Total and Out-of-Pocket Costs Surrounding Emergency Department Care Among Older Adults Enrolled in Traditional Medicare and Medicare Advantage.

STUDY OBJECTIVE: We sought to quantify differences in total and out-of-pocket health care costs associated with treat-and-release emergency department (ED) visits among older adults with traditional Medicare and Medicare Advantage. METHODS: We conducted a repeated cross-sectional analysis of treat-and-release ED visits using 2015 to 2020 data from the Medicare Current Beneficiary Survey. We measured total and out-of-pocket health care spending during 3 time periods: the 30 days prior to the ED visit, the treat-and-release ED visit itself, and the 30 days after the ED visit. Stratified by traditional Medicare or Medicare Advantage status, we determined median total costs and the proportion of costs that were out-of-pocket. RESULTS: Among the 5,011 ED visits by those enrolled in traditional Medicare, the weighted median total (and % out-of-pocket) costs were $881.95 (13.3%) for the 30 days prior to the ED visit, $419.70 (10.1%) for the ED visit, and $809.00 (13.8%) for the 30 days after the ED visit. For the 2,595 ED visits by those enrolled in Medicare Advantage, the weighted median total (and % out-of-pocket) costs were $484.92 (24.0%) for the 30 days prior to the ED visit, $216.66 (21.9%) for the ED visit, and $439.13 (22.4%) for the 30 days after the ED visit. CONCLUSION: Older adults insured by Medicare Advantage incur lower total health care costs and face similar overall out-of-pocket expenses in the time period surrounding emergency care. However, a higher proportion of expenses are out-of-pocket compared with those insured by traditional Medicare, providing evidence of greater cost sharing for Medicare Advantage plan enrollees.

Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study.

INTRODUCTION: As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes. METHODS: This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test. RESULTS: From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant. CONCLUSION: Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.

Critical Care Units in Malawi: A Cross-Sectional Study.

Background: The global burden of critical illness falls disproportionately outside high-income countries. Despite younger patient populations with similar or lower disease severity, critical illness outcomes are poor outside high-income countries. A lack of data limits attempts to understand and address the drivers of critical care outcomes outside high-income countries. Objectives: We aim to characterize the organization, available resources, and service capacity of public sector critical care units in Malawi and identify barriers to improving care. Methods: We conducted a secondary analysis of the Malawi Emergency and Critical Care Survey, a cross-sectional study performed from January to February 2020 at all four central hospitals and a simple random sample of nine out of 24 public sector district hospitals in Malawi, a predominantly rural, low-income country of 19.6 million in southern Africa. Data from critical care units were used to characterize resources, processes, and barriers to care. Findings: There were four HDUs and four ICUs across the 13 hospitals in the Malawi Emergency and Critical Care Survey sample. The median critical care beds per 1,000,000 catchment was 1.4 (IQR: 0.9 to 6.7). Absent equipment was the most common barrier in HDUs (46% [95% CI: 32% to 60%]). Stockouts was the most common barriers in ICUs (48% [CI: 38% to 58%]). ICUs had a median 3.0 (range: 2 to 8) functional ventilators per unit and reported an ability to perform several quality mechanical ventilation interventions. Conclusions: Although significant gaps exist, Malawian critical care units report the ability to perform several complex clinical processes. Our results highlight regional inequalities in access to care and support the use of process-oriented questions to assess critical care capacity. Future efforts should focus on basic critical care capacity outside of urban areas and quantify the impact of context-specific variables on critical care mortality.

Older adults' perspectives on emergency department costs during COVID-19.

Objectives: COVID-19 has strained the household finances of many Americans who are already experiencing increasing health care expenses. Concerns about the cost of care may deter patients from seeking even urgent care from the emergency department (ED). This study examines predictors of older Americans' concerns about ED visit costs and how cost concerns may have influenced their ED use in the early stages of the pandemic. Study Design: This was a cross-sectional survey study using a nationally representative sample of US adults aged 50 to 80 years (N = 2074) in June 2020. Methods: Multivariate logistic regressions assessed the relationships of sociodemographic, insurance, and health factors with cost concerns for ED care. Results: Of the respondents, 80% were concerned (45% very, 35% somewhat) about costs of an ED visit and 18% were not confident in their ability to afford an ED visit. Of the entire sample, 7% had avoided ED care because of cost concerns in the past 2 years. Of those who may have needed ED care, 22% had avoided care. Predictors of cost-related ED avoidance included being aged 50 to 54 years (adjusted odds ratio [AOR], 4.57; 95% CI, 1.44-14.54), being uninsured (AOR, 2.93; 95% CI, 1.35-6.52), having poor or fair mental health (AOR, 2.82; 95% CI, 1.62-4.89), and having an annual household income of less than $30,000 (AOR, 2.30; 95% CI, 1.19-4.46). Conclusions: During the early COVID-19 pandemic, most older US adults expressed concerns about the financial impact of ED use. Further research should examine how insurance design could alleviate the perceived financial burden of ED use and prevent cost-related care avoidance, especially for those at higher risk in future pandemic surges.

Implementation of the SIMPL (Society for Improving Medical Professional Learning) performance assessment tool in the emergency department: A pilot study.

Background: Feedback and assessment are difficult to provide in the emergency department (ED) setting despite their critical importance for competency-based education, and traditional end-of-shift evaluations (ESEs) alone may be inadequate. The SIMPL (Society for Improving Medical Professional Learning) mobile application has been successfully implemented and studied in the operative setting for surgical training programs as a point-of-care tool that incorporates three assessment scales in addition to dictated feedback. SIMPL may represent a viable tool for enhancing workplace-based feedback and assessment in emergency medicine (EM). Methods: We implemented SIMPL at a 4-year EM residency program during a pilot study from March to June 2021 for observable activities such as medical resuscitations and related procedures. Faculty and residents underwent formal rater training prior to launch and were asked to complete surveys regarding the SIMPL app's content, usability, and future directions at the end of the pilot. Results: A total of 36/58 (62%) of faculty completed at least one evaluation, for a total of 190 evaluations and an average of three evaluations per faculty. Faculty initiated 130/190 (68%) and residents initiated 60/190 (32%) evaluations. Ninety-one percent included dictated feedback. A total of 45/54 (83%) residents received at least one evaluation, with an average of 3.5 evaluations per resident. Residents generally agreed that SIMPL increased the quality of feedback received and that they valued dictated feedback. Residents generally did not value the numerical feedback provided from SIMPL. Relative to the residents, faculty overall responded more positively toward SIMPL. The pilot generated several suggestions to inform the optimization of the next version of SIMPL for EM training programs. Conclusions: The SIMPL app, originally developed for use in surgical training programs, can be implemented for use in EM residency programs, has positive support from faculty, and may provide important adjunct information beyond current ESEs.

High Deductibles are Associated With Severe Disease, Catastrophic Out-of-Pocket Payments for Emergency Surgical Conditions.

BACKGROUND: Out-of-pocket spending has risen for individuals with private health insurance, yet little is known about the unintended consequences that high levels of cost-sharing may have on delayed clinical presentation and financial outcomes for common emergency surgical conditions. METHODS: In this retrospective analysis of claims data from a large commercial insurer (2016-2019), we identified adult inpatient admissions following emergency department presentation for common emergency surgical conditions (eg, appendicitis, cholecystitis, diverticulitis, and intestinal obstruction). Primary exposure of interest was enrollment in a high-deductible health insurance plan (HDHP). Our primary outcome was disease severity at presentation-determined using ICD-10-CM diagnoses codes and based on validated measures of anatomic severity (eg, perforation, abscess, diffuse peritonitis). Our secondary outcome was catastrophic out-of-pocket spending, defined by the World Health Organization as out-of-pocket spending >10% of annual income. RESULTS: Among 43,516 patients [mean age 48.4 (SD: 11.9) years; 51% female], 41% were enrolled HDHPs. Despite being younger, healthier, wealthier, and more educated, HDHP enrollees were more likely to present with more severe disease (28.5% vs 21.3%, P <0.001; odds ratio (OR): 1.34, 95% CI: 1.28-1.42]); even after adjusting for relevant demographics (adjusted OR: 1.23, 95% CI: 1.18-1.31). HDHP enrollees were also more likely to incur 30-day out-of-pocket spending that exceeded 10% of annual income (20.8% vs 6.4%, adjusted OR: 3.93, 95% CI: 3.65-4.24). Lower-income patients, Black patients, and Hispanic patients were at highest risk of financial strain. CONCLUSIONS: For privately insured patients presenting with common surgical emergencies, high-deductible health plans are associated with increased disease severity at admission and a greater financial burden after discharge-especially for vulnerable populations. Strategies are needed to improve financial risk protection for common surgical emergencies.

A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies.

As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.

Financial Outcomes After Traumatic Injury Among Working-Age US Adults With Commercial Insurance.

This cross-sectional study links insurance claims and consumer credit report data to evaluate the experience of financial distress in commercially insured adults after traumatic injury.

Identifying Strategies to Boost COVID-19 Vaccine Acceptance in the United States.

This study presents the results of an evaluation of the root causes of COVID-19 vaccine hesitancy to inform strategies to boost vaccine acceptance among vaccine-hesitant populations in the United States. The authors conducted a literature review of the causes of vaccine hesitancy and vaccine acceptance; focus groups with patients, pre-hospital first responders, and hospital-based health care providers; a social media platform sentiment analysis to review attitudes regarding the COVID-19 vaccine; and a roundtable discussion with experts on vaccine hesitancy. Drawing on this mixed-methods analysis, the authors recommend strategies to help boost COVID-19 vaccine acceptance in the United States, grouping them according to three overall goals: boosting confidence in the safety and effectiveness of the COVID-19 vaccines, combating complacency about the pandemic, and increasing the convenience of getting vaccinated. The authors emphasize that combating misinformation about the COVID-19 vaccine is key to achieving these goals. These recommendations can inform the development of a toolkit of strategies to reach herd immunity and end the pandemic.

The Malawi emergency and critical care survey: A cross-sectional national facility assessment.

BACKGROUND: Data on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage. METHODS: We developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility. FINDINGS: A total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80-0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021). INTERPRETATION: This is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts. FUNDING: Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.

Estimating health care delivery system value for each US state and testing key associations.

OBJECTIVE: To estimate health care systems' value in treating major illnesses for each US state and identify system characteristics associated with value. DATA SOURCES: Annual condition-specific death and incidence estimates for each US state from the Global Burden Disease 2019 Study and annual health care spending per person for each state from the National Health Expenditure Accounts. STUDY DESIGN: Using non-linear meta-stochastic frontier analysis, mortality incidence ratios for 136 major treatable illnesses were regressed separately on per capita health care spending and key covariates such as age, obesity, smoking, and educational attainment. State- and year-specific inefficiency estimates were extracted for each health condition and combined to create a single estimate of health care delivery system value for each US state for each year, 1991-2014. The association between changes in health care value and changes in 23 key health care system characteristics and state policies was measured. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: US state with relatively high spending per person or relatively poor health-outcomes were shown to have low health care delivery system value. New Jersey, Maryland, Florida, Arizona, and New York attained the highest value scores in 2014 (81 [95% uncertainty interval 72-88], 80 [72-87], 80 [71-86], 77 [69-84], and 77 [66-85], respectively), after controlling for health care spending, age, obesity, smoking, physical activity, race, and educational attainment. Greater market concentration of hospitals and of insurers were associated with worse health care value (p-value ranging from <0.01 to 0.02). Higher hospital geographic density and use were also associated with worse health care value (p-value ranging from 0.03 to 0.05). Enrollment in Medicare Advantage HMOs was associated with better value, as was more generous Medicaid income eligibility (p-value 0.04 and 0.01). CONCLUSIONS: Substantial variation in the value of health care exists across states. Key health system characteristics such as market concentration and provider density were associated with value.

Healthcare spending in U.S. emergency departments by health condition, 2006-2016.

BACKGROUND: Healthcare spending in the emergency department (ED) setting has received intense focus from policymakers in the United States (U.S.). Relatively few studies have systematically evaluated ED spending over time or disaggregated ED spending by policy-relevant groups, including health condition, age, sex, and payer to inform these discussions. This study's objective is to estimate ED spending trends in the U.S. from 2006 to 2016, by age, sex, payer, and across 154 health conditions and assess ED spending per visit over time. METHODS AND FINDINGS: This observational study utilized the National Emergency Department Sample, a nationally representative sample of hospital-based ED visits in the U.S. to measure healthcare spending for ED care. All spending estimates were adjusted for inflation and presented in 2016 U.S. Dollars. Overall ED spending was $79.2 billion (CI, $79.2 billion-$79.2 billion) in 2006 and grew to $136.6 billion (CI, $136.6 billion-$136.6 billion) in 2016, representing a population-adjusted annualized rate of change of 4.4% (CI, 4.4%-4.5%) as compared to total healthcare spending (1.4% [CI, 1.4%-1.4%]) during that same ten-year period. The percentage of U.S. health spending attributable to the ED has increased from 3.9% (CI, 3.9%-3.9%) in 2006 to 5.0% (CI, 5.0%-5.0%) in 2016. Nearly equal parts of ED spending in 2016 was paid by private payers (49.3% [CI, 49.3%-49.3%]) and public payers (46.9% [CI, 46.9%-46.9%]), with the remainder attributable to out-of-pocket spending (3.9% [CI, 3.9%-3.9%]). In terms of key groups, the majority of ED spending was allocated among females (versus males) and treat-and-release patients (versus those hospitalized); those between age 20-44 accounted for a plurality of ED spending. Road injuries, falls, and urinary diseases witnessed the highest levels of ED spending, accounting for 14.1% (CI, 13.1%-15.1%) of total ED spending in 2016. ED spending per visit also increased over time from $660.0 (CI, $655.1-$665.2) in 2006 to $943.2 (CI, $934.3-$951.6) in 2016, or at an annualized rate of 3.4% (CI, 3.3%-3.4%). CONCLUSIONS: Though ED spending accounts for a relatively small portion of total health system spending in the U.S., ED spending is sizable and growing. Understanding which diseases are driving this spending is helpful for informing value-based reforms that can impact overall health care costs.

US Health Care Spending by Race and Ethnicity, 2002-2016.

Importance: Measuring health care spending by race and ethnicity is important for understanding patterns in utilization and treatment. Objective: To estimate, identify, and account for differences in health care spending by race and ethnicity from 2002 through 2016 in the US. Design, Setting, and Participants: This exploratory study included data from 7.3 million health system visits, admissions, or prescriptions captured in the Medical Expenditure Panel Survey (2002-2016) and the Medicare Current Beneficiary Survey (2002-2012), which were combined with the insured population and notified case estimates from the National Health Interview Survey (2002; 2016) and health care spending estimates from the Disease Expenditure project (1996-2016). Exposure: Six mutually exclusive self-reported race and ethnicity groups. Main Outcomes and Measures: Total and age-standardized health care spending per person by race and ethnicity for each year from 2002 through 2016 by type of care. Health care spending per notified case by race and ethnicity for key diseases in 2016. Differences in health care spending across race and ethnicity groups were decomposed into differences in utilization rate vs differences in price and intensity of care. Results: In 2016, an estimated $2.4 trillion (95% uncertainty interval [UI], $2.4 trillion-$2.4 trillion) was spent on health care across the 6 types of care included in this study. The estimated age-standardized total health care spending per person in 2016 was $7649 (95% UI, $6129-$8814) for American Indian and Alaska Native (non-Hispanic) individuals; $4692 (95% UI, $4068-$5202) for Asian, Native Hawaiian, and Pacific Islander (non-Hispanic) individuals; $7361 (95% UI, $6917-$7797) for Black (non-Hispanic) individuals; $6025 (95% UI, $5703-$6373) for Hispanic individuals; $9276 (95% UI, $8066-$10 601) for individuals categorized as multiple races (non-Hispanic); and $8141 (95% UI, $8038-$8258) for White (non-Hispanic) individuals, who accounted for an estimated 72% (95% UI, 71%-73%) of health care spending. After adjusting for population size and age, White individuals received an estimated 15% (95% UI, 13%-17%; P < .001) more spending on ambulatory care than the all-population mean. Black (non-Hispanic) individuals received an estimated 26% (95% UI, 19%-32%; P < .001) less spending than the all-population mean on ambulatory care but received 19% (95% UI, 3%-32%; P = .02) more on inpatient and 12% (95% UI, 4%-24%; P = .04) more on emergency department care. Hispanic individuals received an estimated 33% (95% UI, 26%-37%; P < .001) less spending per person on ambulatory care than the all-population mean. Asian, Native Hawaiian, and Pacific Islander (non-Hispanic) individuals received less spending than the all-population mean on all types of care except dental (all P < .001), while American Indian and Alaska Native (non-Hispanic) individuals had more spending on emergency department care than the all-population mean (estimated 90% more; 95% UI, 11%-165%; P = .04), and multiple-race (non-Hispanic) individuals had more spending on emergency department care than the all-population mean (estimated 40% more; 95% UI, 19%-63%; P = .006). All 18 of the statistically significant race and ethnicity spending differences by type of care corresponded with differences in utilization. These differences persisted when controlling for underlying disease burden. Conclusions and Relevance: In the US from 2002 through 2016, health care spending varied by race and ethnicity across different types of care even after adjusting for age and health conditions. Further research is needed to determine current health care spending by race and ethnicity, including spending related to the COVID-19 pandemic.

An Implementation Research Approach to Re-orient Health Supply Chains Toward an Equity Agenda in the COVID-19 Era.

The Covid-19 pandemic has exposed critical inequities in global healthcare supply chains and the need for these systems to be analyzed and reoriented with an equity lens. Implementation research methodology can guide the use of evidence-based interventions to re-orient health supply chains towards equity and optimize health outcomes. Using this approach, private and public sector entities can adapt their strategies to focus not just on efficiency and cost savings but ensuring that vulnerable populations have access to essential medications, vaccines, and supplies. Findings can inform regulations that address supply chain inequities at the global level, strengthen existing systems to fill structural gaps at the national level, and address contextual challenges at the subnational level. This methodology can help account for historical practices from prior health initiatives, identify contemporary barriers and facilitators for positive change, and have applicability to the Covid-19 pandemic and ongoing vaccine distribution efforts. An implementation research approach is critical in equipping health supply chains with a path for more resilient and equitable distribution of necessary supplies, vaccines, and delivery of care.

Addressing the mental health needs of children affected by HIV in Rwanda: validation of a rapid depression screening tool for children 7-14 years old.

BACKGROUND: Depression in children presents a significant health burden to society and often co-exists with chronic illnesses, such as human immunodeficiency virus (HIV). Research has demonstrated that 10-37% of children and adolescents living with HIV also suffer from depression. Low-and-middle income countries (LMICs) shoulder a disproportionate burden of HIV among other health challenges, but reliable estimates of co-morbid depression are lacking in these settings. Prior studies in Rwanda, a LMIC of 12 million people in East Africa, found that 25% of children living with HIV met criteria for depression. Though depression may negatively affect adherence to HIV treatment among children and adolescents, most LMICs fail to routinely screen children for mental health problems due to a shortage of trained health care providers. While some screening tools exist, they can be costly to implement in resource-constrained settings and are often lacking a contextual appropriateness. METHODS: Relying on international guidelines for diagnosing depression, Rwandan health experts developed a freely available, open-access Child Depression Screening Tool (CDST). To validate this tool in Rwanda, a sample of 296 children with a known diagnosis of HIV between ages 7-14 years were recruited as study participants. In addition to completing the CDST, all participants were evaluated by a mental health professional using a structured clinical interview. The validity of the CDST was assessed in terms of sensitivity, specificity, and a receiver operating characteristic (ROC) curve. RESULTS: This analysis found that depression continues to be a co-morbid condition among children living with HIV in Rwanda. For identifying these at-risk children, the CDST had a sensitivity of 88.1% and specificity of 96.5% in identifying risk for depression among children living with HIV at a cutoff score of 6 points. This corresponded with an area under the ROC curve of 92.3%. CONCLUSIONS: This study provides evidence that the CDST is a valid tool for screening depression among children affected by HIV in a resource-constrained setting. As an open-access and freely available tool in LMICs, the CDST can allow any health practitioner to identify children at risk of depression and refer them in a timely manner to more specialized mental health services. Future work can show if and how this tool has the potential to be useful in screening depression in children suffering from other chronic illnesses.

Assessing Catastrophic Health Expenditures Among Uninsured People Who Seek Care in US Hospital-Based Emergency Departments.

Importance: Uninsured people uniquely rely on the emergency department (ED) for care as they are less likely to have access to lower-cost alternatives. Prior work has demonstrated that most uninsured patients are at risk of catastrophic health expenditure (CHE) after being hospitalized for life-saving care. The risk of CHE for a single treat-and-release ED visit that does not result in a hospitalization among uninsured patient encounters is currently unknown. Objective: To estimate the overall national risk of CHE among uninsured patients after a single treat-and-release ED visit from 2006 through 2017, and to characterize this risk across key traits. Design Setting and Population: This cross-sectional study is based on a nationally representative sample of hospital-based ED visits between 2006 and 2017 in the United States (US) from the Nationwide Emergency Department Sample (NEDS). It examined outpatient ED visits among uninsured patients. Main Outcomes and Measures: Risk of CHE for ED care defined as an ED charge that exceeds 40% of one's estimated annual post-subsistence income. Results: From 2006 to 2017, there were 41.7 million NEDS encounters that met inclusion criteria for this analysis, equating to a nationally weighted estimate of 184.6 million uninsured treat-and-release ED encounters over this period. The median ED charge for a single treat-and-release encounter grew from $842 in 2006 to $2033 by 2017. Approximately 1 in 5 uninsured patients (18% [95% CI, 18.0%-18.0%]) were at risk of CHE for a single treat-and-release ED visit over the study period. This estimated CHE risk increased from 13.6% (95% CI, 13.6%-13.6%) in 2006 to 22.6% (95% CI, 22.6%-22.7%) in 2017. Those living in the lowest income quartile faced a disproportionate share of this risk, with nearly 1 in 3 (28.5% [95% CI, 28.5%-28.6%]) facing CHE risk in 2017. In 2017, an estimated 3.2 million patient encounters nationally were at risk of CHE after a single treat-and-release ED visit. Conclusions and Relevance: This cross-sectional analysis from 2006 to 2017 of 184.6 million uninsured treat-and-release visits found that 1 in 5 uninsured patient encounters are at risk for CHE. This risk has grown over time. Future policies designed to improve access for unscheduled care must consider the unique role of the ED as the de facto safety net and ensure that uninsured patients are not at undue risk of financial harm for seeking care.

Medical Student Mobilization During a Crisis: Lessons From a COVID-19 Medical Student Response Team.

PROBLEM: On March 17, 2020, the Association of American Medical Colleges recommended the suspension of all direct patient contact responsibilities for medical students because of the COVID-19 pandemic. Given this change, medical students nationwide had to grapple with how and where they could fill the evolving needs of their schools' affiliated clinical sites, physicians, patients, and the community. APPROACH: At Harvard Medical School (HMS), student leaders created a COVID-19 Medical Student Response Team to: (1) develop a student-led organizational structure that would optimize students' ability to efficiently mobilize interested peers in the COVID-19 response, both clinically and in the community, in a strategic, safe, smart, and resource-conscious way; and (2) serve as a liaison with the administration and hospital leaders to identify evolving needs and rapidly engage students in those efforts. OUTCOMES: Within a week of its inception, the COVID-19 Medical Student Response Team had more than 500 medical student volunteers from HMS and had shared the organizational framework of the response team with multiple medical schools across the country. The HMS student volunteers joined any of the 4 virtual committees to complete this work: Education for the Medical Community, Education for the Broader Community, Activism for Clinical Support, and Community Activism. NEXT STEPS: The COVID-19 Medical Student Response Team helped to quickly mobilize hundreds of students and has been integrated into HMS's daily workflow. It may serve as a useful model for other schools and hospitals seeking medical student assistance during the COVID-19 pandemic. Next steps include expanding the initiative further, working with the leaders of response teams at other medical schools to coordinate efforts, and identifying new areas of need at local hospitals and within nearby communities that might benefit from medical student involvement as the pandemic evolves.