Thank you @DrJessePines & @arjunvenkatesh, both ER docs & Health Policy experts, for this explanation of the unique economic state of ERs & why #Benchmarking for #SurpriseBilling would be devastating. @SenateGOP @senatemajldr @SenateDems @SenSchumer @SpeakerPelosi @GOPLeader https://twitter.com/DrJessePines/status/1245786940168962056

"Of nearly 139 million yearly U.S. ED visits in 2017, about 8 million involve out-of-network bills. This is lower than the 11 million visits by the uninsured patients who receive care delivered by federal mandate but are unfunded and largely ignored by policymakers."

"Protecting patients from OON bills is everyone’s goal. Yet, media discussions have demonized doctors as opportunists using OON bills to greedily generate excessive profits. The problem: this narrative fails to capture the financial realities of EDs, nor does it discuss the

efforts by emergency physicians to protect patients. We, emergency physicians, need to set the record straight. We are the caregivers who are risking our lives in the COVID-19 crisis. We are there at the bedside for the ill and injured 24/7/365: weekends, nights, holidays, and as

first responders during disasters.[...] We care for everyone; COVID-19 patients, but also the uninsured, homeless, mentally ill, & physically violent -regardless of whether they can pay. This is required by federal law. No other doctors do this." https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA

"Becoming an emergency physician involves 7-8 years of post-college training. Like other doctors, emergency physicians have substantial loans: $200,000 of avg debt. It takes years to earn the privilege to care for patients at their most vulnerable moments, and even longer to

financially recover from medical school debt. ER docs are paid appropriately but work hard: 48% are burnt out from constant stress, the chaos of our nation’s EDs and working nights and weekends, and during public health crises like the one we face today." https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056#3

"In society, EDs serve valuable functions treating the critically ill (e.g., heart attacks and strokes), as 24/7 diagnostic & treatment centers for potentially serious illnesses, as the safety net for the uninsured, and for disaster response such as our current crisis. -

EDs deliver the best of American medical care and backstop health care’s many failures. Many other nations model their emergency care systems to resemble ours. ED critics decry the costs of such a system, at least until they or their family need one."

"OON billing discussions don't account for the economics that support today’s system. Academic papers focus exclusively on what people see as outsized payments from private insurance - often relying on data from a single, unnamed health plan[...]

No papers have adequately described a comprehensive picture of the unit economics of EDs." @JohnArnoldFndtn @LorenAdler @sarahkliff @sangerkatz @RosenthalHealth @KHN @GtownCHIR @SurpriseBills @FamiliesUSA @efusebrown @zackcooperYale @SenAlexander @FrankPallone lean into this:

"Let us explain how it actually works:
EDs require highly trained staff 24/7/365: 168 hours per week, ready for whatever walks through the door. Compare that to 40-60 hours in clinics that are not open on holidays and weekends.

ED financing is derived from Medicare and Medicaid insurance, private insurer payments, and to a lesser extent, patients. But not every patient pays the same. Running an ED is mostly fixed costs, and all payments need to cover those costs to make it work.

Public programs pay less and do not adequately cover costs requiring payments from private insurance to make up the difference.

In our 139 million visits, 32% have Medicaid, which pays $105 per visit and is the largest growing population. For the 14% uninsured, payments are

minimal (~$20). ED economics are “fragile” compared to other physicians not required to care for everyone. The average orthopedic practice has only 6% of uninsured plus Medicaid while we have 46%.

For our 23% of visits covered by Medicare, we get $145 on average. The trouble with Medicare: Payments haven’t kept up with inflation. A MedPAC study found that the 2017 profit-margin on Medicare patients was -9.9% and declined to -11% in 2019.

Finally, there’s the 31% with private insurance left to help support a system expected to deliver care to everyone. For private insurance, the average ED payment is $275. All told, emergency physician bills represent only 1% of a private insurance plan’s annual cost. That’s for

around-the-clock access for everything from heart attacks & strokes to broken ankles. Major efforts are underway to lower private insurance payments & address OON bills. Starting April 1, @UHC will be systematically downing-coding ED visits billed using the complex 99285 code.

As a direct result, emergency staffing groups have announced physician pay cuts. Notably, these cuts are occurring when insurer gross margins/member/month spiked to $146 in Q3 2018, compared to $36 in Q3 2011. Congress has been actively discussing out-of-network billing.

One solution allows insurers to pay median in-network rates for out-of-network care. The trouble: there is no objective standard for an in-network rate. This proposal dramatically benefits insurers at the expense of physicians, hospitals, and patients.

It will cause a slippery slope of lower payments that will bleed America’s EDs of highly-trained physicians, and drain America’s capacity to respond to disasters like COVID-19.

Also missing from media reports: emergency physicians have worked to implement real state-level

solutions to fix out-of-network billing. A great ex. of sensible legislation is Texas, which protects patients & ensures insurers pay fair prices through an arbitration process between insurers and providers.

Ultimately, emergency physicians want to serve everyone, but our ability to complete this mission is under fire. No ED patient should face financial hardship, but America needs to answer a larger question:

do we want 24/7/365 highly-trained emergency physicians available to all Americans, including the poor & uninsured, and to respond to public health crises?

If yes, we need to carefully consider the effects of disrupting the fragile economics of EDs."

@amychomd @813JAFERD @Valleus556 @GRKatz123 @EdGainesIII @ercoderguy @CPakTeng @RealCedricDark @mass_marion @drdanchoi @SunnyJhaMD @purviparikhmd @Docbasia @GallaherCaren @pppforpatients @Free2CareHC @A4Horg @GrassrootsEM