They probably won't soon. Basically, EM physicians could bill what was deemed "reasonable" in the past, but that has been struck down, and now insurers can pay them whatever low amount they choose to, while EM physicians are forced to see any and all patients under the EMTLA. What this amounts to is you're forced to work for whatever wages the government or private insurers decide to pay you, even if it is less than your services are worth. And since you can't turn their patients away, you have no bargaining power. My bet is salaries are going to decline 30% or more in the coming years.
As to why they were paid that much, the reasonable rate clause meant they charged everyone whatever they deemed reasonable. 95% of patients in the ED should have gone to a PCP for a $75 visit, but instead they've gone to the ED, which charges the reasonable rate for an emergency, typically around $750-2,000, even for a primary care level of complaint. So often you're billing 5-10 times what a PCP would for the same care, which obviously adds up to piles of cash. Now that the reasonable rate clause has been rescinded, it is likely ED physicians will be paid urgent care rates for primary care level services, which are about a third of what they currently bill.
First of all, you need to understand how ER doctors get paid.
ER is universally a group specialty. They work in private groups, and the group gets a contract for coverage at the local ED. Most pay their doctors one of three ways
1. straight hourly
2. straight RVU (how much you personally billed for)
3. Combination of both
Additionally members of the group may also become partner and share in the total take from that group, but that is beyond this discussion
The ED group is hired to solve a single problem, and that is that people keep showing up at the hospital. It used to be that all doctors who had hospital rights had to put their time in at the ED. Pediatricians, surgeons, everyone. Soon ED developed as its own specialty that focused on the immediate identification and treatment of life-threatening illness. We have many unique skills. All the other doctors were free to just do what they wanted to do, and not have to put 2 days a month in at the ED.
The ER is critical to a hospital, because that is where admissions come from. Direct admit from a doctor's office is rare, most PCP's just send them to the ED. To get admission, you need an exam and diagnosis from a physician that demonstrates they meet criteria for inpatient admission. We get paid because we provide that, and we take on the liability for everyone we discharge. That is why we are so valuable. Most ED's have a 20-30% admission rate, so it really isn't as much nonsense as you think.
Not all ED visits are the same, nor are they coded for and billed the same way. There are different levels of management, and procedures and radiology are billed for differently, but you need to have a physician who can verify that their problem warrants labs or an XRay, No physician, no order, no billing. The more complex the case, the more resources it uses, the higher it bills for.
To deal with the hordes of non-emergent ED visits, most departments develop a fast track so quickly shunt those people to a different area, have them seen by a PA, and then quickly discharged with a script for their UTI. The reimbursement is low, but so is the allocation of resources. Those simple cases never got paid $1000, they get paid like $80, which is nothing new.
EMTALA isn't new. Balanced billing isn't new. Nothing about this is new. EM physician compensation has increased steadily since the passage of the ACA, and the field is looking great for the future.
