Improving care

Cost of an ER visit? Study finds most doctors have no idea

New research in the JAOA finds 62% of emergency department doctors struggle with estimating costs of care. Take our quiz to test your acumen.


Results of a survey published in the Journal of the American Osteopathic Association found on average only 38 percent of emergency medicine healthcare professionals—including physicians, physician assistants, and nurse practitioners—could accurately estimate the costs for common emergency department treatments.

Kevin Hoffman, DO, an emergency medicine resident at Lakeland Health in Saint Joseph, Michigan, led the research.

“Early in my residency, I realized I had no idea how much money I was spending with all the tests and medications I ordered—mostly because it’s just not discussed,” Dr. Hoffman says. “I began to wonder if any of my colleagues knew.”

The survey presented three cases with details about patient symptoms, diagnosis and treatment. The conditions chosen were common to emergency department patients: abdominal pain, labored breathing and sore throat. Respondents were then given a multiple choice for ranges in costs of standard treatment for each patient.

The correct cost range was chosen by 43 percent of respondents for the first scenario, followed by 32 percent on the second and 40 percent on the third.

Demographic data was collected for each respondent, showing that geography had no bearing on correct answers. However, those working in larger institutions did lean toward higher cost estimates. Worth noting, respondents with higher levels of training believed they had a greater understanding of costs, yet performed no better in accurately selecting the correct range.

Prior research has shown that, when doctors understand the cost of care, healthcare spending goes down, while maintaining positive patient outcomes. Dr. Hoffman hopes his research can nudge emergency medicine physicians toward becoming more conscious of spending.

A balancing act: Economy and efficacy

“ER docs want to save lives, they’re not usually worried about the associated costs,” Dr. Hoffman says. “But the truth is some of our patients are not here for medical emergencies. They simply don’t have insurance or access to primary care.”

He says this highlights the importance of being economical in treatment. “The bills generated by emergency department care can potentially financially cripple these patients or add to the mounting burden on taxpayers.”

Dr. Hoffman adds that physicians must reassess their treatment protocols and find ways to deliver the same quality of care, while being cost conscious. He gives an example: “If I order a drug to be given via IV, it’s going to be a lot more expensive than if I give it orally, as a pill.”

He explains that IV-delivered medications come with multiple charges. Patients are charged for the IV itself, for a nurse to establish the line, and then for a nurse to administer the drug.

“That’s three separate charges on top of the cost of the drug itself—which is also more expensive in IV form. But much of the time the pill is equally effective.”

Unlike other departments, the emergency room cannot turn patients away, and Dr. Hoffman says many of his patients without insurance or access to primary care often come in for one specific complaint but then get several issues addressed.

He suggests that emergency department staff can address the most acute symptoms of the patient but then give a referral to schedule future diagnostic tests and follow-up care at an outpatient clinic.

“Everything is more expensive in the ER: Getting labs drawn, taking X-rays, everything,” says Dr. Hoffman. “The people who come in need care but they don’t need it all to happen here.”

Test your understanding of the costs of care

Presentation: 35-year-old obese woman with no medical history presents to the ED with a chief complaint of right-sided progressive cramping abdominal pain for the past 2-3 d. She reports nausea and vomiting (3 times) without fever/chills. Her pain worsens with eating, but she is still drinking liquids normally. No changes to urinary or bowel habits; no vaginal bleeding or discharge.

Physical Examination: Vital signs are normal. Heart and lungs are without notable abnormality. Abdomen is soft; tender in the RUQ and RLQ without rebound. Pelvic examination is normal. Diagnostics: CBC, CMP, urinalysis, urine pregnancy test, abdominal RUQ ultrasonography, CT of the abdomen/pelvis with IV/oral contrast. No significant pathologic cause is identified.

Diagnostics: CBC, CMP, urinalysis, urine pregnancy test, abdominal RUQ ultrasonography, CT of the abdomen/pelvis with IV/oral contrast. No significant pathologic cause is identified.

Intervention: Morphine, 4 mg IV, and ondansetron, 4 mg IV. Symptoms resolve and patient is discharged home.

Presentation: 57-year-old man with medical history of CHF presents to the ED with chief complaint of 3 d of progressive dyspnea, lower extremity edema, and 2-3 pillow orthopnea. No chest or abdominal pain or changes in urinary or bowel habits.

Physical Examination: Mildly distressed. Vital signs are stable but notable for tachypnea at 24/min and a room air pulse oximetry of 84% at triage and 96% on BiPAP. S3 heart sound present with bilateral rales above the midlung field. Bilateral and symmetric 2+ pitting edema in the lower extremities to above the knee.

Diagnostics: EKG, CBC, CMP, BNP, chest radiography, troponin, D-dimer. EKG shows LVH without signs of ischemia or infarction. Radiograph shows bilateral pleural effusions and moderate diffuse pulmonary edema. BNP is elevated at 20,000 pg/mL. No other notable abnormalities.

Intervention: Furosemide, 60 mg IV. Patient is admitted to the hospital for stabilization.

Presentation: 7-year-old boy with no medical history presents to the ED with chief complaint of sore throat for 24 h. He is reported to have had a fever of 102.4°F without a cough. He is eating and drinking normally. No other symptoms.

Physical Examination: Mildly distressed. Vital signs are stable. Heart, lung, and abdomen are unremarkable. Throat examination shows diffuse pharyngeal erythema with 2+ tonsils with exudate without signs of abscess. Airway is patent. Neck examination shows anterior cervical lymphadenopathy.

Diagnostics: Rapid strep test is positive.

Intervention: The patient is discharged home with a prescription for amoxicillin liquid and follow-up with his PCP in 24-48 h.


Show me the answers!

Case 1: The correct answer is $4,713.

Case 2: The correct answer is $2,423.

Case 3: The correct answer is $596.

You answered them all right!


  1. Pingback: Can You Guess the Hospital Bill for 3 Common ER Scenarios? Most Doctors Can't | Healthy Backyard

  2. William Turcotte, DO

    Similarly, very few primary care providers know the costs of their treatments. And even fewer can give a patient an accurate estimate of the cost the patient can expect.

  3. George Williams

    I am a family practitioner working the emergency room in my town. I am apalled by the number of tests ordered by people that are not involved in primary care, mainly family medicine. Most internists, surgeons and other people that work the emergency room have not a clue nor do they care about how much they spend in the emergency room. Not everybody seen in the emergency room needs a CBC, chest x-ray or other test related to what is wrong with the patient when it is obvious if you do a good history and physical exam. There are way too many “little folders” that are used by doctors that have too many tests hidden inside them that mean nothing much whoever what’s wrong with the patient. We need to order tests separately for what is wrong for the patient. Our system in the emergency room here has folders for abdominal pain, chest pain, altered mental status as well as other things that are wrong with patients. We need to quit ordering things that come in “batches or folders” and quit acting like Martha Stewart cookbook.

    1. Dr. Bob, DO

      I agree completely. The way things are currently, it seems like many ED physicians are forced to play defensive medicine. Either because they don’t want to get sued or the hospital that employs them requires a predetermined set of tests/images/referrals for certain complaints (to avoid getting sued). Example, 21 year old male with chest pain that is obviously secondary to chest wall etiology gets an EKG, troponins, chest x-ray, echocardiogram, CBC,…etc. Many of these policies can be attributed to clipboard toting administrators who have never been to medical school.

  4. Dr. Bob, DO

    Nothing surprising about this article. Anyone with any healthcare exposure knows this truth. Go get an x-ray at a hospital and ask the registration how much it will cost, you will never get an answer until the bill comes 10 days later. Consumers are barred from knowing virtually all information about healthcare associated costs, including the ED. It should be clearly posted or at the least provided upon inquiry of the cost of acquiring services.

  5. Beth Thompson

    A friend went to the ER with a possible stroke. He was diagnosed with Bell’s palsy. After CT, MR, etc, his insurance was billed $30K, not including physician charges.

  6. Otto F Sabando DO FACOEP FACEP

    The cost is dependent on various factors. All bills are negotiated with insurance companies (in network and out of network) and the cost for service will vary due to the final contractual cost between the hospital and insurance companies. Only when the patient receives the itemized bill with they realize what the cost of their care was. There is even a reduced rate for patients who don’t have insurance and pay cash. The idea is some money is better that no money at all…

  7. Pingback: Can You Guess the Hospital Bill for 3 Common ER Scenarios? Most Doctors Can’t – Family – Better Health

  8. Pingback: Can You Guess the Hospital Bill for 3 Common ER Scenarios? Most Doctors Can't - Health News

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