Ateev Mehrotra on a controversial Texas emergency medicine study

In February, Annals of Emergency Medicine published a paper by Vivian Ho, Leanne Metcalfe, Cedric Dark, Lan Vu, Ellerie Weber, George Shelton Jr., and Howard Underwood. The main finding was that in a sample of Texas patients, it cost more for patients to be treated at emergency departments compared to comparable patients treated at urgent care centers. According to Health Data Buzz, the paper “caused an uproar among emergency department physicians.”

Subsequent to publication, errors were found in an appendix, which the authors corrected and with no implications for the study’s main findings.

Nevertheless, “the journal [conducted] another investigation, triggered by emergency physicians with reimbursement expertise in Texas, who raised additional concerns about the accuracy of the data.” During this investigation, the paper was temporarily removed from the journal’s website.

After further review, Annals of Emergency Medicine republished the paper in September. It is available here, along with numerous commentaries, critiques, and rebuttals in the right-hand sidebar. One critique is by Paul Kivela, president-elect of the American College of Emergency Physicians, the publisher of Annals of Emergency Medicine. Asserting discrepancies between the paper’s findings and that of his own analysis, he requested the paper be retracted. The authors responded to Dr. Kivella’s critiques here.

About this incident, I corresponded with Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center who has worked extensively with health plan claims data and is conducting research on free-standing emergency departments.

Austin: What is a freestanding emergency department? What is an urgent care center? How are they different?

Ateev: As implied by the name, FSEDs are emergency departments that are not within the confines of a hospital. Though they are free-standing FSEDs should still be able to address the full spectrum of illnesses treated at a hospital-based ED and when necessary transfer patients to a hospital when a hospital admission is required.

In contrast an urgent care center does not offer care for the full spectrum of illness. Urgent care centers typically focus on low-acuity illnesses (e.g., sinusitis, strep throat) as well as sprains, strains, and simple fractures. Problems that are more complicated than this are referred to an emergency department.

While both FSEDs and urgent care centers have extended and weekend hours, hospital-based EDs are typically open 24 hours a day and some free-standing EDs are also open around the clock. Urgent care centers are typically not open all the time.

I’ve used the word “typically” a number of times in these descriptions. It is important to highlight that word as there is notable variation within FSEDs and urgent-care centers in their capacity. For example, some urgent care centers are simply after-hours clinics at a primary care practice with no laboratory or radiology services. At the other extreme, some urgent care centers have both x-ray and CT scans and can provide many IV medications.

Austin: The study found that prices for patients with the same diagnosis were 10 times higher at freestanding EDs than at urgent care centers. For example, the study found that a routine urinalysis at a freestanding ED cost $51 versus only $3 at an urgent care center. How much of this could be due to differences in patient severity? What other factors that could explain it?

Ateev: None of these results are surprising. It is widely recognized that hospital-based EDs are much more expensive than UCC. Because FSEDs are paid at similar rates as hospital-based EDs than we should also expect them to be more expensive.

In the current payment system in the US, the relative price or reimbursement of a test such as a urinalysis or CT scan does not depend on patient severity. Rather, the level of reimbursement is primarily driven by where the care was provided.

Austin: The study used data from one insurer (Blue Cross Blue Shield) in one state (Texas). How far would you generalize the findings beyond this one insurer and state?

Ateev: As with any scientific study, we must be cautious when generalizing the results. However, I would not expect the results to be different in other states or with a different insurer, because the underlying reason for the price differences are similar in those contexts. FSEDs have been successful financially because they have been paid similar rates as hospital-based EDs.

Austin: In his critique, Dr. Kivela used reported charges (not allowed amounts) from a freestanding facility in a Dallas suburb, finding significant differences with the paper’s results. How do reported charges differ from allowed amounts? To what extent could this explain the differences between Dr. Kivela’s analysis and the paper’s? How far would you generalize results based on one freestanding facility?

Ateev: Charges are fiction. They have little relationship to what is the actual reimbursement. The best analogy is to the “rack rate” at a hotel. The rack rate is the rate for a night in the hotel you see posted in the room. But no one pays that rate for a night in the hotel.

I have argued that we should simply eliminate the publication and dissemination of charge data. They are a relic of the past and all they do is cause confusion.

Austin: This paper was controversial, particularly among some emergency physicians who didn’t want it to be published. Why?

Ateev: The easy answer is money. Outside the controversy about FSEDs, the emergency medicine community is frustrated by the rhetoric around “overuse” of the emergency department for low-acuity conditions such as sinusitis or ear infections. Though they might have a straightforward diagnosis such as sinusitis, many in the emergency medicine community have argued that these patients had more severe symptoms and are not directly comparable to the care provided in a primary care office or urgent care. Concerns about emergency department spending among insurers has increased over the last decade as they have observed a dramatic increase in the reimbursement for the average emergency department visit. The severity of this conflict is illustrated in Anthem’s recent decision to deny emergency department claims for what it deems unnecessary visits.

In that context come FSEDs. They are likely big profit generators for their investors and they also employ many emergency medicine physicians. Dr. Kivela is both an investor in FSEDs as well as a head of an organization of emergency medicine physicians. Feeling threatened by this research, ACEP is naturally going to attack the article.

ACEP’s response was similar with when the New England Journal of Medicine published an article on balance billing in emergency departments. The findings of this balance billing article were also viewed as threatening by the emergency medicine community and again, ACEP attacked the methodology as flawed and accused the researchers of being biased.


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