Critical Condition: How to Save the ER

Deanna Lee

You're listening to Policy Minded, a podcast by RAND. I'm Deanna Lee. Today, we're taking you inside America's emergency rooms, which handle up to 140 million visits each year. ERs serve as the front line of the nation's health care system and as its health care safety net. But the viability of emergency care as we know it is at risk. Here to tell us why is Dr. Mahshid Abir. She's a policy researcher at RAND and a practicing emergency physician. Dr. Abir, thanks for being here.

Mahshid Abir

Thanks for having me.

Deanna Lee

You're a policy researcher, and a lot of what we're going to discuss today is based on your work here at RAND, and one report in particular is what we're going to focus on. But as I mentioned in the intro, you're also an emergency physician. So can you walk us through what a typical day in the emergency department is like if if there is such a thing?

Mahshid Abir

Almost every day in the emergency department, especially recently, there are many patients that need to be seen. Oftentimes there are long wait times with people waiting in the waiting room for hours on end. When they get into a room, oftentimes they have to wait even more. And if they get admitted to the hospital, they may have to wait in a bed in the emergency room for days until they're able to be moved upstairs to an inpatient bed.

Deanna Lee

A harrowing patient experience it sounds like for sure in the ER. Can you tell us a little bit about the the variety of conditions you're seeing? I imagine the severity is is incredibly wide ranging in terms of of how serious a condition is or how mild it might be.

Mahshid Abir

Absolutely. So we see anything from very basic medical presentations, like minor injuries, minor cuts, skin rashes, to catastrophic injuries from motor vehicle accidents, heart attacks, strokes, and everything in between. There's really nothing that the ER doesn't see and doesn't handle. And it is absolutely the case that in the recent years both patient acuity, how sick they are, and complexity has increased in a way that many patients present with both medical conditions and social needs, and intensive care needs. And many ERs patients of all ages and they all see patients of all walks of life and no one's turned away.

Deanna Lee

We're gonna talk a little bit more about those patient acuity and complexity issues in a minute. But before we do, let's take a step back and talk a little bit more about why emergency departments are so important. A lot of those reasons are going to be obvious to our listeners. We we just heard the range of conditions that are treated, that must be treated urgently. But what are some of the key functions that might not spring to mind right away when most people think of emergency departments?

Mahshid Abir

Emergency departments are one of the few health care delivery sites in America that are open twenty four seven. And the only other services that are similar are law enforcement, 911 and emergency medical services. So if someone has an emergency in the middle of the night, if they have a medical emergency, that's where they're gonna go because that's the only door that is open and would respond to the needs of patients. And historically that was a big role of ERs is is having a door open for medical conditions on a twenty-four-seven year-long basis. Over the decades, there has been a growth in the roles that emergency departments play. As far as being a key diagnostic and therapeutic center and also being a place where patients can access specialty care, oftentimes get the kind of imaging and testing that they need that they otherwise would have to wait for weeks, if not months, in the outpatient setting to receive. Also ERs play a big role more and more in public health. So many ERs screen for depression, for suicidality. They screen for the need for patients getting vaccinated, and also for various infectious diseases like HIV and sexually transmitted diseases. Also ERs in the past couple of years have a major emergency response role in the setting of mass casualty incidents and disasters. When we have seen terrorist attacks across the U.S. or mass casualty incidents related to mass shootings, the ERs are the receiving part of the health system where they receive the patients and oftentimes save lives, stabilize patients until patients are taken to the inpatient or operating room setting for definitive care.

Deanna Lee

We've established how essential ERs are, but let's get into some of those challenges you you've already touched on a little bit. Growing patient complexity, long wait times. Can you run through the biggest issues facing EDs as they try to deliver these essential services?

Mahshid Abir

One of the biggest issues is the growing volume of patients and having to take care of the sicker patients with more acute needs along with increases in volumes. That puts not just patients at risk, but also increases the risk of burnout among all providers, physicians, physicians' assistants, nurses, and others that work in ERs. There has been mission creep over the years in a way that not really something that ERs have desired or signed up for, the list of of expectations from the health system and communities and societies and society of patients has increased. So, you know, all of this puts more and more pressure on ERs and importantly, even preceding the COVID-19 pandemic, the world was dealing with a mental health pandemic that only grew during and has probably not plateaued yet since the pandemic. And ERs that are are at the receiving end of it. So when you have patients come in with serious mental health issues, sometimes those are the hardest cases to deal with and care for in the ER. So really to kind of the icing on the cake here is the fact that based on the RAND study that my RAND colleagues and I recently completed, it is not just that all the scope is growing, the volume, the acuity, the number and types of things that that ERs do, but payment is decreasing. So what we found in our study that between 2018 and 2022, payment by Medicaid and Medicare adjusted for inflation dropped by about 4%. During the same time frame, in-network commercial payment adjusted for inflation decreased by about 11%. And and most shockingly, the out of network commercial payment dropped by about 48%. And we find that in many instances patients and insurance companies just don't pay the payment that they need to pay for the care that they received.

Deanna Lee

I wanna ask you a little bit more about two separate issues you mentioned there and what might be behind them. First, let's talk about the factors that are driving the increased patient acuity or sicker patients with more complex issues and the increasing volume. You mentioned the pandemic and mental health being a problem. Do we know anything else about what might be responsible for those numbers going up for those trends?

Mahshid Abir

There are a couple of drivers. For some of them there's more data to support, for others not as much. One thing we do know is that the U.S. population is aging and getting older with baby boomers entering their last decades. So that is definitely a factor, as we know when people age, their medical needs increase. And they also often may have more acute care needs and more complex care needs, depending on the specific patient population. There are other factors that are likely contributing, lack of capacity in the outpatient setting, where patients are not able to see primary care or specialty care in a timely manner. They may have to wait for time-sensitive conditions to be seen for weeks, if not months. So what ends up happening is that people get sicker, they end up ultimately coming to the ED sometimes out of desperation and nowhere else to go, and at that point they're sicker and may require a hospitalization. So those are some of the contributing factors. I think that as far as the complexity is concerned, the issue is twofold as far as hypotheses behind why the complexity is increasing. One of the key drivers potentially can be the fact that we are collecting more data around social needs. So historically we didn't used to collect that information as far as how many days in this month or week have you been hungry? Do you have adequate transportation? Do you have food insecurity, or are you able to keep the light on or the gas on in your home? We didn't used to ask those questions. So now we are asking folks those questions, and in fact, many ERs have embedded social workers and case managers that help address those issues. So that potentially can be driving it. Another issue can be that that perhaps these social problems are becoming bigger and more more frequent in the populations that particularly seek care in the ER.

Deanna Lee

Now let's talk a little bit more about declining payments. You mentioned that there were declines both from Medicare and from commercial insurance providers. Do we know what is behind those declines?

Mahshid Abir

I'll speak first to commercial payment. Private insurance companies are more and more declining to make payments. They are underpaying. They're also down-coding payment for ER visits. And what that means is the ER may bill the insurance company at a higher level, saying this patient was really sick, it took a lot of time, they were complex. And the insurance company may look at it and say, no, I I don't agree with you, and you deserve less payment for this case. That is happening more and more often. And ER providers have less and less bargaining ability to be able to push back on these cases where they're either underpaid or completely not paid.

Deanna Lee

And what about payments from the Centers for Medicare and Medicaid Services?

Mahshid Abir

So those payments have also been dropping during the study years, the five years that we looked at. So Medicaid and Medicare payments adjusted for inflation dropped by close to four percent over the study years. And in our study we really didn't evaluate the root causes of why CMS payment has dropped.

Deanna Lee

Okay, so insufficient capacity and increased demand plus decreased payments. It sounds like a double whammy or or maybe a triple whammy for those of you that are working in emergency rooms. How are these issues affecting day to day operations for ER staff?

Mahshid Abir

It's definitely a perfect storm, Deanna, as you pointed out. It makes doing the job much more difficult. It definitely affects morale. It leads to moral injury and really attrition of the workforce across the board. We are seeing that people and this happened during the pandemic, really retiring early from emergency care, or some people entirely leaving, either entirely leaving medicine or going to work in settings that are just not as demanding. So I think the challenge is that the more people realize how much trouble ERs are in, less and less people are gonna want to do this important work. And that is gonna be a situation where less and less workforce is available and really we won't be able to meet the demand of communities across the U.S.

Deanna Lee

Absolutely. We could have another episode on healthcare worker burnout to be sure. I'm married to a nurse, so seen it firsthand. Let's move on and talk about the broader effects of this and some potential solutions. What happens if nothing is done to address some of the issues that we've discussed? What are the stakes for providers, for patients, and for communities?

Mahshid Abir

Particularly if we don't address the payment issue, I think that people are gonna be waiting longer to be seen in ERs, in the waiting rooms, because there's just not enough caregivers or healthcare providers in the emergency room to do the work so there's gonna be a major backlog. Having fewer people because there's not enough payment can also result in more mistakes being made. If you don't have enough people, that means that each healthcare provider will will need to spend less time with each patient. That means that they may not do a as thorough of a history taking or exam or a thorough of a review of the medical record, and it's possible that we will see a drop in the quality of care and a rise in medical errors. At the end of the day, it will mean lives and livelihoods because so much of the U.S. population, whether they're insured or uninsured, no matter how much money they have in their bank accounts, when they get sick or if they have nowhere else to go because no one else is open or will see them, they come to the ER. So that safety net is at risk and if the current situation persists, it may not exist in the way that we know it.

Deanna Lee

You're kind of hinting at the idea of ER's potentially closing, correct?

Mahshid Abir

Yes, and that unfortunately is already happening. So we are seeing across the board, particularly in rural areas in the U.S., many hospital closures, also in very urban areas. And when hospitals close, their ERs close. And when there is no ER, because there's just not you know, and part of the issue of hospital closures in in rural areas, the majority of it is financial. So there is a drop in payment, for example, Medicaid payment or other sources of payment that hospitals receive to keep their doors open, when they are not there or that they're getting paid less, they just won't be able to keep their doors open and the ER is part of the bigger system. So we're already seeing that happen and what that translates to for people is that if, let's say you're a person who lives in a rural community and your hospital on ER closes, that means that if you have a heart attack and an ambulance comes to your door to pick you up, they may have to travel a couple of hours instead of twenty, thirty minutes to get you to a hospital. For conditions like heart attacks and strokes and other time sensitive conditions, that's a matter of life and death and that's a matter of of how if you live then, how how much function do you get back, how much heart function, how much physical function, for example, if you're having a stroke.

Deanna Lee

Absolutely. And what actions can be taken to keep emergency room doors open? How can we address the the payment issue and the other struggles that EDs are facing?

Mahshid Abir

So starting with the payment issue, states need to really start proactively developing payment models to ensure that ERs are adequately compensated for the care they provide to communities and for all the activities that they do that that benefit local and state government. So as you know, many communities the fire department and police budget and sometimes the emergency medical services budget is part of the city budget. Different cities need to consider adding coverage of emergency care, not entirely but at least partially, especially for catastrophic conditions where ERs need to surge in response to let's say a mass casualty incident or you know, any kind of infectious disease outbreak to be able to supplementthe payment that ERs receive to be able to keep their doors open and continue giving the care that that patients and communities desperately need. Also we need to really consider the role of of state government in ensuring that Medicaid coverage for emergency care is sustained. And they need to get creative about where that funding comes from. Whether it is from philanthropy or large employers which have major skin in the game to make sure that they keep their employees healthy. These models need to be developed proactively so patients continue going to ERs and depend on emergency care for themselves and loved ones.

Deanna Lee

This makes me think even more about rural areas. Like where I grew up, first responders are, you know, volunteer fire departments, not city-funded or city-managed services. So it's kind of another just strain, another thing that communities have to come kind of keep running by themselves and, you know, worrying about that on top of when when hospitals or EDs might be closing.

Mahshid Abir

True.

Deanna Lee

What is the top priority? You talked about some really important potential solutions, but if you had a magic wand and could only change one thing based on your research, what would it be?

Mahshid Abir

Medicaid parity with Medicare so that particularly for emergency care that when patients come to the emergency department that Medicaid pays at the level of Medicare. That is the way to ensure that the safety net can still exist and provide the level of care that it's currently providing. In the absence of that and given the increase in demand for emergency services, I think that we will end up with a sicker population that will ultimately need much more intensive care and cost the country a lot more.

Deanna Lee

Before we go, I'm wondering are there any common misconceptions about emergency care that you'd like to clear up for our listeners?

Mahshid Abir

There is one big one that I've heard, I started hearing when I was in medical school and persisted hearing, continued to hear it during residency and during all my years of practice, which emergency care and emergency doctors are glorified triage providers. And in my mind, emergency care is so much more than triage. Emergency providers need to know a lot about many, many different topics and they have to be able to respond in order to save a life with very little information. And that is the kind of skill and training that I think the country really benefits from and whether it is saving lives or improving lives, it is going on in communities all across the country and is truly a national treasure.

Deanna Lee

Finally, we try to end on a positive note often on this show. What makes you hopeful about the future of emergency medicine?

Mahshid Abir

The people, the people that go into emergency medicine, whether it is nurses, nurse practitioners, physicians assistants, physicians, pharmacists, respiratory therapists, technicians, social workers. These are really, really committed people. And they show up day after day in spite of all the challenges that I mentioned, and try to give the best possible care to their communities, and that gives me hope.

Deanna Lee

You've convinced me. Okay. Mahshid, thank you so much for being here. We really appreciate your time.

Mahshid Abir

Thank you so much for having me.

Deanna Lee

Our discussion today outlined findings from a 2025 RAND study co-authored by Dr. Abir. You can find a link to the full report at rand.org/policyminded. Thanks for listening. This episode was produced and recorded by me, Deanna Lee. It was also recorded by Emily Ashenfelter, who edited today's episode. RAND's director of digital outreach is Pete Wilmoth. We'll see you next time on Policy Minded. RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis.