The specialty of emergency medicine has often found itself under attack, particularly by insurance plans and consumer advocates. The former is understandable, the later never made much sense to me, given that emergency physicians provide more un-reimbursed care to the under- and uninsured than any other specialty. Recently, two different studies, both using health plan claims data, cast aspersions on the house of emergency medicine, leading to inflammatory stories in the press, and raising the ire of EM advocates and leaders within the specialty. The recently published study on ‘Surprise! Out-of-network Billing for Emergency Care in the United States’ by Zack Cooper et al for the National Bureau of Economic Research was a blow to efforts by ACEP, EDPMA, and Physicians for Fair Coverage to try to reframe the message promoted by health insurers and consumer advocates that blamed EM groups for putting patients in the middle of disputes between plans and providers over coverage and fair payment of out of network emergency care services. The authors of this study beat up on in particular on EmCare, a large EM outsourcing group, for allegedly using aggressive surprise balance billing, claims up-coding, unnecessary inpatient admissions and use of excessive diagnostic testing and scanning, and excessive charging practices. Another study by Vivian Ho, et al, recently published, then retracted, and then republished in the Annals of Emergency Medicine along with a number of secondary articles expressing critiques of the original article and defense responses from the authors, purported to show that Freestanding Emergency Centers, particularly those in Texas, were relatively expensive compared to Urgent Care Centers providing care to the same types of patients with less urgent problems. According to Dr. Ho: “Insurers are being forced to pay higher prices for many health care services at freestanding emergency departments that could have been dealt with at much lower cost. These unnecessary medical costs then get passed onto all insurance consumers in terms of higher premiums.” Emergency physicians throughout the country were, needless to say, disturbed by these studies and by the breadth of press coverage and the extent of public reaction that was generated.
The underlying problem with these studies was that data, generated over millions of claims, which the authors relied on for their analysis and conclusions was provided to the authors by health plans that clearly have an agenda. Attempts to access and validate this data have been unsuccessful (no big surprise there), and I really do not think we can feel confident that this data was clean. Nonetheless, it does not take a great stretch of the imagination to accept the possibility that emergency departments, and emergency physicians, often charge a lot more than urgent care centers for the treatment of similar problems. It may be appropriate from a cost standpoint, but it is indeed difficult for legislators and regulators to reconcile the idea that out-of-network charges for EP (and ED and FEC) services can run as high as 4-6 times what these same physicians and facilities charge for these same services when provided on a discounted, in-network basis. The surprise of getting billed for OON EP services at an in-network facility feels like bait and switch to the consumer; and trying to redirect the ire this engenders back on the health plan for aggressive or coercive contract negotiating or excessively restrictive narrow networks and surprisingly inadequate coverage is difficult, at best.
What is a specialty under fire to do? Emergency Medicine organizations can make some effort to police their members and member-groups in order to address outliers and overly aggressive behavior; but that is going to be very difficult, and is likely to hurt the entire specialty more than it curbs the appetites of those who are at the far end of the bell curve. Although I and others have argued that the motive underlying these attacks by plans and regulators has less to do with outliers and the higher cost of ED care and ‘unnecessary ED visits’, and more to do with trying to undermine the real commercial value of all physician services in the entire house of medicine, focusing on EMTALA-obligated providers who may represent the Achilles heel of fee-for-service medicine. If you look, however, at the focus of these complaints about EM, the majority have to do with the high cost of care for lower acuity patients. You don’t hear many complaints about the cost of care in the ED for major trauma patients, or patients with sepsis or cardiogenic shock. In fact, often times EDs and EPs don’t even begin to charge enough to cover their costs when it comes to providing critical care services, or prolonged acute care, in the ED. What you hear is the complaints about the cost of treating sore throats in the ED. My suggestion would be to stretch the charge-master for both professional and facility fees: lower for lesser acuity care, higher for greater acuity care. For those EM groups and hospitals that already charge in the 70th or 80th percentile of fees or higher, ignore that bit about ‘higher for greater acuity care’ and just reduce the fees at the lower end. You have already caused enough trouble.