Health Insurance: When to Use the ER and When to Use Urgent Care
Going to the ER for medical care is expensive. Yet millions of Americans do it every year. Here's why that is--and why you should go to an urgent care center or a doctor if your illness or injury isn't an emergency.
Anyone who has ever gone to an emergency room for medical care knows that doing so is expensive.
Actually, most Americans know that even if they haven't visited an ER.
And yet millions of them head to the nearest hospital every year looking for assistance with an illness or injury.
Some of those trips are more than warranted, of course. A person who thinks he's having a heart attack should go to the ER. As should a person who thinks she's having a stroke. And that's true even if a doctor or nurse shoots down those self-diagnoses in the end.
Others trips to the ER are less warranted. Or at least they are in hindsight, after the fact. A few examples: going to the ER for help with flu-like symptoms, earaches, minor cuts, or sprained ankles.
Of course, it's easy to say that when you're not the person dealing with the aches and pains in question. In the heat of the moment, many injuries and illnesses seem like emergencies. As such, who's to say that someone who feels miserable--or worse--should "wait it out" and call the doctor in the morning?
Still, the fact remains that trips to the emergency room are expensive. Another fact: many of the illnesses and injuries Americans go to ERs for could be treated elsewhere, and cost them a lot less money.
Physicians are one option, but they're also often inaccessible. (We've all called our doctor about some pressing issue or other only to be told he or she can't see us for a week or more.) Far better options are urgent care centers and walk-in clinics.
So when should you go to your doctor? And when should you go to urgent care or even the ER? Look for answers to both of those questions and more--such as why ER visits are so pricey--below.
Everything You Need to Know About ER Usage and ER Costs
First, let's tackle those vague "millions of Americans go to the ER every year" and "going to the ER is expensive" statements made earlier.
According to the most recent data provided by the Centers for Disease Control and Prevention (CDC), U.S. emergency rooms treated just over 141 million visitors in 2014.
Note: that doesn't mean 141 million Americans went to the ER that year. Some went more than once. Still, it's safe to say many, many millions of Americans sought medical care in an emergency department or room in 2014.
For the sake of comparison, consider that U.S. physician offices saw nearly 885 million visitors that same year. (Again, according to the CDC.)
Granted, many people see their doctor multiple times a year, while few go to an emergency room even once in the same timeframe. Which may be for the best, given how much trips to the ER cost.
Speaking of which, the least you're likely to pay for an ER visit is about $1,000. Unfortunately, the sky is the limit from there.
Why the $1,000 baseline? Hospitals charge a "facility fee" to anyone treated in their ERs. That fee usually ranges from $300 to $500, reports npr.org. It helps pay for all the staff and equipment an ER has to have on hand to deal with any emergency that comes its way. It also helps cover people who don't pay the bills they receive for their emergency room visits.
That fee is just the beginning. Once a doctor or nurse starts treating you, the costs add up quickly.
As explained by 9news.com, when a hospital bills you for coming to the emergency room, it does so using codes that differ depending on the care provided. The more ER staffers do, the higher the code (from level 1 to 5) that's tied to your visit.
Also, the higher the code, the more you have to pay for that particular trip to the ER. For example, level 3 visits often result in bills of $2,000 and up. Level 5 visits can lead to bills that approach $10,000.
You'll probably pay less than either of those amounts if you have health insurance. Why? For starters, insurers negotiate with hospitals to lower rates. Also, plan deductibles usually bring down the price even more.
Still, if yours is a high-deductible health plan, as many are these days, you'll probably have to spend a good amount of money any time you go to the ER--even if it's for something seemingly minor.
Not sure if your health plan pays for ER visits? Read our article, "How to Find out What Your Health Insurance Plan Covers." Also, see this article, "How to Appeal a Health Insurance Claim Denial," if your insurance company refuses to cover some or all of your ER bill.
Do Americans Overuse the ER? And if So, What Does That Mean for the U.S. Healthcare System?
You may have heard that, despite how expensive they are, Americans overuse emergency rooms. What journalists, politicians, experts, and others mean when they say this is: too many people go to the ER for ailments that should be treated elsewhere.
Although that may be true, at least to an extent, it's not the whole story.
There's no question some Americans go to the ER for medical issues that are "non-urgent" or that aren't putting their lives in danger. Plenty of statistics exist that prove it.
One statistic often used to show that a lot of people go to the ER when they shouldn't: just 8 percent of emergency room visits in 2014 resulted in someone being admitted to the hospital. (Source: the CDC.)
Some take that number to mean many--or even most--of those visits were unnecessary and should be reduced.
A couple of other statistics that people quote in this situation: a CDC report from 2014 revealed that about 12 percent of ER patients went there because their doctor's office was closed. Also, 7 percent went to the emergency room because they had nowhere else to go or because the ER was the closest provider.
And then there are the findings from a 2017 study conducted by University of Maryland School of Medicine (UMSOM) researchers about ER usage. The gist: certain groups of people are more likely than others to use emergency rooms as their main source of healthcare.
In particular, the UMSOM study found that:
- People in the “other” insurance category, which includes without health insurance, are most likely to visit ERs.
- People living in the South also are more likely to visit the ER than people living in other areas of the U.S.
- African-Americans are significantly more likely to go to an ER for care than other racial groups.
For David Marcozzi, associate professor in the UMSOM Department of Emergency Medicine and co-director of the UMSOM Program in Health Disparities and Population Health, all of these data points just prove "patients seek care in emergency departments for many reasons." Among them:
- access to healthcare
- consumer-driven needs
- an appreciation for the comprehensive care delivered by emergency rooms
- the ability of ERs to fill a critical gap with regard to care delivered to vulnerable populations
"The data might suggest that emergency care provides the type of care that individuals actually want or need, 24 hours a day," Marcozzi added.
Dr. Shoshana Herzig, director of hospital medicine research at the Beth Israel Deaconess Medical Center, seconded that suggestion while talking with healthline.com.
“Not only do we likely need greater access via increased availability of primary care doctors and appointment slots," she said. "But we need greater flexibility in appointment times to accommodate working adults and greater flexibility in scheduling."
Everything You Need to Know About Urgent Care
In the meantime, Americans looking for more flexible healthcare options should turn to urgent care centers when they need timely medical treatment. They're both faster and far cheaper than emergency rooms.
If this is the first you're hearing of urgent care, or if you don't know much about these clinics, here are the basics:
- Urgent care centers first emerged in the 1970s.
- They've grown rapidly since then, thanks in large part to hospitals opening urgent care centers to reduce pressure on their ERs.
- Private companies and entrepreneurial physicians also own a lot of these clinics.
- Most are found in convenient, high-traffic locations, such as near grocery stores, pharmacies, or other types of retail outlets.
- Most are fairly small, often no larger than 1,500 square feet in size.
- They usually have x-ray machines and can process lab tests on site.
- Urgent care centers typically are open seven days a week, Monday through Sunday. They're often open on holidays, too.
- They also tend to be open at least 12 hours a day, although some are open for a full 24 hours.
- Walk-ins are welcome. No appointments needed.
- Wait times tend to be short--often 30 minutes or less. (ER wait times, on the other hand, average over two hours.)
- Many urgent care clinics have a wide range of medical professionals on hand at any given time. Most common are nurses and nurse practitioners, but physicians and physician assistants aren't uncommon. Some have radiological technologists on staff, too.
- These staffers can give flu shots, test blood-sugar levels, provide IV fluids, treat some strains and fractures, and more.
- Some also do sports and school physicals or administer travel vaccinations.
All of the above help keep the costs of operating an urgent care center low. Especially when they're compared to the costs of running an emergency room.
Thankfully, urgent care clinics pass those cost savings on to their patients. Specifically, someone who seeks treatment at an urgent care clinic and has health insurance usually pays between $50 and $150 for a visit.
Where you might fall in that range depends on a number of factors, such as:
- The kind and amount of treatment you receive
- Type of health insurance you have
- Your health plan's deductible and copay requirements
Most urgent care centers take both private insurance and Medicare, by the way. Some don't accept Medicaid, however. (Various sources say Medicaid reimbursement doesn't cover the cost of providing care.)
What if you don't have health insurance? You can still go to one of these clinics for care, but you'll have to pay for it in cash.
Also, uninsured patients often have to pay more for services like shots, lab tests, or x-rays. As a result, what they pay for treatment at an urgent care center can be much higher than what someone with health insurance pays.
Do you need health coverage? Read our article, "Everything You Need to Know to Apply for Health Insurance." Also, see this article once you start shopping for it: "How to Pick a Health Insurance Plan."
When to Use the ER and When to Use Urgent Care
Although urgent care clinics can deal with a lot of medical situations, there are a couple of things they can't--or don't--do.
One is they don't keep medical histories of patients like physicians or doctors. So, if you go to urgent care more than once, don't expect the staff on hand to know or have access to that information.
More importantly, urgent care centers can't handle life-threatening medical conditions. That's because they don't have the high-tech equipment needed to treat those kinds of illnesses and injuries.
Obviously that suggests you should head right to the ER if you ever develop an extreme or severe medical condition--one that may threaten your life. But what does that mean, exactly? Here are some examples of when you should go to the emergency room and when you should go to urgent care.
Go to the ER if you have or are experiencing:
- Severe chest or abdominal pain
- Shortness of breath or breathing difficulty
- Sudden vision or speech loss
- Sudden weakness or paralysis
- Sudden dizziness, fainting, or loss of balance
- Sudden confusion or changes in mental status (including suicidal thoughts)
- High fever (especially in children)
- Fever with rash
- Uncontrolled bleeding
- Intestinal bleeding
- Vaginal bleeding during pregnancy
- Vomiting or coughing up blood
- Non-stop or persistent vomiting
- New-onset seizures
The emergency room also is the place to go for treatment of:
- Compound fractures (bone is pushing or sticking through the skin)
- Deep cuts or wounds
- Electrical shock
- Severe burns
- Severe head or eye injuries
Go to urgent care if you have or are experiencing:
- Seasonal allergies
- Cold or flu symptoms
- Low-grade fever
- Sore throat
- Breathing discomfort, such as moderate asthma
- Earache, ear pain, or ear infections
- Vomiting or diarrhea
- Minor back pain
- Abdominal pain that isn't severe
- Cuts and bleeding that may require stitches
- Sprains or broken bones
- Painful urination or urinary tract infections
- Animal or insect bites
- Limited rashes
To be sure, you should not only go to the ER but also call 911 for some medical emergencies. If you think you're having a heart attack or a stroke, for example, don't go to urgent care first. Although urgent care facilities can transfer you to an emergency room if needed, the delay in treatment could put your health and even your life at risk.
Also, although the lists above aim to clarify when you should head to the ER and when you should head to urgent care, the line between the two isn't always clear. If you think an ailment, injury, or symptom is an emergency, go to the ER.
And then, of course, there are those non-emergency situations that still take you to the emergency room. What are you supposed to do when an urgent health or medical issue pops up late at night or early in the morning?
If you don't live near an urgent care clinic that's open 24 hours a day and you can't wait for one--or for your doctor's office--to open, the ER may be your only option. Just know that if you decide to go, you may pay for it in the end. Especially if you don't have health insurance. (Or if you have a health plan with a high deductible.)
Frequently Asked Questions
Q: How many Americans go to the emergency room every year?
A: If we go by the most recent data gathered by the CDC (in 2014), U.S. ERs treat about 141 million visitors a year. That doesn't mean 141 million Americans go to the ER each year, however, as some people go more than once over a 12-month period. Still, that CDC statistic gives you a pretty good idea of how many people turn to emergency rooms for medical care.
Q: How many ERs are in the U.S.?
A: According to the American Hospital Association, there were 5,534 registered hospitals in the U.S. in 2016. Not all hospitals have emergency rooms, though. Also, not all ERs are attached to hospitals.
Facilities called freestanding emergency departments (FSEDs) or freestanding emergency centers look and (mostly) act just like traditional ERs but aren't associated with hospitals. FSEDs first emerged in the 1970s to provide emergency care to rural areas that were too small to maintain hospitals. Curiously, many are located in affluent urban areas today.
Various studies and reports--such as from Harvard and The Washington Post--put the number of FSEDs in the U.S. at between 350 and 400. Combine that figure with the number of hospitals, and it's safe to say there are thousands of ERs operating in the U.S. right now. It's hard to be more specific than that, unfortunately.
Q: How much does it cost to go to the ER?
A: A trip to the emergency room can cost you anywhere from around $1,000 to upwards of $10,000. The more care an ER's staff provides, the more they charge you. Because of this, even going to the emergency room for something that isn't life-threatening can cost you a lot of money.
Health insurance helps, of course, but only to an extent. If your plan has a high deductible, you'll likely pay for most of the care you receive in an emergency room out of your own pocket.
Q: Why do ER visits cost so much?
A: Owning and operating an emergency room is expensive. ERs have to maintain certain staff levels 24 hours a day so they can deal with all sorts of medical situations. They also have to have a lot of high-tech equipment on hand. On top of that, many Americans who go to the ER for care don't pay for it afterward. ERs basically charge everyone more than they would otherwise to cover those lost costs.
Q: What is the difference between urgent care and the ER?
A: Emergency rooms exist to treat life-threatening injuries and illnesses. Urgent care centers exist to treat less severe medical conditions--flu-like symptoms, minor cuts, even some broken bones--that need immediate attention and can't wait for a trip to the doctor.
Q: How many urgent care centers are in the U.S.?
A: Most reports and studies put the number of U.S. urgent care clinics at around 10,000.
Q: How much does it cost to go to urgent care?
A: On average, a trip to an urgent care center will cost you between $50 and $150--if you have health insurance. You may pay more than that, though, if your health plan has a high deductible or high copays. Also, you'll pay more than that if you don't have health insurance. The kind of care you receive while at an urgent care clinic impacts your final bill, too.
Q: Do urgent care centers accept health insurance?
A: Yes. Most urgent care facilities accept private health insurance as well as Medicare. However, some don't take Medicaid.
To learn more about what Medicare does and doesn't cover, read our "Guide to Medicare: Everything You Need to Know."
Q: Can I go to urgent care if I don't have health insurance?
A: Yes, but you'll probably have to pay in cash. And you'll likely pay more for the care you receive than someone who has health insurance.
Q: When should I go to a doctor rather than urgent care or the ER?
A: Most medical experts will tell you to see your physician or doctor rather than go to urgent care or the ER if your ailment or injury doesn't need immediate attention.
In the end, though, you have to decide what that means given your current situation. If you feel terrible or worried and you can't get in to see a doctor, go to the nearest urgent care center. And if the emergency room is the only option, go there if you think it's needed. Just know what you're getting into if you choose the ER.
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