Viability of hospital-based emergency care in US faces peril, report suggests

The viability of hospital-based emergency care in the U.S. is at risk, threatened by issues such as patients with increasingly complex needs and falling payments for physicians, according to a new RAND report.

Many of the problems facing emergency medicine are expanding in scale, including long emergency department wait times, boarding patients in emergency department beds and a high amount of uncompensated care.

The issues are in focus as the use of hospital emergency departments return to levels seen before restrictions prompted by the COVID-19 pandemic limited use of emergency departments, according to researchers.

“Urgent action is needed to sustain hospital emergency departments, which act as a safeguard for patients who use the services and communities that rely on them during a crisis,” said Mahshid Abir, the report’s lead author and a senior physician policy researcher at RAND, a nonprofit research organization.

“Unless these challenges are addressed, there is an increasing risk that emergency departments will close, more doctors and nurses will leave emergency medicine, and patients will face even longer waits for care.”

Researchers say a key problem facing hospital-based emergency medicine is that many of the services provided are not directly reimbursed by public or private payers.

Under federal law, all people who arrive at emergency departments must be assessed and stabilized, regardless of their ability to pay. In addition, activities such as coordination of follow-up care, responding to mass casualty incidents and preparing for public health emergencies are not directly reimbursed.

RAND researchers recommend a new, tiered payment model that would build upon the existing payment system to address those shortcomings.

The recommendations include new payments from public and private payers to emergency health care professionals for the public health services not already covered by insurance, such as mental health and infectious disease screening.

Researchers also recommend expanding Medicaid payments directed to hospitals that care for large numbers of uninsured patients and increasing payments from public insurance programs to reduce the gap between private and public reimbursements.

Hospital-based emergency departments have been at the forefront of responding to the opioid and gun violence epidemics, and played a critical role in providing care throughout the COVID-19 pandemic.

Nationally, hospital emergency departments handle 120 to 140 million visits each year, compared with about 1 billion physician office visits annually. The number of hospital emergency departments is declining, with most closures occurring in rural areas.

The RAND study found that the scope of work for emergency physicians in the U.S. health system is expanding, with evidence that emergency departments have become hubs that offer various services beyond emergency care. This expanded focus includes inpatient observation care, hospital-at-home and remote patient-monitoring programs, and emergency department critical care units.

Researchers found that Medicare and Medicaid payments to emergency department physicians fell 3.8% from 2018 to 2022. Reductions in payments for commercially insured patient visits were much steeper, dropping 10.9% for commercial in-network and 48% for commercial out-of-network visits over the period.

The RAND report is based on interviews and focus groups with emergency medicine professionals, a survey of more than 200 emergency medicine department leaders, case studies, a review of other published research, and analysis of administrative data.

The study was overseen by a 13-member advisory board that included emergency medicine professionals, emergency care policy experts and other health care experts.