On April 7th, RAND released a report entitled “Strategies for Sustaining Emergency Care in the United States.” The report can be viewed as a sequel to its 2013 release “The Evolving Role of Emergency Departments in the United States” — only in this case, the outlook laid out across its 187 pages is significantly more dire.

We have long discussed the mounting issues with emergency care in the United States. This report confirms many of our fears, stating that there is a crisis in the industry marked by declining reimbursement rates, increased demand for services, and mounting pressures on emergency department (ED) staff and resources.

However, the vision laid forth in this report isn’t entirely hopeless. That’s why today, we’ve decided to go through the report to tell you some of the major takeaways you should understand about the current state of emergency care and how it can, hopefully, improve in the future.

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What Does the Report Say About the Current State of Emergency Care?

First, the report details the tenuous state of emergency department reimbursement. From 2018 to 2022, Medicare and Medicaid payments per visit declined by 3.8% (adjusted for inflation), while commercial payments saw an even more dramatic decline; a 10.9% reduction for in-network claims, and a staggering 47.7% reduction for out-of-network claims. 

Additionally, the report notes that, according to revenue cycle management vendor data, insurance companies often underpay or deny payment for substantial portions of the amounts they are required to cover. This poses a particular risk for independently-owned ED physician practices and independent emergency physicians, as they do not receive the benefit of facility payments and economies of scale enjoyed by larger hospital systems.

Exacerbating the problem is a surge in demand for emergency care. The report notes that EDs have recently faced sicker patients with more complex cases, as EDs are often the only places where patients can — regardless of their ability to pay — receive 24/7 unscheduled acute care, thanks to the Emergency Medical Treatment and Labor Act (EMTALA).

While EMTALA unquestionably benefits patients, it can cause an increased workload and financial strain for an ED. This leads to ED crowding, longer waits, and an unpleasant or potentially unsafe on-the-job environment for healthcare workers — aspects that can, in turn, result in clinician burnout and a lower quality of care.

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How Can We Fix What’s Broken?

In order to rectify the issues currently plaguing emergency care, the RAND report recommends a multifaceted approach with the goal of creating an emergency care landscape that is not only better for patients and providers, but one that can sustain itself into the future.

To start, the report states that fair reimbursement rates must be set that reflect the essential and complex nature of emergency care. This includes advocacy for Medicaid expansion and parity with Medicare reimbursement, which will improve access in states that have yet to adopt these measures.

Next, the report notes that conditions must be improved for workers currently in the healthcare industry. This can be done in several ways. For example, efforts should be made to expand primary care capacity and implement strategies to reduce ED crowding. However, care must also be given to the workers themselves, and the report suggests that legislators implement laws that will increase penalties for violence against healthcare workers.

Another aspect of improving conditions for ED workers, according to the report, involves decreasing the amount of time and money that they spend attempting to resolve payment issues themselves. This can be done by requiring insurance companies, rather than health care providers, to collect deductibles and copays from enrollees. Furthermore, revisions to the No Surprises Act could be made to ensure that payors promptly comply with independent dispute resolution judgments, fully compensating prevailing physicians within a defined timeframe.

In the meantime, preventative care must be provided and funded so that patients are able to improve their condition without going directly to the emergency room; examples of such efforts could include care for substance use disorders and mental health care.

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A Call to Action

As unsettling as this report is to read, its findings do not come as a significant surprise. EDs have been discussing such issues for years, and while there has been disagreement over how such problems can be resolved, the report drives home the need to pass such reforms sooner than later.

This is easier said than done. Accomplishing the goals laid out in the report will require cooperation between federal and state governments, insurers, provider organizations and more — all groups that are, historically,  slow-moving. Through this report, it seems that RAND is telling them that solutions must be expedited if the country’s ED infrastructure is to be sustainable in the future.

As the industry digests this report, one thing is clear: the future of emergency care depends on bold, decisive action — action that must be performed incredibly soon.