If you're in the emergency room (ER), you're not having a good day. Whether you're having a heart attack or stroke, you were in a major (or minor) car accident, you have an infection, you ran out of your medication on a Saturday and need a prescription, you are suicidal or just sad and lonely, or you are homeless and need a safe place to sleep for a few hours—you may find yourself in an ER and you will get the care you need regardless of whether you can pay or not.
In spite of all the benefits that ERs provide patients, communities, health systems, public health, government, and payers, a new RAND study shows that the viability of these 24/7 care delivery centers is at risk because of growing challenges. Unless multifront policy action is taken, many ERs, which the country has learned to rely on, may have to shut their doors.
Over the last 50 years, America's ERs have become the “safety-net of safety-nets;” not only for taking care of patients with emergency conditions (as the name “emergency room” implies), but serving as a place where patients, primary care and specialty care offices, and other parts of the U.S. health system go for treatment of urgent and nonurgent conditions. ERs often secure follow-up care for discharged patients. Many assume leadership roles in care innovation.
Unless multifront policy action is taken, many ERs, which the country has learned to rely on, may have to shut their doors.
Although insurance companies often call out emergency care as wasteful and expensive, many ERs save health care costs by treating and discharging patients, sparing both patients and insurance companies costly hospitalizations. ERs also save insurance companies money by preventing delays in time-sensitive care that, if not rendered quickly, can result in the need for much more expensive interventions.
ERs play a major public health role. For example, they were at the forefront of responding to the COVID-19 pandemic and have been key in responding to the nation's ongoing opioid, gun violence, and mental illness epidemics. Many ERs screen for suicidality and infectious diseases (such as HIV) and offer patients vaccination. Some ERs deliver violence prevention programs and programs directed at preventing sexually transmitted diseases.
Given the critical role of ERs in responding to mass-casualty incidents and disasters, they are key to health system and community resilience. ERs have been treating casualties of terrorist attacks and mass shootings for more than two decades—making them important not just for health security but for broader national security. Yet, these ER activities are chronically unfunded or underfunded.
Many ERs are being forced to confront increasing patient, community, and health system reliance on the services they provide for nonemergent conditions. Concurrent with this mission creep, patients have become sicker with conditions that are increasingly complex—often presenting to ERs with both medical and social needs. What's more, ER wait times and “boarding,” where admitted patients stay in the ER while awaiting an inpatient bed, have also increased. All these issues can put patients and their caregivers on edge, increasing the risk of violence toward ER staff.
As if these challenges weren't enough, the RAND study shows that, after adjusting for inflation, Medicare and Medicaid payments for emergency physicians fell by 3.8 percent per visit from 2018 to 2022. Visits covered by private insurance saw an even steeper drop—by 10.9 percent for commercial in-network and 47.7 percent for commercial out-of-network visits. Insurance companies and patients routinely underpay or deny payment they owe.
On the other hand, adjusted for inflation, insurance-negotiated prices for hospitals (where a majority of ERs are based) increased by an average of over 18 percent, while insurance-negotiated professional prices for ER physicians decreased by more than 7 percent. A drop in doctor salaries, all while hospitals bring in more funds, can make emergency work even less palatable, increasing the risk of early retirement among emergency physicians and decreasing the likelihood that medical students will choose emergency medicine as their specialty of choice.
Overall, the United States has seen a rise in uncompensated and undercompensated emergency care that, if not mitigated, may lead to the closure of many ERs. Past ER closures have resulted in adverse effects for patients—who will need to travel farther for emergency care—and for neighboring ERs and hospitals that will shoulder the burden of care for the population that lost its ER.
There are a number of factors driving the increase in uncompensated and undercompensated care. One is the unfunded Emergency Medical Treatment and Active Labor Act (EMTALA) that requires ERs to evaluate patients regardless of their ability to pay. A second is the No Surprises Act (NSA) that does not allow billing patients for care provided by out-of-network emergency physicians at in-network facilities. Insurance company payment denials and downcoding, where insurance pays at a lower level of care than what an ER billed for, also increase uncompensated and undercompensated care. Other contributing factors are the increasing disparity between hospital and professional prices and increasing disparity between pay from private insurance compared to Medicaid and Medicare.
The United States has seen a rise in uncompensated and undercompensated emergency care that, if not mitigated, may lead to the closure of many ERs.
Critical actions needed to ensure the viability of ERs include
- enacting federal legislation that increases the legal consequences of assaulting health care workers
- implementing effective programs to support emergency care worker mental health
- instituting state or federal incentives (and penalties) that encourage hospitals to address patient boarding in the ER
- funding the EMTALA mandate through a percentage of commercially insured ER visits and federal (or state) stipends
- allocating local, city, and state funds to ER mass-casualty incident and disaster preparedness and response
- implementing penalties for insurance companies that fail to make timely payments and to ensure that contract terms with insurance companies are enforced
- increasing Medicaid and Medicare payment for emergency care to decrease the gap between them and private insurance payment
- instituting federal laws that prevent hospital and professional negotiated prices for emergency care from diverging above a certain percent.
None of us are immune to health emergencies, and any of us can find ourselves in an ER needing lifesaving care. That is why everyone has a stake in emergency care—regardless of where we live or the size of our bank accounts.
