Health Policy Journal Club, Health Policy, Administration & Operations, Health Care Administration, COVID-19

Health Policy Journal Club: Show Me the Money

ED Economics During the COVID-19 Pandemic

The COVID-19 pandemic has had a notable effect on U.S. 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 from 136, 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.


Article: Pines JM, Zocchi MS, Black BS, et al. The Effect of the COVID-19 Pandemic on the Economics of Unites States Emergency Care. Ann Emerg Med. 2021;78(4):487–499.

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.

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.