A new RAND Corporation report, funded by the Emergency Medicine Policy Institute, confirms what many emergency physicians feel daily: payments are falling, administrative burdens are rising, and the No Surprises Act (NSA) has tilted the playing field toward insurers. This article explores the report’s findings on Independent Dispute Resolution (IDR), how insurers are using the NSA to cut payments, and what emergency physician leaders see as the path forward for fair reimbursement and sustainable emergency care.

A System Built on a Crumbling Business Model

Emergency physicians are accustomed to practicing in crisis mode. But the RAND report, “Strategies for Sustaining Emergency Care in the United States,” concludes that the system of emergency care itself is now in crisis, mainly because of how it is funded.

The data are stark. Between 2018 and 2022, real (inflation-adjusted) payments per emergency department (ED) visit fell by 3.8 percent for both Medicare and Medicaid, while commercial payments dropped by 10.9 percent for in-network visits, and by a staggering 47.7 percent for out-of-network visits. At the same time, roughly 20 percent of allowed amounts across all payers were never actually paid — about $5.9 billion annually in unpaid professional services for ED clinicians.

Facility and professional payments are also diverging. RAND’s national analysis found that from 2018 to 2022, ED facility-allowed amounts increased 18.65 percent in real terms, while professional-allowed amounts for emergency physicians fell 7.42 percent. Hospitals are increasingly paid more for keeping the doors open, while the clinicians providing the care are paid less.

For ACEP President L. Anthony Cirillo, MD, FACEP, the big-picture message from the RAND report comes down to three points. “The three things that everybody should know about the RAND report are, number one, they [report authors] basically said, ‘Wake up, America.’ The system of emergency care that we’re all going to need and rely on someday is failing.”

He added that the current financing model is fundamentally flawed. “The second lesson was that the current construct of financing emergency care, particularly on the physician side, is flawed and has been flawed since it was created. And it’s just that the system of payment is getting worse.”

Finally, federal and state policies have steadily expanded the responsibilities of emergency departments without expanding how those services are funded. The third message from Dr. Cirillo is that “We’ve been asked or told by the federal government to do many, many more things beyond what the original fee schedules were paying us to do, and we have to think outside of the traditional fee schedule box if we’re going to make the system sustainable.”