The viability of hospital-based emergency care is at risk after facing epidemics, a pandemic, increased patient acuity and complexity, and unsustainable declines in payment, an April 7 RAND report found.
The report authors assessed the current value of emergency care, the challenges facing it, measured trends in payment and identified alternative strategies. They used expert input from a study advisory board, conducted interviews and focus groups, a survey, a case study, an environmental scan of peer-reviewed and gray literature and an analysis of administrative data.
Here are five key findings:
1. Emergency departments are the safety net of the nation’s health system. They are one of a few settings that provide care regardless of a patient’s ability to pay, provide 24/7 access to advanced diagnostics and treatment, and are a port of call for unscheduled medical care. EDs also improve community and system resilience by adding care capacity and care after mass casualty incidents, disasters and public health emergencies, as well as play a vital role in public health threat prevention, detection and intervention.
2. In 2024, ED visit numbers almost reached prepandemic numbers nationally, with a consistent rise between 2020 and 2024. ED demand outstrips its capacity, leading to long waits, overcrowding and violence toward staff.
3. Patient complexity and acuity is also on the rise, increasing in demand for critical care services, and complex medical and social needs in EDs.
4. Meanwhile, payments to physicians per ED visit fell 3.8% in real inflation-adjusted payment per visit from 2018 to 2022. Reductions in payments from commercially insured patient visits also dropped 10.9% for those in-network and 47.7% for out-of-network visits over the same period.
5. Payment data from revenue cycle management companies found both insurance providers and patients regularly underpay or deny payment for significant portions of what they are obligated to pay.
To improve the sustainability of EDs, RAND recommends that:
1. The American College of Emergency Physicians, systems and other stakeholders advocate funding for the Emergency Medical Treatment and Labor Act, which guarantees access to emergency care regardless of an individual’s ability to pay.
2. Local governments pursue policies that direct city and local funds to ED care.
3. The ACEP, systems and others develop uninsured and underinsured patient compensation benchmarks so EDs are compensated commensurate based on indigent care they provide.
4. Legislators institute state and federal laws that increase legal consequences for violence against healthcare workers; invest in expanding primary care capacity; develop and implement strategies to address ED crowding; require insurance entities to collect deductibles and copays rather than making ED professionals and hospitals perform that task, as well as implement a fix to No Surprises Act flaws so payers must pay in full any independent dispute resolution judgements to physicians within a preset time frame.
5. Patient advocacy groups and other stakeholders advocate for Medicaid expansion in states that have not adopted it and advocate Medicaid parity with Medicare.
