Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries

Abstract

Importance: There has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers.

Objective: To evaluate the association of GED programs with Medicare costs per beneficiary.

Design, setting, and participants: This cross-sectional study included data on Medicare fee-for-service beneficiaries at 2 hospitals implementing Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) (Mount Sinai Medical Center [MSMC] and Northwestern Memorial Hospital [NMH]) from January 1, 2013, to November 30, 2016. Analyses were conducted and refined from August 28, 2018, to November 20, 2020, using entropy balance to account for observed differences between the treatment and comparison groups.

Interventions: Treatment included consultation with a transitional care nurse (TCN) or a social worker (SW) trained for the GEDI WISE program at a beneficiary's first ED visit (index ED visit). The comparison group included beneficiaries who were never seen by either a TCN or an SW during the study period.

Main outcomes and measures: The main outcome evaluated was prorated total Medicare payer expenditures per beneficiary over 30 and 60 days after the index ED visit encounter.

Results: Of the total 24 839 unique Medicare beneficiaries, 4041 were seen across the 2 EDs; 1947 (17.4%) at MSMC and 2094 (15.4%) at the NMH received treatment from either a GED TCN and/or a GED SW. The mean (SD) age of beneficiaries at MSMC was 78.8 (8.5) years and at NMH was 76.4 (7.7) years. Most patients at both hospitals were female (6821 [60.8%] at MSMC and 8023 [58.9%] at NMH) and White (7729 [68.9%] at MSMC and 9984 [73.3%] at NMH). Treatment was associated with statistically significant mean savings per beneficiary of $2436 (95% CI, $1760-$3111; P < .001) at one ED and $2905 (95% CI, $2378-$3431; P < .001) at the other ED in the 30 days after the index ED visit. The association between treatment and mean cumulative savings at 60 days after the index ED visit per beneficiary was also significant: $1200 (95% CI, $231-$2169; P = .02) at one ED and $3202 (95% CI, $2452-$3951; P < .001) at the other ED.

Conclusions and relevance: Among Medicare fee-for-service beneficiaries, receipt of ED-based geriatric treatment by a TCN and/or an SW was associated with lower Medicare expenditures. These estimated cost savings may be used when calculating or considering the bundled value and potential reimbursement per patient for GED care programs.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hwang reported receiving grants from the John A. Hartford Foundation, the Gary and Mary West Health Institute, and the Centers for Medicare & Medicaid (CMS) Innovations Program during the conduct of the study. Dr Dresden reported receiving grants from the CMS during the conduct of the study and from the National Institute on Aging and the Patient-Centered Outcomes Research Institute outside the submitted work. Dr Kang reported receiving grants from Northwestern University during the conduct of the study. Dr Loo reported receiving grants from the CMS during the conduct of the study. Dr Cruz reported receiving grants from the Gary and Mary West Health Institute during the conduct of the study. Dr Richardson reported receiving grants from the CMS during the conduct of the study. Dr Aldeen reported receiving grants from the CMS Innovation Center given to his institution during the conduct of the study. Dr Gravenor reported receiving grants from the CMS Innovation Center. No other disclosures were reported.

Figures

Figure.. Entropy Covariate Balancing Across Treatment and Comparison Groups at Mount Sinai Medical Center and Northwestern Memorial Hospital

ACO indicates accountable care organization; ED, emergency department; ESI, Emergency Severity Index; and ISAR, Identification of Seniors at Risk Score.