Trends in Hospital Pricing for Vulnerable Emergency Department Users, 2021-2023

ABSTRACT

Objective: To assess the correlates of changes in emergency department (ED) prices for self-pay patients from 2021 to 2023.

Study Design: Retrospective longitudinal analysis of self-pay prices for ED facility fees (Current Procedural Terminology [CPT] codes 99283-99285) from 2021 to 2023, using multivariate weighted linear regression to examine the relationship between hospital- and area-level characteristics and trends in self-pay prices and correcting for selective noncompliance with price transparency reporting regulations.

Methods: We created a unique longitudinal database of self-pay rates for CPT codes 99283-99285 using national hospital price transparency data from September 29, 2021, and September 29, 2023. Hospital- and area-level characteristics were derived from the 2021 quarter 2 CMS Provider of Services File, the Agency for Healthcare Research and Quality’s 2021 Compendium of US Health Systems, and the 2021 American Community Survey.

Results: From 2021 to 2023, self-pay prices increased by a mean of $98.69, $392.85, and $642.74 for CPT codes 99283, 99284, and 99285, respectively. Price increases were notably higher at for-profit hospitals compared with nonprofits, and system affiliation and serving a community with higher levels of uninsured Hispanic/Latino individuals were associated with greater relative price increases for CPT codes 99284 and 99285.

Conclusions: Self-pay patients face growing affordability issues in ED access. For-profit and system-affiliated hospitals saw the largest increases. With Medicaid enrollment declines stemming from the end of continuous coverage requirements, which started in mid-2023, the self-pay population may rise, highlighting the need to understand their financial risk exposure.

Am J Manag Care. 2025;31(12):In Press

Takeaway Points

This study examines changes in emergency department (ED) self-pay prices from 2021 to 2023.

• We created a unique data set by leveraging snapshots of price transparency data, which allowed us to examine trends in self-pay pricing over time.
• Self-pay ED prices increased approximately 9% to 10% from 2021 to 2023, outpacing medical inflation.
• For-profit hospitals and system-affiliated hospitals saw the largest increases in self-pay pricing, and hospitals in counties with high proportions of uninsured Hispanic/Latino individuals raised self-pay prices significantly.
• The unwinding of Medicaid’s continuous coverage provision, which began in mid-2023, may further increase the self-pay population. Understanding the financial risks faced by self-pay patients is essential for informing health policy.

The emergency department (ED) is often the first point of care for many vulnerable groups, including uninsured and undocumented individuals,1 making affordable ED access a key health equity issue. The emergent nature of ED care limits patients’ provider choice and the potential for price shopping, rendering ED users uniquely financially vulnerable. Although self-pay patients represent a minority of all ED visits, they still accounted for 9.1 million visits in 2021 (down from 12.2 million in 2019 and 10.8 million in 2017).2-4 Average charges for self-pay visits are high, with 2021 Healthcare Cost and Utilization Project data showing a mean charge per of $5454 per self-pay visit,5 although actual payments were likely lower. Cost concerns are a well-documented barrier to ED use even for commercially insured individuals, who, in 2019, incurred a mean of $646 in out-of-pocket costs for an ED visit.6,7

Assessing financial burden for vulnerable ED users is especially challenging because many of them (eg, the uninsured, undocumented immigrants, high-deductible health plan enrollees) are likely to self-pay, rendering them invisible to the main source of health care research patient cost data: administrative claims. Given this, it is unsurprising that, to date, only a handful of studies have been able to empirically evaluate ED costs for self-pay patients. Existing research shows significant variation in self-pay ED prices, with higher prices at for-profit and larger hospitals and lower prices in high-poverty areas.8,9

Recent trends may have influenced self-pay pricing. On the demand side, expanded Medicaid enrollment during the public health emergency may have reduced the self-pay population,10 and inflation has eroded purchasing power disproportionately for the bottom quintile of the income distribution11; assuming all else is equal, to the extent that hospitals seek to compete for self-pay patients, both factors should tend to depress self-pay ED prices. On the supply side, hospitals reported significant financial strain in 2022 despite federal aid seemingly effectively offsetting operational losses in 2020 and 2021.12 Rising labor and supply costs, along with declining investment income and broader financial pressures, may have also contributed to changes in self-pay prices. Self-pay prices for shoppable services are often set at a fixed fraction of chargemaster rates, varying widely across hospitals.13 At the same time, to our knowledge, self-pay hospital rates are only regulated in Maryland, through the all-payer rate setting model, and Minnesota, where uninsured self-pay rates are capped at the “most favored insurer” rate.14,15 Thus, hospitals have broad discretion in setting self-pay prices, which could be used to offset financial strain from both COVID-19 and other financial pressures.

To better understand how the costs for vulnerable ED users have changed in the post–COVID-19 era, we leveraged novel hospital price transparency data, the first data set to allow systemic examination of self-pay prices, to empirically describe trends in ED prices for self-pay patients from 2021 to 2023. Because certain community and hospital characteristics may be important determinants of change in pricing for self-pay patients, we also assessed the relationship between a selected array of county- and hospital-level attributes and change in ED pricing for self-pay patients. We focused our analysis on ED facility fees rather than total ED visit cost because these fees are incurred as part of every ED visit and are the main driver of ED visit cost growth.7 Moreover, despite media attention16 and recent policy interest in hospital facility fees writ large,17 ED facility fees remain largely unregulated and represent a potential area of policy intervention.

METHODS

Self-pay prices for ED facility fees from 2021 and 2023 were derived from the Turquoise Health Hospital Price Transparency Research Dataset (academic license).18 This data set compiles hospital standard charge files mandated by the federal Hospital Price Transparency rule and is widely used by researchers.9,13,19 As of January 1, 2021, most hospitals have been required to publicly share their standard charge data, including a machine-readable file listing the costs of all items and services provided. The file must include various pricing categories, including gross charges (ie, charges), self-pay prices (ie, rates for cash-paying patients), payer-plan negotiated rates, and anonymized figures representing the lowest and highest negotiated rates. We used the self-pay prices reported in the Turquoise Health data set, which reflect the actual rates hospitals set for cash-paying patients, distinct from chargemaster rates.

Hospital characteristics (bed size, ownership, state, and setting) were derived from the 2021 quarter 3 CMS Provider of Services (POS) File,20 system affiliation from the 2021 Agency for Healthcare Research and Quality Compendium of US Health Systems,21 and community characteristics from the 2021 American Community Survey.22

Study Population

Our sample included all CMS-certified hospitals providing ED services from 2021 to 2023, excluding federally owned hospitals not subject to the transparency rule.23

ED Facility Fees

ED facility fees, charged for every ED, reflect the fixed costs of providing 24-hour emergency care and theoretically scale with visit complexity (levels 1-5).24 In practice, however, levels 1 and 2 are rarely used, so we restricted our analyses to levels 3 through 5 (Current Procedural Terminology [CPT] codes 99283, 99284, and 99285).8,25

Change in Prices for Self-Pay Patients

We created a unique longitudinal data set by linking national hospital ED pricing snapshots from September 29, 2021, and September 29, 2023. Hospitals missing data in either year were excluded. Prices were inflation adjusted to September 2023 US$ using the Consumer Price Index for medical care.26

Correlates of Changing Prices

We examined the relationship between self-pay price changes and hospital- and area-level factors, including setting (urban vs rural) and bed size. Because large hospital systems rely heavily on investments as a source of nonoperating income and privately owned hospitals, in particular, may be more affected by stock market fluctuations, we also assessed ownership structure (for-profit, nonprofit, public, and other) and system affiliation.

Ownership structure was based on CMS POS classifications. Public hospitals were defined as state, local, or hospital district/authority hospitals. Hospitals were classified as other if they were church- or physician-owned or did not fit into the other categories (for-profit, nonprofit, public, federal, or tribal). Federal and tribal hospitals were excluded from the study.

Although all hospitals were impacted by the COVID-19 pandemic, albeit unequally, we hypothesized that hospitals in communities with higher proportions of likely self-pay patients, specifically, uninsured individuals who are unlikely to apply for charity care, may have been more likely to raise self-pay prices to offset operational losses. Because willingness to apply for charity care could not be measured directly, we used a proxy based on the assumption that racial and ethnic groups with high levels of health care system distrust are less likely to seek financial assistance.27 To capture this, we examined the relationship between self-pay pricing changes and county-level estimates of the uninsured population who are Black or Hispanic/Latino.

Noncompliance

To address selection bias from noncompliance with the transparency rule, we used inverse probability of treatment weighting (IPTW), a method commonly used to adjust for selection bias in health services research.9,28-30 We compared covariates between compliant hospitals (in both 2021 and 2023) and all eligible hospitals and then used logistic regression to estimate the probability of inclusion based on hospital characteristics. After confirming that the overlap assumption was met, we applied the inverse of these probabilities as weights in our regression analyses to improve the generalizability of our estimates.

Statistical Analysis

We estimated descriptive statistics for self-pay price trends across ED levels and used multiple linear regression to analyze the relationship between hospital and community characteristics and price changes from 2021 to 2023, applying IPTW to adjust for selection bias. To address potential data quality issues, we conducted 2 robustness checks: (1) limiting analyses to hospitals with complete CPT data in both years and (2) excluding extreme 2021 outliers. To ensure that IPTW was not driving the results, we also reestimated regressions without weights. Finally, because large hospital systems may dominate the for-profit hospital group, potentially limiting generalizability, we ran additional specifications using robust SEs clustered by hospital system, although this approach cannot account for system affiliation due to perfect collinearity within clusters. All analyses were conducted using Stata/MP 18 (StataCorp LLC).

RESULTS

Of 4408 US hospitals with active EDs required to comply with the transparency rule, 926 (21.0%) reported self-pay ED facility fees in both 2021 and 2023 and 730 (16.6%) reported self-pay ED facility fees for every single emergency level studied (CPT 99283-99285). Reporting hospitals were generally larger, nonprofit, system affiliated, and urban (Table 1).

From 2021 to 2023, mean self-pay ED facility fees increased markedly across all visit levels. Across all hospitals, mean prices rose by $98.69 for level 3 visits, $392.85 for level 4 visits, and $642.74 for level 5 visits. Price growth for all levels was substantially higher at for-profit hospitals, where mean increases exceeded $2100 for level 5 visits, compared with $385.55 at nonprofit hospitals and $216.84 at public hospitals (Table 2). Descriptive statistics based on median prices (eAppendix Table 1 [eAppendix available at ajmc.com]) showed more modest differences between for-profit and nonprofit hospitals. Results of our sensitivity analyses were substantively similar and are presented in eAppendix Tables 2 and 3.

Regression Analyses

In our main specification, we found that for-profit hospitals experienced a larger increase in self-pay prices compared with nonprofits across all visit levels. The most pronounced effect occurred at level 5 visits, where for-profit hospitals raised prices by an additional $1589.18, or 393.1%, relative to nonprofit hospitals (Table 3). System affiliation also correlated with higher price growth but only for level 4 and 5 visits. We found no significant relationship between the number of uninsured Black individuals in a community and self-pay price growth. However, each 1% increase in the uninsured Hispanic/Latino population was associated with a 7.7% ($89.38) and 10.4% ($166.17) greater increase in self-pay prices for level 4 and level 5 visits, respectively (Table 3). Hospital size, region, and rural status were not significantly associated with self-pay ED price growth. In our sensitivity analysis using robust SEs clustered at the health-system level, for-profit affiliation was no longer significant the .05 level and the role of system affiliation could not be estimated due to perfect collinearity within clusters; our other trends remained the same (eAppendix Table 4). Our other sensitivity analyses yielded substantively similar results to our main analysis (eAppendix Tables 3, 5, and 6).

DISCUSSION

This study leveraged newly available hospital pricing data to assess trends in self-pay prices for ED facility fees. As previously reported, hospital compliance with federal price transparency requirements was low, particularly among small, rural, and unaffiliated hospitals.28,31 After adjusting for incomplete reporting and inflation, we found a growing price difference between visit levels: Mean ED facility fees for self-pay patients rose substantially from 2021 to 2023, with especially sharp increases for high-acuity visits.

Certain systematic pricing patterns emerged. For-profit and system-affiliated hospitals raised self-pay ED facility fees more than their nonprofit and independent counterparts. Although this post–COVID-19 differential increase may reflect hospitals responding to financial strain from the pandemic, broader economic pressures likely played a role. The S&P 500 fell approximately 20% in 2022, its worst performing year since 2008.32 Because large hospital systems rely heavily on investments as a source of nonoperating income and because investor-owned, for-profit hospitals, such as HCA Healthcare hospitals, are publicly traded, a reduction in stock market performance may have increased the need to recoup losses through higher prices.33 Rising labor and supply costs, alongside margin pressures, may have further contributed to price increases. A rigorous test of this hypothesis is beyond this study’s scope, warranting future research.

Public hospitals maintained the lowest self-pay prices across all visit levels in both 2021 and 2023. This trend could be consistent with efforts to support care for uninsured patients. Public hospitals, defined here as state, local, or hospital district/authority hospitals, may face different financial and policy pressures than other hospital types, which could explain their distinct pricing patterns. However, public hospitals have faced well-documented challenges in price transparency compliance,28 and early data quality issues may partly explain this finding. In early reporting, some public hospitals may have initially reported charges (ie, list prices) rather than actual self-pay prices, later correcting these discrepancies.

Descriptive statistics based on median prices showed relatively modest differences across ownership types. However, mean prices revealed much starker disparities: For-profit hospitals charged significantly higher mean prices across all ED visit levels, with mean increases exceeding $2000 for level 5 visits. These high-end outliers suggest that a subset of for-profit hospitals is driving much of the observed growth. Although median prices capture typical patient experiences, mean prices better reflect the financial risk to self-pay patients, especially those who cannot avoid high-cost hospitals in emergencies.

Hospitals in areas with higher proportions of uninsured Hispanic/Latino individuals increased self-pay prices more for level 4 and 5 visits than hospitals in other areas. This pattern may reflect financial pressures post COVID-19, with hospitals that serve more self-pay patients having stronger incentives to raise self-pay prices. Although hospitals cannot directly measure local self-pay populations, undocumented immigrants, who are ineligible for Medicaid, the Children’s Health Insurance Program, or Affordable Care Act marketplace plans,34 likely represent a significant share. As of 2023, an estimated half of undocumented immigrants were uninsured.35 Additionally, barriers such as language, trust, and immigration concerns may reduce their likelihood of applying for financial assistance. Because most undocumented immigrants in the US are from Latin America,36 area-level uninsured Hispanic/Latino rates may serve as a reasonable proxy for undocumented populations.

This study makes several contributions. To our knowledge, it is the first to examine changes in self-pay ED prices, building our understanding of the financial pressures experienced by a potentially vulnerable population. Additionally, although the Healthcare Cost and Utilization Project tracks ED visit charges for self-pay patients, its data lag, reliance on hospital charges rather than actual prices, and conflation of acuity5 with underlying prices limit its utility. In contrast, this study provides a novel, timely data source that isolates self-pay ED pricing trends independent of patient acuity.

Limitations

This study has several limitations. First, hospital compliance with the federal price transparency regulation remains low, with larger, system-affiliated hospitals more likely to report data.28 This may affect the external generalizability of our findings. We attempted to mitigate the impact of selective noncompliance by weighting our analyses using IPTW.

Second, this study focuses on one aspect of ED visits: the ED facility fee. Although this narrow focus is informative because ED facility fees are incurred in every ED visit and are typically set at hospital discretion, making them more likely to vary than other components of ED bills, it limits the generalizability of our findings to other services. Similar trends could exist for other services or care settings, but exploring this was beyond the scope of the current study. However, given the growing policy attention to outpatient facility fees, future research could assess whether the patterns observed here extend to outpatient facility fees and other service lines, which would clarify the broader implications of these findings.

We also note that, although it was outside the scope of this present study, a comparison of self-pay prices with commercial rates may be informative to policy makers. We encourage future research in this area, although we acknowledge that it may be complicated by data standardization challenges, such as the inconsistent identification of payer plans across hospitals.

Third, although we accounted for hospital ownership and system affiliation in our main models, we acknowledge the limitations in disentangling the role of hospital system membership. In robustness checks, we clustered SEs by health system to account for the potential influence of large hospital systems. However, this specification results in system affiliation being dropped as a covariate due to perfect collinearity within clusters. Given that system affiliation is likely to be an important factor in self-pay pricing, our approach is constrained by these data limitations.

Finally, the No Surprises Act (NSA) went into effect on January 1, 2022, coinciding with our study period. The NSA has 2 potentially relevant provisions: (1) It prohibits balance billing for out-of-network emergency services for insured patients, with disputes mediated through an independent dispute resolution (IDR) process, and (2) it requires hospitals to provide self-pay patients with estimates of expected charges before a scheduled service or upon request.37 The NSA is expected to have a significant impact on the national health landscape, with the Congressional Budget Office estimating a 1% reduction in premiums and early data showing a much higher than expected volume of IDR cases.38,39 Although self-pay ED patients are not directly covered by the NSA’s provisions, we acknowledge that the NSA may still have indirect effects on our estimates of self-pay ED facility fee increases.

CONCLUSIONS

Self-pay patients face increasing financial barriers to ED access in the post–COVID-19 era. These challenges may be intensifying as Medicaid coverage declines due to the unwinding of the continuous enrollment provision after the end of the public health emergency, likely expanding the uninsured, and, thus, self-pay, population.10 Although hospitals must treat and stabilize ED patients regardless of ability to pay, self-pay prices remain largely unregulated.40

High self-pay prices for ED facility fees can contribute to medical debt, which is linked to stress, poor health, and even premature death.41 Although recent policy efforts, such as changes to the Fair Credit Reporting Act, have sought to limit the downstream effects of medical debt, long-term protections remain uncertain.42

We found that self-pay ED prices were rising fastest at for-profit hospitals, especially for more complex visits. Although median price changes appeared modest, mean price changes were large, highlighting the influence of a small number of extremely high-priced hospitals. This skew reflects real exposure for patients and has meaningful implications for financial risk. Policy makers could advance transparency goals by focusing on outlier hospitals with unusually high self-pay prices, ensuring accountability without overburdening the entire sector.

Author Affiliations: The Hilltop Institute (MCM, MAH) and Department of Economics (MAH), University of Maryland, Baltimore County, Baltimore, MD; Department of Health Management and Policy, University of Michigan (MCM, SS), Ann Arbor, MI.

Source of Funding: This work was supported, in part, by funding from the University of Maryland, Baltimore County.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MCM, SS, MAH); acquisition of data (MCM, MAH); analysis and interpretation of data (MCM, MAH); drafting of the manuscript (MCM, SS); critical revision of the manuscript for important intellectual content (MCM, SS, MAH); statistical analysis (MCM, MAH); provision of patients or study materials (MCM); obtaining funding (MCM); and administrative, technical, or logistic support (MCM).

Address Correspondence to: Morgane C. Mouslim, DVM, ScM, University of Maryland, Baltimore County, 1000 Hilltop Circle, Sondheim Hall, 3rd Floor, Baltimore, MD 21250. Email: mmousli1@umbc.edu.

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