- Throughout the U.S., emergency departments often charge uninsured and out-of-network insured patients higher charges than internal medicine for the same procedures, a new study in JAMA Internal Medicine concludes.
- Across hospitals, the ED markups ranged from 1.0 to 12.6, internal medicine markups ranged from 1.0 to 14.1. The highest ED rates were associated with for-profit hospitals, those with a greater share of uninsured patients and hospitals located in the southeastern U.S.
- The American College of Emergency Physicians (ACEP) says the study has "significant methodologic" flaws, including not analyzing internist charges from office visits.
Researchers analyzed Part B Medicare claims from 2013 for 12,337 ED doctors and 57,607 internal medicine physicians in thousands of hospitals in all 50 states. The overall markup ratio for ED docs was 4.4, versus 2.1 for internal medicine
Laceration repairs had the highest markups in the ED (7.0), while emergency medicine physician review of a CT head scan had the greatest variation (1.6 to 27.7), the researchers found. They said legislation is needed to protect uninsured and out-of-network patients from excessive ED charges.
“The ongoing trends in underinsurance, hospital consolidation and narrowing insurance networks since implementation of the Affordable Care Act are poised to increase the potential for patient financial harm in years to come,” the authors write. “Now, more than ever, protecting uninsured and out-of-network patients from highly variable hospital pricing should be a policy priority.”
ACEP said another problem with the study was using data from Medicare, which it said "does not reflect actual costs and has not kept pace with inflation." Also, ED physicians provide more care for the poor and uninsured. "Emergency physicians treat every patient equally based on their need, not finances," ACEP President Dr. Rebecca Parker said in the statement. "Most emergency physicians have no idea what insurance coverage a patient has."
A growing problem that excess charges can cause is surprise medical bills — unexpectedly high bills that patients receive after receiving care outside their network or for uninsured care. In a study earlier this year in JAMA, a majority of physicians in 54 specialties reported charging 2.5 times more than what Medicare reimburses for their services. Another study in Health Affairs found that one in five inpatients admitted through the ED wind up with surprise medical bills.
The problem has prompted some states to enact legislation to curb the practice. Last summer, California lawmakers approved a bill that would protect Medicare beneficiaries in the state from surprise medical bills for observational services. Providers now have to notify patients when they are receiving observational care so they can determine if the care is covered or will charged an out-of-network rate. The state also requires health plans to pay out-of-network providers either the greater of average contracted rates or 125% of Medicare rates.
Maryland has also taken steps to rein in excess charges with legislation that requires HMOs to pay out-of-network providers 125% of their average in-network rates or 140% of Medicare rates.