RAND Report: Strategies for Sustaining Emergency Care in the United States
Published Apr 7, 2025
Emergency medicine’s newest report independently shows that emergency physicians across the U.S. are facing increasing financial and operational pressures which threaten their ability to provide lifesaving care.
The findings, authored by RAND and supported by the Emergency Medicine Policy Institute (EMPI) — of which ACOEP is a supporting member and ACEP, underscore the urgent need for policy and payment reforms to preserve the essential role of emergency departments in the U.S. health care system. Your membership in ACOEP supports important work like this, helping to advance advocacy efforts that protect the future of emergency care.
Over the past decade, much has changed in the emergency care landscape in the United States. Hospital-based emergency departments (EDs) and the health care professionals who provide care in them have been at the forefront of responding to the opioid and gun violence epidemics and the coronavirus disease 2019 (COVID-19) pandemic, with reported increases in patient acuity and complexity. During the same time frame, there have been unsustainable declines in payment for emergency care, putting the viability of EDs at risk.
In this report, the authors (1) assess the current value of emergency care, (2) evaluate challenges to sustaining emergency care, (3) measure trends in emergency care payment, and (4) identify alternate funding strategies for emergency care.
The authors find that EDs offer many types of value to various stakeholders in the United States but that, because of the stresses EDs have faced over the past decade, the viability of emergency care as we know it is at risk. The authors offer policy actions that need to be taken on multiple fronts to preserve emergency care.
KEY FINDINGS
EDs are the safety net of the U.S. health system
- EDs are one of the few health care settings in which care is provided regardless of an individual’s ability to pay.
- The ED is the main location where patients seek acute unscheduled medical care and care for time-sensitive conditions.
- EDs provide 24/7 access to advanced diagnostics and treatment in a one-stop shop, increasing timeliness of care and potentially improving outcomes by preventing diagnosis and treatment delays.
- EDs bolster both health system and community resilience by adding care capacity routinely and during mass casualty incidents, disasters, and public health emergencies.
- Many EDs play a role in public health threat prevention, detection, and intervention.
- In 2024, ED visit numbers almost reached prepandemic numbers nationally, with a consistent rise between 2020 and 2024.
- Patient complexity is on the rise, with EDs managing patients with complex medical and social needs.
- ED patient acuity is rising, translating to an increase in demand for critical care services in the ED.
- Increases in demand and insufficient capacity can lead to ED crowding, longer wait times, and violence toward ED staff.
- Medicare and Medicaid payments to ED physicians 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 and 47.7 percent for commercial out-of-network visits over this period.
- 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.