The No Surprises Act has further affected emergency physician groups because UnitedHealthcare and other payers have called emergency department bills “surprise bills” and refused to pay them, Dr. Augustine said. “Our local EMS service using a helicopter system was getting paid zero by any commercial insurer for taking their critical patients from one hospital to another, so it went bankrupt.”

Indeed, the consolidation of commercial insurers has been as-sociated with lower payments to clinicians, attributable to their relative market share, Dr. Grover said. How can health care teams, including both hospitals and physicians, command adequate market power to negotiate in order to keep pace and maintain their leverage for negotiations with insurers? Health care may need to consolidate in response, or at least collectively bargain.

“I can tell you there are numerous examples of academic medical centers asked by local leaders to acquire community hospitals on the verge of failing,”² Dr. Grover said. Another alternative is to collectively bargain through associations or confederations of practitioners, although he could not offer a relevant recent example in emergency medicine.

Private equity-based aggregations of health care practices have gotten a lot of negative press recently.^3,4 For emergency medicine, this has included recent spectacular fails by private equity or similar companies. Dr. Grover noted, however, that private equity doesn’t have to be all bad and can offer a path to achieving needed consolidation and leverage for physicians. Some private equity acquisitions follow an arbitrage model of quickly selling things off and leaving behind the shell of a company. Others take a longer view, emphasizing quality of care.

How do health care teams make the best choices to ensure their practices survive within the limits of what’s possible? Dr. Grover asked. “How do we make these decisions at a practice level? What are the questions we should be asking? As with any merger or acquisition, you need to ask the tough questions beforehand.”

Unfortunately, this kind of negotiation and advocacy is something few emergency physicians are trained to do. “Can we help inform the emergency medicine community about those questions through bad and good examples of private equity acquisitions?” Dr. Grover asked. Perhaps that is an opportunity for ACEP to help prepare its members for future merger mania.

In any case, he concluded, “we need to look at the whole picture of the health care field and its many interrelationships. Can we talk about what we want that field to look like?”