Top Diagnoses by Payer Among Emergency Department Visits (Treat-and-Release)
Key takeaways
- Americans made 143.5 million visits to emergency departments in 2018, 439 visits per 1,000 people
- The most common treat-and-release ED visits were for abdominal pain, respiratory infection, and chest pain
- Among the 15 top treat-and-release diagnoses, the 4 payer types (Medicare, Medicaid, private, self-pay) have in common just 6
- The average cost of an ED visit by payer is: $660 (Medicare), $560 (private insurance), ($460) self-pay, and $420 (Medicaid)
- Americans in the lowest income quartile visit EDs at a rate of 641 per 1000, compared to 281 per 1000 for the highest income quartile
- ED visits by privately insured and self-pay Americans declined over time (2009-2018), while visits by people with Medicare and Medicaid grew
Americans with different kinds of health insurance visit emergency departments for different reasons. A HealthCare.com analysis of federal data shows that, among the 15 top conditions behind treat-and-release visits, the four main payer types (private insurance, self-pay, Medicare, Medicaid) have in common just six conditions.
The above figure shows the six conditions are:
- Nonspecific chest pain
- Abdominal pain/diarrhea
- Superficial injury
- Musculoskeletal pain
- Urinary tract infections
- Sprains and strains
At the same time, five conditions behind treat-and-release ED visits are among the top 15 for only one payer type.
- Headaches are among the top 15 for people with private insurance
- Teeth and gum disorders are among the top 15 for self-payers
- Chronic obstructive pulmonary disease is among the top 15 for people on Medicare
- Pregnancy nausea and ear infections are among the top 15 for people on Medicaid
For all payers, abdominal pain was either the first (for private insurance and self-pay/no charge) or the second (for Medicare and Medicaid) most common condition.
The different attributes of each payer group account for the differing mix of conditions that bring them to emergency departments. Amy Faith Ho, an emergency medicine physician and nationally-published writer, says each group represents a different population. “For example, with Medicare, if you’re an older patient you’re going to come in more with diagnoses associated with getting older,” she explains. “You’re going to see a lot more strokes and urinary infections, but fewer motorcycle accidents and that sort of thing.”
Medicaid tends to represent younger groups and can be heavily pediatric, Ho says, “So you’ll see a lot of kid viruses, and pregnant mothers with pregnancy-related complaints.”
On the other hand, self-payers are often low-income, and may not have the wherewithal to visit dentists regularly. “Perhaps self-pay patients wait until they are really sick to go to the ER,” Ho says. “It makes sense that dental complaints would rank higher for self-paid emergency care visits.” Self-payers, who are mostly uninsured, may not be getting regular dental care.
Emergency Department Visits Nationwide
In 2018, U.S. hospitals saw 143.5 million emergency department (ED) visits, representing 439 visits per 1,000 population. 14% of ED visits resulted in hospital admission (61 per 1,000 population). The majority of ED visits (86%) resulted in treatment and release.
Among all diagnoses with the highest number of treat-and-release ED visits, the below figure shows the top 10.
Top 10 Treat-and-Release Emergency Department Visits (Millions)
Emergency Department Visits by Cost and Income Level
The cost of a trip to the emergency department differs significantly depending on what kind of health insurance a person has.
At $420, Medicaid recipients’ ED visits have the lowest average cost, another government brief shows.
Self-payers are next at $460, followed by people on private insurance at $560 per emergency department visit.
At an average of $660, Medicare recipients’ ED visits are the most pricey.
Low-income people, many of whom are Medicaid recipients, are much more likely to visit emergency departments than high-income people.
Americans in the lowest income quartile visit EDs at a rate of 641 per 1000 people, compared to just 281 per 1000 people for the highest income quartile.
The low cost of Medicaid and self-pay Americans’ ED visits may be linked to the higher likelihood of them visiting EDs for less serious conditions like earaches, pregnancy nausea, and dental issues.
It’s also the case, Ho says, that the cost of ED visits reflects the negotiating power of the payer. Large government programs like Medicare and Medicaid are known for negotiating lower prices with healthcare providers.
In terms of outcomes, research shows that emergency departments are an area where folks who don’t have insurance will be at greater risk for financial strain and for putting off critical care.
“We know that expanding health insurance leads to better health and financial security for families,” Ben Sommers, Deputy Assistant Secretary at the U.S. Department of Health and Human Services, told HealthCare.com.
“The emergency department is one area where disparities can show up prominently. That’s why the department’s focus has been making sure that we have as good coverage and access as we can, and we’ve seen that in near historic lows in the uninsured rate in the past year, and the record high of people enrolled in Affordable Care Act coverage and Medicaid. If you don’t have coverage you’ll face big bills and risk not getting the care you need.”
In peer countries with single-payer healthcare systems like Canada or Japan, such coverage and cost disparities do not exist, for the simple reason that there is only one payer.
“The emergency department is one area where disparities can show up prominently…If you don’t have coverage, you’ll face big bills and risk not getting the care you need.”
Ben Sommers, Deputy Assistant Secretary, Department of Health and Human Services
Use the interactive data visualization below to search emergency department costs for your demographic.
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The Cost of Emergency Department Visits
Emergency Department Visits over Time
Over the last decade for which data is available (2009-2018), emergency department visits by privately insured and uninsured (self-pay) people have declined, while visits by people with Medicare and Medicaid have risen.
This tracks with the overall growth of the Medicare and Medicaid programs during that timeframe.
In particular, the proportion of visits by self-payers dropped between 2013 and 2015, coinciding with the large reduction in the uninsured rate nationally under the Affordable Care Act during that period.
“The Medicaid expansion has shifted people away from being uninsured to being covered by Medicaid,” Sommers says. “So what you’re seeing is a result of the major changes brought by the Affordable Care Act over time.”
The rise of urgent care and retail clinics in recent years brought hopes for an easing of expensive emergency department visits. But the dividend hasn’t materialized. A Report to Congress says that “thus far, these care settings do not appear to have resulted in a reduction in the national rate of ED visits.”
Doctor Ho says that, after spiking during the early part of the covid pandemic, emergency departments are no longer jam-packed. “I don’t think EDs are overwhelmed anymore,” she says. “Nationally, volume is actually down a bit. There are a lot of places in the U.S. that are seeing very little covid, that are back to the usual mix of patients and diagnoses.”
For the foreseeable future, it looks like Americans will continue to utilize emergency departments for medical issues that could be resolved more cheaply by primary care physicians, or at urgent care centers. And the conditions for which they tend to visit EDs, and the cost and volume of their visits, will continue to break down along the lines of the nation’s Balkanized health insurance landscape.
