Strategies for Sustaining Emergency Care in the United States

In a 2013 RAND report, funded by the Emergency Medicine Action Fund (EMAF), the authors describe the value of emergency care at that time as the “safety net of the safety net”: (1) a system in which no patient is turned away, (2) an advanced diagnostic center in the health system that cares for patients referred by ambulatory care physicians and clinics, and (3) the primary decisionmaker for patient hospitalization in the United States (Gonzalez Morganti et al., 2013, p. 3). More than a decade later, EMAF, now called the Emergency Medicine Policy Institute and with an enhanced focus on funding emergency care policy (Emergency Medicine Policy Institute, undated), sponsored this second RAND study to identify strategies to sustain emergency care in the United States. This study had four objectives:

• assess the current value of emergency care
• evaluate challenges to sustaining emergency care
• measure trends in emergency care payment
• identify alternate funding strategies for emergency care.

Approach

To achieve these objectives, we sought expert input in the form of a study advisory board and conducted interviews and focus groups, a survey, case studies, an environmental scan of peer-reviewed and gray literature, and analysis of administrative data. The study's 13-member advisory board included emergency medicine health care professionals (physicians, a nurse, and a physician assistant), emergency care policy experts, emergency care executives and academic leaders, a non-emergency medicine health services researcher, and a non-emergency medicine physician hospital leader. The interview and focus group participants included primarily emergency physicians with expertise in emergency care policy, health services research, public health, and disaster preparedness and response, as well as two nurses, three emergency medicine residents, two payers, and a nonphysician representative from a community organization that works closely with emergency departments (EDs) to identify alternate care sites for non-emergency conditions. Furthermore, the study survey was administered by the American College of Emergency Physicians (ACEP) and distributed to ED directors and financial directors who are members of ACEP's Medical Directors Section.

We integrated results from these analyses using a mixed-methods approach to arrive at recommendations for strategies to sustain emergency care in the United States. Our research was determined to be exempt from oversight by the RAND Human Subjects Protection Committee.

Key Findings

Our study showed that EDs offer many types of value to different stakeholders in the United States but that, because of various stresses EDs have faced over the past decade, the viability of emergency care as we know it is at risk. To preserve emergency care quality and coverage, policy action is needed on multiple fronts.

Value of Emergency Care

EDs have long been recognized as the safety net of the U.S. health system and are one of the few health care settings in which care is provided regardless of an individual's ability to pay, largely due to the federal Emergency Medical Treatment and Labor Act (EMTALA) mandate. The ED is the main location where patients seek acute unscheduled medical care and care for time-sensitive conditions.

In our study, we identified multiple ways in which EDs and the health care workers who make up the nation's emergency care system provide value to patients, the broader health system, society and its government representatives, payers, and public health. The key values for each stakeholder group are summarized in Table 1.

Stakeholder Group	Values
Patients	Providing 24/7 care access to advanced diagnostic and treatment in one-stop-shop acute care for time-sensitive or life-threatening conditions and both urgent and non-urgent conditions increased timeliness of care, with potentially improved outcomes by preventing diagnosis and treatment delays increased access to specialty care identification and management of social issues management of complex medical conditions
Health system	Bolstering health system resilience by adding care capacity and facilitating access assisting ambulatory care and inpatient care with time-sensitive medical workups and treatment initiation conducting care coordination being on the front line of mass casualty incidents, disasters, and public health emergencies being key partners in the health system Incident Command System contributing to care innovations that create operational efficiency
Society and its government representatives	Caring for uninsured, underinsured, and service-intensive populations: unhoused individuals veterans older adults with special care needs individuals with palliative care needs undocumented immigrants populations with substance use disorders access to care for rural populations Building community resilience: playing a critical role in mass casualty incident, disaster, and public health emergency preparedness and response identifying victims of human trafficking acting as a key component of the nation's health care critical care infrastructure
Payers	Improving patient outcomes and potential cost savings by guaranteeing access to emergency care for beneficiaries due to EMTALA mandate increasing the timeliness of diagnosis and treatment for time-sensitive conditions reducing hospitalizations through treating and discharging patients
Public health	Public health threat prevention, detection, and intervention, such as for emerging infectious diseases, substance use disorders, and gun violence frontline response to public health emergencies education (e.g., use of helmets, seatbelts, car seats)

Challenges to Sustaining Emergency Care

Despite the multifaceted value that the emergency care system provides to multiple stakeholders, the system faces a variety of challenges that need to be mitigated so that the value conferred by EDs to different stakeholders across the nation can persist. We identified the following key challenges.

Growth in patient complexity, acuity, and demand for critical care services. The nation saw a decline in the overall number of ED visits during the coronavirus disease 2019 (COVID-19) pandemic compared with prepandemic years (Phend, 2023). In 2024, ED visit numbers almost reached prepandemic numbers nationally, with a consistent rise between 2020 and 2024. Furthermore, patient complexity is on the rise, with EDs managing patients with complex medical and social needs, such as older adults, patients with mental illness, survivors of violence, veterans, unhoused individuals, and undocumented immigrants. Importantly, ED patient acuity has also been on the rise over the past dozen years, translating to an increase in demand for critical care services in the ED (Ruxin et al., 2023). Increases in demand and insufficient capacity can lead to ED crowding, boarding, longer wait times, and sometimes violence toward ED staff.¹ These factors can also compromise the quality of care and can lead to burnout, moral injury—negative psychological, social, and spiritual effects—and attrition among emergency care health workers.

Payment to physicians per ED visit is falling, placing particular strain on the finances of ED physician practices that operate independently of hospital or health system ownership. Medicare and Medicaid payments to ED physicians both fell 3.8 percent in real (inflation-adjusted) payment per visit from 2018 to 2022. Reductions in payments for commercially insured patient visits were much steeper, dropping 10.9 percent for commercial in-network visits and 47.7 percent for commercial out-of-network visits over this five-year period. These real drops in payment resulted from falling commercial prices, low payment rates (failure to fully pay the agreed-upon prices, including nonpayment or denial of payment), and inflation.

Payment data from revenue cycle management companies confirm that both insurance administrators and patients regularly underpay or deny payment for significant portions of the allowed amounts they are obligated to pay. Independently owned ED physician practices bear the greatest financial burden of falling professional payment because they have no access to revenues that ED facilities collect. This dynamic places many independent ED physician practices at high risk of closure or buyout. When emergency care is provided, physicians and ED facilities bill separately for their services. When the physician or other emergency care professional works for the hospital or health system, they collect salaries that may be partially funded by facility revenues and partially funded by professional revenues. However, when ED physician employment is independent of the hospital where they work, diverging payment trajectories materially affect each entity's finances—in this case, hitting the independent physicians the hardest. For example, falling commercial professional prices for ED physicians affect independent ED physicians the most: Professional physician allowed amounts (negotiated total prices) fell in real terms from 2018 through 2022, while ED facility allowed amounts rose. Our nationwide claims data analysis revealed that, since 2018 (an arbitrary starting point dictated by data availability), commercial allowed amounts for ED facility care rose 18.65 percent in real terms, while average ED professional allowed amounts dropped 7.42 percent in real terms.

Increase in uncompensated and undercompensated care. Although EMTALA is considered an essential part of the practice of emergency medicine as the public's health care safety net, the unfunded nature of this mandate puts many EDs at risk of understaffing and/or closure. Other factors driving the increase in uncompensated and undercompensated emergency care include the rise in the proportion of ED visits by Medicaid patients, the drop in Medicare and commercial insurance payments over time, Medicare anti-inflationary policies, insurer downcoding—in which a health care service claim is changed to a lower care level by the payer, resulting in a lower payment—and payment denials, and the negative financial impacts of the No Surprises Act (NSA).

Expanding scope of work. The scope of work has grown in many EDs to include geriatric care (in geriatric EDs, which specialize in the care of older adults); palliative care; care coordination; public health prevention; surveillance, detection, and treatment; screening for victims of human trafficking; and preparedness and response for mass casualty incidents, disasters, and public health emergencies. Although these activities may confer significant value to many stakeholders in U.S. communities, there are no steady funding streams to sustain them.

Competing stakeholder expectations. Our study interviewees indicated that competing expectations from various stakeholders make the work in EDs even more challenging, such as the need to do screen and release EMTALA exams—in which patients presenting to the ED are screened to ensure that their condition is not emergent before redirecting them to a lower acuity care setting—to reduce ED crowding while achieving high scores on patient satisfaction surveys. Emergency health care professionals must balance legal and ethical considerations, patient satisfaction surveys, and the financial impact on EDs.

Payment for emergency care. Many emergency medicine leaders are very concerned that the existing payment model for emergency care—which relies mainly on fee-for-service (FFS)—increasingly fails to appropriately compensate EDs for the services they provide. Professional fees (those paid to emergency physicians) have not kept up with inflation, and 20 percent of all U.S. ED physician expected payments went unpaid across all payer types, totaling roughly $5.9 billion per year of unpaid ED physician services. Uninsured and underinsured patients are more likely to be cared for in the ED, and the sum of all other payments (commercial, Medicare and Medicaid, other) are inadequate to cover the costs of providing care to those populations.

New value-based models of emergency care payment have been proposed, but emergency physicians have little opportunity to participate in the move toward value-based payments through such means as accountable care organizations, particularly due to the lack of accompanying mechanisms in these models to pay for the independent emergency physicians who often are not employed by hospitals. Furthermore, perspectives of emergency physicians on global payments as an alternate payment model were mixed because of concerns about whether sufficient payment would reach EDs or emergency health professionals (including physicians, nurse practitioners, and physician assistants) through this mechanism. Other previously proposed alternate payment models we identified have not been successfully implemented.

In the standard model, physician practices are compensated for physician work, practice expenses, and professional liability insurance. This payment system does not fully compensate emergency health professionals or EDs for also providing care coordination services; public health services; mass casualty incident, disaster, and public health emergency preparedness and response activities; or uncompensated clinical care. Emergency health professionals and EDs provide these services despite this funding shortfall, causing significant financial strain.

Our analysis indicated a need for alternate payment strategies for emergency care to ensure that the services offered by EDs 24/7 are sustained in the United States. To develop alternate payment strategies for emergency care, we categorized the services that EDs provide, along with their funding status, into four value categories: (1) acute unscheduled care services (compensated), (2) acute unscheduled care services (uncompensated or undercompensated), (3) public health services (uncompensated or undercompensated), and (4) catastrophic standby services (uncompensated or undercompensated).

The reality of non-emergent ED visits. Some ED crowding is driven by patients' and the overall health system's overreliance on EDs for non-emergency conditions. The demand for ED services for non-emergent conditions is (at least partially) a function of insufficient ambulatory care capacity and capabilities for rapid medical condition diagnosis and treatment and may result from a desire on the part of ambulatory health care providers to reduce delays in care by circumventing the insurance requirement for prior authorization.

Proposed Tiered Payment Model for Emergency Care

Our study indicated a decrease in payment for emergency care professional services nationally over the course of the years studied. Also, we demonstrated the need for sustained sufficient funding to address the challenges faced by EDs and retain the value they offer to communities across the nation. Given that services provided by EDs across the United States are variable in nature, and because incremental adjustments to a complex health system are more practical to implement than a complete system overhaul, we propose a tiered payment model (Figure 1) that builds on the existing payment system while implementing several payment innovations (adjustments to existing payment tiers) and adding new funding sources (new payment tiers). Tier 1 represents funded emergency care—including the funded portion of the ED care provided as a safety net. Tier 2 represents the unfunded safety net emergency care provided by EDs as a result of visits by uninsured and underinsured patients. Tier 3a represents unfunded or partially funded ED public health roles. Lastly, Tier 3b represents unfunded or underfunded ED roles in mass casualty incident, disaster, and public health preparedness and response.

The current FFS and capitation payment systems fund the “foundational” Tier 1 layer of emergency care payment. When purchasers of commercial or private insurance attempt to rein in their payments, this exposes ED health care professionals and other parts of the health system to unsustainable financial pressure if not accompanied by a corresponding increase in public funding (and/or budget reallocation within the hospital or health system) for Tiers 2 and 3. To finance (and therefore preserve) the Tier 2 and 3 emergency care values, we propose reducing the funding indicated by the red arrows in Figure 1 while replacing it with the new funding mechanisms (represented by dotted arrows).

Tier 1, at the bottom, is funded health care (visits to EDs for chronic conditions, injuries, and emergencies). Existing funding is from public payors (Medicare and Medicaid) and commercial insurance.

Tier 2, in the middle, is the funded safety net. Existing funding is from public payors (Medicare and Medicaid).

Tier 3a is ongoing public health (vaccinations, opioids, etc.)

Tier 3b, at the top of the pyramid, is rare public health emergencies, disasters, and mass casualty incidents.

Currently, commercial funding from Tier 1 is used to fund the public services (the safety net and Tiers 2, 3a, and 3b). The proposed new public funding mechanism(s) would be used to fund Tiers 2, 3a, and 3b instead.

NOTE: MCI = mass casualty incident; PHE = public health emergency.

No recommendation will fit all EDs, hospitals, or geographic contexts. However, we offer a variety of recommendations that will fit different contexts, including recommendations to

• establish a payment mechanism administered by the Health Resources and Services Administration to pay emergency health care professionals for specific public health services not already covered by insurance, including EMTALA-mandated screening exams
• expand Medicaid disproportionate share hospital (DSH) payments and extend to physicians (i.e., “DSH for Docs”)
• increase public payer allowed amounts to reduce the gap between them and private payer allowed amounts and address insurer payment reduction practices (such as downcoding and prudent layperson denials) to ensure adequate funding of public ED safety net and public health services
• enact federal legislation mandating that ED facility and professional allowed amounts (i.e., negotiated prices) for each type of ED visit do not diverge beyond a given percent
• establish a new Emergency Department Standby Capacity Payment System, funded primarily by state and/or local governments, to provide emergency care funding for disaster, mass casualty incident, and public health emergency preparedness and response.

Recommendations

We developed recommendations for strategies to sustain the value of emergency care and mitigate the challenges that emergency care faces, including recommending payment mechanisms to compensate each value category that EDs provide (Tables 2–5). Given the interconnectedness of the ED with other settings in the U.S. health system—including prehospital care, ambulatory care, and inpatient care—some of the recommendations have relevance for health services settings other than the ED. Because the large majority of study advisory board members, interview and focus group participants, and survey respondents were emergency medicine health care professionals, these recommendations were largely informed by the perspectives of emergency medicine stakeholders. These recommendations were developed based on the completed study analyses in October 2024.

Evidence Level	Description
Level 1	Level 1 recommendations are strongly supported by the analyses. The strategies (1) are supported by the literature review,a (2) were identified multiple times across the interviews and focus groups,b and (3) are supported by our quantitative analysis and/or the study survey.
Level 2	Level 2 recommendations are moderately supported by the analyses. These interventions are supported by the literature review and were identified multiple times across the interviews and/or focus group data.
Level 3	Level 3 recommendations have some support in the literature review or were identified in the interviews and/or focus group data.

^a Support for a strategy in the literature means that we identified prior work that shows that the strategy is promising and/or that it is associated with achieving the outcome of interest.

^b Support for a strategy in the qualitative work indicates that the factor has valence—or is deemed as an attractive option by interviewees—but it does not indicate whether the factor will have a positive effect on sustaining emergency care.

Evidence Level	Value Strategy Category (Key Stakeholdersa)	Specific Strategies
Level 1	Patients (ACEP,b health care organizations, patient advocacy groups, legislature)	Advocate funding for the EMTALA mandate through one or more of the following strategies: allocating a percentage of commercially insured ED visits to cover EMTALA-related care, allocating state and/or federal stipends for EMTALA-related care, and instituting cost-sharing policies between hospitals that transfer uninsured patients to tertiary and quaternary facilities and receiving hospitals.
Level 1	Society at large (ACEP, health care organizations, patient advocacy groups, local government)	Pursue policies to allocate city and local funds to ED care and related activities that confer value to the broader community—e.g., care for undocumented immigrants, unhoused populations, substance use disorders, mental health conditions, and, as warranted, veterans without other local options for care.
Level 2	Health systems (ACEP, EDs, health care organizations)	Work to effectively communicate ED value toward fostering broader health system resiliency and health care innovation and secure payment for related activities—e.g., through a share of facility payments.
Level 2	Government (ACEP, hospital associations, legislature)	Pursue policies to get ED preparedness and response activities consistently funded through city or state funding. Bolster EDs' role as critical national infrastructure in the context of mass casualty incidents, disasters, and public health emergencies, especially in areas of the country at high risk for such incidences, through funding from the Department of Homeland Security and/or the Department of Defense.
Level 3	Payers (EDs, health care organizations, legislature)	Partner with payers to advocate making EMTALA a funded mandate through state and/or federal contributions. Work to demonstrate the value of emergency care to payers using data related to (1) cost savings and improved patient outcomes through timely diagnosis and treatment and (2) hospitalizations prevented by treating and releasing ED patients.
Level 3	Society at large (EDs, health care organizations, community organizations, first-responder agencies, health departments)	Contribute to community resilience by joining existing community coalitions to improve both routine resilience and community resilience in the context of mass casualty incidents, disasters, and public health emergencies.

^a Key stakeholders include those that are important for and invested in implementation and/or those that will benefit as a result of the strategy.

^b This could be ACEP or other organizations that advocate for emergency medicine.

Evidence Level	Challenge Strategy Category (Key Stakeholdersa)	Specific Strategies
Level 1	EMTALA (ACEP,b payers, health care organizations, legislature)	Secure funding for unfunded care that EMTALA mandates—for example, through a federal stipend based on the number of uninsured and underinsured patients cared for by individual EDs or multiple EDs in the same health system. Develop uninsured and underinsured patient compensation benchmarks so that EDs are compensated commensurate with the level of indigent care they provide.
Level 1	ED crowding (health care organizations, legislature)	Invest in expanding primary care capacity. Develop and implement strategies to address ED boarding—a root cause of ED crowding.
Level 1	ED boarding (health care organizations, legislature)	Advocate state or federal ED boarding policies that provide financial incentives and/or penalties for hospitals to address ED boarding. Improve hospital space utilization through in-patient hallway boarding, using flexible expansion areas for patient care, “smoothing” elective admissions, and using strategies for efficient inpatient and observation discharge.
Level 1	ED violence (ACEP, health care organizations, legislature)	Enforce hospital anti-violence policies. Institute state or federal laws that protect health care workers by increasing the legal consequences for violence against health care workers.
Level 2	Emergency care advocacy (ACEP, EDs)	Improve communication of the value of EDs to the public through coordinated public relations campaigns.
Level 2	Workforce attrition (ACEP, EDs, health care organizations, legislation)	Leverage voice recognition and artificial intelligence technology to reduce documentation burden. Work to retain the emergency nurse workforce by providing supportive management, maintaining manageable nurse-to-patient ratios, retaining older and more experienced nurses to increase nurse workplace engagement, improving workplace professionalism, and using licensed practical nurses to reduce nurse workload. Address burnout and attrition among emergency health professionals, especially among resident emergency physicians, by addressing mistreatment in the ED, including targeted interventions to reduce attrition among female residents and ethnic/racial minority groups who are at higher risk of leaving emergency medicine residency. Increase emergency medicine resident recruitment by increasing emergency medicine physician payment and/or lowering the cost of medical education, expanding loan repayment programs, and improving the image of the ED work environment.
Level 2	ED crowding (health care organizations, legislature)	Use nonphysician practitioners (NPPs) in EDs to expand care capacity across the range of patient acuity, under the supervision of emergency physicians and through robust protocols for NPP oversight to ensure care quality.
Level 3	ED closures (ACEP, EDs, legislature)	Prevent rural ED closures by charging marginal amounts on local, state, and/or federal property or sales taxes. Tailor solutions by geography, given differences in the nature of challenges across communities at risk of hospital-based ED closure.
Level 3	Emergency care advocacy (ACEP, health care organizations, legislature)	Improve emergency medicine advocacy by identifying common objectives with hospital associations and medicine more broadly.
Level 3	NSA (ACEP, other hospital-based physician specialties, regulators, legislature)	Advocate policies to lower independent dispute resolution (IDR) administrative fees, expedite the IDR process, and allow for batching. Implement audits to validate initial payments under the NSA. Implement penalties for insurers that do not make timely payment after arbitration decisions to ensure accountability. Implement policies that ensure that contract terms with insurers are enforced and unfair cancellations are prevented.
Level 3	Insufficient resources for public health roles (ACEP, EDs, health departments, legislature)	Develop special Current Procedural Terminology (CPT) codes for public health–related work. Develop partnerships with health departments that include information- and resource-sharing for public health prevention, detection, and intervention.
Level 3	ED boarding (health care organizations, educational entities)	Collaborate with skilled nursing facilities and mental health services to improve ED patient flow. Put processes in place for direct patient admissions from the ED, circumventing emergency workup. Create an inpatient area in the ED dedicated to the care of admitted patients. Advocate the development of federally mandated hospital boarding metrics to track and more effectively address ED boarding. Use full-capacity protocols that distribute admitted ED patients to any open bed in the hospital. Use a hospitalist-led team to care for ED-boarded patients.
Level 3	ED crowding (EDs, health care organizations, emergency medical services, educational entities)	Implement public awareness campaigns on indications for patients to present to the ED for care, encourage community-based care alternatives, and develop ED and urgent care partnerships to divert non-urgent cases. Use tele-intake for off-site patient triage. Use telehealth for communication with emergency medical services for patient triage in the field or en route. Implement physician in triage (PIT).
Level 3	Workforce attrition (EDs, health care organizations)	Institute employee wellness programs to address workforce burnout and related poor mental health and attrition, particularly among pediatric emergency health care professionals.
Level 3	Rise in patient acuity (ACEP, EDs)	Use NPPs to manage lower acuity patients so emergency physicians can focus on higher acuity patients in the ED.

^a Key stakeholders include those that are important for and invested in implementation and/or those that will benefit as a result of the strategy.

^b This could be ACEP or other organizations that advocate for emergency medicine.

Evidence Level	Payment Strategy Category (Key Stakeholdersa)	Specific Strategies
Level 1	Medicaid payment (ACEP,b patient advocacy groups, Centers for Medicare & Medicaid Services [CMS], legislature)	Advocate Medicaid expansion in states that have not adopted it yet. Advocate Medicaid parity with Medicare. Advocate Medicaid coverage of uninsured screening exams.
Level 1	Commercial payment (ACEP, legislature)	Advocate policies requiring a minimum emergency physician professional fee as a percentage of facility fees. Legislate mandatory commercial coverage for all ED visits, at the level of services provided, paid promptly and in full.
Level 2	Medicare payment (ACEP, CMS, legislature)	Legislate annual inflationary increases to the physician fee schedules (as already exists for facilities).
Level 2	Commercial payment (ACEP, legislature)	Require insurance entities, not the emergency care professionals or hospitals, to collect deductibles and copays from their enrollees.
Level 2	Uncompensated care (ACEP, payers, legislature)	Partner with payers to advocate changing EMTALA to a funded mandate through payment mechanisms from local, state, and federal funding sources.
Level 3	Medicaid payment (ACEP, CMS, legislature)	Mandate Medicaid to pay for EMTALA screening exams, regardless of the final diagnosis. Legislate mandatory annual inflationary adjustments built in to the fee schedules for physicians for Medicaid.
Level 3	Commercial payment ( ACEP, EDs, legislature)	Implement federal or state policies to prohibit retrospective payment denials based on failure to comply with the “prudent layperson standard.” Advocate for EDs to be directly involved in hospital contract negotiations with insurers. Implement a legislative fix to NSA flaws so that payers must pay in full any IDR judgment to the prevailing physicians within a preset time frame. Advocate for emergency physician groups to be directly involved and supported in hospital contract negotiations with insurers.

^a Key stakeholders include those that are important for and invested in implementation and/or those that will benefit as a result of the strategy.

^b This could be ACEP or other organizations that advocate for emergency medicine.