Emergency Department Out-of-Pocket Expenditures by Insurance, 1999 to 2016

Abstract

Study objective: Per visit, emergency department (ED) expenditures have increased more for private insurance than Medicare and Medicaid during the past 20 years, but it is unknown whether ED out-of-pocket expenditures show a similar pattern of increase. We compare increases in per-visit ED out-of-pocket expenditures over time for visits that did not result in hospitalization or observation admissions for private insurance, Medicare, and Medicaid.

Methods: This repeated cross-sectional analysis of out-of-pocket expenditures used data from the 1999 to 2016 Medical Expenditure Panel Survey, a nationally representative survey of the noninstitutionalized US civilian population. We used 2-part models-logistic regression followed by a generalized linear model with a γ distribution and a log link function-to compare per-visit out-of-pocket expenditures over time among different payers. Models contained insurance type, year, an interaction between year and insurance type, region of country, sex, and 5 visit-level variables (magnetic resonance imaging/computed tomography scans, ultrasonography, surgical procedures, radiographs, and ECGs).

Results: In our sample of 107,519 ED visits, mean annual per-visit out-of-pocket expenditures increased $7.31 a year (95% confidence interval $6.22 to $8.41) for private insurance and did not increase for Medicare or Medicaid. Most private insurance and Medicare visits had out-of-pocket expenditures less than $100 and nearly all Medicaid visits had no out-of-pocket expenditures. There was no strong evidence suggesting that out-of-pocket expenditures at different total expenditure amounts increased appreciably for private insurance.

Conclusion: Per-visit out-of-pocket expenditure increases for private insurance ED visits were predominantly related to overall increases in per-visit total expenditure.