In November, The New England Journal of Medicine (NEJM) published an article of great concern for all emergency physicians as it has the potential to damage and disparage America’s safety net with biased and self-serving data.

“Out-of-Network Emergency-Physician Bills—An Unwelcome Surprise” attacks emergency

physician balance billing practices.¹ Unfortunately, what the authors failed to mention is the data biases of the study, the essential difference of emergency medicine from other specialties, the underlying reasons for balance billing, and the motivation behind the study.

ACEP leaders and our members have pushed back hard on this flawed “study.” A media release was picked up by several news sources across the United States, multiple letters to the editor were sent to various influential publications, and we used the social media megaphone to provide facts that underscore our mission and refute the inflammatory assumptions of the NEJM piece. ACEP also submitted a letter to the editor to NEJM and requested an in-person meeting with the NEJM editorial board. This request, to date, has been declined.

The study published by NEJM relies on a limited amount of data from a single commercial insurer representing fewer than 2 percent of the total US emergency patient visits, hardly representative of the US emergency patient population. It did not account for details such as deductibles and co-pays, making erroneous assumptions about patients’ financial responsibilities. Finally, the data were unavailable for review and include atrocious claims, such as balance bills of more than $19,000, without substantiating evidence or sources. These limitations, apparent biases, were not discussed by the authors or NEJM.

The authors also tried to lump emergency medicine into the result of medical practices. Emergency medicine isn’t a choice. Emergency departments and emergency physicians don’t choose who they treat. We see anyone at any time without consideration of coverage or ability to pay, a federal mandate known as EMTALA. We provide the best care possible to every patient.

Patients are experiencing balance billing because more and more insurance companies refuse to fairly reimburse for the care provided in emergency departments nationwide.

The issue isn’t whether emergency physicians try to contract with insurance companies—it is that insurance companies have no interest in contracting with emergency physicians. It isn’t in their best interest to take on the responsibilities of the uncompensated care we provide. Why would an insurance company be interested in “negotiating a fair price” for a service that is mandated and having a portion of the economic impact successfully shifted to someone else?