Declining payments for emergency department care, 1996-1998.

Study Objective: We describe recent trends in payments from different payer classes and assess their relative importance to the financial solvency of emergency departments.

Methods: We used Medical Expenditure Panel Survey data from 1996 and 1998. The unit of analysis was the ED visit. Primary outcome measures were ED charges and payments. The independent variable of interest was payer class, and therefore, we limited our analysis to those either uninsured or covered by Medicare, Medicaid, or private insurance.

Results: From 1996 to 1998, a declining percentage of total charges were paid, from 60.3% to 53.0% (difference -7.3%; 95% confidence interval [CI] -11.3% to -3.5%). Although the percentage of total charges paid by Medicaid, Medicare, and the uninsured remained constant, the percentage of total charges paid by the privately insured declined from 75.1% to 63.4% (difference -11.7%; 95% CI -16.6% to -6.7%). Overall, adjusted mean ED charge increased from 695 dollars to 798 dollars (difference 103 dollars; 95% CI 61 dollars to 146 dollars). Two payer classes experienced statistically significant increases in adjusted mean charge: the uninsured, from 544 dollars to 740 dollars (difference 196 dollars; 95% CI 62 dollars to 330 dollars), and the privately insured, from 658 dollars to 813 dollars (difference 151 dollars; 95% CI 103 dollars to 199 dollars). Although the adjusted mean payment rate for the uninsured remained stable, the adjusted mean payment rate for the privately insured declined from 77.7% to 65.7% (difference -12.0%; 95% CI -13.4% to -10.7%).

Conclusion: The ability of EDs to provide emergency care to all regardless of ability to pay is increasingly threatened by declining overall payment rates. Cost shifting to fund care for the uninsured is an increasingly untenable financing strategy.