emergency room hospital visits

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Estimates of Emergency Department Visits in the United States, 2016-2021

The National Hospital Ambulatory Medical Care Survey (NHAMCS), conducted by the National Center for Health Statistics (NCHS), collects annual data on visits to emergency departments to describe patterns of utilization and provision of ambulatory care delivery in the United States. Data are collected from nonfederal, general, and short-stay hospitals from all 50 U.S. states and the District of Columbia, and are used to develop nationally representative estimates.

This visualization depicts both counts and rates of emergency department visits from 2016-2021 for the 10 leading primary diagnoses and reasons for visit, stratified by selected patient and hospital characteristics. Rankings for the 10 leading categories were identified using weighted data from 2021 and were then assessed in prior years; however, rankings were relatively consistent over the evaluated years. See tables in the Definitions section below the visualization for changes in leading primary diagnoses and reasons for visit from 2016-2021. Estimates in this visualization highlight and expand on information provided in the annual NHAMCS web tables , which can be used to assess how these categories and rankings changed over the evaluated years.

Use the tabs at the bottom of the visualization to select between “Primary Diagnosis” and “Reason for Visit”. Use the drop-down menus at the top of the visualization to select the estimate type, the estimate category, and the group breakdown of interest.

Access Dataset on Data.CDC.gov (Export to CSV, JSON, XLS, XML) [?]

Definitions

Based on International Classification of Diseases, 10th Revision, Clinical Modification (ICD–10–CM). See Table 11 of the NHAMCS: 2020 Emergency Department Summary Tables for code ranges of diagnosis categories, available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2020-nhamcs-ed-web-tables-508.pdf .

SOURCE: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2016-2021

Based on the patient’s own words and coded according to: Schneider D, Appleton L, McLemore T. A reason for visit classification for ambulatory care. National Center for Health Statistics. See Appendix II of the 2020 NHAMCS public-use documentation for code ranges of reason categories, available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc20-ed-508.pdf .

Calculated by dividing the number of ED visits by estimates of the U.S. civilian noninstitutionalized population (obtained from the U.S. Census Bureau’s Population Division) for selected characteristics including age, sex, and race and ethnicity. Visit rates for MSA are based on estimates of the U.S. civilian noninstitutionalized population from the National Health Interview Survey, compiled according to the Office of Management and Budget definitions of core-based statistical areas. More information about MSA definitions is available from: https://www.census.gov/programs-surveys/metro-micro.html . Visit rates for patient’s expected source of payment are based on patient’s primary expected source of payment and proportional insurance data from the National Health Interview Survey.

During data collection, all sources of payment were collected. For patients with more than one source of payment, the hierarchy below was used (with Medicare counted first and self-pay and no charge counted last) to collapse payments into one mutually exclusive variable (expected source of payment). Visits that had a missing or unknown expected payment source were excluded (between 10-14% [weighted] from 2016-2021).

Medicare: Partial or full payment by Medicare plan includes payments made directly to the hospital as well as payments reimbursed to the patient. Charges covered under a Medicare-sponsored prepaid plan are included.
Medicaid: Partial or full payment by Medicaid plan includes payments made directly to the hospital or reimbursed to the patient. Charges covered under a Medicaid-sponsored prepaid plan (HMO) or “managed Medicaid” are included.
Private: Partial or full payment by a private insurer (such as BlueCross BlueShield), either directly to the hospital or reimbursed to the patient. Charges covered under a private insurance-sponsored prepaid plan are included.
Uninsured: Includes self-pay and no charge or charity. Self-pay are charges paid by the patient or patient’s family that will not be reimbursed by a third party. Self-pay includes visits for which the patient is expected to be responsible for most of the bill, even if the patient never actually pays it. This does not include copayments or deductibles. No charge or charity are visits for which no fee is charged (such as charity, special research, or teaching).
Other: Includes Worker’s Compensation and other sources of payment not covered by the above categories, such as TRICARE, state and local governments, private charitable organizations, and other liability insurance (such as automobile collision policy coverage).

Race and Hispanic ethnicity were collected separately and converted into a single combined variable that includes non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic other people. Non-Hispanic other people includes Asian, Native Hawaiian or Other Pacific Islander, and American Indian or Alaska Native people, and people with two or more races. Missing values for race and ethnicity were imputed as described in the 2019 NHAMCS public-use documentation, available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc19-ed-508.pdf .

Please send comments or questions to [email protected] .

Data Source

National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2016-2021

Suggested Citation

National Center for Health Statistics. Emergency Department Visits in the United States, 2016-2021. Generated interactively: from https://www.cdc.gov/nchs/dhcs/ed-visits/index.htm

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When to Visit the ER

Unsure when to visit the ER? Learn about common signs and symptoms that indicate you should seek emergency care.

This article is based on reporting that features expert sources.

Patients sitting in waiting room. Confident doctor and nurse are walking in corridor. They are in hospital.

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It's 2 a.m., and you wake up with a terrible pain in your lower back . It's 5 p.m. on a Sunday afternoon, and you suddenly feel extremely nauseous. It's 9 a.m. on a Wednesday morning, and the cough that's been bothering you suddenly seems to take a turn for the worse. What should you do?

Depending on the severity of the problem and your overall health, the answer to that question may be to head to the emergency room – a unit within your local hospital that handles all manner of emergent medical issues.

“ER providers are able to very quickly assess and treat sudden, serious and often life-threatening health issues,” explains Dr. Sameer Amin, chief medical officer with L.A. Care Health Plan, the largest publicly operated health plan in the country that serves nearly 2.9 million members.

The ER, also known as the emergency department, is open 24/7 and can handle a wide range of illnesses, including physical and psychiatric issues, adds Patrick Cassell, patient care administration, emergency services, with Orlando Health in Florida.

Some ERs are Level 1 trauma centers that can handle “very high-level stuff,” he explains, while others, such as those in a community hospital or more rural settings, might need to transfer patients to a larger facility. These transfers happen when the acuity (severity) of the need exceeds the hospital's capacity to care for the patient on-site.

Common Reasons to Visit the ER

So, what constitutes an emergency?

“For us, an emergency is what the patient thinks is an emergency,” Cassell says. “It’s something that we don’t get judge-y about.”

According to a report from the Healthcare Cost and Utilization Project at the Agency for Healthcare Research and Quality, in 2018 (the most recent year data was available), U.S. residents made 143.5 million emergency room visits. Circulatory and digestive system conditions were the most common reasons for an emergency room visit, and 14% of those seen in the ER were admitted to the hospital .

Some common reasons to visit the ER include:

Chest pains .
Shortness of breath or difficulty breathing.
Abdominal pain, which may be a sign of appendicitis , bowel obstruction, food poisoning or ulcers .
Uncontrollable nausea or vomiting.
COVID-19, influenza and other respiratory infections .
Severe headaches .
Weakness or numbness.
Complications during pregnancy .
Injuries, such as broken bones, sprains, cuts or open wounds.
Urinary tract infections .
Dizziness, hallucinations and fainting .
Mental health disorders or suicide attempts.
Substance use disorders.
Back pain .
Skin infections, rashes or lesions on the skin.
Foreign object stuck inside the body.
Tooth aches .

When to Seek Urgent Care Instead of the ER

If you're questioning where to seek care, you should opt for the emergency room if you might have a potentially serious condition or are in severe pain, advises Dr. Brian Lee, medical director of the Emergency Care Center at Providence St. Joseph Hospital in Orange, California.

However, if you’re having a medical issue that’s not a full-blown emergency, but your primary care provider can’t get you in for an appointment, that’s a good time to head to an urgent care provider.

“Urgent care clinics are best equipped for a less dire level of care,” Amin explains. “They fill the gaps when the health concern will not require a hospital stay but still needs immediate treatment.”

Deciding between the ER and urgent care also depends on your medical history, notes Dr. Christopher E. San Miguel, clinical assistant professor of emergency medicine with the Ohio State University Wexner Medical Center in Columbus. For example, most people with a cough and a low-grade fever can be treated at an urgent care clinic without difficulty.

“If, however, you have a history of a lung transplant, you should probably be seen for your cough and fever at an ED,” he recommends.

Because urgent care centers typically offer less robust interventions than what you’d find at the emergency room, they can’t help in all situations. They can, however, refer you to a local ER if you do require more intensive care. They also tend to have a lower deductible than the ER, “and if you’re paying out of pocket, urgent cares can be cheaper than an emergency department typically,” Cassell says.

Cost of Urgent Care vs. ER

On the cost front, San Miguel says there are a few factors to be aware of, particularly if funds are an issue.

“Urgent cares are like any other outpatient health care office – they can require payment up front and decline to see patients who are unable to pay,” San Miguel explains.

Emergency departments, however, are compelled by federal law – the Emergency Medical Treatment & Labor Act, which was enacted in 1986 – to see patients and assess them for “life- or limb-threatening illness and injuries regardless of their ability to pay,” he says.

While this means that the ER must see you, they can “decline to treat non-life-threatening problems once they determine that they are non-life-threatening,” San Miguel adds.

You won’t be charged a fee upfront to be seen in the emergency room, but the hospital can and will bill you after you’ve been discharged.

When you accept treatment at the emergency department, “you’re still ultimately accepting responsibility for the bill ,” San Miguel points out. “And because of the nature of providing a 24-hour service that is prepared to handle any emergency, the cost of care in the ED is much higher than the cost in an urgent care.”

If you find yourself in a situation where you’ve received emergency care but are unable to pay, you should call the billing office as soon as possible to talk about your options.

“Often the bill will be reduced and you’ll be placed on a reasonable payment plan,” San Miguel says.

For any non-urgent or ongoing health concerns, visit with your primary care provider, Amin adds.

“It’s always better to have longstanding issues taken care of in a calm and collected manner during normal business hours,” he explains.

How Long Is the Wait at an ER?

Before you arrive, consider that you could be in for a long wait, depending on the type of problem you’re having and the situation inside the ER.

“We don’t operate on a first-come, first-served basis. It’s based on how sick you are,” Cassell explains.

For instance, he says, patients with more severe illnesses, such as a suspected heart attack or stroke , will take precedence over less severe problems, such as a sprain or an earache .

Even though you may walk in and find an empty waiting room and assume you’ll be seen quickly, there could be all sorts of activity going on behind the scenes. Especially in larger ERs, ambulances may be arriving with sick patients or the ER may already be very busy with sicker patients. You will get the same triage if you come by ambulance or walk in to the ER.

So rest assured that if you are very sick, you will get brought back immediately if you walk into ER. Similarly, if you take an ambulance for broken toe, it wont get you in sooner. You will likely be placed in waiting room if ER full.

San Miguel adds, “The best thing you can do is to let the triage/registration team know if there has been a change in your symptoms while you are waiting. For instance, if your chest pain is getting worse or if you are now having trouble breathing, this should prompt the team to reassess you and make sure you are triaged appropriately.”

What Should You Do While You're Waiting to Be Seen?

While you’re waiting, Amin recommends considering what the provider will ask you, such as:

When did symptoms start?
How long have they been going on for? Have they changed in severity or frequency?
Are symptoms related to a health issue you’re being treated for?
What triggered your visit to the ER today?

You should also bring a list of your medications, health conditions and history, such as chronic conditions and previous surgeries. It's also a good idea to have the names of the providers on your care team, including your primary care doctor and any specialist. Having this information at the ready is especially helpful if you’re headed to an ER that’s outside of the health system you typically use.

“It’s immensely valuable if patients are able to provide us with an accurate history of their medical problems and current medications,” San Miguel notes. “Unfortunately, not all electronic health systems communicate with each other, and in the middle of the night, it can be impossible to request records from another hospital.”

What Happens When You See an ER Provider

When you are brought in to see a provider, the initial aim of the interaction is to assess what’s going on and make sure you’re stabilized.

For some patients, a "big point of frustration is the need to tell their symptoms to more than one person," San Miguel says. "It seems like we’re quite unorganized and not communicating with each other, but in reality, we just know that the patients themselves are the best source of information about their own symptoms.”

As the physician, San Miguel always reads the notes that come from the initial intake, “but I want to confirm the details directly with you.”

While you will receive some care on the spot, most of your treatment will take place elsewhere, Cassel adds.

“With the exception of putting in stitches to fix a cut, the emergency department is not in and of itself a definitive care spot. Definitive care takes place outside of the ED,” he says.

This means that once the care team determines what’s going on and what care you need, you’ll either be admitted to the hospital for more intensive treatment or sent home with care instructions and a plan for additional follow-up if necessary.

For example, if you are having a heart attack , you’ll be admitted to an inpatient unit in the hospital for more testing and stabilization. If you’ve come in for an earache, you’ll probably be given a prescription and sent home. You'll then use those medications and recover with instructions to follow up with your primary care provider as soon as they can see you.

Lee underscores that “emergency and urgent care is not complete care. It is an acute intervention that addresses specific issues that often require further attention in the ambulatory office setting.”

Lastly, remember that the providers you’re working with are doing their best to look after you in a timely, helpful fashion. The ER staff understand you have been waiting, but they have no control over how many patients show up at once. If a surge of patients show up in an hour, the ER doesn't have the ability to suddenly bring on more staff. This happens more frequently than people realize.

Cassell says that the people who staff the emergency department are there “because we love it. We are task-focused, and we’re often very busy going from place to place, but we really do care.”

Keep in mind that the ER is not generally a calm place and the patient experience will be different from what you might get if you’re admitted in the hospital.

What to Pack in Your Hospital Bag

Senior woman packing her luggage in bedroom.

The U.S. News Health team delivers accurate information about health, nutrition and fitness, as well as in-depth medical condition guides. All of our stories rely on multiple, independent sources and experts in the field, such as medical doctors and licensed nutritionists. To learn more about how we keep our content accurate and trustworthy, read our editorial guidelines .

Amin is chief medical officer of L.A. Care Health Plan, the largest publicly operated health plan in the U.S.

Cassell is patient care administrator, emergency services, with Orlando Health in Florida.

Lee is medical director of the Emergency Care Center at Providence St. Joseph Hospital in Orange, California.

San Miguel is clinical assistant professor of emergency medicine with the Ohio State University Wexner Medical Center in Columbus.

Tags: health , patients , patient advice , hospitals

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What to expect at the ER: A guide to navigating the emergency room

Your ER experience and wait time will depend on the severity of your condition.
Reasons to go to the ER might be excessive bleeding, a high fever, a seizure, or chest pains.
If you need to see a doctor immediately, but it's not an emergency, urgent-care is another option.

When you or a loved one arrives at an emergency room (ER) in the US, you should expect to have a nurse briefly assess you shortly after arrival. The nurse will determine the severity of your condition, which will determine your wait time. If you're in serious condition, you may be brought by paramedics or EMTs and be taken directly to a trauma ward, or seen by a doctor immediately depending on your condition.

People in the ER are treated in order of how sick they are, says Eric Chu , MD, an emergency medicine physician at the University of Connecticut School of Medicine.

"For example, if you are brought in after having a cardiac arrest, you will be taken to the resuscitation bay where you will be seen immediately. In other cases, you may walk into the waiting room, be assessed by a nurse, and then depending on your acuity, have to wait until a room is open for you," says Chu.

Average wait times in the ER can range from 25 to 50 minutes , depending on how busy the hospital is. "I think the biggest factor on how long it'll take to be seen in the ER is where you live and which hospital you go to. I have seen patients wait six hours just to be put into a room. It also depends on what time and which day you go. Mondays are notorious for being the busiest day of the week and the weekends are usually the least," says Chu.

Here are some instances when you might need to go to an ER, and what you can expect once you're there.

What to expect at the ER

When you arrive at the ER, a trained emergency nurse will assess your condition and determine the urgency of your situation; this process is referred to as " triage ."

While you're waiting to see a doctor, you may be x-rayed, given medications for your symptoms, or be asked to provide blood or other samples, according to Chu.

"You will be seen by a doctor, physician assistant, or nurse practitioner when you are moved to a room. Treatment or further tests may be done at this time. Consultants, including cardiologists, nephrologists, or neurologists, may also be involved in your care, if required. Then, depending on how sick you are, you may be discharged or admitted to the hospital," says Chu.

When should you go to the ER?

As the name suggests, an ER is essentially for emergencies that could be fatal or cause permanent disability.

You may also need to go to the ER if you or a loved one have been in an accident or have experienced trauma and require immediate attention.

On the other hand, if you're feeling unwell and need to see a doctor immediately, but it's not an emergency, you can go to your primary care doctor if they have a same-day opening or go to an urgent-care clinic .

Many urgent care clinics are open every day, and you can get treated faster and for a substantially lower cost than at an ER. If your symptoms are mild and you can wait a day, you can also visit your primary care physician during clinic hours.

What to bring to the ER

If possible, you should try to gather some essentials before you go to the ER, to help the ER physicians understand your medical history and any allergies you might have.

"Things that are helpful to bring to the ER include your home medication list, the names of your doctors, any paperwork from recent hospital or doctors' visits, and your insurance information (if you have insurance). For example, if you had a recent heart attack, it may be helpful to bring the paperwork from that admission and what medications you have been taking," says Chu.

You should also try and take a trusted family member or friend along with you to help with paperwork and answer any of the physician's questions, if you are too ill to do so yourself.

If you're not going to the ER under acute circumstances, Chu recommends bringing a book or a phone charger, since you could be waiting a long time.

What is the cost of an ER visit?

The cost of your ER visit will depend on the tests conducted, medication and treatment provided, and your health insurance coverage, says Chu. This can vary from hospital to hospital. "One hospital may charge you $30 for a medicine while another may charge you $300," he says. This variation in cost can be due to several factors . For example, larger hospitals, teaching hospitals, or hospitals that provide highly specialized services may charge considerably higher fees.

The average cost of an ER visit is around $1,500 . Sprains, which are among the top causes for ER visits, could cost around $1,100, whereas treating a kidney stone could cost around $3,500. If you have insurance, it may help cover some of this cost, depending on your insurance plan.

Whether your ER visit is covered by insurance can depend on several factors, including whether the hospital or provider are included in the insurance provider's network, says Chu.

"It can also depend on whether your insurance covers certain costs, like an ambulance ride, for example. An ambulance ride that is not covered by insurance can be quite expensive," says Chu. Ambulance rides can range between $224 and $2,204 per transport.

Insider's takeaway

You may need to visit the ER for life-threatening situations. The course of your visit can vary quite a bit depending on your condition. While ERs provide necessary and oftentimes lifesaving services, they can involve long wait times and expensive bills, making urgent care or your primary care provider a better option if the situation isn't an emergency.

10 Most Common Reasons for an ER Visit

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When you think about emergency rooms , the dramatic, gurney-rolling scenes from TV and movies might flood your mind. But the truth is these portrayals overlook much of what typical ERs deal with regularly. Emergency services provide expert care to save lives, but they're also places people seek treatment for mysterious symptoms or when most doctors' offices are closed.

As we'll discuss, a few common reasons people venture to the emergency room might surprise you. Some reveal a bizarre side of the profession, while others represent the majority of cases seen in departments.

Because ER care varies worldwide, we'll focus more on cases in the United States. In 2008, the Centers for Disease Control and Prevention logged approximately 124 million visits to the ER, with only 42 million of those being injury-related [source: CDC ].

Although you might not associate some reasons on the list with visiting the ER, it's important to keep in mind the causes for illness and how people react to it differs greatly. If you believe you're experiencing a medical emergency , don't be afraid to call 911 and talk to an expert if you don't know what to do or need help. People can be taken to the ER by ambulances with paramedics or, in non-life-threatening cases, a friend or family member can drive the patient to the hospital.

So what are 10 common reasons to make a trip to the ER?

First, we'll look at a condition that typifies perceptions of emergency rooms. Read more on the following page.

Chest Pains
Abdominal Pain
Sprains and Broken Bones
Upper Respiratory Infections
Cuts and Contusions
Skin Infections
Foreign Objects in the Body

10: Chest Pains

We're all familiar with depictions of heart patients in the ER. In classic cases, trained emergency personnel will pick up defibrillators to jumpstart or regulate the patient's heartbeat. "Clear!" Bzzzzz!

Emergency room experts know how to deal with dire cardiac situations, but even more common than heart attacks are chest pains , which might be precursors or signs of other health problems.

Though chest pains are still common in ERs, some reports suggest they're declining while other conditions such as stomach pains are on the rise [source: Brophy Marcus ].

Still, doctors want patients to be aware of other signs that might indicate a situation is life-threatening. "Pressure-like" or "burning" chest pain coinciding with nausea , sweating or shortness of breath may signify a dangerous situation requiring emergency medical attention [source: Howell].

Chest pains should be examined particularly if the patient has a history of other medical conditions such as diabetes or coronary heart disease. In the United States, heart disease , which may result in emergency cardiac situations, is the leading cause of death, with more than a half a million people dying each year from heart complications [source: CDC ].

Still, chest pains are by no means a death sentence. Although it's better to err on the safe side by visiting the ER, many chest pain cases result from temporary discomfort associated with gastrointestinal flare-ups [source: Mayo Clinic Staff ].

The next reason to visit the ER has increased in recent years. Keep reading to see if you or someone you know has required emergency care for this condition.

Triage is a system of prioritizing patients when they enter the ER, regardless of who got there first. Patients who need medical attention the most are those usually rushed in by ambulances and paramedics. They are at the top of the list to receive treatment. For people driving themselves or being brought by someone else, a nurse will ask a series of questions and take their vitals to determine how soon they need treatment. Although the system might seem unfair for patients waiting in discomfort or pain, prioritizing care through triage saves lives and helps emergency experts do their jobs as efficiently as possible [source: Agency for Healthcare Research and Quality ].

9: Abdominal Pain

Abdominal pain is an increasingly common reason to make a trip to the ER [source: Brophy Marcus ]. Usually extending beyond normal indigestion , abdominal pain can result from a slew of health complications including food poisoning , kidney stones, or more serious medical conditions or illnesses.

According to one government survey from 2007, abdominal pain was one of the leading reasons people visited emergency rooms [source: Niska et al. ]. Before moving forward to treat patients with abdominal pain, doctors will try to find out if the pain stems from a health problem directly related to the digestive system or if it's a sign of problems in other areas of the body.

Poisoning is likely to contribute to abdominal pain cases as well, as it sends approximately 1,940 people to emergency departments each day in the United States [source: CDC ]. Bacterial and viral infections, as well as organs not functioning properly, can give rise to abdominal pain, too.

People should seek emergency treatment if they're experiencing continual nausea or uncontrolled vomiting, experts say [source: American College of Emergency Physicians Foundation].

Up next: This mouth pain frequently sends people to the ER.

8: Toothaches

Tooth-related issues might not come to mind when you think about the ER, but they're surely presented to ER doctors [source: American College of Emergency Physicians Foundation]. Toothaches remain a common reason to pursue emergency treatment, especially at times when dentist offices are closed after-hours or during the weekends.

Often, patients come in with abscesses , or areas filled with pus, within teeth or in surrounding gum tissue. In situations in which the abscess can be reached, ER doctors will drain it and prescribe pain medications. For pain within teeth resulting from gradual tooth decay or sudden trauma to the tooth, doctors will be limited to giving medications to alleviate pain until patients can make it to the dentist.

Depending on the cost differences, urgent care might be a better option than emergency care. Urgent care centers are often open later than doctors' offices to treat non-life-threatening medical problems and are generally less expensive than a trip to the ER [source: Preidt].

Sprains and broken bones make emergency room appearances as well. Read more on the next page.

While experts in emergency medicine are highly specialized to provide emergency care in different areas ranging from pediatrics to cardiology, your treatment might rely on being referred to another health specialist. For toothaches, for example, ER specialists can help you get your tooth pain under control temporarily, but it's likely you'll still need to be referred back to your dentist to receive the treatment needed to address the problem.

7: Sprains and Broken Bones

Sprains and broken bones can happen to anyone, regardless of health or age.

Sprains occur when ligaments attached to joints in the body are pushed to their limit or outright torn. Sometimes they happen alongside broken bones and can be caused by twisting an area of the body during movement or physical activity.

But not all sprains require ER care. Most can be deferred to urgent care, where doctors are equally equipped to treat patients and have imaging tools such as X-ray machines to rule out broken or fractured bones.

Broken bones, on the other hand, are more likely to require emergency care, especially if they pose risks to other systems in the body. For instance, a broken rib caused by a car wreck has the potential to puncture vital organs in the chest, whereas a broken toe might not pose such a risk and is a case more suitable for urgent care.

If you're experiencing consistent pain after receiving treatment for sprains or broken bones, it might be a good idea to receive urgent or emergency care to figure out why the area isn't healing properly.

Can the common cold bring people to the emergency room? Doctors see more of these cases than you'd expect. Find out more by clicking over to the next page.

6: Upper Respiratory Infections

Infections as regular as the common cold can send people to the ER, too. Upper respiratory infections caused by viruses, including those responsible for the common cold and flu , are fairly widespread among emergency rooms.

Like most illnesses, upper respiratory infections may call for emergency care if symptoms are severe enough in a patient. For example, someone with the flu who is experiencing frequent vomiting might consider heading to the ER. Other symptoms such as fainting, continual diarrhea, changes in vision, and chest or abdominal pressure are ER-worthy, doctors say [source: American College of Emergency Physicians Foundation].

With that in mind, it's also true that most cases can be handled through urgent care, where trained professionals can provide expert treatment as well. To lessen the strain on emergency rooms, consider making it to an urgent care facility or see your primary physician before heading to the ER.

Our upcoming reason to visit the ER usually involves sharp objects. Read on to learn more.

Emergencies come unexpected, and experts say it's important to know details about your health. Carrying a small list in your wallet that documents your allergies, current medications and immunization history makes it easier to receive treatment in the event you cannot speak for yourself in an emergency [source: American College of Emergency Physicians Foundation].

5: Cuts and Contusions

Cuts are as common to Hollywood ERs as they are to real life ones.

But reality deviates from movies when we examine the cause for most cuts. In films, the cut patients often end up in the ER because of violence, but that's not always the case in actual emergency rooms.

In fact, most cuts are unintentional and result from an accident with a knife or glass. Overall, the need for emergency care depends on the depth of the cut, whether it hit bone, the amount of bleeding , and whether there is any debris in the cut area [source: American College of Emergency Physicians Foundation]. Smaller cuts with controllable bleeding can be addressed at urgent care.

Contusions -- bruises -- and head trauma are also up there in common reasons to visit the ER. In 2009, cuts, broken bones, contusions and trauma injuries sustained in nonfatal motor vehicle crashes sent more than 2.3 million adults to U.S. emergency rooms [source: Beck ].

The next common reason for making a trip to the hospital's emergency room relates to an area we might take for granted. Think you've experienced it? Check the next page to find out.

4: Back Pain

Believe it or not, back pain is an increasingly common case in the ER.

Even though some instances of back pain involve gradual soreness, an accident or faulty movement might push someone to strain a back muscle or even harm one of the many bones comprising the spinal column.

In 2008, back pain earned its spot as the No. 1 reason for patients to visit the ER, doctor or other health clinics [source: Owens et al .]. In the majority of instances, a condition called spondylosis , or the degeneration of cervical or lumbar discs, contributes to patients' pain.

According to health experts, back pain may be caused by daily activities, lifting or twisting the area the wrong way, or a lack of muscles to strengthen the back [source: American College of Emergency Physicians Foundation]. On the other hand, such pain may signify another health problem such as kidney stones , arthritis or a herniated disc. This is why back pain in older individuals is worth investigating if it's not already chronic.

Skin protects us from the outside world and elements. Unfortunately, it can also bear the brunt of harmful things we encounter. Head over to the next page for more details.

Although it's important to get immediate treatment when an adult or child needs it, there might be other instances in which being seen by a doctor can wait until the next day or two. Clinics and health insurance companies have special hotlines to call -- even at unusual hours -- to talk to someone about whether an injury warrants a visit to the ER.

3: Skin Infections

Skin's role defending our bodies is compromised when there's a hole in the system -- a chink in the armor, you can say. Pus-filled abscesses and other skin infections can create abnormal reactions in the body that are both painful and bring on other symptoms. Skin infections also open up the body to microbes normally blocked by skin itself or the immune system.

Fortunately, ER doctors can drain abscesses and investigate skin problems, prescribing medications to battle infection and pain. Some infections that move rapidly or are resistant to antibiotics require speedy treatment, while others may not. One superbug bacterium, called methicillin-resistant Staphylococcus aureus (MRSA), is increasingly common in emergency rooms [source: Champeau ].

On the next page, we'll examine the more bizarre side of emergency rooms: when medical experts find objects in unexpected places.

Though fevers pose health risks for adults, they can be even more dangerous for children if left untreated. But only certain circumstances warrant taking a child to the pediatric ER for fever. If your child is 8 weeks or younger and has a rectal temperature of 100.4 degrees Fahrenheit (38 degrees Celsius) or higher, it's time to head to the doctor [source: MedlinePlus ]. For children between 3 and 36 months, the threshold is 102.2 degrees Fahrenheit (39 degrees Celsius). Duration of fever matters too, with cases lasting longer than one to two days requiring immediate attention as well.

2: Foreign Objects in the Body

ERs around the world aren't spared from bizarre cases in which patients end up with foreign objects such as coins inside their bodies.

Though there's little data on how often doctors encounter foreign objects, we're more likely to hear about them. The outlook for the patient depends on the object and whether it can be removed or passed. According to one medical source, small objects passing through the upper intestinal tract have a 90 percent chance of moving through, while those larger than 2 centimeters (about .78 inches) in diameter have a smaller chance [source: Munter ]. Another analysis shows that roughly 1,500 deaths per year result in foreign object complications [source: Chen and Beierle ].

In some cases, patients may also come in with a food item or foreign objects stuck in their esophagus as a result of choking [source: WebMD ].

And it's not unheard of for inmates or drug smugglers to try to hide objects in their body' cavities, either [source: Munter ]. Items can also be intentionally inserted into the body for sexual stimulation and can get stuck [source: Barone et al. ].

Our last reason patients visit the ER occurs in most people. Can you guess what it is?

1: Headaches

ER doctors see more headache cases than you'd expect.

While headaches usually don't require emergency attention, patients often find themselves in enough pain to show up at ERs. Cases include chronic migraines , which may require further testing with referred neurologists. Although rarely, headaches can be signs of more serious illness such as "meningitis, cerebral hemorrhaging or a brain tumor," according to emergency doctors [source: American College of Emergency Physicians Foundation].

The thing with headaches is they can coincide with patients feeling sick to their stomachs and vomiting, which can cause them to suspect having a more serious condition. Fortunately, ERs have special imaging equipment that can peer into patients' brains to see if there's anything unusual or worth investigating.

For more resources on emergency care and reasons people use it, check out the following page.

Depending on how a person's injury is prioritized -- with more life-threatening cases always receiving treatment first, anecdotal estimates for waits in the ER can range from minutes to 3.5 hours [source: Bowman]. Wait times are likely to increase in the future since ER visits are on the rise and emergency departments are declining [source: CDC ]. One analysis from the Centers for Disease Control and Prevention states that less than one-fifth of patients receive treatment within 15 minutes of arriving at the ER [source: CDC ].

Lots More Information

Emergency department services

Medicare Part B (Medical Insurance) usually covers emergency department services when you have an injury, a sudden illness, or an illness that quickly gets much worse.

Your costs in Original Medicare

You pay a copayment for each emergency department visit and a copayment for each hospital service you get.
After you meet the Part B deductible , you also pay 20% of the Medicare-Approved Amount for your doctor's services.
If your doctor admits you to the same hospital for a related condition within 3 days of your emergency department visit, you don't pay the copayment(s) because your visit is considered part of your inpatient stay.

Find out cost

To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:

Other insurance you may have
How much your doctor charges
If your doctor accepts assignment
The type of facility
Where you get your test, item, or service

Things to know

Medicare only covers emergency services outside of the U.S. under rare circumstances.

Related resources

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Why An ER Visit Can Cost So Much — Even For Those With Health Insurance

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When to use the emergency room - adult

Whenever an illness or injury occurs, you need to decide how serious it is and how soon to get medical care. This will help you choose whether it is best to:

Call your health care provider
Go to an urgent care clinic
Go to an emergency department right away

It pays to think about the right place to go. Treatment in an emergency department can cost 2 to 3 times more than the same care in your provider's office. In addition, your health insurance may require you to pay a higher copayment for care in an emergency department. Think about this and the other issues listed below when deciding.

Signs of an Emergency

How quickly do you need care? If a person or unborn baby could die or be permanently disabled, it is an emergency.

Call 911 or the local emergency number to have the emergency team come to you right away if you cannot wait, such as for:

Stopped breathing
Head injury with passing out, fainting, or confusion
Injury to neck or spine, particularly if there is loss of feeling or inability to move
Electric shock or lightning strike
Severe burn
Severe chest pain or pressure
Seizure that lasted more than 1 minute or from which the person does not rapidly awaken

Go to an emergency department or call 911 or the local emergency number for help for problems such as:

Trouble breathing
Passing out, fainting
Pain in the arm or jaw
Unusual or bad headache, particularly if it started suddenly
Suddenly not able to speak, see, walk, or move
Suddenly weak or drooping on one side of the body
Dizziness or weakness that does not go away
Inhaled smoke or poisonous fumes
Sudden confusion
Heavy bleeding
Possible broken bone, loss of movement, particularly if the bone is pushing through the skin
Serious burn
Coughing or throwing up blood
Severe pain anywhere on the body
Severe allergic reaction with trouble breathing, swelling, hives
High fever with headache and stiff neck
High fever that does not get better with medicine
Throwing up or loose stools that does not stop
Poisoning or overdose of drug or alcohol

If you are thinking about hurting yourself or others, call or text 988 or chat 988lifeline.org . You can also call 1-800-273-8255 (1-800-273-TALK). The 988 Suicide and Crisis Lifeline provides free and confidential support 24/7, anytime day or night.

You can also call 911 or the local emergency number or go to the hospital emergency room. DO NOT delay.

If someone you know has attempted suicide, call 911 or the local emergency number right away. DO NOT leave the person alone, even after you have called for help.

When to go to an Urgent Care Clinic

When you have a problem, do not wait too long to get medical care. If your problem is not life threatening or risking disability, but you are concerned and you cannot see your provider soon enough, go to an urgent care clinic.

The kinds of problems an urgent care clinic can deal with include:

Common mild illnesses, such as colds, the flu, earaches, sore throats, migraines, low-grade fevers, and limited rashes
Minor injuries, such as sprains, back pain, minor cuts and burns, minor broken bones, or minor eye injuries

If you are not Sure, Talk to Someone

If you are not sure what to do, and you don't have one of the serious conditions listed above, call your provider. If the office is not open, your phone call may be forwarded to someone. Describe your symptoms to the provider who answers your call, and find out what you should do.

Your provider or health insurance company may also offer a nurse telephone advice hotline. Call this number and tell the nurse your symptoms for advice on what to do.

Prepare now

Before you have a medical problem, learn what your choices are. Check the website of your health insurance company. Put these telephone numbers in the memory of your phone:

Your provider
The closest emergency department
Nurse telephone advice line
Urgent care clinic
Walk-in clinic

American Academy of Urgent Care Medicine website. What is urgent care medicine. aaucm.org/what-is-urgent-care-medicine/ . Accessed July 25, 2022.

American College of Emergency Physicians website. Emergency care, urgent care - what's the difference? www.acep.org/globalassets/sites/acep/media/advocacy/value-of-em/urgent-emergent-care.pdf . Updated April 2007. Accessed July 25, 2022.

Findlay S. When you should go to an urgent care or walk-in health clinic: knowing your options in advance can help you get the right care and save money. www.consumerreports.org/health-clinics/urgent-care-or-walk-in-health-clinic . Updated May 4, 2018. Accessed July 25, 2022.

Review Date 7/25/2022

Updated by: Linda J. Vorvick, MD, Clinical Professor, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington, Seattle, WA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

How Much Does an ER Visit Cost? Free Local Cost Calculator

It’s true that you can’t plan for a medical emergency, but that doesn’t mean you have to be surprised when it’s time to pay your hospital bill. In 2021, the U.S. government enacted price transparency rules for hospitals in order to demystify health care costs. That means it should be easier to get answers to questions like how much an ER visit costs.

While the question seems pretty straightforward, the answer is more complicated. Your cost will vary based on factors such as if you’re insured, whether you’ve met your deductible, the type of plan you have, and what your plan covers.

There is a lot to consider. This guide will take you through specific scenarios and answer questions about insurance plans, deductibles, co-payments, and discuss scenarios such as how much it costs if you go to the ER when it isn’t an emergency.

You’ll learn a few industry secrets too. Did you know that if you don’t have insurance you might see a higher bill? According to the Wall Street Journal , it’s common for hospitals to charge uninsured and self-pay patients higher rates than insured patients for the same services. So, where can you go if you can’t afford to go to the ER?

Keep reading for all this plus real-life examples and cost-saving tips.

How Much Does an ER Visit Cost Without Insurance?

Everything is more expensive in the ER. According to UnitedHealth, a trip to the emergency department can cost 12 times more than a typical doctor’s office visit. The average ER visit is $2,200, and doesn’t include procedures or medications.

If you want to get a better idea of what an ER visit will cost in your area, check out our medical price comparison tool that analyzes data from thousands of hospitals.

Compare Procedure Costs Near You

Other out-of-pocket expenses you may incur include bills from third parties. A growing number of emergency departments in the United States have become business entities separate from the hospital. So, third-party providers may bill you too, like:

EMS services, like an ambulance or helicopter
ER physicians
Attending physician
Consulting physicians
Advanced practice nurses (CRNA, NP)
Physician assistants (PA)
Physical therapists (PT)

And if your insurance company fails to pay, you may have to pay these expenses out-of-pocket.

How Much Does an ER Visit Cost With Insurance?

The easiest way to estimate out-of-pocket expenses for an ER visit (or any other health care service) is to read your insurance policy. You’ll want to look for information around these terms:

Deductible: The amount you have to pay out-of-pocket before your insurance kicks in .
Copay: A set fee you pay upfront before a covered medical service or procedure.
Coinsurance: The percentage you pay for a service or a procedure once you’ve met the deductible.
Out-of-pocket maximum: The most you will pay for covered services in a rolling year. Once met, your insurance company will pay 100% of covered expenses for the rest of the year.

Closely related to out-of-pocket expenses like deductibles and co-insurance are premiums. A premium is the monthly fee you (or your sponsor) pay to the insurance company for coverage. If you pay a higher premium, you’ll have a lower deductible and fewer out-of-pocket costs whenever you use your insurance to pay for services such as a visit to the ER. The opposite is also true — high deductible health plans (HDHP) offer lower monthly payments but much higher deductibles.

Sample ER Visit Cost

Using a few examples from plans available on the Marketplace on Healthcare.gov (current as of November 2021), here’s how this might play out in real life:

Rob is a young, healthy, single guy. He knows he needs health insurance but he feels reasonably sure that the only time he’d ever use it is in case of an emergency. Here’s the plan he chooses:

Plan: Blue Cross/Blue Shield Bronze Monthly premium: $394 Deductible: $7,000 Out-of-pocket maximum: $7,000 ER coverage: 100% after meeting the deductible

Rob does the math and considers the worst case scenario. If he does go to the ER, he’ll pay full price if he hasn’t yet met his deductible. But since both his deductible and his maximum out-of-pocket are the same, $7,000 is the most he’ll have to pay before his insurance kicks in at 100%.

Now imagine that Rob gets married and is about to start a family. He might need a different insurance plan to account for more hospital bills, doctors appointments, and inevitable emergency room visits.

Since Rob knows he’ll be using his insurance more often, he picks a plan with a lower deductible that covers more things.

Plan: Bright HealthCare Gold Monthly premium: $643 Deductible: $0 Out-of-pocket maximum: $6,500 ER coverage: $500 Vision: $0 Generic prescription: $0 Primary care: $0 Specialist: $40

This time Rob goes with a zero deductible plan with a higher monthly premium. It’s more out-of-pocket each month, but since his plan covers doctor’s visits, prescription drugs, and vision, he feels more prepared as his lifestyle shifts into family mode.

If he has to go to the ER for any reason, all he’ll pay is $500 and his insurance pays the rest. And worse case scenario, the most he’ll pay out-of-pocket in a year is $6,500.

How Much Does an ER Visit Cost if You Have Medicare?

Medicare Part A only covers an emergency room visit if you’re admitted to the hospital. Medicare Part B covers 100% of most ER costs for most injuries, or if you become suddenly ill. Unlike private insurance and insurance purchased on the Affordable Care Act (ACA) Marketplace, Medicare rarely covers ER visits that happen while you’re outside of the United States.

To learn more, read: How to Use the Healthcare Marketplace to Buy Insurance

How Much Does an ER Visit Cost for Non-Emergencies?

When you have a sick child but lack insurance, haven’t met your deductible, or if you’re between paychecks, just knowing you can go to the ER without being hassled for money feels like such a relief. ER staff won’t demand payment upfront, and they usually don’t ask about insurance or assess your ability to pay until after discharge.

There are other reasons, too. You might be tempted to go to the ER for situations that are less than emergent because emergency departments provide easy access to health services 24/7, including holidays and the odd hours when your primary care physician isn’t available. If you’re one of the 61 million Americans who are uninsured or underinsured , you might go to the ER because you don’t know where else to go.

What you may not understand is the cost of an ER visit without insurance can total thousands of dollars. Consumers with ER bills that get sent to collections face some of the most aggressive debt collection practices of any industry. Collection accounts and charge-offs could affect your credit score for the better part of a decade.

Did you know that charges begin racking up as soon as you give the clerk your name and Social Security number? There are tons of horror stories out there about people receiving medical bills after waiting, some for many hours, and leaving without treatment.

4 ER Alternatives Ranked by Level of Care

First and foremost, if you’re experiencing a medical emergency, call 911 or go to the closest emergency room. Do not rely on this or any other website for advice or communication.

If you’re not sure whether your condition warrants immediate, high-level emergency care, you can always call your local ER and ask to speak to their triage nurse. They can quickly assess how urgent the situation is.

If you are looking for a lower-cost alternative to the ER, this list provides a few options. Each option is ranked by their ability to provide you with a certain level of care from emergent care to the lowest level, which is similar to the routine care you would receive at a doctor’s office.

1. Charitable Hospitals

There are around 1,400 charity hospitals , clinics, and pharmacies dedicated to serving low-income families, including the uninsured. Most charitable, not-for-profit medical centers provide emergency room services, making it a good option if you’re uninsured and worried about accruing substantial medical debt.

ERs at charitable hospitals provide the same type of medical care for conditions like trauma, broken bones, and life-threatening issues like chest pain and difficulty breathing. The major difference is the price tag. Emergency room fees at a charity hospital are usually flexible and almost always based on your income.

2. Urgent Care Centers

Urgent care centers are free-standing facilities designed to treat patients with serious but not life-threatening conditions. Also called “doc in a box,” these ambulatory care centers are a good choice for treating stable but chronic health issues, fever, urinary tract infections, back pain, abdominal pain, and moderately high blood pressure, to name a few.

Urgent care clinics usually have a medical doctor on-site. Some clinics offer point-of-care diagnostic tests like ultrasound and X-rays, as well as basic lab work. The average cost for an urgent care visit is around $180, according to UnitedHealth.

3. Retail Health Clinics

You may have noticed small retail health clinics (RHC) popping up in national drugstore chains like CVS, Walgreens, and in big-box stores like Target and Walmart. The Little Clinic is an example of an RHC that offers walk-in health care services at 190 supermarkets across the United States.

RHCs help low-acuity patients with minor medical problems like sore throat, cough, flu-like symptoms, and other conditions normally treated in a doctor’s office. If you think you’ll need lab tests or other procedures, an RHC may not be the best choice. Data from UnitedHealth puts the average cost for an RHC visit at $100.

4. Telehealth Visits

Telehealth, in some form, has been around for decades. Until recently, it was mostly used to provide access to care for patients living in the most remote or rural areas. Since 2020, telehealth visits over the phone, via chat, or through videoconferencing have become a legitimate and extremely cost-effective alternative to in-person office visits.

Telehealth is perfect for some types of mental health therapies, follow-up appointments, and triage. For self-pay, a telehealth visit only costs around $50, according to UnitedHealth.

Tips for Taking Control of Your Health Care

How much does an ER visit cost; happy couple drinking coffee

Don’t procrastinate. Delaying the care you need for too long will end up costing you more in the end.
Switch your focus from reactive care to proactive care. Figuring out how to pay for an ER visit is a lot harder (and costlier) than preventing an ER visit in the first place. Data show that preventive health care measures lead to fewer illnesses and better outcomes.
Plan for the unknown. It’s inevitable that at some point in your life you’ll need health care. Start a savings account fund or better yet, enroll in a health savings account (HSA). If you’re employed (even part-time) you already qualify for an HSA. A contribution of just $9 a paycheck could add up to $468 tax-free dollars for you to spend on health care every year. Unlike the use-it-or-lose-it savings plans of the past, modern plans don’t expire. You can use HSA dollars to pay for out-of-pocket costs like copayments, deductibles, and for services that your health insurance may not cover, like dental and vision services.
Advocate for yourself. There is nothing more empowering than taking charge of your health. Shop around for services and compare prices on procedures to make sure you’re getting the best prices possible.
If you are uninsured or doing self-pay, negotiate your bill and ask for a cash discount.

Estimate the Cost of the ER Before You Need It

It’s stressful to think about money when you’re facing an emergency. Research the costs of your nearest ER before you actually need to go with Compare.com’s procedure cost comparison tool .

All you have to do is enter your ZIP code and you’ll immediately see out-of-pocket costs for ER visits at your local emergency rooms. It works for other medical services too, like MRIs, routine screenings, outpatient procedures, and more. Find the treatment you need at a price you can afford.

Disclaimer: Compare.com does not offer medical advice and is in no way a substitute for any medical advice received from health professionals. Compare.com is unable to offer any advice on any medical procedure you may need.

Nick Versaw leads Compare.com's editorial department, where he and his team specialize in crafting helpful, easy-to-understand content about car insurance and other related topics. With nearly a decade of experience writing and editing insurance and personal finance articles, his work has helped readers discover substantial savings on necessary expenses, including insurance, transportation, health care, and more.

As an award-winning writer, Nick has seen his work published in countless renowned publications, such as the Washington Post, Los Angeles Times, and U.S. News & World Report. He graduated with Latin honors from Virginia Commonwealth University, where he earned his Bachelor's Degree in Digital Journalism.

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Introduction
Conclusions
Article Information

A, Emergency department visit counts in 5 EDs in New York and US coronavirus disease 2019 (COVID-19) cases (plotted on a log scale) are shown. B, Hospital admission rates from the ED and New York’s new daily confirmed COVID-19 cases per 1 million population are shown. New York data are plotted separately to avoid obscuring trends in states with lower daily ED visit counts.

Emergency department visit counts in 19 EDs in 4 states and US coronavirus disease 2019 cases (plotted on a log scale) are shown. Circles indicate specific daily values for each variable. UCHealth indicates University of Colorado Health; UNC, University of North Carolina.

Hospital admission rates from the ED in 4 states and each state’s new daily confirmed coronavirus disease 2019 cases per 1 million population are shown. Circles indicate specific daily values for each variable. UCHealth indicates University of Colorado Health; UNC, University of North Carolina.

eFigure 1. Daily Emergency Department Visit and Admission Counts in 5 EDs in NY

eFigure 2. Daily Emergency Department Visit and Admission Counts in 5 EDs in CO

eFigure 3. Daily Emergency Department Visit and Admission Counts in 4 EDs in CT

eFigure 4. Daily Emergency Department Visit and Admission Counts in 5 EDs in MA

eFigure 5. Daily Emergency Department Visit and Admission Counts in 5 EDs in NC

Changes in Patterns of Acute MI or Ischemic Stroke Hospitalization During COVID-19 Surges JAMA Research Letter July 6, 2021 This study evaluates changes in rates of patients hospitalized for acute myocardial infarction (AMI) or suspected stroke during COVID-19 surges in the US as a measure of willingness to seek care during the pandemic. Matthew D. Solomon, MD, PhD; Mai Nguyen-Huynh, MD; Thomas K. Leong, MPH; Janet Alexander, MSPH; Jamal S. Rana, MD, PhD; Jeffrey Klingman, MD; Alan S. Go, MD
Learning from the Decrease in US Emergency Department Visits in Response to the COVID-19 Pandemic JAMA Internal Medicine Invited Commentary October 1, 2020 David L. Schriger, MD, MPH

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Jeffery MM , D’Onofrio G , Paek H, et al. Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US. JAMA Intern Med. 2020;180(10):1328–1333. doi:10.1001/jamainternmed.2020.3288

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Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US

1 Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
2 Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
3 Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
4 Information Technology Services, Yale New Haven Health System, New Haven, Connecticut
5 Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill
6 Department of Emergency Medicine, University of Massachusetts Medical School–Baystate, Springfield
7 Department of Emergency Medicine, University of Colorado, School of Medicine, Aurora
8 Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
Invited Commentary Learning from the Decrease in US Emergency Department Visits in Response to the COVID-19 Pandemic David L. Schriger, MD, MPH JAMA Internal Medicine
Research Letter Changes in Patterns of Acute MI or Ischemic Stroke Hospitalization During COVID-19 Surges Matthew D. Solomon, MD, PhD; Mai Nguyen-Huynh, MD; Thomas K. Leong, MPH; Janet Alexander, MSPH; Jamal S. Rana, MD, PhD; Jeffrey Klingman, MD; Alan S. Go, MD JAMA

Question How did emergency department visits and hospitalizations change as the coronavirus disease 2019 (COVID-19) pandemic intensified in the US?

Findings In this cross-sectional study of 24 emergency departments in 5 health care systems in Colorado, Connecticut, Massachusetts, New York, and North Carolina, decreases in emergency department visits ranged from 41.5% in Colorado to 63.5% in New York, with the most rapid rates of decrease in visits occurring in early March 2020. Rates of hospital admissions from the ED were stable until new COVID-19 case rates began to increase locally, at which point relative increases in hospital admission rates ranged from 22.0% to 149.0%.

Meaning The findings suggest that clinicians and public health officials should emphasize to patients the importance of continuing to visit the emergency department for serious symptoms, illnesses, and injuries that cannot be managed in other clinical settings.

Importance As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known.

Objective To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US.

Design, Setting, and Participants This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states’ COVID-19 case counts.

Exposures Time (day) as a continuous variable.

Main Outcomes and Measures Daily counts of ED visits, hospital admissions, and COVID-19 cases.

Results A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina.

Conclusions and Relevance From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.

As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, the delivery of acute care changed to accommodate an influx of patients with a highly contagious infection about which little was known. Initial public health messaging advised avoiding unnecessary health care use to reduce transmission of the virus and to ensure capacity to accommodate surges in COVID-19 cases. 1 An early report 2 suggested that use of health care services for elective and emergency conditions decreased during this period. Reductions in emergency department (ED) use could reflect (1) failure by patients with serious or life-threatening conditions to seek care, including conditions unrelated to COVID-19 3 ; (2) avoidance of the ED for nonemergency conditions; or (3) displacement of ED care to other venues, such as telemedicine visits. 4 We studied changes in ED use in 5 health care systems representing geographically diverse areas in 5 states in the first months of the COVID-19 pandemic in the US.

This cross-sectional study used data from a number of large US health care systems that were collected as part of an ongoing trial of ED prescribing practices for opioid use disorder; the original study protocol was approved by the Western Institutional Review Board with reliance agreements by the individual institutions’ institutional review boards. 5 The Western Institutional Review Board approved an amendment to this study protocol with an exemption of informed consent to collect data on ED visits and hospital admissions to better understand the association of COVID-19 with trial enrollment. The study also used deidentified quality improvement data from Mount Sinai Health System (New York City) that were collected to assess staffing and resource use during the COVID-19 outbreak and were considered exempt from institutional review board review under 45 CFR §46.101(b)(4).

For January 1 to April 30, 2020, we examined trends in daily ED visits and the rate of hospital admissions from EDs that are part of 5 large, independent health care systems in 5 states. One data set came from Mount Sinai Health System (New York), and four came from health systems in the EMBED trial: Baystate Health (Massachusetts), University of Colorado Health (UCHealth, Colorado), Mount Sinai Health (New York), University of North Carolina (UNC) Health, and Yale New Haven Health (Connecticut). We analyzed these trends in the context of publicly reported national and state COVID-19 case counts. We abstracted visit data from electronic health record databases at each health care system with structured queries of their local Epic Clarity databases (Epic Systems), with the exception of Baystate Health, which uses Cerner (Cerner Corporation). We retrieved daily COVID-19 case counts from the Johns Hopkins University Center for Systems Science and Engineering public data feed. 6 We standardized new confirmed state COVID-19 cases to state populations using US Census Bureau data on estimated population as of July 1, 2019. 7

We display the data as scatterplots with overlaid nonparametric smoothed curves generated with a locally weighted scatterplot smoothing (LOWESS; bandwidth 0.2) method. This method computes a separate least-squares regression for each data point, using a subset of points around the central data point in the regression and applying greater statistical weight to nearer points. 8 In addition to being a useful visualization technique, LOWESS can be used to estimate fitted values of the dependent variable for each value of the independent variable. These values were used to compute relative changes in admission rates and case counts to minimize the effect of outliers by estimating minima and maxima based on a local weighted mean, rather than using the more extreme observed maxima and minima; relative changes were calculated based on the LOWESS-estimated extrema. All analyses were performed using Stata statistical software, version 16.1 (StataCorp).

The 24 EDs varied widely in size and setting; data came from 5 EDs in Connecticut, Massachusetts, New York, and North Carolina and 4 EDs in Colorado. Annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; 15 of the EDs were in urban areas, 5 were suburban, and 4 were rural; 7 were academic and 17 were community sites ( Table ).

In all 5 states, there were large decreases in ED visits, with the most rapid decrease beginning the week of March 11, 2020, as the increase in the US case count for COVID-19 accelerated ( Figure 1 and Figure 2 ). The largest decrease in LOWESS estimates of visits was seen in New York (63.5%), followed by Massachusetts (57.4%), Connecticut (48.9%), North Carolina (46.5%), and Colorado (41.5%). In 3 states, (Massachusetts, Colorado, and North Carolina), small increases in ED visits occurred in late April 2020. Trends in rates of hospital admissions from the ED were associated with state-level new COVID-19 case counts ( Figure 1 and Figure 3 ). Hospital admission rates were stable in each state until that state’s COVID-19 case rate began to increase. The largest relative increase in LOWESS estimates of admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina.

Hospital admission rates were initially steady despite decreasing ED visits because trends in hospital admission counts were associated with ED visit counts (eFigures 1-5 in the Supplement ). The temporal association between the increase in each state’s COVID-19 caseload and hospital admission rates was less apparent when hospital admission counts were plotted. The exception is in the Mount Sinai Health System, where smoothed hospital admission counts appeared to peak approximately 1 week before the peak of the New York COVID-19 case rate. The ED visit count in the Mount Sinai Health System continued to decrease as hospital admission counts and state COVID-19 cases increased; there was a similar although less pronounced pattern for Yale New Haven Health.

As the COVID-19 pandemic developed and intensified in the US during the first 4 months of 2020, we found that ED visit counts decreased and the rates of hospital admissions from the ED increased in 5 health care systems in 5 states. From their height in January to their lowest point in April, ED visits decreased by more than 40% in all the health care systems and by more than 60% in New York, where the pandemic was most severe. Rates of hospital admission from the ED were stable until COVID-19 cases increased locally, suggesting lower patient volume and higher acuity in the ED as the COVID-19 pandemic spread. Despite different timing and increased rates of COVID-19 cases locally, we observed similar patterns and timing of ED visits across the 5 health care systems, with the steepest decrease in visits beginning the week of March 11, 2020. A possible explanation for these temporal associations is that the public responded more to national-level risk messaging about COVID-19 than to changes in the local situation with regard to reported cases. For example, individuals may have avoided seeking emergency care because of a fear of being exposed to COVID-19 in the ED, concerns about the possibility of extended wait times, or a sense of civic responsibility to avoid using health care services that others may have needed. 2

Even as ED visits decreased most rapidly, initial admission rates from the ED were initially stable, indicating that admission counts were decreasing as well. However, a temporal association was found between the increase in each state’s COVID-19 caseload and admission rates. We did not attempt to identify ED visits possibly associated with COVID-19, so we cannot report the decrease in non–COVID-19 ED visits. The association between COVID-19 and ED visits by patients seeking care for reasons unrelated to COVID requires further study.

Although our study could not establish the reasons for the changes in ED visits and hospital admissions that we observed, it provides insight into the COVID-19 pandemic for the medical community and the public during the COVID-19 pandemic. First, practitioners and public health officials should emphasize the importance of continuing to visit the ED for serious symptoms, illnesses, and injuries that cannot be managed in other settings, such as telemedicine visits. Second, infection control measures that protect patients and staff are essential in the ED and other clinical settings. Third, public health authorities and health care systems should provide guidance and resources to help patients determine the best place to receive care as the available health care capacity changes during the pandemic. 9

Among the limitations of our study is that the findings may not be generalizable outside the 5 health care systems that we studied. Moreover, the study data did not include diagnoses; therefore, we could not assess how the ED patient case mix may have changed during the study period. Although the data revealed a steep decrease in the use of the ED in the 5 health care systems from the middle of March to the middle of April 2020, they cannot be used to determine whether people with serious symptoms, illnesses, and injuries went untreated because of the COVID-19 pandemic. 10

From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.

Accepted for Publication: June 6, 2020.

Published Online: August 3, 2020. doi:10.1001/jamainternmed.2020.3288

Corresponding Author: Edward R. Melnick, MD, MHS, Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Ste 260, New Haven, CT 06519 ( [email protected] ).

Author Contributions: Drs Jeffery and Melnick had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jeffery, D’Onofrio, Nath, Melnick.

Acquisition, analysis, or interpretation of data: Jeffery, Paek, Platts-Mills, Soares, Hoppe, Genes, Melnick.

Drafting of the manuscript: Jeffery, D’Onofrio, Paek, Hoppe, Genes, Nath, Melnick.

Critical revision of the manuscript for important intellectual content: Jeffery, D’Onofrio, Paek, Platts-Mills, Soares, Hoppe, Melnick.

Statistical analysis: Jeffery, Paek, Soares, Nath, Melnick.

Obtained funding: D’Onofrio, Melnick.

Administrative, technical, or material support: Paek, Platts-Mills, Hoppe, Nath, Melnick.

Supervision: D'Onofrio, Hoppe, Melnick.

Conflict of Interest Disclosures: Drs. Jeffery, D'Onofrio, Platts-Mills, Soares, Hoppe, Nath, and Melnick reported receiving grants or contracts from the National Institutes of Health (NIH) during the conduct of the study. No other disclosures were reported.

Funding/Support: This work is supported within the NIH Health Care Systems Research Collaboratory by the NIH Common Fund through cooperative agreement U24AT009676 from the Office of Strategic Coordination within the Office of the NIH Director and cooperative agreement UH3DA047003 from the National Institute on Drug Abuse.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Additional Contributions: Bill K. Ross, North Carolina Translational and Clinical Sciences Institute, University of North Carolina School of Medicine; Haiping Li, MD, Department of Emergency Medicine, University of Massachusetts Medical School–Baystate; and Sean S. Michael, MD, Department of Emergency Medicine, University of Colorado, School of Medicine, assisted with data collection, and Oliver Hulland, MD, Department of Emergency Medicine, assisted with editing. None of these individuals were compensated for their work.

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v.55; Jan-Dec 2018

Reducing High-Users’ Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study

Meng-han tsai.

1 University of South Carolina, Columbia, USA

Sudha Xirasagar

Scott carroll.

2 Providence Health, Columbia, SC, USA

Charles S. Bryan

Pamela j. gallagher.

3 Community Hospital Corporation, Plano, TX, USA

Edward C. Jauch

4 Medical University of South Carolina, Charleston, USA

Associated Data

Supplemental material, SupplTableAndAppendixRev3Jan25-2018 for Reducing High-Users’ Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study by Meng-Han Tsai, Sudha Xirasagar, Scott Carroll, Charles S. Bryan, Pamela J. Gallagher, Kim Davis, and Edward C. Jauch in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use–based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users’ mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users’ rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention.

Introduction

Emergency departments (EDs) are mission-critical for hospitals, and a key source of inpatient admissions, accounting for 50% of all inpatient admissions nationally in 2011. About 14.7% of ED visits end in inpatient admission. 1 - 3 However, EDs also present financial and medical resource challenges, being mandated to provide care to all patients under the Emergency Medical Treatment and Active Labor Act. In 2011, uninsured patients accounted for 16% of 131 million ED visits, nationwide. 3 ED crowding steadily increased since 1997 through 2007, partly due to ED closures exceeding new EDs opened by 23.7%, while ED visit volumes increased 30%. 4 , 5 Since 2003, crowding has been aggravated by a new role served by EDs, as intermediate care zones (Observational Units) to preempt medically unnecessary inpatient admissions. 2 These developments have led to the current ED capacity crisis, requiring evidence-based initiatives to reduce nonemergent ED visits.

The Society for Academic Emergency Medicine’s ED Crowding Task Force noted that ED crowding has resulted in several adverse impacts on patient outcomes related to patient safety, care timeliness, patient centeredness, efficiency, effectiveness, and equity. 6 - 8 Suboptimal outcomes noted were delayed life-saving care (eg, pneumonia, myocardial infarction), increased mortality, and increased hospital-acquired infection rates. 6 , 9 We used a before-after, observational cohort study design to examine the impact of free primary care access via an in-hospital primary care clinic on annual ED visit frequency and mean emergency severity of adult high-users.

Study Design

This is a retrospective, observational study of one nonprofit, religious missionary hospital’s attempt to reduce low-severity ED visits through a primary care intervention. The hospital is located in the inner-city neighborhood of Columbia, South Carolina, with pockets of minority- and poor-population concentration. In the hospital vicinity, there are 2 other functioning EDs—one about 3 miles away at a county nonprofit hospital that serves as a teaching hospital for the University of South Carolina School of Medicine, and another at a nonprofit secular hospital in an adjacent county about 8 miles away in a different direction. The teaching hospital ED is typically overcrowded, known for its long ED waiting time. We studied adult ED patients’ visit patterns at the study hospital before and after implementation of a primary care intervention at a nonprofit urban hospital in South Carolina. Preintervention period patients, classified into ED high-users and occasional users, were studied for their mean annual visit rates and emergency severity, before and after the clinic start date. We also compared preintervention high-users with new high-users of the postintervention period.

On August 16, 2011, the hospital established a primary care intervention that included an adult walk-in primary care clinic on-campus, which remains operational to date. The intervention consisted of 2 components, an adult primary care clinic on-campus, free of cost for uninsured patients under 200% of poverty. Another component of the intervention was to actively urge insured ED patients who were ED high-users or having a chronic disease/primary care–preventable condition, to either acquire a primary care physician (PCP) if they did not have one, or regularly visit their existing PCP. The hospital management sent the ED staff a directive to educate qualifying patients at discharge about the importance of primary care for their condition, and to (1) visit their own PCP regularly, (2) visit one of the hospital’s primary care practices (if insured but did not have a PCP), or (3) visit the clinic if uninsured. Uninsured patients below 200% of poverty income qualified for free clinic services. Patient education at discharge consisted of a one-time, short conversation by the ED staff nurse, reinforced, in some cases with a detailed work-up by the clinic social worker if she was available. ED staff compliance with the directive was not monitored, and the predischarge advice was subject to the prevailing urgencies in the ED environment.

The clinic is free for uninsured patients up to 200% of poverty income (self-reported by the patient with minimal supporting documentation), and it charges a modest, sliding-scale fee above this income. It is staffed by an internal medicine, osteopathy-trained physician; a nurse-practitioner; nurse; social worker (to assist chronically ill patients with sociomedical needs, and liaise with charity care sources for pharmacy, laboratory, and imaging); and medical assistants. Clinic hours are Monday to Wednesday 8 am to 4:30 pm , Thursday 10 am to 7 pm , and Friday 8 am to 12 pm , supplemented by phone access to on-call physicians (for registered clinic patients) during off-clinic hours and weekends. The clinic PCP and staff provide a primary care medical home environment, including education about primary care and self-management of chronic conditions. After-hours call service is shared by PCPs of the hospital’s 7 office-based practices including the clinic. The physician on call logs in remotely to access the electronic medical record (EMR) system, evaluates the patient’s medical history and resolves the call as appropriate (eg, verbal advice or reassurance, calling in repeat prescriptions, advice to attend the clinic the next day or the ED immediately).

Free clinical care is complemented by orchestrating patient access to a network of charity care options available in the region. The social worker provides navigation assistance for the paperwork needed to access prescriptions through Welvista, a statewide, charitable donation-supported, mail-order pharmacy that dispenses free medications donated by leading pharmaceutical manufacturers for uninsured patients. This source is reinforced by GoodRx, an Internet-based, discounted prescription drug program, and partnerships with low-cost generic drug offerings by large retailers (eg, Walmart). Together, these initiatives have resulted in almost full access for indigent patients to either free or negligible cost medications including most state-of-the-art prescription drugs. For essential laboratory services, the clinic has negotiated very low patient co-pays ($5 for basic lab work) with the leading corporate provider of lab services in the South Carolina Midlands. Specialized lab tests are provided as a charitable donation by the same firm on a case-by-case basis. Similar arrangements are in place for radiology services, supplemented by gratuitous service by the hospital-employed own radiologists/hematologists/other physicians and gratuitous use of the hospital’s diagnostic equipment when the out of pocket costs of external providers are beyond a patient’s financial reach. Limited specialist services are provided through a low-cost referral network maintained by a nearby rural county hospital, which includes this clinic in its network. These arrangements are supplemented by gratuitous consultations by the hospital’s specialists when needed. Most patients, however, are managed by the clinic internist and nurse. Specifically, ED high-users with high medical need are eligible for free hospital outpatient procedures including imaging, free of charge. In addition to active referral of qualifying ED patients to the clinic, potential future ED patients from the community are solicited from patients who register with the clinic. These patients are encouraged by the clinic staff to ask their medically needy, indigent friends and neighbors to use the clinic services. Word-of-mouth dissemination among social networks of clinic users was thought to be a cost-effective way to preempt avoidable ED use from the surrounding community. However, upon arrival at the clinic, the same income criteria were applied to walk-in patients to identify those who qualified for free services and sliding-scale fees.

Our primary measures of interest were overall hospital ED visit volumes contributed by high-users, patient-level annual visit rates, and mean emergency severity. These measures were compared pre- versus postintervention. High-users and occasional users of the preintervention period were tracked through the postintervention period. The secondary outcome of interest was postintervention convergence of mean annual visit rates and emergency severity between returning preintervention high-users and new (postintervention) high-users. We considered this an important outcome because the primary care intervention continues to date, and should preempt nonemergent ED visits by emerging new high-users from the community. The study was approved by the hospital Ethics Committee and the university’s Institutional Review Board.

Study Protocol

We extracted billing data on all ED visits of adults aged 18 years or older during 2 periods. The preintervention period was August 16, 2009-August 15, 2011, and the postintervention period, August 16, 2011-August 15, 2014. Data were organized to group visits by patient (based on name, social security number [SSN], date of birth [DOB]). To minimize exclusions due to missing/erroneous identifiers, we linked ED data to the ED patient registration and inpatient admission databases using the above as link variables, followed by manual review to rectify errors/missing data. This step reduced sample exclusions from 7.6% to 2.7% of visits. De-identified data were extracted into University of South Carolina computers for analysis. We excluded patients with a single ED visit during the 5-year study period if that visit ended in inpatient admission, implying a clearly appropriate use of the ED for a true, occasional emergency. The study intervention did not target such visits, nor was there a subsequent visit by these patients to study longitudinal ED use behavior. These visits constituted similar proportions of the total ED visit volume, pre- and postintervention, 19.7% versus 18.3%, respectively ( Table 1 ), suggesting that the study results may be robust to their exclusion. We studied ED patients with all payer sources because significant proportions of insured patients in the preintervention period did not have a primary care provider (22% of Medicare patients, 60% of Medicaid, and 47% of privately insured patients), and because the intervention targeted the uninsured as well as insured patients without a PCP. All ED visits of study patients during the study period were included in the study.

Preintervention and Postintervention ED Patients: Demographic Characteristics, ED Use Frequency, and Medical Status.

Note. ESI is a calculated discharge ESI in the billing database. The original AHRQ ESI score is the initial triaged status 1-5, higher score indicating lower severity. In this hospital, the ESI is revised to reflect true emergency and clinical severity by calculating it at discharge, based on final diagnosis, resources used to treat, and discharge disposition. The documented ESI is also reverse coded (relative to the AHRQ scale) to align with the billing convention, higher ESI = higher severity. ED = emergency department; ESI = emergency severity index; AHRQ = Agency for Healthcare Research and Quality.

Due to distinct and independent patient registration systems at the clinic and hospital, there was no way to link clinic visits with specific ED patients except through matching name, SSN, and DOB. However, emergency service users are known to provide inaccurate SSN/DOB. One study reported a 66.6% discrepancy between SSNs documented by emergency medical service providers versus hospital-recorded SSNs among acute chest pain patients, compared with a discrepancy rate of 19.7% in the names and 18.3% in DOB for the same patients. 10 Reluctance to provide accurate SSN is widely thought to be due to patient concerns about billing department follow-up for dues collection, especially among poor or uninsured patients. (Anecdotally, inaccurate SSN or refusal to provide an SSN was also a frequent experience at this clinic.) Triangulation of the clinic patient data with the hospital inpatient and ED billing databases to correct SSN/DOB errors (as done with ED billing data) could not be accomplished.

We defined high-users as patients with 3 or more ED visits in a continuous 12-month period. The state of South Carolina’s Department of Health and Human Services defines high-users as those making 3 or more visits in a year, asking hospitals to use this definition to monitor ED utilization in an effort to minimize the overall health system cost, part of which is reimbursed by the State through Disproportionate Share Hospital (DSH) payments. We found this definition to satisfy the recommendation of the research literature that high-users being targeted for interventions should account for at least 25% of total visits to produce a meaningful impact on ED volumes. 11 In the preintervention period, our high-user definition attributed 47.5% of total ED visits to high-users. Other studies have also used this definition. 12 We identified preintervention high-users as follows. For patients with an ED visit during the preintervention period, their visits during the year before the calendar start date of the preintervention period (August 16, 2008-August 15, 2009) and year after (August 16, 2011-August 15, 2012) were drawn into a temporary analytic dataset to flag high-users who would qualify as high-users based on their visits in the months adjacent to the calendar duration of the preintervention period. This preempts misclassification bias due to the calendar limits of the study period. Similarly, to flag new high-users of the postintervention period, we used visits during August 16, 2010-August 15, 2011 (1 year prior to the calendar postintervention period). However, after identifying high-users of the 2 periods, visits were used for analysis only if they occurred in the calendar period of study. Visits that occurred before the study period were excluded from analysis. Study period visits were assigned to the pre- or post-period as applicable. Patients other than high-users were defined as “occasional users.”

We chose to study 2 preintervention years to avoid biased results from a single, potentially outlier year (eg, preintervention year). We limited it to 2 years to minimize cohort maturation bias due to disease evolution among comorbid patients. We selected 3 years for the postintervention period to allow adequate time for the 2-year cohort of preintervention patients to visit the ED postintervention, potentially receive a primary care referral, and then manifest changes in their ED use behavior. Despite imbalanced pre- and postintervention periods, we ensure comparable measures by using the average annual patient visit rate in each period, and averaging the emergency severity across a patient’s visits in each period.

At the hospital level, we compared preintervention versus postintervention ED patient volumes, total, high-users, and occasional users. We define emergency severity as the patient’s discharge emergency severity index (ESI), a calculated measure that adjusts the nurse-triaged AHRQ ESI score with the resources used to treat (total charges), and their discharge disposition. The calculation is based on an internal hospital algorithm and uses the AHRQ categories of severity but reverse coded, so that increasing score represents higher severity to align with the hospital billing convention (5 = life-threatening, 4 = emergent, 3 = urgent, 2 = nonurgent, 1 = fast track). 13 A calculated ESI approach (in contrast to initial nurse-triaged score) is consistent with the prevailing consensus that the initial triaged ESI has poor replicability and predictive validity for outcomes, largely because subsequent diagnostic assessments and treatments are highly variable relative to the initial, symptom-based triage. 14

Patient-level mean annual visit rates and mean ESI scores were aggregated across the total ED population in each period, grouping patients as high-users and occasional users. We hypothesized that longitudinally tracked high-users’ annual visit rates would decline following the intervention, and mean ESI would increase due to fewer low-severity visits. For preintervention high-users, we compared these measures pre- versus postintervention, both overall, and classified into quartiles based on mean annual visit frequency. Preintervention high-users were also compared with preintervention occasional users. Returning high-users were compared with new high-users of the postintervention period. Finally, we classified preintervention high-users into severity quartiles based on their preintervention average severity, and compared each quartile’s pre- versus post-mean severity.

We assigned serious comorbidity to the patients if, at any preintervention visit, their primary or secondary diagnoses (up to 3) showed one of 10 serious conditions (HIV and the 9 Dartmouth conditions—serious malignant or metastatic cancer, chronic pulmonary disease, coronary artery disease, severe congestive heart failure, peripheral vascular disease, severe chronic liver disease, diabetes with end-organ damage, renal failure, dementia). The Dartmouth comorbidities are validated predictors of in-hospital mortality and inpatient care intensity. 15 We also identified the presence of ambulatory care sensitive conditions (ACSCs; 24 conditions, see supplementary appendix ). Because these are chronic conditions, a given patient was assigned the comorbidity/ACSC to all their visits. Analyses were performed using SAS version 9.4.

Of total 108 717 adult ED visits, 2898 (2.7%) were excluded due to missing patient identifying information. Figure 1 shows the distribution of 105 819 visits by year and user type. Overall ED volumes increased over the study period. After excluding 1-time ED patients whose visit ended in inpatient admission, the mean annual visit volume was 16 372 preintervention, and 18 496 postintervention. Annual visit volumes contributed by preintervention high-users declined in the postintervention period, by 53.8% ( P < .001).

An external file that holds a picture, illustration, etc.
Object name is 10.1177_0046958018763917-fig1.jpg

Pre- and postintervention ED visit volumes, total visits, and distributed by user type.

Note. ED = emergency department; IP = inpatient; Int = intervention.

a One-time use, IP admitted: These are patients who visited the ED only once during the entire 5-year period and were admitted as inpatients. Because they did not visit any other time, they are excluded from the subsequent analysis which focused on tracking patient use behavior over time.

b New high-users are those who were not high-users in the preintervention period. They consist of occasional users of the preintervention period and new patients from the community.

Table 1 presents the distribution of preintervention and postintervention ED patients (the latter including returning preintervention patients). We present their demographics, average annual visit frequency, insurance status (uninsured at any visit in the study period/insured at all visits), residential proximity (based on zip code at first visit), serious comorbidity, ACSC, mean ESI, and user type (high-user/occasional user). Of preintervention patients, 77.4% were of working age, 56.6% Black, 34.1% were uninsured at 1 or more ED visits, and 25.4% were high-users who accounted for 47.5% of all preintervention visits. Prevalence of serious comorbidity was 19% and ACSC, 27.2%, total with comorbidity, 46.2%. About 43.4% lived in the hospital zip code or adjacent zip codes. Preintervention, the mean annual visit rate per patient was 1.91 (±2.37), and mean ESI score, 3.62 (±0.94). By comparison, fewer postintervention patients were high-users (22.4%), the mean annual visit rate was lower, and ESI score was higher (all P < .001). Serious comorbidity and ACSC rates were similar in the pre- and postintervention periods.

Table 2 presents the pre- versus postintervention, mean visit rates and mean ESI scores of preintervention high-users (Section A) and occasional users (Section B). Each group was classified into quartiles based on their preintervention mean annual visit rate. A large number of high-users had a visit rate equal to the quartile cutoff frequencies; we assigned all these patients to the quartile below the cutoff point (consistent with the definition of percentile values). The lowest and top quartile values, preintervention, were 0.94 and 5.43, respectively (highest value for an individual patient was 27.5). About 41.7% did not visit the ED in the postintervention period and are excluded from the denominators for postintervention visit rates and severity calculations. Across returning high-users, their mean annual visit rate was 7.3% lower than the mean visit rate of all high-users before the intervention (1.51 reduced to 1.40). Significant visit rate reductions postintervention were noted in every quartile (mean visit rates were 1.11-1.72; and the highest individual annual visit rate fell to 14.0). We noted a statistically significant postintervention increase in the overall mean ESI score (3.51-3.61), with significant increases noted within each of the lower 3 quartiles of high-users ( P < .001, P = .009, P = .013, respectively).

Preintervention Patients Classified Into Quartiles by Preintervention Visit Frequency: Pre- Versus Postintervention Visit Characteristics.

Note. Quartile cut-points are 1.5, 2.0, 3.0, and 27.5 visits annually for high-users. ESI = emergency severity index—adapted AHRQ ESI and reverse coded; higher ESI = higher severity; ED = emergency department; AHRQ = Agency for Healthcare Research and Quality.

Among occasional ED users, the annual visit rate of the top quartile nearly halved, from a preintervention rate of 1.02 to 0.67 postintervention, P < .001 ( Table 2 , Section B). Their mean ESI score increased from 3.54 to 3.66 ( P < .001). The lower 3 quartiles of occasional users had to be pooled (all these patients had only 1 visit in the preintervention period). A smaller change in mean severity is observed in this group (3.69 and 3.73, respectively, P = .039) along with a slight increase in mean visit rate (0.5 vs 0.6). Overall, the top quartile and the lower quartiles of occasional users converged to one common profile in the postintervention period (0.67 vs 0.6).

Table 3 presents the postintervention period comparison of new high-users with returning high-users. For new high-users, the lowest quartile and top quartile values were 0.6 and 3.23 visits, respectively. These values are higher than the corresponding values for returning high-users (1.11 and 3.21, respectively), but lower than those of preintervention high-users in the preintervention period (0.94 and 5.43, respectively). In the postintervention period, visit rates of new high-users and returning high-users show similarity among the lower quartiles (0.60 for quartiles 1 and 2 combined vs 1.11 and 1.45 for the first and second quartiles of returning high-users). The latter’s corresponding rates in the preintervention period were 0.94 and 2.0, respectively. New high-users’ mean ESI scores in the top quartile and lowest quartile are 3.62 and 3.68, compared with 3.53 and 3.62, respectively, for returning high-users. Upon reviewing the preintervention period ESI of high-users ( Table 2 ) against the postintervention mean ESI of returning high-users and new high-users ( Table 3 ), all quartiles show higher ESI levels in the postintervention period.

Visit Frequency and Emergency Severity in the Postintervention Period: New High-Users Versus Returning Preintervention High-Users.

Note. Despite statistically significant difference between quartile mean values between the 2 patient groups, the numeric values show convergence of visit rates and severity of new high-users and preintervention high-users in the postintervention period. ESI = emergency severity index—adapted AHRQ ESI and reverse coded; higher ESI = higher severity; ED = emergency department; AHRQ = Agency for Healthcare Research and Quality.

A subgroup analysis was performed of preintervention high-users of working age 18 to 64 years. They were classified by insurance status (insured, including private and government sources) and uninsured, and the results are shown in Supplemental Table 2 in the supplementary materials. Similar to the main analysis, uninsured high-users tracked into the postintervention period also showed substantial and statistically significant reductions in annual visit rates, concurrent with an increase in emergency severity. Insured working-age high-users showed an increase in emergency severity but no change in the visit rate. Postintervention, a convergence of mean visit rates of uninsured and insured high-user groups is also observed.

We also studied preintervention high-users classified into quartiles by their mean ESI score in the preintervention period (table presented in supplemental materials). The lowest severity quartile showed the highest postintervention increase in mean ESI, from 2.65 to 3.30, a 24.5% increase. The mean ESI decreased among the upper quartiles of severity. Mean ESI of the top quartile (4.66, which is close to the “life-threatening” score, 5.0) declined to 4.09. The mean ESI of the next quartile (3.93, almost at the “emergent” level of 4.0) also declined to 3.76. It is notable that the above changes occurred despite similar rates of serious comorbidity and ACSCs among the preintervention and postintervention ED patients ( Table 1 ).

Following the primary care access intervention, we observed a large reduction in ED visit rates of both high-users and higher end occasional users. The reductions were sustained even when the analysis was restricted to uninsured working-age patients, showing substantial changes in visit rates and severity among uninsured high-users tracked through the postintervention period, compared with the modest or no change observed among tracked insured high-users. The visit volume reductions of the uninsured occurred concurrent with increasing emergency severity of visits. The study intervention consisted of 2 components. First, an active offer of free primary care access, on-campus, to poor uninsured ED patients, prioritizing ED high-users and chronic disease patients, supplemented by 24/7 phone access to primary care doctors, was provided. For insured patients who were high-users or chronic disease patients, an educational conversation on the importance of regularly using a primary care doctor was provided at a “teachable moment,” when the patient has just survived a scary, possibly life-threatening episode. Given the broad scope of the intervention, this evaluation study included ED patients with all types of payers: Medicare, Medicaid, private insurance, and the uninsured. Medicare beneficiaries are documented to have a usual source of care (>95%). 16 However, 26% to 35% of beneficiaries use a specialist as their usual source of care, and they are more likely to be the highest-cost beneficiaries, compared with PCP users. 16 In this study, 22% of Medicare ED patients, 60% of Medicaid, and 47% of privately insured patients did not have a primary care provider as reported at their first ED visit.

While 41.7% of high-users did not return to the ED postintervention, among returning high-users, there were dramatic reductions in the annual visit frequency within every quartile (by 28%-68%). The 3-year duration of the postintervention period provided adequate time for the primary care intervention to be availed as and when a patient returned to the ED, and for patients to manifest a change in their ED use patterns. This may mitigate the likelihood of spurious findings due to chance. A definitive, intervention impact is supported by the concurrent increase in the discharge ESI, averaged over this large high-user cohort. Furthermore, the differentiation of severity changes between patient quartiles classified on severity is notable—a dramatic increase in ESI among the lowest severity patients, and clinically salient severity reductions among the emergent and life-threatening severity quartiles to lower severity levels (see supplemental materials ). (The opposite directions of effect among the low- and high-severity quartiles explain the modest (0.10) increase in average severity across all high-users, shown in Table 2 .) A note of caution, however, is appropriate. The ESI scale as computed by this hospital is not empirically validated for predictive accuracy. The original AHRQ ESI scale was designed to capture initial, nurse-triaged severity of a patient before diagnostic investigations are done to finalize the diagnoses and treatment needs, and is therefore, more a measure of symptomatic emergent severity rather than true disease state emergent severity. At this hospital, the concern regarding the severity validity of the original AHRQ ESI is mitigated because the ESI is calculated with an algorithm that uses initial triage, resources used to treat patient outcome. Intuitively, this method is superior to the AHRQ ESI scale, because it captures the true emergent status of the patient by differentiating symptom-driven emergencies versus life-threatening conditions. However, the hospital’s algorithm is proprietary (used across hospitals owned by the parent missionary group), not validated by empirical research.

A true primary care impact would be best verified by identifying ED patients who visited the free clinic and those who acquired an office-based PCP to study their ED use changes. The former proved logistically impossible due to unlinkable clinic IT and hospital EMR systems. No data are available to quantify the latter. The free clinic registered 5701 visits over 3 years, made by 741 patients, mostly uninsured patients.

The decline in preintervention high-users’ visit rates could be argued as a secular, natural regression from sporadic high ED use caused by transient medical exacerbations. With stabilization of their medical condition, these patients should regress to the mean pattern of the local population. Two findings mitigate this explanation. First, if the historic high-users’ visit reductions were due to this effect, new high-users should repeat the historic visit rates and severity levels of the preintervention period, which is not the case. On the contrary, their visit rates are much lower than the historic rates of preintervention high-users in the preintervention period. Notably in the postintervention period, new high-users and returning high-users show convergence of both visit rates and ESI levels among the lower quartiles of visit frequency. Serious comorbidity and ACSC prevalence rates were similar among the pre- and postintervention groups of ED patients ( Table 1 ). Collectively, the findings suggest that more patients may have used primary care, resulting in less need for ED visits, and when they used the ED, it was more appropriate, for emergent needs. Also supporting an intervention effect is the similar direction of change, although of lower magnitude among higher-end occasional users. The top quartile of occasional users (containing a large number of patients who fell short of the 3-visits-in-12-months criterion) showed large postintervention changes (a 75% decrease in visit frequency), and an increase in mean ESI score to similar levels as those of the lower quartiles of returning high-users.

The pattern of visit rate declines among high-users is reinforced by the observed longitudinal changes in visit ESI among patients of different severity levels. When preintervention high-users were classified on emergency severity, the lowest severity quartile, accounting for the largest fraction of preintervention high-users (39.1%), showed a 25% ESI increase in their postintervention visits. Concurrently, the higher severity patients (with emergent and life-threatening range of ESI) showed ESI reductions toward less life-threatening levels. The combination of visit rates and ESI changes in these longitudinally tracked patients supports a primary care impact. Potentially, the observed increase in ESI could be argued as a manifestation of disease evolution of chronically comorbid patients. If such was the case, one would expect a concurrent increase in the visit rate. Advancing chronic disease should cause more ED visits (for various complications) and more severe visits. On the contrary, we find a much-reduced visit rate by the same high-users, postintervention, concurrent with increased severity among the lower ESI quartiles, and reduced severity among the highest ESI quartiles.

The postintervention increase of emergency severity among low-severity patients and a decrease among high-severity patients validate the normative expectations from this primary care intervention. Primary care is the first level of contact with the health care system. The study hospital’s intervention was carefully crafted and executed to ensure a primary care medical home environment, continuity of providers (who were full-time and salaried), collaborative chronic disease management activities, care coordination, almost free access to accessory care needs such as specialist care, diagnostic and imaging services, and prescription drugs. This approach would be expected to help patients to mitigate or eliminate acute exacerbations through proactive chronic disease management, and may have helped patients to substitute ED use with primary care office visits for some low-severity episodes. Among patients with emergent and life-threatening severity preintervention, primary care may have reduced the likelihood and severity of complications of their chronic disease, or provided a medical home for early treatment of exacerbations before the condition became emergent. The collective internal consistency of findings across multiple subgroups of this ED population mitigates some of the methodological limitations, which, however, cannot be ruled out as potential explanatory factors. One methodological limitation of the study is the group-level analysis. However, individual, subject-based analysis requires accounting for medical diagnoses, which in turn requires a consolidation schema to group disparate diagnoses into a usable medical status variable for statistical analysis. Such an effort is beyond the scope of this study. Second, we are unable to identify ED patients who used the clinic. Up to 67% of SSNs in emergency service system databases may be inaccurate. 10 Anecdotal experiences at the study clinic confirm this issue.

Another major limitation is the absence of data on patient visits to other EDs in the area. The presence of 2 hospitals in the region (3 and 8 miles away, respectively) may give pause about offsetting visits to those hospital EDs that may partly account for the volume reduction at this ED. Both hospitals pose significant logistic deterrents to neighborhood patients. The teaching hospital ED had a community-wide reputation for very long waiting times for all but life-threatening and emergent patients. The second ED, located in an adjacent county, is quite distant from the study hospital’s patient source neighborhoods, a key factor in a city with limited public transportation, with no buses operating in the direction of the second hospital. Furthermore, the study hospital and its ED are focused on specialized services such as maternity and pediatrics, services that are not targeted by the study hospital. Countering the expected natural response of high-users to disperse their ED visits across hospitals, is the religious mission of the study hospital, which translated into management’s expectation that hospital staff adhere to the key creed, including an accepting attitude toward the indigent. The hospital’s hinterland is a low-income, minority-dominated neighborhood with poor transportation options. Therefore, it is likely that this study limitation is mitigated by the above factors.

The study overcomes several limitations of previous studies that showed disparate findings. Some cross-sectional studies and patient surveys showed that primary care access was associated with fewer ED visits, while others show the opposite. Supportive evidence largely consisted of cross-sectional, population-based survey data, comparing self-reported ED use by respondents with and without primary care access, or comparing the self-reported primary care access of persons reporting ED use versus nonuse. 17 - 22 Other cross-sectional studies report higher ED use by persons having a primary care provider. 23 - 26 Notably, these studies do not account for medically substantiated emergency severity. In the current study, our measure of discharge ESI (based on staff-triaged severity, resources used to treat, and final discharge disposition) represents medically robust severity and urgency representation, compared with patient-perceived need for ED care that is captured in cross-sectional surveys.

One cross-sectional study examined the likelihood of low-emergency visits to the ED by patients enrolled at one of 4 free-standing free clinics versus unenrolled ED patients at 4 hospitals in Virginia. The study reported reduced likelihood of a low-emergency visit by free clinic users, but no difference in the likelihood of an avoidable, primary care–amenable visit. 20 Acknowledged study limitations were the cross-sectional nature of the study, lack of information on the composition of each free clinic’s services, nature and continuity of medical providers, processes (if any) for care continuity, care coordination and chronic disease self-management (the essential elements of primary care), and the presence of a primary care medical home environment. As acknowledged in the paper, most free clinics depend on an uncertain roster of volunteer physicians based on availability of spare time. As such, it is difficult to expect that avoidable ED visits (that are primary care–amenable and preventable) would be reduced by the typical free clinic. Possibly due to this issue, the study showed no association of free clinic enrollment with avoidable visits. Their study also did not examine associations with ED visit volumes of the study patients. ED visit volumes are a critical issue for hospitals. As such, the significance of findings for policy-making remains limited.

Our study addresses several limitations of the above study, notably, (1) offering a longitudinal study of the ED population; (2) tracking individual patients’ ED use patterns before and after implementation of the intervention to examine utilization changes by user type; (3) studying a hospital-funded, on-campus primary care clinic which ensured prompt patient acceptance into primary care; (4) a clinic with a systematic approach to care continuity and care coordination implemented by salaried medical and ancillary providers offering dependable provider availability; and (5) a systematized approach to facilitate real access to ancillary medical services (pharmaceuticals, laboratory, and imaging services) that are critical to make a primary care intervention meaningful for the goal of reducing avoidable medical care.

Longitudinal cohort studies are critical to study ED use changes within nested subgroups. Crude, before-after volume comparisons are deceptive, due to the complex and dynamic composition of the ED population. High-users of a given year may remain high-users, or become low-users/nonusers due to complex reasons: health status changes (eg, chronic disease deterioration, resolution of acute exacerbations, new complications, death), insurance changes, acquiring a PCP, and patient preferences (eg, convenience of a snap visit to the ED vs scheduling an office visit). These dynamics of returning high-users are constantly being churned by new high-users from the community who will cycle through these processes. Secondary data sources (eg, the Healthcare Cost and Utilization Project (HCUP) nation-wide hospital discharge database) cannot accommodate patient tracking beyond a calendar year. Moreover, missing or misreported SSN and DOB (reportedly more likely by high-users) result in significant patient exclusions in HCUP data–driven studies. Triangulation of claims data with internal hospital databases is critical; our sample exclusions were reduced from 7.6% to 2.7% by such triangulation.

Few longitudinal interventional studies are documented. A 42-hospital collaborative used process reengineering to reduce ED waiting times, but it did not target the medical care content. 27 In another study, ED staff referred 965 consenting, nonemergent ED patients without a personal physician to the in-hospital primary care clinic. Of them, 50% visited the clinic versus 39% of control patients, with no subsequent difference in ED use. 28 Indigent ED patients who were generically referred to local safety-net clinics showed no change in their ED visit rates. 29 Reduced ED use was reported when uninsured patients were provided an insurance plan requiring adherence to one PCP. 30 Patients of primary care practices transformed into primary care medical homes used the ED less than comparison practice patients. 31 Overall, the evidence supports that a definitive assumption of primary care responsibility by an entity offering dependable clinic hours, and implementing key primary care principles may be the key to success.

In addition to the limitations noted earlier, other limitations include retrospective, single-hospital study, lack of data on after-hours teleconsultations, and not accounting for 2 issues: the 2008-2009 economic recession and disease maturation. Bias due to the economic recession is partly mitigated by similar time trends of the study hospital’s ED volumes to those of South Carolina and the neighboring states. 32 , 33 One unmeasured source of bias remains: policy changes at the national, state, or local level.

Disease maturation and new comorbidities that arose postintervention may underestimate the primary care impact, because they would necessitate more, not less ED visits. We observe a significant decline in visit rates. Our study, therefore, potentially underestimates the visit rate reduction attributable to the primary care intervention. Generalizability to other hospitals may be a concern, although mitigated by the study hospital’s similarity to the typical, urban hospital on many indicators: ED patient-to-visit ratio of 1:1.6 (1:1.9 among nonteaching hospitals, and 1:1.6 at a teaching hospital 20 , 34 ); 19% of adult ED visits ending in inpatient admission (14.7% nationally for adult and pediatric visits combined 3 ); 34% uninsured (31.7% in another study 35 , 36 ). Overall, the study findings support proactive, well-organized primary care interventions as a strategy to reduce avoidable ED visits.

Supplemental Material

Acknowledgments.

The authors gratefully acknowledge Sisters of Charity Providence Hospitals, Columbia, South Carolina (now known as Providence Health) for financial support to carry out the study and providing the data. They are grateful to Lib Cumbee, Elizabeth Sears, Kenneth Beasley, Lindsey Kilgo, and Carmen Wilson of Providence Hospitals for data extraction assistance and informational input. They are particularly grateful to Scott Campbell, Chief Executive Officer of Providence Health, for his support and insightful comments to improve the study.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was partially supported by the Sisters of Charity Providence Hospitals, Columbia, South Carolina.

Health Care

I read 1,182 emergency room bills this year. Here’s what I learned.

A $5,571 bill to sit in a waiting room, $238 eyedrops, and a $60 ibuprofen tell the story of how emergency room visits are squeezing patients.

by Sarah Kliff

A drawing of a hand-held magnifying glass over a hospital bill

For the past 15 months, I’ve asked Vox readers to submit emergency room bills to our database. I’ve read lots of those medical bills — 1,182 of them, to be exact.

My initial goal was to get a sense of how unpredictable and costly ER billing is across the country. There are millions of emergency room visits every year, making it one of the more frequent ways we interact with our health care system — and a good window into the health costs squeezing consumers today.

I started my project focused on one specific charge: the facility fee . I found this charge for walking through an emergency room’s doors could be as low as $533 or well over $3,000, depending on which hospital a patient visited and how severe her case was. I also learned that the price of this charge had skyrocketed in recent years, increasing much faster than other medical prices for no clear reason.

But given the volume and diversity of bills I received, I’ve learned so much more.

I’ve read emergency room bills from all 50 states and the District of Columbia. I’ve looked at bills from big cities and from rural areas, from patients who are babies and patients who are elderly. I’ve even submitted one of my own emergency room bills for an unexpected visit this past summer.

Some of the patients I read about come in for the reasons you’d expect: a car accident, pains that could indicate appendicitis or a heart attack, or because the ER was the only place open that night or weekend.

Some come in for reasons you’d never expect. Like the little girl who swallowed a coin to hide it from her sister, the 12-year-old boy who was hit by a home run ball at a professional baseball game (who, incidentally, was given a $60 ibuprofen at the local children’s hospital), and the adult who ate an entire bag of chocolate candy … without realizing it was edible marijuana. Rest assured, they are all fine!

From our series: A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill.

In so many ways, patients find themselves in a vulnerable position during these encounters with the health care system. The result is often high — and unpredictable — bills. Hospitals are not transparent about the cost of their services, their prices vary wildly from one ER to another, and it’s hard to tell which doctors are covered by insurance (even if the hospital itself is covered). In many cases, patients can’t be certain what they owe until they receive a bill in the mail, sometimes weeks or months later.

I’ve also learned that there is a lot of interest in fixing these types of situations. Since we started this project, multiple senators have introduced bills to prevent surprise emergency room bills — including one directly inspired by our project .

I’ll stop collecting emergency room bills on December 31. But before I do that, I wanted to share the five key things I’ve learned in my year-long stint as a medical bills collector.

1) The prices are high — even for things you can buy in a drugstore

One bill that left an impression on me came from a woman seen in the emergency room the day after her wedding. Her eye was irritated from the fake eyelashes she’d worn the night before, and she worried that her cornea might have been scratched.

The providers checked out her eye, squeezed in some eyedrops, and sent her home. She later got a bill that charged $238 for those eyedrops, a generic drug called ofloxacin. According to GoodRX , a website that tracks drug prices, an entire vial of this drug can be purchased at a retail pharmacy for between $15 and $50.

This is something that I saw over and over again reading emergency room bills: high prices for items that a patient could have picked up at a drugstore.

From our series: Toe ointment, a $937 bill, and a hard truth about American health care

I see this a lot, for example, with pregnancy tests. They happen in emergency rooms for good reason: Doctors often need to know whether a woman is pregnant to determine her course of care. But the prices I’ve seen for pregnancy tests are really high.

The bills in our database include a $236 pregnancy test delivered in Texas, a $147 pregnancy test in Illinois, and a $111 test in California. The highest price I saw? A $465 pregnancy test at a Georgia emergency room. For that amount, you could buy 84 First Response tests on Amazon.

Or look at the price of a common antibiotic ointment called bacitracin (you might know it better by its brand name, Neosporin). The bills in our database show that one hospital in Tennessee charged a patient a pretty reasonable $1 for bacitracin — while another hospital in Seattle charged $76 for the exact same ointment. Since prices aren’t made public, it was impossible for these (or any) patients to know whether they were at a hospital that charges $1 for a squirt of antibiotic ointment or one that charges 76 times that amount.

These bills submitted to our database were in situations where there was not a life-threatening emergency, where a provider presumably could have sent the patient to a place where their drug is available cheaper, often over the counter. But that doesn’t seem to happen. Perhaps emergency room providers don’t know the price of the care they provide, either. Instead, patients are getting drugstore items in the emergency room at a significant markup — and paying higher bills as a result.

2) Going to an in-network hospital doesn’t mean you’ll be seen by in-network doctors

On January 28, 34-year-old Scott Kohan woke up in an emergency room in downtown Austin, Texas, with his jaw broken in two places, the result of a violent attack the night before. Witnesses called 911, which dispatched an ambulance that brought him to the hospital while he was unconscious.

Kohan, who submitted his bill to our database, ended up needing emergency jaw surgery. The hospital where he was seen was in network; he Googled this on his phone right after regaining consciousness. But the jaw surgeon who saw him wasn’t. Kohan ended up with a $7,924 bill from the surgeon, which was only reversed after I wrote about his bill in May.

Kohan’s case is something I see regularly in our database: patients who end up with big bills because they went to an in-network hospital but were seen by an out-of-network doctor.

Here’s how that happens: When doctors and hospitals join a given health insurance plan’s network, they agree to specific rates for their services, including everything from a routine physical to a complex surgery.

Doctors typically end up out of network when they can’t come to that agreement — when they think the insurance plan is offering rates that are too low but the insurer argues that the doctor’s prices are simply too high.

Unless states have laws regulating out-of-network billing — and most don’t — patients often end up stuck in the middle of these contract disputes.

3) You can be charged just for sitting in a waiting room

Before I started reporting this project, I knew from my decade as a health care reporter that America has sky-high medical prices. But what I didn’t know was that patients can face steep bills even if they don’t see a doctor or have their ailment treated. They can decline treatment and still end up with a hefty fee.

I learned about this from a bill sent to me by Jessica Pell. She told me about going to an emergency room in New Jersey after she fell and cut her ear. She was given an ice pack but no other treatment. She never received a diagnosis. But she did get a bill for $5,751.

“It’s for the ice pack and the bandage,” Pell said of the fee. “That is the only tangible thing they could bill me for.”

4) It is really hard for patients to advocate for themselves in an emergency room setting

Since I started working on this project, one of the questions I get most frequently is: How do I avoid a surprise ER bill? Or how can I get my ER bill lowered?

I wish I had a good answer, but I don’t. Patients are usually at the mercy of the hospital when it comes to ER billing.

I have talked to some patients who have successfully negotiated down their emergency room bills. Most of those people applied for financial aid, requested a prompt pay discount, or found an error on their bill.

From our series: An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay.

Some especially savvy patients have even had luck arguing that their facility fee charge was coded incorrectly — that the hospital used a billing code that should be reserved for really intense, complex visits when their visit was actually pretty simple. I’ve noticed that these patients tend to have a doctor in their family who can help them make this type of argument.

Most patients who have successfully negotiated down a bill tell me it wasn’t easy. Erin Floyd from Florida told me about her experience reducing two of her daughter’s bills — one by 90 percent and one by 45 percent — through a combination of financial aid and prompt care discounts.

On the one hand, she was happy to have the bills lowered. In total, she ended up saving $4,369. On the other hand, the whole process was exhausting. There were lots of phone calls and faxes involved.

“I spent at least three hours on the phone working on this,” she says. “I was scanning, faxing, emailing, all while I was at work.” Over email, she described it as an “incredibly stressful and long process.”

And then there are, as Slate has noted , patients who have had their bills reversed after journalists wrote about them. Our project, for example, has resulted in $45,107 in medical bills being reversed after Vox began inquiring about those charges.

But for all of investigative journalism’s merits, reporters writing about medical bills isn’t a great solution for the health care system’s woes.

What stands out to me is that in all these cases, it’s essentially the hospital that gets to decide whether it wants to negotiate or reverse a bill. And if a hospital says no? If it won’t change the facility fee code, or doesn’t offer a prompt payment discount? The patient is essentially stuck. The hospital has the trump card: It can send the bill to a collection agency, a move that could devastate a patient’s credit. In those situations, there isn’t anything a patient can do to stop them.

5) Congress wants to do something about the issue

As more journalists write about ER bills, there is a growing outcry on Capitol Hill — and more senators on both sides of the aisle who want to do something about it.

There are now two proposals in Congress that would make the types of bills I write about a thing of the past. One comes from Sen. Maggie Hassan (D-NH) and another from a bipartisan group of senators including Sens. Bill Cassidy (R-LA) and Claire McCaskill (D-MO).

“It’s unacceptable”: Sen. Maggie Hassan explains her plan to end surprise ER bills.

While the two bills aim to do the same thing (prevent surprise bills in the emergency room), they take different policy approaches. The Cassidy-McCaskill proposal essentially bars out-of-network providers from billing patients directly. Instead, they would have to seek payment from the health insurer, who would be required to pay a price similar to local market rates. ( I’ve written in greater detail about how this works .)

Will either of these bills become law? It’s hard to tell. On the one hand, the safest bet with Congress is often inaction. But this issue seems to be gaining momentum. Just this week, for example, a large coalition of health plans and consumer advocates put out a statement supporting federal action on the issue. What’s more, there is bipartisan interest in working on this — making it the rare issue that just might bring Democrats and Republicans together on health care.

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The right choice

May 29, 2024

How to determine whether to visit Rapid Care, the ER, or primary care

There are instances of injury and illness in everyone’s lives that may not warrant a visit to an emergency room, yet are too urgent to wait for an opening with a primary care physician. For such circumstances, consider a rapid care or urgent care clinic.

“It’s a same-day, walk-in clinic that fills that hole in health care needs,” explained Levi Gore, FNP-C.

Rapid care or urgent care clinics operate best when patients know the proper level of care to seek for their needs. Gore offered tips to help people determine when Rapid Care is the right choice.

“Trust your gut and call 9-1-1 or seek emergency help if you’re in doubt. I’d rather people err on that side if there’s ever a question. But if it’s less urgent and they’re on the fence about where they need to go, they can ask themselves a few questions to help make that determination.

“The first question is, ‘Is this potentially life-threatening?’ The second is, ‘Is this something that needs to be seen right now?’ If the answer is yes to either, then please call 9-1-1 or go to an emergency room. If it’s something that can wait a while then make an appointment with primary care, but if it can’t wait that long that’s where rapid care comes in.”

Gore cites minor cuts and burns, coughs, colds, mild headaches, urinary tract infections, and simple sprains and strains as appropriate causes for a rapid care visit. Young children with high fevers, falling from a substantial height, or losing consciousness are examples of reasons for an immediate ER visit.

“On the other side, routine medication refills and workups for conditions that have been present for a long time are better handled by a primary care provider. Your doctor can do those things better … they know their patients and have that relationship with them.”

Whatever the condition, Gore urged patients to seek all levels of care in a timely manner: “We see a lot of people that put things off for too long, and by the time they come to us something that could have been simple becomes a much bigger deal. They might end up needing a hospital visit because they’ve become much sicker.”

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Baptist & Wolfson Oakleaf Emergency Room temporarily closed due to car with ‘suspicious material’

B aptist Health has confirmed to Action News Jax that its Oakleaf emergency room is temporarily closed due to a law enforcement investigation.

This is located near Argyle Forest Boulevard and the First Coast Expressway.

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Police are investigating “a vehicle with suspicious material in the parking lot,” Baptist said in a statement.

Patients who need emergency care are encouraged to call 911 or visit the next closest ER.

Action News Jax has reached out to the Jacksonville Sheriff’s Office to get more information about the investigation.

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Here is the full statement from Baptist Health:

Law enforcement is investigating a vehicle with suspicious material in the parking lot. Out of an abundance of caution, the Baptist & Wolfson Oakleaf Emergency Room will be temporarily closed during this time. For patients seeking emergency care, please call 911 or visit the next closest ER. Safety is our No. 1 priority.

We will provide an update when the ER reopens.

Click here to download the free Action News Jax news and weather apps, click here to download the Action News Jax Now app for your smart TV and click here to stream Action News Jax live.

Google Maps entry shows Baptist Oakleaf ER is temporarily closed

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What an expert suggests you bring to the emergency room

Nobody plans to go to the emergency room. You especially don’t plan for that visit to result in an extended stay.

When an emergency arises, you may find yourself scrambling to grab things on the way out of the door. To make sure you don’t forget anything or waste precious time, it can be helpful to prepare in case you get admitted to the hospital.

Ann Iglesias , a nurse practitioner at Advocate Health Care , recommends the following:

Take an advocate with you

One of the most helpful things you can do is have a friend or family member with you to advocate on your behalf. Your advocate can ask questions and write down answers, bring you a drink or a snack, and provide emotional support.

Bring your hearing aids and eyeglasses

People who use hearing aids or eyeglasses should always bring them to the emergency room. Lack of these aids can be disorienting. You may find it prevents you from understanding your care team, making it harder to make decisions about your care.

Pack a bag with essential supplies

In reality, some emergency room visits are too much of an emergency to allow time to pack a bag. That’s why it’s a good idea to pack one ahead of time.

In addition to glasses and hearing aids, consider pre-packing the following:

A printed list of medications and supplements you are currently taking. You should also keep this list updated on patient portals.
A printed list of phone numbers for family members, preferred pharmacy, your primary care doctor and any specialists
Fresh hearing aid batteries
Dental appliances
Maintenance medications
Books, crossword puzzles or something else to pass the time
Eye mask and ear plugs
Phone charger or power bank

Cell service may be spotty in the emergency room or at an immediate care, so it pays to have printed lists of important information.

Want to learn more about your risk for heart disease? Take a free online quiz to learn more.

About the Author

Jo Linsley, a health enews contributor, is a freelance copywriter at Advocate Health Care and Aurora Health Care. With decades of experience in writing and editing, she continues to aspire to concise and inspiring writing. She also enjoys knitting and singing as creative outlets and for their meditative qualities.

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Children's Wisconsin's emergency room saw over 70,000 visits last year. A new, expanded ER seeks to meet the need

Children's Wisconsin is opening a new, expanded emergency department on Thursday that hospital officials say will better serve patients.

The new emergency department, which has 50 treatment rooms, is located at the front of Children's hospital in Wauwatosa and will replace the existing 34-room department that Children's Wisconsin workers say they have long outgrown.

The existing emergency department was built to handle only around 40,000 visits per year, said spokesman Andy Brodzeller. Children's Wisconsin reported nearly 73,000 visits last year, according to data reported to the Wisconsin Hospital Association Information Center .

"We (will) have the ability to see more patients and see more patients quickly" in the new space, said Dr. Jean Pearce, a pediatric emergency medicine physician at Children's Wisconsin.

"Even the last shift I worked, I could have seen more patients, but I didn’t have the rooms to see patients, which can be really frustrating seeing a waiting room fill up and know that I could do something but I just don't have the space.”

Department opens as busy season kicks in

The new emergency department is opening just as the respiratory virus season is ramping up, normally the busiest time of year for the emergency department. Last year, monthly visits to Children's emergency room peaked at nearly 8,400 visits in November , driven by a high number of cases of respiratory syncytial virus , or RSV.

The project has been in the works for years and first was announced in 2018 , as part of a larger expansion project that also included a six-story building for physician offices and the consolidation of surgical services onto one floor. Initially, the plan was to renovate Children's existing emergency department, but then, in 2020, Children's announced it would instead build a new emergency department at the front of the hospital.

With the emergency department expansion, hospital officials hope to cut down on the time patients and their families spend in the waiting room and move them to treatment rooms more quickly, a strategy called "direct bedding."

"Our goal is to have a smaller waiting room, but with more rooms," Pearce said. "Rather than having patients and families wait out in the waiting room, where it's a shared space, everyone's all together — which is not what you want in the middle of respiratory season — we're going to get patients back to rooms."

In many cases, patients will go from check-in to one of six "care initiation" rooms directly off the waiting room, Pearce said. Children with less serious cases can be seen and discharged from there. If a child is very sick, health care workers can begin treatment there before moving that child to a larger room in the emergency department.

Aim is to reduce time in the emergency department

They also hope the expansion will help connect patients to care quickly and move them efficiently through the emergency department. One of the metrics that Children's Wisconsin is tracking to gauge the success of the project is the amount of time that some patients stay in the emergency department.

"Families want to be home, or they want to go (on) to their next phase in care," said Sam Green, project director for Children's overall expansion, called the Milwaukee Campus Improvement Project.

Children's officials also expect the space to be more welcoming and inviting than the existing emergency room. The new space was designed with a nature theme, is brighter and has a much more kid-friendly feel, Green said.

The waiting room features a tree-like pillar in the center and brightly colored walls. The six treatment rooms off the waiting room have baby blue accent walls and murals of nature images, including trees, flowers, deer and dragonflies.

The new emergency room also is more visible from the main road, at the front of the hospital, and is closer to the visitor parking garage. The existing emergency department was sometimes difficult for families to find, in the southeast corner of the hospital.

Training for staff included simulated emergencies

Last week, Pearce took some of the last groups of nurses, physicians and other health care workers through simulations of situations they will likely encounter in the new emergency department to familiarize them with the new space and work through any questions they had.

One simulation took place in one of the two trauma and resuscitation rooms and involved a dummy patient arriving at the emergency room with a seizure.

Nurses and other health care workers were peppered with questions about where to find certain equipment and medications.

The new treatment rooms are all similarly sized, have glass doors and are outfitted with the same equipment — a difference from the existing emergency department, where the rooms have different layouts and some have wooden doors that make it hard to keep a constant eye on patients.

"We have such a dedicated team that does such an awesome job in a space that doesn’t really work for them," said Marissa Hoffman, a registered nurse at Children's. "Now the space will support the work they do, as opposed to them making the space work."

The expansion also includes a new ambulance bay with room for four ambulances at a time, along with an adjoining decontamination bay with showers for patients who have been exposed to toxic chemicals or other contaminants, Pearce said. Children's hospital previously shared an ambulance bay with Froedtert Hospital.

The new emergency department also has imaging capabilities, including two X-ray rooms, a room with a CT scanner and an ultrasound room, which physicians hope will speed up the process and reduce the need for nurses or physicians to leave the department for imaging, Pearce said.

"If we have patients that are on oxygen or patients that require continuous monitoring, then (currently) we have to have one of our nurses physically leave the department to accompany that child, which then is pulling resources from us where they could be otherwise managing two to three patients at a time," Pearce said.

There also is a new pharmacy on the second floor of the building, with expanded hours from 8 a.m. to 11 p.m. on weekdays, Pearce said. The pharmacy offers a home-delivery program and a "meds-to-beds" program that delivers prescribed medications to admitted patients before they leave the hospital.

The new emergency room opens at 6 a.m. on Thursday.

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If you get a bill for emergency care at a non-VA facility and you think we should cover the cost, we can help. Call us at 877-881-7618 ( TTY: 711 ). We're here Monday through Friday, 8:00 a.m. to 8:00 p.m. ET. We'll go over the charges with you and help figure out who should cover the cost of your care. We can also help resolve billing ...
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Baptist & Wolfson Oakleaf Emergency Room temporarily closed due ...
Patients who need emergency care are encouraged to call 911 or visit the next closest ER. Action News Jax has reached out to the Jacksonville Sheriff's Office to get more information about the ...
What an expert suggests you bring to the emergency room
In reality, some emergency room visits are too much of an emergency to allow time to pack a bag. That's why it's a good idea to pack one ahead of time. In addition to glasses and hearing aids, consider pre-packing the following: A printed list of medications and supplements you are currently taking. You should also keep this list updated on ...
Aim is to reduce time in the emergency department
Children's hospital's emergency room had nearly 73,000 visits last year, many more than it was built to handle. It hopes to better serve patients with a bigger space.
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As Us Weekly shared on April 13, Johnson's 2-year-old son Jett was whisked off to the emergency room at Vanderbilt Children's Hospital after getting injured. She shared the details via now ...