Even With Insurance, EDs Can Cost a Bundle

If you've gone to the emergency room recently, you likely know how much such a visit can cost. A new study by researchers at the Kaiser Family Foundation finds that even for people with private insurance who are employed by large companies, the average out-of-pocket cost of an ER visit can exceed their savings.

In 2019, the study shows, patients enrolled in big companies' health plans paid an average of $646 in copays and deductibles for each ER visit. A quarter of visits cost more than $907 out of pocket, and another quarter cost under $128.

About half of households can't afford to pay the average deductible in an employer-sponsored insurance plan, the report notes. And more than a third of U.S. adults are unable to afford a $400 medical expense without borrowing.

While it's not known how many people don't go to an emergency room because of the anticipated cost, almost half of U.S. adults report that they've delayed care due to costs, according to a recent Kaiser survey.

One problem that people often face when deciding whether to visit an ER is that they don't know how serious their condition is and what emergency care will cost, says Hope Schwartz, lead author of the report.

"When they go to the [ER], they don't always know what their diagnosis will be and what their treatment costs will be. What we highlighted is that those costs could be very high or very low, and there's no way to tell beforehand," she says.

What Costs So Much?

Based on the paid claims data used in the study, health plans and patients paid a combined average of $2,453 for an ER visit. A quarter of visits cost $970 or less, and a quarter cost $3,043 or more.

Emergency room claims include professional fees and facility fees. The facility fees, which cover the cost of a hospital maintaining an ER 24/7, made up 80% of total costs, including a portion of doctors' claims as well as laboratory and imaging fees.

But doctors' claims for evaluation and management services were the largest part of costs, averaging $1,134 per visit. Procedures and treatments cost over $1,100 per visit, on average, while the average imaging claim cost $483, and the average cost for lab work was $230.

Over half of visits generated imaging claims, and about half of visits included lab claims.

The Kaiser Family Foundation report also looked at the costs of several common ER diagnoses. The most expensive diagnosis was appendicitis, which cost nearly twice as much as heart attacks, partly because it often led to surgery in the emergency room. On average, a visit for appendicitis cost $9,535, of which $1,717 was an out-of-pocket expense.

In addition, the researchers examined lower-cost diagnoses that generally do not require imaging or extensive treatment in the ER. These included upper respiratory tract infections ($1,535 total, $523 out of pocket), skin and soft tissue infections ($2,005 total, $572 out of pocket), and urinary tract infections ($2,726 total, $683 out of pocket).

While these diagnoses can sometimes require admission to the hospital, in otherwise healthy adults they are typically evaluated with basic lab tests, and patients are discharged with prescriptions, according to the report.

Complexities of Billing

ER visits are given codes to help show how complex the task or service was during the billing process. These codes have five levels.

Less complex visits require straightforward medical decision-making, such as rashes or medication refills. Patients with level 5 codes require highly complex decision-making and include life- or limb-threatening conditions, such as severe infections or heart attacks.

The less complex visits cost $592, on average, with patients responsible for $205 of that. For the most complex visits, the health plan covered $3,015, on average, or eight times the cost of the lowest-coded visits.

On average, patients paid $840 out of pocket for the most complex visits — four times the average costs for the less complex visits.

One reason for the rise in spending for ER visits is a national shift to higher-level ER billing codes, says Schwartz, who is a Kaiser Family Foundation health policy fellow and a medical student, "There has been good work done showing that [ER] visits are increasingly being billed as a level 4 or 5, whereas in previous years, they might have been billed as a level 3.

"Whether a hospital bills a level 4 or a level 5 code for your visit can make a really big difference in how much you pay. And if you come in not knowing what services you're going to get, you don't know if you're going to get a level 3, 4, or 5 code, and the costs increase pretty quickly," she says.

Costs Vary by Region

The report includes an analysis of emergency room costs in the 20 largest metropolitan areas in the U.S. Overall, the researchers found, San Diego had the most expensive ER visits. Emergency rooms in San Diego charged about twice as much per visit, on average, as those in Baltimore.

While there were expensive areas all across the country, many of the costliest places were in Texas, Florida, California, Colorado, and New York. The report noted that the most expensive regions for ER care did not align with the regions that had the most expensive health care overall.

"These comparisons suggest that our findings are not solely related to overall high health care prices in these areas and may reflect other factors, including the age and medical complexity of the population or differences in local norms and practice patterns," the report says.

Healthier People

In addition to these geographical differences, the incidence of emergency room visits by those with employers' insurance differed from that of the general population.

During the study year, the report found, 12% of the insured had at least one ER visit — a percentage that didn't vary for any age group under 65, including children. (No patients 65 or older were included in the study.)

By comparison, a government survey shows that in 2019, 21% of all U.S. adults 18 to 44 had one or more emergency room visits. Among those 45 to 64, 20% made at least one ER visit.

Sources

Health System Tracker: "Emergency department visits exceed affordability threshold for many consumers with private insurance."

Kaiser Family Foundation: "Americans' Challenges with Health Care Costs."

Hope Schwartz, health policy fellow, Kaiser Family Foundation.

CDC: "Emergency department visits within the past 12 months among adults aged 18 and over, by selected characteristics: United States, selected years 1997–2019."

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.