead, already emerging access problems -- even among those who actually have a primary care doctor -- are prompting some of these seniors to wait to get care until their ailments worsen enough to warrant an ED visit, Dr. Suter said.

"We are seeing more Medicare seniors who come into the ER with congestive heart failure after they started having problems with their medication," he said. "We find out that they couldn't get in to see their regular doctor, or their physician couldn't afford to spend the time with them on full chronic disease management."

Anatomy of a potential disaster

Physicians can expect to see many more of these types of cases if the Medicare cuts prompt a rash of access problems, but the patients won't show up right away, Dr. Suter said.

"We'll start to see them six or so months down the line, when the cumulative damage overwhelms their systems," he said.

Although physicians plan to make every effort to keep treating their current Medicare patients even if rates are reduced in 2006, many new program enrollees will be left in the lurch, Dr. Hill said. Those incoming seniors could find that their chronic conditions turn into emergency situations while they spend months looking for a doctor who can afford to see them and can make the time to do so.

A surge in elderly patients without primary care access would impact the entire hospital system, which cannot afford to let more preventable problems progress to the point at which costly hospitalizations and procedures become necessary, Dr. Hill said.

"The emergency rooms are already clogged. We have wait times of three and four hours or even longer to get a bed for an emergency room patient in the hospital," he said. "I can see the perfect storm building here."

Meanwhile, ED patients with less serious conditions move farther down the priority list. Some emergency departments already have put processes in place to turn away patients with nonurgent problems, but Dr. Suter said these visitors are becoming harder to find.

"We're seeing insured, sick patients that need to be admitted," he said. "We're not talking about people with sore throats that you can leave waiting in the ER."

Longer wait times have the potential to feed the problem. ED doctors are reporting that some seniors who don't come into the department until their conditions are truly life-threatening cite the prospect of long periods in the waiting room as the reason why they didn't show up earlier.

Hospitals in urban and rural areas with high Medicare populations can expect to be at especially high risk for these troubles. But because private insurers often base rates on Medicare, cuts and their associated access problems would affect every hospital across the country, Dr. Suter said.

For the AMA, the news from the CDC and the heightened level of alarm from emergency physicians provide more ammunition in the fight to reverse the Medicare cuts.

"We will certainly use [the report] as another piece of information that shows how critical this problem is and how much worse it can get," Dr. Hill said. "If anybody can be depended on for credible data, the Centers for Disease Control certainly can."

New efforts

Leaders of the AMA and the Texas Medical Assn. recently launched a Medicare "National House Call" in Texas during which the groups aimed to raise awareness of the impending cuts. During visits to major cities in the state and in radio ads that ran throughout the week, the leaders urged seniors to voice their support for Medicare rate fixes to their representatives in Congress.

The first state on the tour is one that is most at risk for patient access problems if Medicare is cut next year, said Bohn Allen, MD, a surgeon in Arlington, Texas, and the immediate past-president of the TMA.

"Texas is still a frontier of wide-open spaces dotted by little one-physician towns," he said. "These cuts may be enough to force rural physicians into retirement, leaving some Medicare patients with limited health care options."

The AMA is supporting bills in the House and Senate that would turn next year's estimated 4.3% Medicare pay reduction into a 2.7% increase. The House legislation would change the formula that determines physician reimbursements starting in 2007 in an effort to better match rates with costs, but the Senate bill would not implement any long-term reform.

The Association has said it would prefer a permanent fix to the formula but stressed that Congress must pass some measure addressing the issue before the year ends.

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Emergency in the ED

Emergency department visits among seniors ages 65 to 74 have climbed, and physicians worry this could intensify if impending Medicare cuts reduce patient access to primary care.

Visits per
100 seniors
2003 39.5
2002 37.5
2001 36.2
2000 36.9
1999 36.3
1998 35.3
1997 34.3
1996 32.6
1995 33.1
1994 31.8
1993 29.0

Source: Centers for Disease Control and Prevention, June

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Coming to the right place

Although visits to emergency departments are on the rise, evidence suggests that the vast majority of patients have a legitimate reason for coming to the ED. Here's how ED visits broke down in 2003 according to type of emergency:

Urgent 35%
Semi-urgent 20%
Emergent 15%
Nonurgent 13%
No triage or unknown 17%
Total 100%

Source: Centers for Disease Control and Prevention, June

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