Trump Does Health Care ‘End Run’ Around Congress – Critics Call Executive Order ‘Callous Sabotage’

Interestingly in a country where many debate the psychological state of this president, the American Psychological Association says Donald Trump is taking us backward in healthcare. Other critics are much, much harsher.

For much of the year, Trump has been upset that one of his signature campaign themes was not realized, the overturning of Obamacare. After all, for his base, his hard-core supporters, what had he done, beyond the mood swings? Every once in a while, in between tweets denouncing “false media” or criticizing the NFL, he took stabs at Congress for not passing a bill to rid the Affordable Care Act.

He wanted the wrecking ball and the GOP leadership didn’t come through.

Yesterday, he went off the legislative track and stayed on the executive: Trump signed an executive order to take steps that he says were designed to expand choices and alternatives to Obamacare, while increasing competition to reduce costs. Not so fast, critics say.  Trump also is moving to end billions of dollars of key so-called “cost-sharing” payments by insurers that help lower-income people pay for insurance, opponents say. The actions could undermine the entire Obamacare marketplace, and result in insurance policies with reduced benefits.

Many groups are concerned that the Trump action targets the most vulnerable: those people who need services the most may be left out in the cold. Some say that they are concerned that health plans ultimately would not provide the essential health services such as maternity care and services for children, and cheap and narrow plans would be structured outside of the Affordable Care Act  that might draw healthy people, but leave sicker people or those with pre-existing conditions facing what some term as “impossibly higher premiums.”

In a tweet this morning, Trump suggested he wants to work with Democrats on Obamacare. “The Democrats ObamaCare is imploding,” he wrote. “Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!.”

“The time has come to give Americans the freedom to purchase health insurance across state lines, which will create a truly competitive national marketplace that will bring costs way down and provide for better care,” Trump said in an earlier statement.

Trump poked at the flaws of Obamacare: the percentage of workers at small firms receiving coverage through their employer had declined from nearly half in 2010 to about one-third in 2017, according to the White House.

The subsidies that Trump seeks to get rid of impact about 6 million people, the Department of Health and Human Services says, costing about $7 billion in 2017, according to CNN.

Once again, instead of trying to rebuild flaws in the current system, Trump seems intent on undoing it. He’s an interesting kind of developer. He destroys and then….His critics say with the executive action and others, healthcare in the country is becoming Trumpcare and the problems are his, at least politically.

“The executive order begins by reciting perceived failures of the Affordable Care Act; rising premiums for ACA coverage, reduced insurer participation in exchanges and reduced exchange enrollment,” Timothy Jost, a contributing editor at Health Affairs and emeritus professor at the Washington and Lee University School of Law, wrote in a Health Affairs blog. “However, many of the problems the individual market is experiencing are certainly due to actions the Trump administration has taken to undermine ACA coverage, and there is good evidence that the ACA market could have stabilized absent those actions,” Jost added.

The order essentially encourages health plans “to pick and choose” services they cover and won’t help those who desperately need mental health, substance use, and other critical services,” Antonio Punte, PhD, president of the American Psychological Association said in a statement. “Before the Affordable Care Act, more than one-third of individual market plan plans chose not to cover mental health services and nearly half chose not to cover substance abuse.”

Punte noted these are especially tough times: 91 Americans a day, for instance, are dying from opioid overdoses.

“Today health plans are competing on how efficiently and effectively they provide care, but the president’s executive order, if carried out, would take us backward by letting plans once again compete on how fewer services they cover and ignore state health insurance protections,” Punte said. “We are deeply disappointed that the administration continues to try to dismantle our health care system, instead of trying to increase enrollment and stabilize insurance markets.”

“Now that President Trump and the Republican Congress failed to end the Affordable Care Act by legislation, the president is sabotaging the law by executive action,” said Vanita Gupta, president and CEO of The Leadership Conference on Civil & Human Rights. “Today’s move is their effort to put another nail in the coffin. This order will only drive up costs for the sick and put the health of millions at risk.”

Trump’s executive order “will result in fewer protections for the most vulnerable Americans, such as those with pre-existing conditions, and will encourage sham, loosely regulated health insurance plans that won’t provide adequate benefits,” said Randi Weingarten, head of the American Federation of Teachers in a statement. “Ultimately, this could lead to the collapse of individual health insurance markets through which millions of Americans obtain coverage.”

“Donald Trump owns the unwinding of the Affordable Care Act,” Weingarten said. “He is ignoring the rule of law, refusing to compromise, and doing an end-run around Congress in order to strip people of their healthcare. Millions of Americans will be worse off because of his actions. There is an ongoing pattern of the Trump administration’s callous sabotage of Obamacare, and it will cause real harm to American families.” – Joe Cantlupe

To Err In An Electronic Medical Record

After spending a lot of my time recently visiting my mom in a hospital, I couldn’t help but think every time the nurse came by, with pills and a small plastic cup of water, about what physicians, nurses and patients must confront: what is the right medication, when is it too much, what isn’t enough? What if they make a mistake about those medications?

Yes, despite electronic medical records, which have enabled sweeping changes in healthcare over the last few years to improve coordination efficiency, and quality of care, there are still wide gaps in the information that exists and not used properly.

That’s one of the reasons some numbers, like those of medication errors, are not where we want them to be.

According to the FDA, medication errors increased from 16,689 in 2010, to over 93,930 in 2016 – showing a whopping 463 percent jump. Those errors contributed to at least 230,000 deaths annually, some studies show, making them responsible for being the third largest cause of fatalities.

As in any error, there are many variables and reasons for each of them. Ironically, the increasing errors come at a time when hospital officials say there have been many data significant improvements in medical data systems. They include “alerts” in electronic medical records when the computers identify something that procedurally may be wrong, such as the kind of – or amount of – medications being given to a patient.

The latest statistics on medication errors show that more safeguards and tools are needed to help physicians, nurses and other staff overcome human flaws in assessing these alerts, such as “alert fatigue” when too many red lights go off, and the staff believe they know better than what machines are telling them, as if the computers are crying wolf once too often, and the physicians or nurses just walk on by to the next patient.

Shobha Phansalkar, MD

Shobha Phansalkar, RPh, PhD, director of informatics and clinical innovation at Wolters Kluwer, has spent years evaluating these so-called clinical information systems, especially the ins-and-outs of how healthcare handles medications and how they are given to patients. Also an assistant professor in the division of general medicine and primary care at Brigham and Women’s Hospital and Harvard Medical School, Phansalkar has worked diligently on analytical tools and yes, has examined the human factor in medication errors. In extensive studies she has carried out with colleagues over the years, and in an interview with HealthDataBuzz earlier this year, Phansalkar says the push toward adopting electronic medical records have been key initiatives for hospital quality and safety, but they are deeply flawed and their potential benefits have not been reached, not by any stretch.

In fact, Phansalkar’s studies on medication errors, particularly related to alerts related to drug-interaction, have exposed significant weaknesses in healthcare electronic medical systems and the so-called alerts. One of the major problems, she says, is that there are unclear messages in these alerts, and physicians decide to ignore or “override” them because they are not presented in a clear manner, or give context to what the doctors are doing. Studies by Phansalkar and her colleagues show that as many as 49 to 96 percent of all alerts are ignored, depending on the setting. Or as she and her colleagues have written: Alerts have “lagged behind expectations.”

As such, Phansalkar and her colleagues have been working to develop alert systems that have tools to overcome these limitations, with the “human element” very much a key focus. Wolters Kluwer Clinical Drug Information technology has developed programs to revise the alerting “logic” in electronic medical records to improve patient safety, she says.

“Errors are continuing to take place in every aspect of healthcare,” she says. “And they are taking place especially at the point of care such as when the right medications are chosen or supposed to be chosen. One of the problems is that providers are inundated with these alerts and are overriding a large number of them.”

Electronic medical records are limited in their ability to evaluate drug interactions, which could have sharp negative impacts on patients. This is becoming of greater importance as patients take more prescription medications than ever and often physicians still don’t have access to the entire patient history – despite the electronic medical records, Phansalkar says.

“It’s an age where we can exchange information easily, but somehow healthcare has lagged behind,” she says. “We’ve become more aware of the problem and we have better mechanisms in place, but with a fragmented system, and patients seeking care from multiple numbers of providers, whether it’s by choice or driven by health insurance, providers don’t have access to the entire patient profile. The physician doesn’t have access to all the medications and relies on a piece of the pie and that results in errors.

When a physician gets these “alerts” there are some built-in problems that Phansalkar and others are trying to fix. The lack of context about the medications being prescribed, such as the dose-toxicity or potential dependency of the patient, Phansalkar says.  Also, alerts should be identified as to whether they should be a priority or not, or the impact to the patient when a doctor decides to override them, she adds.  In addition, physicians have to evaluate similarities in different medications to ensure there is a “right bar code,” for instance, that is coordinated with pharmacies, according to Phansalkar.

Another problem in how these alerts are put together, she and colleagues say in a study. That relates to how “designers and vendors sharply limit the ability to modify alert systems because they fear being exposed to liability,” they wrote. That can be overcome through “finely tailored or parsimonious warnings that could ease alert fatigue without imparting a high risk of litigation for vendors, purchasers, and users,” the authors added in the study.  In addition, they said, more government regulation and development of international practice guidelines should highlight the warnings.

As Phansalkar wrote in Health System Management last year, “Alert fatigue remains one of the greatest hindrances to optimal use of clinical decision support at the point of care. Finding the right balance of the volume of alerts to display has been an elusive pursuit for EMR and CDS vendors.”

Phansalkar and her colleagues are working to change the alert system through various new models to improve patient care.

“Warnings could be tailored to a particular clinical environment, taking into account the individual care setting, such as adjusting the type or state of a medication interaction alert if a particular community of physicians is found to respond inappropriately to it,” they said in one study. “A tailored system might advise adjusting a patients medication dosage only when other patient data, such as age, or specific comorbidities, such as a rental function, raise concern, as opposed to alerting indiscriminately for all patients.”

Some healthcare organizations have taken steps to do just that – tinkering with their alert systems, such as the Group Health Cooperative of South Central Wisconsin, which used “filtering mechanisms” to address potential alert fatigue. Using guidelines developed by Wolters Kluwer, the healthcare system reduced the number of alerts from 87 percent to 27 percent, Phansalkar wrote.

MetroHealth in Ohio reduced and streamlined drug dose alerts by some 80 percent to avoid physician fatigue, she added.

Phansalkar is examining the impact of medication errors through and beyond the hospital stay or at a physician’s office.

“We’re are studying the downstream impact, what happens when a patient leaves the hospital, or the provider. Are they being counseled appropriately about medications or drug interactions?” she says. “There is a big opportunity to counsel these patients at that time.”

Indeed, health officials must ensure proper medication adherence from the beginning of a patient’s journey through the healthcare system, from the moment at “the gateway of patient interaction,” Phansalkar says . – Joe Cantlupe.




Let’s Come Together And Have An ‘Apolitical” Approach to End Gun Violence, Johns Hopkins Researcher Says: Multi-Year Health Affairs Study Shows Extensive Gun-Related Injuries

As America reels over the horrendous and heart-breaking mass shooting in Las Vegas, researchers from the Johns Hopkins University School of Medicine coincidentally released a disturbing report about firearm-related injuries in the U.S. that showed more than 700,000 patient visits to hospital emergency departments that resulted from shootings (25 per 100,000 people) between 2006 and 2014.

While shooting deaths are the third leading cause of injury-related mortalities in the U.S., the researchers said they performed the extensive study on firearm injuries because they said there was a lack of information about that aspect of gun violence and the economic impact on EDs.

“I think that the major surprise and interesting finding of our study was the immense number of individuals affected by the issue,” Faiz Gani, postdoctoral research fellow at the Johns Hopkins University School of Medicine’s Department of Surgery and lead author.

In the study published in Health Affairs, the researchers cited the “overall incidence” of ED visits for firearm-related injuries for the period 2006-2014, noting it was 25.3 per 100,000 people. That number was “disproportionately higher” in the U.S. than in other higher high-income countries, such as Germany, Japan and the United Kingdom. Gun-related deaths also are higher in the U.S., with about 36,000 reported in 2015, the researchers said.

The victims’ also were studied, with some possibly startling conclusions. Patients injured in suicide attempts, for instance, were more likely to be from highest income groups, people who were assault victims in shootings had low income, the researchers said.

Suicide attempts involving guns were linked more often – twice as high – among Medicare enrollees, compared to patients enrolled in other insurance, they said.

The results showed that the number of “non-fatal” firearm injuries at EDs was 2.4 times of fatal injuries. Such injuries were about nine times more common among men, ages 20 to 24, then women. Since the study did not include people who died before reaching the hospital or did not seek emergency treatment, the researchers acknowledged the increased burden for hospital EDs.

Not surprisingly, the researchers called for greater gun control laws, noting the immense political debate. Adding to the argument over gun control, the researchers said policymakers should consider universal background checks for gun purchases and limiting access for people with histories of violence or previous convictions, which now isn’t always the case.

“I think it’s extremely tragic that we continue to encounter mass shootings today, particularly given that they are potentially preventable to a degree,” Gani told HealthData Buzz following Sunday’s shooting that resulted in the deaths of 58 concert-goers, the gunman himself, and left more than 500 wounded. “I really hope that moving forward we can all come together and adopt a scientific and apolitical approach to gun violence,” he said.

Gani and his colleagues wrote that policymakers – perhaps in an understatement – “might consider implementing universal background checks” for firearm purchases. In addition, gun access should be limited to “people with a history of violence or previous convictions to reduce the clinical and financial burden associated with these injuries,” they wrote.

They acknowledged that “efforts to reduce firearm-related injuries have been limited as a result of the politicized environment surrounding gun violence and a lack of will to consistently implement proposed policies.”

In their study of gun-related injuries, the cost for each injured person treated at an ED was more than $5,000, and $95,000 for inpatient charges; the total was about $2.8 billion annually or $24.9 billion over the study period.

“It was very interesting to note that over 50 percent of our study population was either uninsured or self-pay,” Gani said. “This finding has broad policy implications. While these patients represent the most financially vulnerable patients, they also often do not have any insurance company negotiating on their behalf and therefore often incur the entire financial charge in the form of high pocket expenses.

Other findings:

  • Among patients who were shooting victims but treated at EDs, handguns were the most commonly used weapons, 27 percent. Then shotguns, 5.9 percent, or hunting rifles, 2 percent.
  • Emergency Care. While there was data that showed reduced shooting related injuries and ED visits for several years, there was an uptick in the most recent year studied, 2014. The incidence of ED admissions for firearm-related injuries decreased from 27.9 ED visits per 100,000 people in 2006 to 21.5 visits in 2013. But there was a “significant increase” in 2014 with 26.6 ED visits per 100,000 people.
  • Mental Health Issues. There was an increase in the number of patients “presenting with a diagnosis of a mental health disorder” at EDs stemming from shootings, from 5.3 percent in 2006-2008, to 7.5 percent in 2012-2014. “Of note, the incidence of mental health disorders was highest among patients injured in an attempted suicide, 40.8 percent patients.” the researchers said. While there have been political debate about gun violence and impacts related to people with mental health issues, the discussion might not be so straightforward, they said. “While policy makers have proposed mental health facilities to curtail gun violence, they would likely reduce the number of deaths associated with mental health disorders, but would have a limited impact on the overall burden of firearm-related injuries, given the small share of patients with such injuries,” the researchers said.

Despite all the debate over guns, research in the field is not funded where it should be – and that’s because of politics, they said.

“Research has been limited due to the politicized nature of this and the lack of appropriate funding despite the high clinical and financial burden associated with this issue,” they added.

As their study was published in in a week of turmoil for the country on gun-related violence, Gani observed: “I hope that our study coupled with work from other gun violence researchers furthers the conversation of gun violence through the use of robust evidence.”

“Only after we understand the complex factors at play can we develop appropriate and effective policies that ensure that we aren’t’ having the same conversation again in a few months,” he said.  — Joe Cantlupe



Helping Doctors Through the Coding and Billing Maze

When they bill a procedure, physicians match their work with a special code for reimbursement. Sometimes – all too often – there is a mismatch, and the numbers don’t add up.

It is becoming so confusing that many docs don’t want to deal with it, but that causes problems up the road, as physicians and health systems evaluate procedures, the kind of diseases being treated, and reimbursement. Lots of money is being lost all around.

Incorrect coding is to blame for nearly half of improper claims submitted to Medicare, and the monetary losses increased from $57.8 billion in Medicare and Medicaid payments in 2015, and $68 billion in 2016. When the government is unsure what’s going on, it carries out what doctors dread: audits.

The audits themselves are causing disarray among physicians and hospital systems. Having conflict with the government is one thing, and that draws big headlines. But there is often the unspoken side to this: doctors and hospital systems are also hurting themselves, by improperly filing codes that cheat themselves out of millions of dollars and undermine their quality of care, says Adrian Velasquez, CEO and founder of predictive analytics provider Fi-Med, based in Brookfield, Wi.

Fi-Med touts its proprietary technology that has helped major hospital systems increase revenues and eliminate compliance risk through their software technology that identifies potential billing errors that can lead to overpayments. His clients include major hospital systems such as Mt. Sinai in New York, the Catholic Health Initiative and University of Alabama health systems.

“More hospitals are ripping themselves off; they aren’t compliant and they don’t have the right protocols, or are doing an effective review of documentation,” Velasquez says. At the same time, “insurance companies have many coders looking at what is submitted by doctors. For doctors, it’s difficult to match the codes for work they are doing,” he says. “It’s humanly impossible to keep track of a specialty.”

Velasquez says studies show a whopping 80 percent of all medical bills contain errors, which he blames on lack of industry staffing and wide-ranging standards, suggesting that it is too low of a priority among doctors and hospitals until it is too late.

One of the problems is the complication of the codes themselves, which must be measured to actual procedures. The health system’s ICD-9 and ICD-10 added thousands of new codes, or revised them, which physicians must match to get proper reimbursement, he says.

As Velasquez said in a statement, compliance is one of the most important areas of any hospital system, or even in physician groups, but the most are “under-resourced when it comes to personnel and budget.”

“It’s viewed as a cost center, not a profit center,” he says. “When cuts are made they are often made in compliance.”

As a result, lots of physicians are caught in the maelstrom, putting inaccurate information into coding systems, either by “undercoding” – that can result in underpayment for the conditions they are treating, or “overcoding” – billing too much for the procedure. While the percentages vary, at least 25 percent occurrence rate for each incident, which Velasquez decries as undermining docs and the system.

“Physicians didn’t become physicians to become compliant,” he says. “They became physicians to heal people and make people well. That’s the real problem.”

In the meantime, there have been many cases in which a host of hospitals and physician groups have been shelling out big money to settle cases in which they have either flouted the law, or having problems dealing with billing. Some are involved in fraud, trying to re-invent their coding to get bigger payments, while others are making big mistakes. Government regulators also are having trouble keeping tabs on all this.

Each week, the government enters into corporate integrity agreements (CIAs) or simply integrity agreements with health care providers as part of federal health care program investigations stemming from a variety of false claim statutes.

In such an analytical world, physicians and hospitals can use data to substantially help themselves with coding issues, and that’s the business Velasquez is in.

Essentially, technology to locate coding issues can prevent incorrect billing, saving hospital networks millions of dollars, he says. “Healthcare providers who use analytics to improve internal processes and identify red flags dramatically improve their compliance risk and bottom line,” Velasquez said in a statement.

He points to one particular case where technology assistance potentially could have played a key role in overcoming significant billing and coding problems.

Earlier this year, the Carolinas Healthcare system settled a Justice Department lawsuit alleging that it “upcoded” lab results to get bigger payments from federal healthcare programs, Healthcare Finance News reported.

The government said the hospital system conducted urine tests coded as “high complexity” for federal reimbursement, which resulted in more than $80 per test than if coded properly as a “moderate complexity.” The event occurred from 2011 to 2015. It resulted in Carolinas Healthcare System paying out $6.6 million.

With great technology, the issue could have been prevented, or as Velasquez says, “proactive technology.” It’s about the interpretation and application of complex and constantly changing billing guidelines, Velasquez says.

Since 1993, Fi-Med has been working alongside healthcare providers to “maximize revenue and reduce risk,” from catching billing errors to providing high-level safeguards. The company  touts a subscription service that analyzes hospital or network billing data that quickly shows if providers are at risk. Its technology tracks “coding behavior, audit risk evaluation, management revenues and over/under charges,” according to the company website.

Its REVEAL/md can identify “in minutes” unusual coding behavior and patterns that fall outside of what would be considered normal numbers based on comparisons to what was submitted to the Centers for Medicare and Medicaid Services (CMS).  Once identified in REVEAL, the hospital or auditor would have to investigate further to determine if an error occurred leading to the overpayments, the company says.

“REVEAL/md cannot determine if fraud has occurred, but this step is essentially the first step that a government auditor/investigator would take to determine if they need to dig deeper,” says Velasquez.

When he created the program, “there wasn’t a lot of interest,” Velasquez says, but he knew it would become a significant issue as there were growing headlines about federal recovery and audit charges.

“Now it’s getting a lot of traction, and a lot of interest,” he says.

The reason? More hospitals are finding they are lost in the maze, even before they start their billing journey.  — Joe Cantlupe

Another Bad CBO Report Card for Latest GOP Healthcare Bill

While Republican Senators try to put together their latest, flailing plan to overhaul Obamacare, the Congressional Budget Office today released some quick calculating of its own:

Not good.

The CBO says the result of the Graham-Cassidy bill would be that insurance coverage for “high-cost medical events would be reduced by millions” of people.  (The deficit would be reduced by $133 billion under the bill with in a 10-year period, the agency says).


The reason, says the CBO:

  • Enrollment in Medicaid “would be substantially lower because of large reductions in federal funding.”
  • Enrollment in nongroup coverage “would be lower because of reductions in subsidies for it.”
  • Enrollment in  “all types of health insurance would be lower because penalties for not having insurance would be repealed.” Those losses would be “partly offset by enrollment in new programs established by states using the block grants and by somewhat higher enrollment in employment-based insurance,” the CBO says.

Because of the quick turnaround, the CBO said it didn’t have time yet to estimate the exact numbers. — Joe Cantlupe

McCain: Statesmanship Over Friendship; (Trump: Chuck Schumer sold him a “bill of goods. Sad.” )

The last time Sen. John McCain, R-Ariz, was in the healthcare debate spotlight came in a tense vote last July to repeal and replace Obamacare. Then, he strolled in the Senate chamber, and put his “thumbs down.”

Yesterday, in another heroic move, he virtually killed the latest last gasp of the GOP to overcome Obamacare, saying he “cannot in good conscience” vote for the Sen. Lindsey Graham, R-SC, and Bill Cassidy, R-LA, proposal, which had been roundly criticized. At last count, GOP leaders were “one senator away from defeat,” The Washington Post said.

McCain said he would vote against the wishes of his good buddies.

In a string of tweets this morning, President Trump  denounced McCain’s action, saying he let his best friend “LG down.” Trump also said that Democratic NY Sen. Chuck Schumer “sold John McCain a bill of goods. Sad.”  (Editorial Note: Gee, what happened to Trump’s pals, “Chuck and Nancy?” …oh, another story)…

“John McCain never had any intention of voting” for the bill, Trump said, adding that the Arizona governor supported it. “He campaigned on Repeal & Replace,” Trump said. “Let Arizona down!”

Trump cited Arizona as having a ” 116% increase in Obamacare premiums last year.” The President is predicting that Sen. Rand Paul “may find a way to get there for the good of the Party!”  (Interestingly, like McCain, Paul has signaled he would vote against the healthcare plan, too)

“I take no pleasure in announcing my opposition,” he said in a statement.” Far from it. The bill’s authors are my dear friends, and I think the world of them. I know they are acting consistently with their beliefs and sense of what is best for the country. So am I.”

“I hope that in the months ahead, we can join with colleagues on both sides of the aisle to arrive at a compromise solution that is acceptable to most of us, and serves the interests of Americans as best we can.” –

– Joe Cantlupe



Annals of Emergency Medicine “Pulls Back the Curtain” on Controversial Urgent Care Study Reposted Today

Five months after the Annals of Emergency Medicine withdrew a controversial academic paper touting the pricing merits of urgent care centers compared to competing free-standing emergency departments in Texas, the AEM today  reposted the study online – its findings almost exactly the way it was the first time, which caused a firestorm in the ED world.

The authors of the study, under pressure to review their initial paper, had fixed some minor technical errors even before the paper was pulled, they said. But their conclusions were virtually similar: free-standing EDs and hospital-based EDs in Texas are overpriced, compared to urgent care centers. It showed a potentially ineffective use of emergency facilities, they said, which is becoming an increasing financial burden in healthcare.

“The main results of the paper are the same,” says lead author, Vivian Ho, the Baker Institute Chair in Health Economics, the Department of Economics, at Rice University. Before the paper was initially withdrawn following publication in May. “We had some median prices in the (paper’s) appendix that were incorrect because I transposed them incorrectly,” Ho says.

In a highly unusual move – citing the controversy involved – the editor in chief, Michael Callaham, MD, wrote that the journal was “pulling back the curtain” and not only published the final article but several editorials and “the background arguments and discussions that took place between the author and their critics.”

When the paper was first published it caused an uproar among emergency department physicians, and AEM said they sought further review, focusing on what they termed serious concerns over data in the study, which was gaining widespread media attention, and showed that patients who were treated at emergency departments instead of urgent care centers paid as much as 10 times higher for similar diagnosis. The Annals of Emergency Medicine is the official journal of the American College of Emergency Physicians.

Since HealthDataBuzzs revealed the AEM decision last spring to remove the paper from the website with the intent of either trying to salvage or scrap the paper,  the organization tapped into many academics and others to review its findings. In the meantime, there was much consternation: the AEM editor Callaham saying he had never been involved in such a situation, and Ho saying she was never so mistreated in the handling of a study.

While some criticized the study, other academics were aghast that the paper would be summarily pulled, based on criticisms from those with self interests. Top emergency department officials criticized the Ho paper as bearing “no relation to what was occurring in the field,” and there were flaws in median prices that investigators used in the study. In response, Ho said the allegations were “baseless and misleading.” As many critics focused on “transcription errors in the tables” of a study appendix, she noted they had no bearing on the article findings. “Honest errors are a part of science and publishing and require publication of a correction when they are detected,” she said.

The Annals of Emergency Medicine today published continued rebuttals to the paper, and Callaham discussed the maze of issues involved in an unusual editorial process  that not only suggested there was information in the paper signifying that it should be published, but there was room for other comments as well.  He declared that some in the media were “sensationalizing certain aspects of the findings, including conclusions that were not the focus of data analysis and were not casually proven.”

With all the back-and-forth, “we chose instead to escalate the level of review and share the results with our readers,” Callaham wrote. The “unusually extensive review” including the work of four peer reviewers, one regular editor and four expert editorial specialists, he says.  Callaham is founding chair and professor emeritus at UCSF Medical Center at Parnassus.

“After digesting all the assessments and arguments, we concluded the article had some original and important data to report (on a topic with a paucity of such information) and believed it should be published,” Callaham wrote. “But because the concerns were also important and could not be conclusively resolved, they should be published too.”

“Additionally,” Callaham wrote, “some of the conclusions in this article are not based on the actual analysis and results, which have been quite misunderstood by the lay press.” That’s why, he said, the journal was not following its usual practice of only presenting the final article and maybe one editorial.

He noted there was an “unusually broad range of potential conflict of interest declarations for the various parties” in the dispute, Callaham says.

Blue Cross Blue Shield of Texas researchers played a key role in the paper, and told Callaham’s team that they “firmly support the work done by non-biased researchers led by (Dr. Ho) and “stand by the accuracy of the data.”

Callaham added: “We sent several letters by FedEx to national officers of Blue Cross Blue Shield inquiring whether they would be willing to have the data reviewed for validity and completeness by an impartial third party, but they did not respond in any way.”

“This raises serious questions about conclusions based on such “black box” data, ” Callaham, referring to a possible conflict of interest and the lack of clinical data. Callaham said there was an “unusually broad range of potential conflict of interest declarations for the various parties to this dispute.”

After the paper was first published, Paul D. Kivela, MD, MBA, FACEP, President-Elect of the American College of Emergency Physicians, charged in a letter to the AEM that the Ho report included data that was “somewhat problematic and incomplete.”

William P. Jacquis, MD, FACEP, Vice-President of the American College of Emergency Board Liaison to the Annals of Emergency Medicine, added: “Comparing the prices between urgent care centers and freestanding EDs is an ‘apples to oranges’ comparison of contracted rates versus charges, which makes the findings flawed.”

Ho and her colleagues said the complaints were much-a-do about nothing; an academic political controversy, with many concerned about their self-interests.

“We welcome the input of other researchers, but Annals’ decision to withdraw our article is suppressing the possibility for an objective, well-informed, public debate about the validity of our findings,” Ho wrote.

In the end, with the journal publishing the story today, the AEM is essentially giving its support, if not to the paper, the overall discussion. At one point, there was so much back-and-forth among academics; Ho said she thought, “this needs to stop.”

The paper come at a crucial time as urgent care centers are trying to create a niche market, and free-standing emergency departments, which are not attached to hospitals are among the fastest growing trends in healthcare, according to the New England Journal of Medicine Catalyst. Urgent care centers are marketing themselves expanded and weekend hours, which are often not available in routine physicians.

Despite the controversy and unsettled fate of the study, Ho says it focuses the importance of “wasteful spending” in healthcare and the “rising costs of premiums.”

“I think the firestorm around the paper is really great and brought the attention of high prices at freestanding emergency departments,” Ho says.  —  Joe Cantlupe