Emergency physicians across the United States are facing increasing financial and operational pressures threatening their ability to provide lifesaving care, according to a new report authored by RAND and supported by the Emergency Medicine Policy Institute (EMPI). ACEP’s press release built on the findings,  underscoring the urgent need for policy and payment reforms to preserve the essential role of emergency departments in the U.S. health care system.

“Emergency physicians serve on the frontline of our health care system, providing care to every patient regardless of their insurance status or ability to afford treatment,” said Alison Haddock, MD, FACEP, president of ACEP. “Our patients—particularly the underinsured or uninsured, rural communities, those with mental and behavioral health needs, and older adults—risk losing access to emergency care unless policymakers take immediate action to address payment disparities, rising uncompensated care, and workforce burnout.”

Emergency physicians ensure crucial access to care for all patients as mandated by the Emergency Medical Treatment and Labor Act (EMTALA). Although emergency physicians comprise only 4 percent of all physicians, they provide approximately two-thirds of uninsured patients’ acute care.

Key findings from the report include:

• Since 2018, ED facility commercial allowed amounts rose 18.65 percent in real (inflation-adjusted) dollars – almost entirely during 2019 and 2020, according to the report. During this same period, professional physician average allowed amounts dropped 7.42 percent in real dollars. The observed discrepancy in the trajectory of facility and physician prices is not a convergence to similar price levels; it is a further widening of price levels, RAND reports. Nationwide 2018 ED facility allowed amounts were already higher than professional physician allowed amounts, so ED facility price growth outpaced physician price growth despite facility prices beginning at a higher starting point. The report states that these national trends are similar to price trends observed in the majority of states. RAND calculated the same allowed amount index for 49 states (excluding Maryland) plus Washington, D.C., noting that, 37 experienced rising ED facility commercial inflation-adjusted allowed amounts from 2018 to 2022, while only seven states experienced a real (inflation-adjusted) rise in ED physician commercial prices. The value of – and need for – emergency care in the US continues to increase even while the system is nearing a breaking point as declining physician payments, rising costs, and an ever-growing burden of uncompensated care threaten the viability of EDs. In addition to providing critical services to patients, they also play a crucial role in mass casualty incidents, public health emergencies, and disaster preparedness.
• Two challenges face emergency physicians, according to the report. Average inflation-adjusted allowed amounts are falling, and not all of those amounts actually get paid. ED visits for patients insured with commercial insurance, Medicaid, or Medicare constitute approximately 88 percent of ED health care professionals’ expected revenues, according to RAND’s calculations that consider each payer’s volume of ED visits and average relative prices. RAND calculated average allowed amounts using the data from revenue cycle management companies, adjusted them for inflation using the same index, multiplied those inflation-adjusted average allowed amounts by each payer’s percentage paid, and then indexed the results to the year 2018. Although an arbitrary starting point dictated by data availability, it is possible that the observed decline in average payment per ED visit began earlier. RAND observed very similar trends in Medicaid and Medicare payments, which both show a 3.8 percent drop in real (inflation-adjusted) payments per visit across the five-year period. Reductions in payments for commercially insured patient visits were much steeper, dropping 10.9 percent for commercial in-network and 47.7 percent for commercial out-of-network visits over this five-year period.
• RAND reports that Medicaid and Medicare make up more than half of all ED visits, 33.6 percent and 32 percent, respectively, yet the price paid per visit is lowest for Medicaid patients and second lowest for Medicare visits. Commercial in-network ($384.54), Commercial out-of-network ($482.75), Medicaid ($83.32), Medicare ($157.95) and Other ($175.76) make up the payment-per-visit findings from RAND. A small amount of self-pay patients paid $711.12 per visit.
• The existing payment model for emergency care increasingly fails to appropriately compensate ED physicians for the services they provide. Across all payer types, 20 percent of expected emergency physician payments go unpaid, totaling approximately $5.9 billion annually.
• Policy solutions are necessary to ensure fair and timely reimbursement for emergency services. The report’s proposed solutions include securing funding for EMTALA-related care (e.g., allocating state and/or federal stipends for unfunded care), strengthening penalties for insurers’ unlawful payment reduction, coverage denial and other practices, and establishing new funding sources for public health emergency preparedness and response.

The report outlines challenges linked to substantial increases in bad payer behaviors and growing vertical consolidation across the health care system.

Tactics that include delaying, denying, reducing, and the chronic under-valuing of emergency care by health insurers create financial instability for emergency departments, making it more difficult for emergency physicians to do their jobs, placing practices at high risk of closing or being acquired, and threatening care for patients.

“Actions can be taken today to address insurer consolidation and rampant bad behaviors that put patient health and emergency physician practices at risk,” said Patrick Velliky, Chair of EMPI said in ACEP’s press release. “If left unchecked, these harmful practices threaten the survival of emergency departments and the patients that rely on them for care when it’s needed most.”

View the full report here.