Show me the Money!

The Covid-19 pandemic has had a notable effect on US patient emergency department (ED) volumes. Decreased patient volumes have led to anecdotal reports of decreased physician hours and a difficult job market, perhaps due to our current fee-for-service model. 

 A study conducted by Pines, et. al. sought to characterize multiple aspects of emergency medicine, pre and post pandemic. This was an observational study comparing data between January to September 2020 and that same time period in 2019 from136, mainly community, EDs. These EDs were in 18 states and staffed by the national staffing group USACS.

When compared to the same periods in 2019, they found a decrease in overall visits across patient age groups, payer source, and ED size. Across all sites, the clinical revenue, on average, fell to 60% of pre-pandemic levels and did not completely recover, reaching a maximum of 90% of pre-pandemic levels by the end of the study period. 

 When expenses were examined based on ED size they found that freestanding EDs and small EDs had a smaller change in expense than medium and large EDs. Additionally, within this group five freestanding EDs were closed during the pandemic period, one of which did not reopen. Both physician and NP/PA hours decreased and then rebounded during the pandemic period. NP and PA hours decreased more significantly than physician hours at all sites but particularly at freestanding EDs and small EDs where they dropped to 30% and 50% respectively and reached a maximum of 60% of pre-pandemic levels. Overall, a total of 174 physician FTE and 193 non-physician provider FTE were lost across the included EDs during the pandemic period.

The current fee for service reimbursement model for emergency medicine puts EDs at risk for decreased revenue in times of national emergencies that lead to decreased patient visits. Small and freestanding EDs have less flexibility in terms of staffing, and thus are less able to make changes in expenses to offset decreased revenue, putting their financial viability in question. Staffing practices during this time have also shown that emergency physician positions are at risk even during a deadly pandemic. We must advocate for physician jobs and consider other reimbursement strategies for emergency medicine to avoid these revenue drops during the next pandemic.

This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. This review was written by Jacquelyn Callahan, MD an EMRA member and emergency medicine resident at Texas A&M Spohn Emergency Medicine Residency.

Abstract

Study objective: We describe how the coronavirus disease 2019 (COVID-19) pandemic affected the economics of ED care (ED).

Methods: We conducted an observational study of 136 EDs from January 2019 to September 2020, using 2020-to-2019 3-week moving ratios for ED visits, complexity, revenue, and staffing expenses. We tabulated 2020-to-2019 staffing ratios and calculated hour and full-time-equivalent changes.

Results: Following the COVID-19 pandemic’s onset, geriatric (age 65), adult (age 18 to 64), and pediatric (age <18) ED visits declined by 43%, 40%, and 73%, respectively, compared to 2019 visits and rose thereafter but remained below 2019 levels through September. Relative value units per visit rose by 8%, 9%, and 18%, respectively, compared to 2019, while ED admission rates rose by 32%. Both fell subsequently but remained above 2019 levels through September. Revenues dropped sharply early in the pandemic and rose gradually but remained below 2019 levels. In medium and large EDs, staffing and expenses were lowered with a lag, largely compensating for lower revenue at these sites, and barely at freestanding EDs. Staffing and expense reductions could not match revenue losses in smaller EDs. During the pandemic, emergency physician and advanced practice provider clinical hours and compensation fell 15% and 27%, respectively, corresponding to 174 lost physician and 193 lost advanced practice provider full-time-equivalent positions.

Conclusion: The COVID-19 pandemic adversely impacted the economics of ED care, with large drops in overall and, in particular, low-acuity ED visits, necessitating reductions in clinical hours. Staffing cutbacks could not match reduced revenue at small EDs with minimum emergency physician coverage requirements. 

Pines et al. Ann Emerg Med. 2021;78:487-499