INVESTIGATION OF HEALTH INSURANCE COSTS OF THE PATIENTS WITH MILD COVID-19 SYMPTOMS IN EMERGENCY ROOM

: Introduction: This study aims to understand the burden of invoice costs of outpatients with mild Covid-19 symptoms on Social Security In-stitution (SSI); also, how it may have influenced the current economic situation. Material and Method: This research is a cross-sectional, retrospective, and descriptive study. The study universe includes the cases who applied to the emergency room (ER) with the symptoms of Covid-19. The sample group was the patients who applied to the Sakarya Training and Research Hospital (SEAH) pandemic ER between 01/09/2020 and 30/06/2021. Results: During the study period, 130,975 patients were admitted to the pandemic ER. The mean emergency service bill of the cases was $10.6 (± 9), and the lowest was $2.2; the highest was $201.7. There was a weak but significant positive correlation between the patients’ age and invoice amount (spearman= 0.051, p=0.001). It was perceived that the emergency service bills of the inpatients (mean=21.9 $) were more than twice that of the outpatients (mean=10.3 $). Conclusion: In pandemic ER, mild symptomatic young patients’ bills can be cheap. It was observed that emergency physicians did not apply too many tests and imaging methods in this patient group and were content only with Rt-PCR scanning. Also, ER bills can increase with age.


INTRODUCTION
The Covid-19 disease rose in China during the last months of 2019 and spread to other countries quickly, and was declared a pandemic by the World Health Organization (WHO) in early 2020 (1).After this date, some countries have closed borders, limiting flights, introducing social isolation rules, and curfews to decrease the spread rate (2).
A historical discount in oil prices, a reduction in industrial production, automobile and restaurant sales, and as a result, it was seen that unemployment rates reached double digits in many countries during the Covid-19 pandemic (3).Therefore many employees experienced losses in their monthly income and welfare (4).At the same time, the health sector was adversely affected by this financial contraction in some countries.The decrease in hospital admissions and the holding of elective operations caused a decrease in hospitals' revenues (5,6).
Most people in Turkey have health insurance under the Social Security Institution (SSI); furthermore, this health insurance covers all emergency health services in public hospitals.This study will make an effort to reveal the SSI invoice amounts of the emergency services of Covid-19 suspected patients with mild symptoms.Thus, it aims to understand the burden of invoice costs of outpatients with mild Covid-19 symptoms on SSI; also, how it may have influenced the current economic situation.

Research Type
This research is a cross-sectional, retrospective, and descriptive study.The study universe includes the cases who applied to the emergency room (ER) with the symptoms of Covid-19, and the sample group was the patients who applied to the Sakarya Training and Research Hospital (SEAH) pandemic ER between 01/09/2020 and 30/06/2021.tests such as reverse transcription-polymerase chain reaction (Rt-PCR), hemogram, blood gas, d-Dimer, biochemical tests, X-ray, and computed tomography (CT) can be studied.In this ER, health service delivery is provided by general practitioners.Rt-PCR test, hydroxychloroquine, or favipiravir drugs are given in the ER are free of charge and are not billed to SSI.Furthermore, if the patients have social health insurance, the examination fee, all other tests (except Rt-PCR), and the treatments applied are invoiced to the SSI.
The Covid-19 signs such as; dry cough, fever, loss of taste or smell, fatigue, conjunctivitis, nasal congestion, headache, sore throat, different types of skin rash, nausea or vomiting, muscle or joint pain, chills, or dizziness, diarrhea assented to mild symptoms (7).
Since the US Dollar ($) exchange rate varied considerably during the study period, the arithmetic average of the $ exchange rate of this period was taken and 1 $ = 7.85 Turkish lire.

Inclusion Criteria
• Patients aged 18 and over, • Cases who applied to the pandemic ER and were examined, • Patients whose data could be reached entirely through the automation system of the hospital were included in the research.

Exclusion criteria
• Cases under the age of 18, • Patients who admitted tooth er units of the hospital except for the pandemic ER, • Subjects who applied to the pandemic ER and left the hospital without being examined, • Patients whose SSI invoices could not be reached were excluded from the study.

Data Collection
Patients' age, gender, Rt-PCR, hemogram, biochemical parameters, d-Dimer, ferritin, CRP, blood gas, X-Ray and computed tomography examination information, hospitalization or outpatient follow-up situation were collected retrospectively from the hospital automation system and patient files.The patients' SSI invoices were obtained from the automation system of the hospital.

Statistical Analysis
The data were analyzed with the statistic program (IBM SPSS Statistics for Windows, Version 21.0.Armonk, NY: IBM Corp.).The values of Skewness and Kurtosis were demanded to to be in the range of -2 / + 2 for the data's normal distribution (8).The independent t-test was applied to compare the values of two independent groups with normal distribution, and the Pearson Chi-Square test was utilized to compare categorical data; moreover, a p-value < 0.05 was considered statistically significant.Spearman correlation test was used for correlation analysis within data groups that did not arrange the normal distribution.

Ethics Approval and Permissions
Approval for this study was obtained from the Sakarya University Faculty of Medicine Ethics Committee [IRB numbers: 71522473/050.01.04].

RESULTS
During the study period, 130,975 patients were admitted to the pandemic ER, and the mean age was 37.6 years (SD = 14, min = 18, max = 108), and the median age was 35.Of these patients, 73,534 (56.1%) were male, and 57441 (43.9%) were female.When comparing patients' age with patients' gender, the mean age of female cases was statistically higher [t(118837) = -16.9,p = 0.001].
The mean emergency service bill of the cases was $10.6 (± 9), and the lowest was $2.2; the highest was $201.7.There was a weak but significant positive correlation between the patients' age and invoice amount (spearman = 0.051, p = 0.001).
The average bill for women was $10.7, while men's was $10.5.However, it was determined that the average invoice cost of the patients in 2020 (mean = 14.7 $) was more than three times the average invoice price in 2021 (mean = 4.6 $).CT was utilized for 4229 (5.4%) patients in 2020; moreover, for 2114 (4%) patients in 2021.It was observed that the number and rate of CT scans decreased over the years.
In 2020, 912 (1.2%) of 77,669 patients were hospitalized, and 1029 (1.9%) of 53,306 patients were hospitalized in 2021.A significant difference was determined in the number of hospitalizations by years (x2 = 124, SD = 1, p = 0.001).Accordingly, it was recognized that the number and rate of hospitalized patients increased.The age of the patients affected the hospitalization status, and the mean age of the hospitalized patients (mean = 57.5)was detected to be significantly higher than that of the outpatients (mean = 37.3) [t(1995) = -61, p = 0.001].Besides, it was perceived that the emergency service bills of the inpatients (mean = 21.9 $) were more than twice that of the outpatients (mean = 10.3 $).

DISCUSSION
Studies in the literature on health insurance costs of patients admitted to emergency services with the suspicion of COVID-19 are very limited.In a study conducted by Edwine Barasa et al. in Kenya, it was stated that the follow-up of asymptomatic and mildly symptomatic COVID-19 patients in the hospital instead of at home increases the treatment costs up to four times (9).In the same study, it was published that the cost of the treatment increased approximately six times when patients were admitted to the general hospital wards (9).It was noticed that the mild symptomatic outpatients' invoice costs were lower than those who were decided to be hospitalized in our study.Although patients' bills after hospitalization were out of our scope, the high invoice costs in the ER were in line with the above research results.
Carmen Guadalupe Rodriguez-Gonzalez et al. notified that the risk of ARDS rises with increasing age in Covid-19 patients receiving hospital treatment in Spain; moreover, the Covid-19 treatment was 408 Euros per patient (10).Erhan Ekingen and Ahmet Yıldız described in their study on the treatment costs of Covid-19 patients hospitalized in Turkey that the average cost per person was $653; also, this cost was higher in patients over 65 years of age (11).For non-Covid-19 patients, Behcet Varislı et al. informed that the bills of the patient group over the age of 85 who applied to the emergency department were more expensive than the younger cases (12).
Moran Dong et al. pointed that the average treatment cost of hospitalized Covid-19 patients was around $2869 per patient, and the treatment costs were higher in males and the elderly in China (13).In another study conducted in China, the average cost of treatment for Covid-19 patients aged 0-34 was $2752, and $11668 for patients over 70 years of age (14).According to our study results, it was observed that insurance costs rise in parallel with the increasing age of the patients.In this respect, our study coincides with the results of the above study.The increase in mortality with age, the more insidious course of Covid-19 pneumonia in elderly patients, and the more frequent observation of severe disease in the elderly, and the need for further examination of elderly patients may explain the increase in the cost of bills in the emergency department with age (15)(16)(17)(18).On the other hand, in contrast to Mo-

CONCLUSION
In pandemic ER, mild symptomatic young patients' bills can be cheap.It was observed that emergency physicians did not apply too many tests and imaging methods in this patient group and were content only with Rt-PCR scanning.Also, ER bills can increase with age.

Table 1 .
Crosstab of applied tests count and patients' gender Square test results, b Percent within patients' gender.ranDong et al., a slightly higher invoice cost was seen in the female gender in our study.The fact that young patients with mild symptoms applied to the ER in the pandemic may have brought the low number of expensive examination requests such as CT.While Rt-PCR was tested in 90% of the cases, simple laboratory tests such as hemogram were only 10% of all patients, and the CT rate was 5% might have caused the low pandemic emergency bills of young mildly symptomatic patients.