A couple of points:
1) Someone mentioned a plumber deciding to charge you $50,000. There is a legal principle in contract law that if a price is not specified in an agreement, the "reasonable and usual" price of the service will be used by a court. For example, you have your neighbor's kid mow your lawn and pay him $20. The next spring he calls and asks if you want him to mow the lawn again, and you agree. A week later he sends you a bill for $10,000. If he sues, a court will almost certainly decide that the "reasonable and usual" fee would be $20 and might award the kid $25 to account for inflation. So if a price is not disclosed as part of the contract that does not mean that a party (i.e., the hospital, or a plumber, or the "robber baron" neighbor kid) is free to stick you with any amount they want. (Well, they can; it just will not hold up in court.)
The question is what is the "usual" fee in a healthcare setting? The Supreme Court in my state addressed the issue recently. First, they affirmed that the standard contract law analysis applied, and the fee was limited to the "usual" amount. The parties disagreed as to what that would be. The hospital argued that it was the chargemaster. The patient argued that since that document was confidential, it would be the "usual and customary" amount provided by the insurance company. The court ruled that the chargemaster rate was the appropriate rate, and they gave great weight to the fact that the chargemaster had to be approved by the state in reaching that conclusion.
So there are limits on what can be charged even without an agreement on price and fee. Also, it appears (and I am not a lawyer and every state is different) that if you want to propose a "usual" charge in this scenario, there must be some rational basis behind that charge, even if it is just state approval.
2) Healthcare today is a "zero-sum" game. In other words, whoever is in the spotlight loses. I have heard some rumblings that primary care groups are debating a proposal to eliminate the "emergency department visit" CPT codes (i.e,, 9928x) and require EM physicians to use the standard outpatient E&M codes with the "savings" being used to raise the reimbursement for these codes. In other words, there are strong reasons for EM physicians to be aware of and address these issues.
3) The fundamental problem is that people are receiving benefits that they are not paying for. If I am sitting in one of our rural EDs at night surfing the web, the community still receives a benefit from our being there, even if they never set foot in the facility. The idea that people will pay $10K if they need the facility is not realistic. We know it does not work on the roads, which is why people are required to have auto insurance. I would propose that there needs to be mandatory "true insurance" for true catastrophic/emergency care. No opt outs... unless you are willing to have "no care" tattooed on your forehead and agree that you will not receive any emergency care in any circumstance. The problem of course is that immediately every special interest group will add in their "critical" service, e.g., mammograms, substance abuse treatment, etc., etc. But the idea that people receive a benefit without paying for it will never work.
