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 to $798 (difference $103; 95% CI $61 to $146). Two payer classes experienced statistically significant increases in adjusted mean charge: the uninsured, from $544 to $740 (difference $196; 95% CI $62 to $330), and the privately insured, from $658 to $813 (difference $151; 95% CI $103 to $199). 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. [Ann Emerg Med. 2003;41:299-308.]