How the COVID-19 pandemic has adversely affected the economics of U.S. emergency care

Abstract

ObjectiveWe describe how the coronavirus (COVID-19) pandemic impacted emergency department (ED) economics, acuity, and staffing.MethodsWe conducted an observational study of visits during January to September 2020 compared to 2019 in 136 EDs staffed by a national emergency medicine group. We created ratios of three-week moving averages for 2020 visits, acuity, costs divided by 2019 moving averages, by age and ED size. We tabulated reductions in clinician hours and FTEs compared to early 2020 staffing.Results2020-2019 ED visit ratios declined in March nadiring mid-April for both adults (to 0.60) and children (to 0.30) and rose thereafter but remained below 2019 levels through September 2020. The ratio of adult RVUs/visit rose to 1.1 for adults and 1.2 for children in the early pandemic, falling to 1.04 and 1.1 through September. The ratio of direct salary expenses in freestanding (FSED) and small EDs declined less dramatically than in medium and large EDs. Clinical revenues in medium and large EDs declined more sharply and recovered slowly but plateaued well below 2019 levels. By September 2020, expenses were still higher than revenues for small EDs, similar for FSEDs, and somewhat higher for medium and large EDs. During the pandemic, physician hours fell 15% and APP hours 27% during COVID-19 translating to 174 lost physician and 193 lost APP FTEs.ConclusionThe COVID-19 pandemic reduced ED visits and increased acuity in the first 7 months of the pandemic, leading to a contraction of the ED workforce, and threatening ED economics, more so in small and FSEDs.

Effect of coronavirus disease 2019 pandemic on children’s visits to the emergency department

“…We found a disproportionate decrease in disease-related visits (e.g., fever). A similar trend was observed in a United States study on children's visits to 148 EDs during the COVID-19 pandemic 11) . Fig.…”

“…Third, the diagnostic codes assigned by clinicians might incur misclassification bias. Finally, compared to other studies 3,11) , our study showed a higher proportion of injury. This flaw was possibly owing to a lack of emergency care facility for injured children other than the ED.…”

Revisioning the ENP Among Emergency Workforce Changes

“…The authors attribute the surplus to several factors including the exponential growth of APP programs and graduates out-pacing the rate of medical school graduates, a 39.4% increase over the past 10 years in the number of board-certified EPs entering the workforce, and a 46% increase in the past 5 years in the number of EM residency programs within the United States. Other factors affecting ED visit rates and demand for EPs include reduced ED volumes since the pandemic, increased costs and disincentives by insurers for patient ED visits, use of telemedicine, and the growth of urgent care and retail clinics (Pines et al, 2021;Reiter & Allen, 2020). Clay et al (2021) analyzed the National Emergency Department Inventory (NEDI)-USA database and state medical association physician registry data, comparing their findings with a prior workforce study by Sullivan, Ginde, Espinosa, and Camargo (2009), noting a similar maldistribution in the ED workforce.…”

“…Of immediate concern among EPs is the EM workforce surplus combined with reductions in ED census levels across all acuities and ages and reduced ED revenues resulting from the COVID-19 pandemic (ACEP, 2021;Bennett et al, 2020;Clay et al, 2021;Pines et al, 2021;Reiter & Allen, 2020). These factors and the increased utilization of APPs are believed to be responsible for increased competition and limited employment opportunities for new EM residency graduates.…”