Examining Trends in ED Costs of Care for Medicare Beneficiaries

According to results of a recent JAMA Network Open study, total 30-day costs of emergency department (ED) care for Medicare beneficiaries has decreased over the last several years, which the authors mostly attribute to declining rates of admission but note that there are other factors at play.

“While there was a small increase in spending on various types of downstream outpatient care, this increase was much smaller than
the decline in spending on inpatient and postacute care,” explained Laura G Burke, MD, MPH, department of emergency medicine, Beth Israel Deaconess Medical Center, Boston, MA, and colleagues.

Dr Burke and coresearchers conducted a cross-sectional study of 14,113,088 ED visits at 4730 EDs from 2011 to 2016, which included a 20% national sample of traditional Medicare beneficiaries aged 65 years and older.

For the analysis, the researchers examined trends in disposition from the ED, 30-day total standardized costs, and various spending components including: index visit cost, physician costs, subsequent ED visit costs, subsequent inpatient costs, subsequent observation
costs, non-ED outpatient care, postacute care, and aggregated total spending after the index ED visit.

“Not surprisingly, in analyses stratified by disposition, the mean cost per index visit rose within each group,” said Dr Burke and colleagues. “However, total Medicare spending on index ED visits fell over time, as fewer beneficiaries were admitted to the hospital for costly inpatient care at the conclusion of their ED stay. The declines in total costs of care were present across nearly every major diagnosis, although the magnitude of the decline varied by condition.”

Significant results of the study included:

• ED patients discharged increased from 53.4% in 2011 to 56.4% in 2016;
• Total adjusted 30-day standardized costs of care for all ED visits declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016
• Decreased total spend on ED visit (−$48/y; 95% CI, −$50 to −$47; P<.001)
• Decreased postacute care spend (−$42/y; 95% CI, −$44 to −$41; P<.001); and 
• Decreased subsequent inpatient care (−$34/y; 95% CI, −$36 to −$32; P<.001).

The study’s results suggest that there may be more to ED utilization and costs than expected: “While there has been understandable attention paid to the fact that an out-patient ED visit is more expensive than an office or urgent care visit, we know less about the ED’s role in total acute care spending.”

The authors explained that EDs present a lower-cost alternative to hospitalization because they are authorized to perform advanced diagnostics and treatments.

“However, even in the era of alternative payment models and episodes of care, there is surprisingly little evidence regarding how total costs of an emergency care episode have changed in recent years,” concluded Dr Burke and colleagues. “Such data are needed to better evaluate whether ED care is generating more value over time or whether greater up-front costs are triggering additional downstream spending and adding to the waste in the health care system.” —Edan Stanley