Abstract
There is little evidence regarding how total costs of care associated with an emergency department (ED) visit have changed, despite increasing policy focus on the value of acute care. To examine trends in total standardized 30-day costs of care associated with an ED visit. This cross-sectional study of 14 113 088 ED visits at 4730 EDs from 2011 to 2016 included a 20% national sample of traditional Medicare beneficiaries aged 65 years and older. Data analysis was conducted from August 2018 to April 2020. Time (year) as a continuous variable. Trends in disposition from the ED and 30-day total standardized costs for all ED visits as well as the following spending components: index visit cost, physician costs, subsequent ED visit costs, subsequent inpatient costs, subsequent observation costs, non-ED outpatient care, postacute care, and aggregated total spending after the index ED visit. The analytic sample consisted of 14 113 088 ED visits at 4730 EDs. The mean (SD) beneficiary age was 78.6 (8.6) years, 8 573 652 visits (60.7%) were among women, and 11 908 691 visits (84.7%) were among white patients. The proportion of patients discharged from the ED rose from 1 233 701 of 2 309 563 visits (53.4%) in 2011 to 1 279 701 of 2 268 363 visits (56.4%) in 2016. Total adjusted 30-day standardized costs of care declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016 (-$126/y; 95% CI, -$130 to -$121; P < .001) for all ED visits. This decrease was primarily associated with a decline in total spending on the index ED visit (-$48/y; 95% CI, -$50 to -$47; P < .001) as well as lower spending on postacute care (-$42/y; 95% CI, -$44 to -$41; P < .001) and subsequent inpatient care (-$34/y; 95% CI, -$36 to -$32; P < .001). There was an increase in spending after the index visit on downstream observation care ($3.6/y; 95% CI, $3.5 to $3.7; P < .001), outpatient ED care ($4.6/y; 95% CI, $4.4 to $4.8; P < .001), and other outpatient care ($15/y; 95% CI, $12 to $18; P < .001). In this study, total 30-day standardized costs of ED care for Medicare beneficiaries decreased in recent years. It may be that more intensive ED spending up front is associated with reductions in total costs of an acute episode.
Highlights
The cost of emergency care has received substantial focus from policy makers and clinical leaders
Total adjusted 30-day standardized costs of care declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016 (−$126/y; 95% CI, −$130 to −$121; P < .001) for all emergency department (ED) visits
This decrease was primarily associated with a decline in total spending on the index ED visit (−$48/y; 95% CI, −$50 to −$47; P < .001) as well as lower spending on postacute care (−$42/y; 95% CI, −$44 to −$41; P < .001) and subsequent inpatient care (−$34/y; 95% CI, −$36 to −$32; P < .001)
Summary
The cost of emergency care has received substantial focus from policy makers and clinical leaders. While an ED visit is generally more expensive than an urgent care or office visit, it has distinct advantages, including the ability to carry out more extensive examinations and to observe patients without admitting them to the hospital This has led some to suggest that high-intensity emergency care may increase total value by substituting for more expensive inpatient care.[2,9] We know that while outpatient ED visit costs have risen in recent years, rates of admission from the ED have declined,[2,10] suggesting that the emphasis on ED visit costs alone may fail to capture the overall health care savings if an expensive hospitalization is avoided.[9] even in the era of alternative payment models and episodes of care, there is surprisingly little evidence regarding how total costs of an emergency care episode have changed in recent years. Such data are needed to better evaluate whether ED care is generating more value over time or whether greater up-front costs are triggering additional downstream spending and adding to the waste in the health care system
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