Recently I posted a piece, describing research out of Johns Hopkins, showing that when patients come to ERs — either with no insurance or insurance that is out-of-network — they often face charges that are four, six, or even ten-fold greater than what Medicare would pay for the same services.
After the post, I was inundated with angry tweets and emails, mainly from emergency medicine physicians outraged that I would blame them for these prices.
Below, I lay out some of these criticisms. I don’t expect I’ll satisfy all my critics, but I certainly want them to know that I’ve heard them, and that much of their concerns were ones I already shared.
Physicians told me that I was blaming them for high ER fees. I even received an irate email from an emergency medicine physician working in Europe, saying I had offended her, a strange response given that I was writing about the United States. But I think I know why she was upset. I presented data on physician fees. But when health policy wonks, like me, talk about “physician fees,” we aren’t referring just to what doctors charge for their services. Instead, we are talking about all health care charges that aren’t part of a hospital bill. Terrible terminology, I know. But it goes back a long ways, to the separate evolution of Blue Cross insurance plans (set up by hospitals to cover their fees) and Blue Shield plans (set up by doctors to cover other medical bills — hence “physician fees”). This terminology even got carried forward into Medicare when it was formed, with Part A paying hospital bills and Part B paying physician services — including things like outpatient X-rays, lab tests, EKGs, and the like.
Here’s the misunderstanding: To Medicare, ER bills are considered physician services, not hospital bills. So when I rightly criticized the high cost of ER care, it sounded like I was blaming physicians.
However, the problem of unreasonably high ER prices is not caused by greedy physicians wringing their hands while charging helpless patients outrageous fees for their services. The problem is a health care system (more on that below) that leads hospitals to charge such outrageous amounts. Most doctors working in ERs do not set their fees; heck, they don’t even know what most things they order in the ER cost. Instead, it is hospital administrators that decide what to charge patients, when those patients do not have insurance (or are out-of-network).
I am happy to blame doctors when they are at fault for problems in our country’s health care system. But that’s not what I’m doing in writing about ER prices. Charging uninsured patients 10x Medicare fees for ER care is wrong, and the lame for setting those charges is on hospital administrators.
Many of my respondents told me that I failed to mention the EMTALA rule in the U.S., which requires emergency rooms to treat patients with emergent illnesses regardless of their ability to pay.
Although I did not bring up EMTALA, the rule definitely costs emergency rooms a lot of money. They’re required to provide care to patients, some of whom won’t be able to pay their bills. But I think EMTALA is good policy. No hospital in the United States should turn an emergently ill patient away for lack of money. What we need are policies that make it less likely that hospitals will provide emergent care to patients who are unable to pay for that care. Obamacare already improved this situation by providing insurance coverage for millions of Americans. But many Americans still lack insurance, and that costs ERs money. And most Americans have insurance that does not include every potential hospital in its network, meaning people experiencing emergent illnesses while traveling might find themselves facing huge out-of-pocket costs for their illness.
Which raises the question: What’s the right way to respond to EMTALA-driven financial losses? As I pointed out in my piece, we should not solve this problem by increasing charges six or more fold on patients with no insurance. Most patients won’t be able to pay that amount, and the size of that bill will make it harder for them to get out of debt. And in many cases, in fact, it will cause them to delay receiving any emergency care, fearing the amount of debt they will accrue.
Nor should we solve this problem by increasing prices six-fold for patients who do have insurance, but who are out-of-network. When hospitals charge those kinds of sums to out-of-network patients, they have to recognize that patients will bear the brunt of those charges. People shouldn’t be crippled by impossible amounts of debt, simply for having the “wrong” kind of insurance.
Part of the solution is legislation to regulate ER prices for uninsured and out-of-network patients. In doing that, we not only need to set price ceilings, but also price floors. We shouldn’t let Medicaid programs or powerful insurers squeeze ER reimbursement so tightly that hospitals feel they have little choice but to dramatically hike prices for other patients.
Another part of the solution is to expand insurance coverage in the United States. It’s egregious that we live in a wealthy country that tolerates policies that leave tens of millions of Americans without insurance.
Clinicians working in emergency rooms should be able to provide care without worrying that they are bankrupting the very patients they are caring for.
Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel. He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. This article originally appeared in Forbes.
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