Counting the Cost: Examining Out-of-Pocket Spending on Emergency Care in Newfoundland and Labrador, Canada

To examine patient-reported non-disease-specific out-of-pocket costs (OOPCs) among emergency department (ED) visitors in a publicly funded health care system, including factors associated with OOPC and to explore patient experiences related to these costs.

This convergent parallel mixed-method study used data collected through telephone surveys and semistructured interviews from March 1, 2021, to July 27, 2023. All patients who visited the 4 EDs (2 rural and 2 urban EDs) in Newfoundland and Labrador, Canada, were randomly selected to participate based on when they visited the ED (date and time). OOPC was defined as the total amount patients incurred from food, transportation, missed work hours, and other related expenses. Quantitative analyses included multivariable binomial and multinomial regression models adjusting for age, gender, ED location, and patient self-reported length of stay (LOS). Sensitivity analyses using multiple imputation assessed the impact of missing data. Qualitative data were analyzed using thematic analysis.

Among the final sample of 818 patients, 24% (199/818) reported OOPC for an ED visit. An ED length of stay of 4+ hours was associated with higher odds of incurring OOPC (adjusted odds ratio [aOR], 2.26; 95% CI, 1.29-4.15) and OOPC of ≥$200 Canadian dollars (CAD; aOR, 3.68; 95% CI, 1.21-11.19). Patients who visited urban EDs were more likely to report OOPC of ≥$200 CAD (aOR, 2.55; 95% CI, 1.09-5.99). Qualitative analysis showed 4 OOPC themes: (1) ED visits are expensive; (2) missing work hours; (3) being forced to choose between care and necessities; and (4) ongoing costs of care.

These findings demonstrate that OOPC persist even within a publicly funded health system and underscore the importance of improving ED efficiency to reduce the financial burden on individuals seeking care.