Recent policymakers and advocacy groups have focused heavily on “surprise billing,” or the phenomenon of unexpected coverage gaps in which patients receive out-of-network medical bills after receiving what they believed to be in-network care. This was especially true in the Emergency Department (ED) setting, where patients have a severely constrained number of provider options. The No Surprises Act, which promotes pricing transparency as a remedy for billing errors, is the legal conclusion of efforts to resolve “surprise bills.” However, it was uncertain how patients felt and what they knew about the cost-transparency of emergency treatment, especially how cost-conscious ED patients are. By evaluating patients’ direct forecasts regarding the cost of their care, researchers aimed to measure the perspective.

Over the course of a 10-month period, they interviewed patients in emergency rooms (EDs) at two campuses of a major academic hospital network in southern Connecticut. At the bedside, they conducted a convenience sample survey of patients to learn more about their demographics, attitudes toward seeking care, and estimates of the overall and out-of-pocket expenses associated with their ED care. First, hospital financial statistics from institutions, including real charges and payments, were matched to survey data. Then, using a paired t-test, they compared the actual expenditures and billed amounts to the patients’ estimates. Results were also examined in light of certain patient demographics.

The survey was offered to 600 patients in total, and data from 455 of them were used in the final study. Patients typically overestimated their out-of-pocket expenses by $144 and the cost of their care by $2,484; both outcomes reached statistical significance (P<.005). Patients who were: college educated or higher, jobless or retired, 65 years of age or older, or had private insurance were better able to anticipate total and out-of-pocket expenses. Patients without insurance could forecast overall expenditures more accurately, but not out-of-pocket prices. One in 4 patients said they had budgeted for their care before going to the emergency room. Only 12 patients said they tried to research that cost before going.

The study was the first that they were aware of that attempted to quantify how patients see the expense of urgent, unplanned care in the ED. They discovered that most ED patients underestimated both the negotiated overall costs of acute, unplanned emergency treatment and their out-of-pocket expenses for care because they did not think about the cost before visiting the ED. Some demographics were less indicative of the connection than others. Notably, individuals on Medicare/Medicaid and those with a high school diploma or less had the worst accuracy in estimating the true cost of care. It supported the general trend of individuals having a poor understanding of the whole cost of healthcare; furthermore, the fact that patients overestimate the cost of their treatment may act as a barrier to getting that care, especially for those who are more disadvantaged. They anticipated that the discovery will provide lawmakers with relevant data as they draft new regulations pertaining to surprise billing.