Emergency Medicine

Modest levels of cost-sharing for emergency department care decrease emergency department visits without worsening health

As health care costs increase in the United States, finding ways to provide access to appropriate care and to pay for this care are critical. Previous studies have found that requiring patients to pay for some of their costs, i.e., cost-sharing, decreases health care spending, but some patients avoid necessary care. These studies have had limited ability to determine whether these changes actually worsen patient outcomes.

John Hsu, M.D., M.B.A., M.S.C.E., of Kaiser Permanente's Division of Research, and colleagues, examined the impact of emergency department (ED) cost-sharing on mortality and other unfavorable clinical events using a large natural experiment in which some patients faced higher ED copayments starting in January 2000, while others had no changes in their copayments. They found that modest copayments for emergency care reduced emergency room visits, without increasing adverse clinical events. Among commercially insured persons, ED visits were 12 percent lower for those with a $20-35 copayment and 23 percent lower for those with a $50-100 copayment, compared with patients with no ED copayment. Among Medicare-insured patients, ED visits were 4 percent lower for patients with a $20-50 copayment compared with no copayment. While ED visit rates decreased substantially as the ED copayment amount increased, the authors did not find an increase in unfavorable clinical events such as hospitalizations, ICU admissions, and mortality.

The results of this study are encouraging in that these modest copayments appeared to reduce ED use without harming patients. However, the results must be interpreted within the context of the study—i.e., an integrated delivery system of insured and generally non-indigent patients with a wide range of care delivery options (e.g., calling or E-mailing providers) and low levels of cost-sharing.

The researchers used automated clinical data on ED visits and unfavorable clinical events over a 36-month period (January 1999 through December 2001) among 2,257,445 commercially insured and 261,091 Medicare-insured health system members. The study was supported by the Agency for Healthcare Research and Quality (HS11434).

More details are in "Cost-sharing for emergency care and unfavorable clinical events: Findings from the safety and financial ramifications of ED copayments study," by Dr. Hsu, Mary Price, M.A., Richard Brand, Ph.D., and others, in the October 2006 HSR: Health Services Research 41(5), pp. 1801-1820.

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