Emergency department use has nearly recovered to prepandemic levels, but rising acuity, insufficient capacity and a laundry list of financial roadblocks are straining their viability and threatening patients’ access to care, according to a new report from RAND’s healthcare research arm.
The nonprofit, nonpartisan organization’s nearly 200-page report (PDF)—sponsored by the Emergency Medicine Policy Institute (EMPI)—paints a distressing picture of the current state of EDs, which are among the few settings where patients receive 24/7 unscheduled acute care regardless of payment thanks to the federal Emergency Medical Treatment and Labor Act (EMTALA).
EDs, the report notes, have lately faced more complex and sicker patients. Steady increases in demand and limited capacity have led to an increase in ED crowding (referred to as boarding), longer waits and potentially violence toward healthcare workers, which compromise care quality and emergency care worker attrition due to burnout. At the same time, EDs are providing more uncompensated care and expanding the scope of their work into specialties like geriatric care and care coordination.
The report also underscores payment system shortcomings for emergency care and its physicians. From 2018 to 2022, Medicare and Medicaid payments to ED physicians fell 3.8% per visit when adjusted for inflation, per the report, while pay cuts for commercially insured patient visits have fallen 10.9% when in network and 47.7% when out of network.
Citing revenue cycle management vendor data, RAND further reported that insurance administrators and patients alike “regularly underpay or deny payment for significant portions of the allowed amounts they are obligated to pay.” Independently owned ED physician practices and independent emergency physicians are at the greatest financial risk because they don’t receive facility payments outlined by current payment systems, the group wrote.
Because EDs and the workers who staff them are providing benefits to stakeholders across the board—patients, systems, payers, public health and the government—the researchers outlined a slew of evidence-based advocacy and policy recommendations they say are needed to sustain the value of emergency care.
Chief among these are calls for new public funding mechanisms directly supporting safety net care for the uninsured, public health-related efforts (vaccination, opioid addiction treatments, etc.) and public health responses conducted via EDs. This would shelter EDs and their work in these areas from the cost reduction pressures of commercial insurers and Medicare—which the report notes has increasingly failed to appropriately compensate EDs for the full range of their services.
Among the report’s other suggestions that were “strongly supported” by the researchers’ analysis and evidence are that:
- Policymakers attach ED funding to the EMTALA mandate
- Local governments provide funding for ED care that brings societal benefits
- State and federal legislatures invest in primary care capacity expansion
- State and federal legislatures impose financial incentives and/or penalties for hospitals with excessive ED boarding
- Stronger enforcement of hospitals’ existing anti-violence policies and greater legal consequences for violence against healthcare workers
- Medicaid expansion in non-expansion states, Medicaid pay parity with Medicare and Medicaid coverage of uninsured screening exams
- Legislation of mandatory commercial coverage for all ED visits “at the level of services provided, paid promptly and in full”
- New policies requiring a minimum emergency physician professional fee as a percentage of existing facility fees
“Our patients—particularly the underinsured or uninsured, rural communities, those with mental and behavioral health needs, and older adults—risk losing access to emergency care unless policymakers take immediate action to address payment disparities, rising uncompensated care and workforce burnout,” Alison Haddock, M.D., president of the American College of Emergency Physicians, a member organization of the EMPI, said in a release outlining the report’s findings.
The group’s release went on to criticize the delaying or denying of emergency care compensation by payers highlighted in the report, with EMPI Chair Patrick Velliky advocating action “to address insurer consolidation and rampant bad behaviors that put patient health and emergency physician practices at risk.”
A separate reaction statement from the Emergency Department Practice Management Association reiterated findings from the report on the widespread stakeholder value provided by EDs.
“Yet, as emergency visits and the complexity of those visits continue to rise yearly, payments to physicians continue to decrease, as shown by the RAND study,” the association said. “Without urgent and significant policy changes to support emergency medicine providers, the availability of, and access to high-quality care will decline, wait times will increase, and patient outcomes will worsen—particularly for those in greatest need of care.”