There is a persistent narrative about emergency rooms that says they are overly expensive places to receive healthcare; they are a cost drain on the hospitals, and they are a key driver of rising healthcare costs.

A RAND study challenges most of that narrative, and lends support to a view that most of us emergency physicians have long held: that the emergency room is a key hub of medical decision- making, as much responsible for saving health care dollars as spending them, and one of the most cost-effective places to get acute care in the country.

According to the report: “Politicians are fond of asserting that ‘emergency department care is the most expensive care there is.’ The numbers suggest otherwise. Emergency departments provide 11% of all outpatient visits and are the portal of entry for roughly half of all hospital admissions; however they acount for only 2%-4% of total annual health care expenditures.”

So if emergency rooms aren’t the massive cost suck that we’ve been repeatedly told they are, then what are they? In fact, emergency departments are occupying an increasingly central role when it comes to determining who is admitted to hospitals, when, and under what circumstances.

One of the study’s key findings is that the share of hospital admissions coming from the emergency departments is growing, mostly because primary care physicians are diverting their patients there. Whereas historically, PCPs sent a larger portion of their patients directly to the hospitals, they are increasingly taking advantage of the emergency room’s capacity to rapidly assess and treat complex diseases.

This trend toward increasing use of the emergency room to diagnose and treat complex health problems fits in to a larger narrative to come out of the report: the increasingly central role that emergency physicians occupy within the nation’s healthcare system. Emergency physicians are now the key decision maker and gatekeeper for nearly half of all hospital admissions. And since inpatient care accounts for 31% of all U.S. healthcare spending, that means emergency physicians are essentially deciding how, when, or even if that money is spent.

Which leads to another key takeaway – that emergency departments are increasingly responsible for money not being spent. If emergency physicians can divert patients from hospital stays, either by effectively managing their treatment through a transition care program, or by placing them in a temporary (and lower cost) observation unit, that means less money spent overall.