Emergency Rooms vs. Urgent Care: Differences in Services and Costs

Emergency medicine is divided into two parts. Pre-institutional care includes the treatment of patients at the scene of an accident or emergency, most often by first responders such as police, firefighters and emergency room technicians (EMTs). It also includes ambulatory transportation to an emergency care facility.

Institutional care is the part of the system that includes hospital emergency departments (EDs), which provide initial treatment for a wide variety of illnesses and injuries, some of which may be life threatening and/or require immediate attention; and urgent care facilities, geared to treating less serious ailments and non-life-threatening injuries.

Emergency Rooms

An emergency department, or emergency room (ER), is generally part of a hospital or medical center. It specializes in the acute care of patients who arrive without an appointment and is typically open 24 hours a day, 7 days a week, 365 days a year.

According to the Centers for Disease Control and Prevention (CDC), Americans made 136.1 million visits to one of the country’s nearly 3,900 emergency rooms in 2012. Approximately 20 million of them arrived by ambulance. About 43 percent of all hospital admissions originate in an emergency room.

Normally, emergency room patients receive one of five levels of care: Level 1 is for minor problems, such as an earache. Level 2 may be for a cut that requires stitches, while level 5 is for more severe problems, like a broken bone. Even higher levels of care exist for critically ill patients.

While the American College of Emergency Physicians reports that 92 percent of emergency visits are from “very sick people who need care within 1 minute to 2 hours,” the National Hospital Ambulatory Medical Care Survey estimates that one-third to one-half of all ER visits are for non-urgent care. In fact, the top three reasons for ER visits in 2007 were for superficial injuries and contusions, sprains and strains, and upper respiratory infections. (The CDC defines non-urgent as “needing care in 2 to 24 hours.”)

The main reason that so many emergency room visits are for non-urgent care is that hospital EDs are required by federal law to provide care to all patients, regardless of their ability to pay. Since they cannot be turned away, patients without health insurance, or the necessary funds to pay out-of-pocket costs, often utilize emergency rooms as their main health care provider. This puts ERs under tremendous strain, and limits their ability to more quickly attend to health emergencies.

It is estimated that more than $18 billion could be saved annually if those patients whose medical problems are considered “avoidable” or “non-urgent” were to take advantage of primary or preventive health care and not rely on ERs for their medical needs.

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Emergency Room Costs

Emergency room costs are difficult to quantify and are most often unknown to a patient when he or she walks, or is wheeled, in the door. Other than knowing the standard co-pay amount for those who have private medical insurance, which can be several hundred dollars, it is impossible to determine how much the final ER bill will be until it is received in the mail  a few weeks after treatment.

ER costs correspond to the severity of a patient’s illness or injury, the number of diagnostic tests and/or treatments performed, physicians’ fees (typically about 20-25 percent of the total charges), radiology or specialist services, and any pharmacy or other hospital expenses. For example, an ambulance ride alone can cost between $400 and $1,200, depending upon location, distance from the hospital and services performed. Costs vary widely in different parts of the country and ultimately depend upon who pays – the individual, a private health insurer or a government agency like Medicare or Medicaid.

According to the Agency for Healthcare Research and Quality (AHRQ), average expenses for all people who had one or more visits to an ER in 2009 were $1,318. According to Kiplinger’s Personal Finance magazine, in 2011 the average in-network cost of an emergency room visit for someone with private health insurance was about $933. An Annals of Internal Medicine study found that the average 2009 cost of an ER visit for three common illnesses – middle ear infection, pharyngitis and urinary tract infection – was $570.

The following estimated costs are for nine of the most common reasons people visit the ER.

They were determined by calculating the average number on claims submitted in 2010 to the Medica Choice Network, a system of more than 4,000 medical offices, clinics and hospitals across four Midwestern states:
  • Allergies: $345
  • Acute bronchitis: $595
  • Earache: $400
  • Sore throat: $525
  • Pink eye: $370
  • Sinusitis: $617
  • Strep throat: $531
  • Upper respiratory infection: $486
  • Urinary tract infection: $665

Urgent Care Centers

Urgent care centers are freestanding, walk-in medical facilities that provide care on a no-appointment basis and are often open for extended hours, including nights and weekends. Sometimes referred to a “doc in a box,” urgent care centers are a cost-effective alternative to emergency rooms for the treatment of  non-life-threatening medical situations such as cuts, sprains, simple bone fractures, flus and fevers, insect bites, infections, etc. Some centers provide basic laboratory and X-ray services, and most can run diagnostic tests and dispense prescriptions.

These care centers have existed in the United States for more than 30 years, and today there are approximately 8,800 facilities nationwide. They accommodate an average of 342 patients a week.

Centers can be owned by doctors, hospitals or corporations and take in approximately $13 billion in revenue annually. Many urgent care centers are staffed by nurse practitioners and physician assistants, in addition to at least one board-certified physician.

Urgent Care Center Costs

Urgent care costs are significantly less than those of ERs, but are also difficult to quantify. The Annals of Internal Medicine study found that the average cost of an urgent care visit for three common illnesses — middle ear infection, pharyngitis and urinary tract infection — was $155. Other estimates place the average urgent care visit at anywhere from $71 to $125. The bottom line is that an urgent care visit is substantially cheaper than an ER visit.

The following costs are from Medica Choice Network estimates for nine common ailments treated at urgent care centers:
  • Allergies: $97
  • Acute bronchitis: $127
  • Earache: $110
  • Sore throat: $94
  • Pink eye: $102
  • Sinusitis: $112
  • Strep throat: $111
  • Upper respiratory infections: $111
  • Urinary tract infections: $110

Paying for Emergency Room Visits

In addition to the expensive procedures, services and equipment offered at the nation’s ERs, one reason emergency room costs are so high is because of the large amount of uncompensated care they deliver. According to the Centers for Medicare & Medicaid Services (CMS), almost half of all emergency services nationwide go uncompensated. So, the burden of paying for this “free” care must be absorbed by the hospitals and their physicians, but also by those who are privately insured and those who self-pay.

Another reason that ER bills are high is that for the most part, hospitals never expect that they are going to be paid in full, either because patients are too poor to pay or because prices have been negotiated beforehand by private insurers or, in the case of Medicare and Medicaid, by the government.

For example, while the uninsured are charged the highest rates – called gross rates – an insured patient may tally $3,000 in charges. His or her insurance company may pay only $1,500, based on an agreement with the hospital.

How the cost of a typical gross emergency room bill gets dispersed:
  • Private insurance: 54 percent
  • Medicare: about 38 percent
  • Medicaid: about 33 percent
  • Uninsured patients: 35 percent

Sometimes an ER bill is so exorbitant that a patient is simply unable to pay all or part of it. Therefore, it always pays to bargain when it comes to paying an ER bill, even if the patient is uninsured and has agreed to self-pay. Most hospitals will offer discounts for self-paying individuals, especially if there is a risk that they might not be paid at all. The same goes for the physician portion of the bill.

Even insured patients, especially if they are willing to contest specific charges, may get a reduction of their ER bill by contacting the hospital’s billing office. In addition, most hospitals will work with patients to create some sort of payment plan that allows reimbursements over time. If the bills are still too high, patients may consider settling their debt through a professional debt relief firm.

Even with its high costs, however, the percentage of the country’s total health care spending on emergency care is actually very small. According to the Agency for Healthcare Research and Quality, in 2008, when the nation’s total health care expenditures was approximately $2.4 trillion, all services provided in American EDs, including physician services, was $47.3 billion –barely 2 percent of the overall amount.

Paying For Urgent Care Visits

Care at urgent care centers is paid for on a fee-for-service basis. They usually accept most private health insurance plans, with co-pays averaging between $25-$50. A self-paying individual will usually be asked to make a down payment for the visit, with other charges billed at a later date. Cash discounts are often offered for the uninsured.

In any instance where medical debt becomes unmanageable, or is charged-off to a debt collection agency, an individual can work with a reputable debt relief company, experienced in debt settlement and/or debt consolidation.  A financial professional can create a plan to help reduce the debt’s principal amount or allow the debtor to consolidate several debts into one manageable payment, potentially with a lower interest rate.

Bill Fay

Author

Bill Fay

Bill Fay is a journalism veteran with a nearly four-decade career in reporting and writing for daily newspapers, magazines and public officials. His focus at Debt.org is on frugal living, veterans' finances, retirement and tax advice. Bill can be reached at bfay@debt.org.

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