The Effect of the COVID-19 Pandemic on the Economics of U.S. Emergency Care

Pines, Jesse M.; Zocchi, Mark S.; Black, Bernard S.; Kornas, Rebecca; Celedon, Pablo; Moghtaderi, Ali; Venkat, Arvind

Objective We describe how the COVID-19 pandemic affected the economics of emergency department (ED) care. Methods We conducted an observational study of 136 EDs January 2019-September 2020, using 2020-to-2019 three-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 (FTE) changes. Results Following the COVID-19 pandemic’s onset, geriatric (65+), adult (18-64), and pediatric (<18) ED visits declined by 43%, 40%, and 73% compared to 2019 visits respectively, rose thereafter, but remained below 2019 levels through September. Relative value units (RVUs)/visit rose by 8%, 9%, and 18% of 2019 respectively, while ED admission rates rose by 32%. Both fell subsequently but remained above 2019 levels through September. Revenues dropped sharply in the early pandemic, 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 free-standing EDs. Staffing and expense reductions could not match revenue losses in smaller EDs. During the pandemic, emergency physician and advanced practice provider (APP) clinical hours and compensation fell 15% and 27% respectively, corresponding to 174 lost physician and 193 lost APP FTE 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 and ED clinician compensation. Staffing cutbacks could not match reduced revenue at small EDs with minimum emergency physician coverage requirements.