- Email: [email protected]
Original Allegations About Data Integrity by Emergency Physicians
CORRESPONDENCE
Original Allegations About Data Integrity by Emergency Physicians To the Editor: April 14, 2017 Thank you for speaking with me this week and considering my request to retract the article titled “Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers,”1 which was recently published in the online edition of Annals of Emergency Medicine. As we discussed, the American College of Emergency Physicians (ACEP) has serious concerns about the validity of the study because a panel of experts in the coding, billing, and revenue cycle management fields conducted a comprehensive review of the study and concluded that “the data used to support the research are flawed and misrepresent the comparative charges between urgent care centers and emergency departments [EDs], both hospital based and freestanding. It is baffling that the researchers did not comprehend the data corruption.” Our ACEP board of directors will discuss this issue further when it meets next week. As I hope you know, our board has the utmost respect for Annals, the integrity of its peer-review processes, and its autonomy in determining what studies are published. However, the legitimacy and severity of concerns related to the validity of this study warrant the unusual request from ACEP for Annals to issue a retraction. Specifically, we have grave concerns about the study’s methodology, the integrity of the data, the potential conflicts of interest on the part of the authors, and the possible serious consequences that the report’s flawed conclusions and recommendations could have in terms of supporting policy changes that could jeopardize access to emergency care and undermine the “prudent layperson” standard. I hope to sufficiently summarize those concerns in this letter in a way that provides clear justification for a decision to retract. The authors’ stated objective in the study is to compare the “price” of care between urgent care centers, hospital-based EDs and freestanding EDs. (The term “price” is not used and has no standard definition in revenue cycle management.) The authors define price as “the ‘total allowed amount,’ which is the amount the provider should be paid by the insurer and patient together.” This determination of the total allowed amount was arbitrarily created by Blue Cross Blue Shield and does not apply equally across all providers. There is a total allowed amount for providers who accept in-network contract rates and a different one for out-of-network providers who, according to Texas law, are to be paid a “usual and customary” rate. The “amount the provider should be paid by the insurer” Volume
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2017
will differ between urgent care centers and EDs simply as a function of whether they have a contract with Blue Cross Blue Shield, not a function of the true cost or price of care provided. Urgent care centers will almost universally be paid an innetwork contract rate, whereas independent freestanding EDs are rarely in network and will be paid a usual and customary rate. Failure to account for these significant differences in the amount Blue Cross Blue Shield pays for care and in how price is calculated differently in the different settings covered by the study is a fundamental and crippling flaw in the study’s methodology that precludes a true apples-to-apples comparison of the price of care and invalidates the study’s findings. Dr. Ho told me that the price was not the “contracted” amount but indeed the “allowable” amount. She also confirmed these were supposedly only commercial claims. The validity of the Blue Cross Blue Shield data relied on by the authors to show the median payments made to physicians in a hospital is also highly questionable, according to a comparison with data gleaned from the FAIR Health database of physician charges, which contains claims submitted from multiple insurers. In the authors’ Table E1,1 which contains the median reimbursement data, they claim that the median amount physicians were paid was $102, whereas FAIR Health shows that the average charge by physicians was $884 and the average of the medians was $896, an astronomical 89% difference. This figure demonstrates that the study’s data are not a realistic reflection of physician business practices. If the median commercial payment were $102, approximately 49% of the payments on commercial claims would be below that number, which would make it impossible for emergency physicians to remain in practice. A comparison of the frequency of levels of care (99281-5) is similar to the frequency cited in the study. Incidentally, we also have in our possession a letter from Blue Cross Blue Shield of Texas that they use the 50th percentile of FAIR Health to determine “allowable” rates, further challenging the accuracy of the data. We are concerned that insurers may use this misinformation to undermine the prudent layperson standard and in the future down-code charts to urgent care codes according to diagnosis, as insurers such as Aetna have indicated. Additionally, the authors’ comparison of the price of the most common diagnoses in these settings also fails to consider key factors, rendering their conclusions not only meaningless but also potentially harmful from a public policy and patient care perspective. Their reliance on claims data and not medical records means that they considered only the final diagnosis and not the patient’s presenting complaint when determining the price. In reality, of course, the resources used to evaluate patients for acute episodic care are Annals of Emergency Medicine 1
Correspondence
driven by the presenting signs and symptoms. Patients who deliberately seek care in the ED are far more likely to have complicating factors such as more severe symptoms or concurrent health issues that can make evaluation more complex than for individuals who don’t feel the need to seek emergency care and go to an urgent care center instead. The study’s failure to consider presenting symptoms when comparing diagnostic pricing and to instead base conclusions solely on final diagnosis not only invalidates its findings but also serves to endorse the dangerous premise that a final diagnosis is all that is necessary to quantify the value and cost of an evaluation. Such a view is antithetical to the vital principle of the prudent layperson standard and the protection it provides emergency patients from predatory insurance practices. Further failure of the study to adequately address the serious mitigating issue of patient disease complexity is its acknowledgement that the authors did not determine which ED visits resulted in hospital admission. Clearly, the study was not appropriately risk adjusted in comparing patient presentations to urgent care centers, hospital-based EDs, and freestanding EDs. The authors also indicate that their determination of the price of a diagnosis or procedure includes an assumption that the providers are paid the total amount owed by the patients. Such an assumption is not based in fact. Per national accounting firm Crowe Horwath’s recent study (see Becker’s Hospital CFO Issue, 3/29/2017 by K. Gooch),2 the average patient payment for self-pay after insurance is approximately 18.2% of the amount owed. To create a price definition based on an assumption that patients pay 100% of what they owe is misleading. Most recently, after a conversation with Dr. Ho, the lead author of the study, I believe she now understands the potential inaccuracy issues with this data. An e-mail exchange with her indicated that she had just forwarded a postpublication request to Blue Cross Blue Shield to have an independent third party review the data, an important step that was not previously taken to verify the validity of data provided by a party with a vested interest in the outcome of the study. The comments above represent the most egregious examples of the methodological and data-based deficiencies of the study. However, there is also cause for concern about potential conflicts of interest by the authors who may have connections to the insurance industry, particularly in light of some of the unsupported claims and recommendations contained in the report, which strongly promote the insurance industry’s public policy agenda. For example, the study’s claim that freestanding EDs potentially “waste societal resources because they represent a high-cost provider for services that 2 Annals of Emergency Medicine
could be delivered in lower-cost settings” ignores the improved access to emergency care that freestanding EDs provide and fails to acknowledge other studies that have shown that freestanding ED charges are often lower than those of hospitalbased EDs. The report includes a recommendation that outof-network balance billing be banned, particularly for freestanding ED facility fees. Such a recommendation is not substantiated by the study because the effect of balance billing and the costs and other issues associated with in-network versus out-of-network care were not explored or even accounted for in the study. We fully recognize that all studies have limitations, and determining which of them qualify for inclusion in a highly prestigious journal such as Annals is a difficult job performed with the highest levels of professionalism. Unfortunately, the problems with this study go beyond the normal limitations to entail fatally flawed methodology, corrupted data, and faulty conclusions. I hope the information in this letter has been helpful to you and has provided you with sufficient evidence to justify a full retraction of this article. Please feel free to contact me if you have any questions. Paul D. Kivela, MD, MBA American College of Emergency Physicians Irving, TX http://dx.doi.org/10.1016/j.annemergmed.2017.08.044
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Kivela derives income from his work and involvement with hospital-based EDs, freestanding EDs, and urgent care centers. His primary income comes from his clinical practice in a single hospital-based group in Napa, CA, and he works as a consultant to other hospitalbased emergency groups. He is also an investor in a Code 3 facility, which operates 4 freestanding emergency centers and an urgent care center in Texas. Dr. Kivela also lectured at the National Association of Freestanding Emergency Centers conference last year. As a member of the Board of Directors, he receives a stipend from the ACEP. 1. Ho V, Metcalfe L, Dark C, et al. Comparing the utilization and costs of care in freestanding emergency departments, hospital emergency departments, and urgent care centers. Ann Emerg Med. 2017. http:// dx.doi.org/10.1016/j.annemergmed.2016.12.006. 2. Becker’s Hospital Review. March 2017 Issue of Becker’s Hospital Review. 2017. Available at: http://www.beckershospitalreview.com/ uncategorized/march-2017-issue-of-becker-s-hospital-review. Accessed April 14, 2017.
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Original Allegations About Data Integrity by Emergency Physicians To the Editor: April 14, 2017 Thank you for speaking with me this week and considering my request to retract the article titled “Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers,”1 which was recently published in the online edition of Annals of Emergency Medicine. As we discussed, the American College of Emergency Physicians (ACEP) has serious concerns about the validity of the study because a panel of experts in the coding, billing, and revenue cycle management fields conducted a comprehensive review of the study and concluded that “the data used to support the research are flawed and misrepresent the comparative charges between urgent care centers and emergency departments [EDs], both hospital based and freestanding. It is baffling that the researchers did not comprehend the data corruption.” Our ACEP board of directors will discuss this issue further when it meets next week. As I hope you know, our board has the utmost respect for Annals, the integrity of its peer-review processes, and its autonomy in determining what studies are published. However, the legitimacy and severity of concerns related to the validity of this study warrant the unusual request from ACEP for Annals to issue a retraction. Specifically, we have grave concerns about the study’s methodology, the integrity of the data, the potential conflicts of interest on the part of the authors, and the possible serious consequences that the report’s flawed conclusions and recommendations could have in terms of supporting policy changes that could jeopardize access to emergency care and undermine the “prudent layperson” standard. I hope to sufficiently summarize those concerns in this letter in a way that provides clear justification for a decision to retract. The authors’ stated objective in the study is to compare the “price” of care between urgent care centers, hospital-based EDs and freestanding EDs. (The term “price” is not used and has no standard definition in revenue cycle management.) The authors define price as “the ‘total allowed amount,’ which is the amount the provider should be paid by the insurer and patient together.” This determination of the total allowed amount was arbitrarily created by Blue Cross Blue Shield and does not apply equally across all providers. There is a total allowed amount for providers who accept in-network contract rates and a different one for out-of-network providers who, according to Texas law, are to be paid a “usual and customary” rate. The “amount the provider should be paid by the insurer” Volume
-,
no.
-
:
-
2017
will differ between urgent care centers and EDs simply as a function of whether they have a contract with Blue Cross Blue Shield, not a function of the true cost or price of care provided. Urgent care centers will almost universally be paid an innetwork contract rate, whereas independent freestanding EDs are rarely in network and will be paid a usual and customary rate. Failure to account for these significant differences in the amount Blue Cross Blue Shield pays for care and in how price is calculated differently in the different settings covered by the study is a fundamental and crippling flaw in the study’s methodology that precludes a true apples-to-apples comparison of the price of care and invalidates the study’s findings. Dr. Ho told me that the price was not the “contracted” amount but indeed the “allowable” amount. She also confirmed these were supposedly only commercial claims. The validity of the Blue Cross Blue Shield data relied on by the authors to show the median payments made to physicians in a hospital is also highly questionable, according to a comparison with data gleaned from the FAIR Health database of physician charges, which contains claims submitted from multiple insurers. In the authors’ Table E1,1 which contains the median reimbursement data, they claim that the median amount physicians were paid was $102, whereas FAIR Health shows that the average charge by physicians was $884 and the average of the medians was $896, an astronomical 89% difference. This figure demonstrates that the study’s data are not a realistic reflection of physician business practices. If the median commercial payment were $102, approximately 49% of the payments on commercial claims would be below that number, which would make it impossible for emergency physicians to remain in practice. A comparison of the frequency of levels of care (99281-5) is similar to the frequency cited in the study. Incidentally, we also have in our possession a letter from Blue Cross Blue Shield of Texas that they use the 50th percentile of FAIR Health to determine “allowable” rates, further challenging the accuracy of the data. We are concerned that insurers may use this misinformation to undermine the prudent layperson standard and in the future down-code charts to urgent care codes according to diagnosis, as insurers such as Aetna have indicated. Additionally, the authors’ comparison of the price of the most common diagnoses in these settings also fails to consider key factors, rendering their conclusions not only meaningless but also potentially harmful from a public policy and patient care perspective. Their reliance on claims data and not medical records means that they considered only the final diagnosis and not the patient’s presenting complaint when determining the price. In reality, of course, the resources used to evaluate patients for acute episodic care are Annals of Emergency Medicine 1
Correspondence
driven by the presenting signs and symptoms. Patients who deliberately seek care in the ED are far more likely to have complicating factors such as more severe symptoms or concurrent health issues that can make evaluation more complex than for individuals who don’t feel the need to seek emergency care and go to an urgent care center instead. The study’s failure to consider presenting symptoms when comparing diagnostic pricing and to instead base conclusions solely on final diagnosis not only invalidates its findings but also serves to endorse the dangerous premise that a final diagnosis is all that is necessary to quantify the value and cost of an evaluation. Such a view is antithetical to the vital principle of the prudent layperson standard and the protection it provides emergency patients from predatory insurance practices. Further failure of the study to adequately address the serious mitigating issue of patient disease complexity is its acknowledgement that the authors did not determine which ED visits resulted in hospital admission. Clearly, the study was not appropriately risk adjusted in comparing patient presentations to urgent care centers, hospital-based EDs, and freestanding EDs. The authors also indicate that their determination of the price of a diagnosis or procedure includes an assumption that the providers are paid the total amount owed by the patients. Such an assumption is not based in fact. Per national accounting firm Crowe Horwath’s recent study (see Becker’s Hospital CFO Issue, 3/29/2017 by K. Gooch),2 the average patient payment for self-pay after insurance is approximately 18.2% of the amount owed. To create a price definition based on an assumption that patients pay 100% of what they owe is misleading. Most recently, after a conversation with Dr. Ho, the lead author of the study, I believe she now understands the potential inaccuracy issues with this data. An e-mail exchange with her indicated that she had just forwarded a postpublication request to Blue Cross Blue Shield to have an independent third party review the data, an important step that was not previously taken to verify the validity of data provided by a party with a vested interest in the outcome of the study. The comments above represent the most egregious examples of the methodological and data-based deficiencies of the study. However, there is also cause for concern about potential conflicts of interest by the authors who may have connections to the insurance industry, particularly in light of some of the unsupported claims and recommendations contained in the report, which strongly promote the insurance industry’s public policy agenda. For example, the study’s claim that freestanding EDs potentially “waste societal resources because they represent a high-cost provider for services that 2 Annals of Emergency Medicine
could be delivered in lower-cost settings” ignores the improved access to emergency care that freestanding EDs provide and fails to acknowledge other studies that have shown that freestanding ED charges are often lower than those of hospitalbased EDs. The report includes a recommendation that outof-network balance billing be banned, particularly for freestanding ED facility fees. Such a recommendation is not substantiated by the study because the effect of balance billing and the costs and other issues associated with in-network versus out-of-network care were not explored or even accounted for in the study. We fully recognize that all studies have limitations, and determining which of them qualify for inclusion in a highly prestigious journal such as Annals is a difficult job performed with the highest levels of professionalism. Unfortunately, the problems with this study go beyond the normal limitations to entail fatally flawed methodology, corrupted data, and faulty conclusions. I hope the information in this letter has been helpful to you and has provided you with sufficient evidence to justify a full retraction of this article. Please feel free to contact me if you have any questions. Paul D. Kivela, MD, MBA American College of Emergency Physicians Irving, TX http://dx.doi.org/10.1016/j.annemergmed.2017.08.044
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Kivela derives income from his work and involvement with hospital-based EDs, freestanding EDs, and urgent care centers. His primary income comes from his clinical practice in a single hospital-based group in Napa, CA, and he works as a consultant to other hospitalbased emergency groups. He is also an investor in a Code 3 facility, which operates 4 freestanding emergency centers and an urgent care center in Texas. Dr. Kivela also lectured at the National Association of Freestanding Emergency Centers conference last year. As a member of the Board of Directors, he receives a stipend from the ACEP. 1. Ho V, Metcalfe L, Dark C, et al. Comparing the utilization and costs of care in freestanding emergency departments, hospital emergency departments, and urgent care centers. Ann Emerg Med. 2017. http:// dx.doi.org/10.1016/j.annemergmed.2016.12.006. 2. Becker’s Hospital Review. March 2017 Issue of Becker’s Hospital Review. 2017. Available at: http://www.beckershospitalreview.com/ uncategorized/march-2017-issue-of-becker-s-hospital-review. Accessed April 14, 2017.
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