Univera Analysis of New York Emergency Visits is Flawed



For Immediate Release
December 5, 2011

Contact:  Laura Gore
202-728-0610 x3008


Methodology was not Designed to Assess Whether Emergency Visits are Appropriate

The American College of Emergency Physicians (ACEP) and its state chapter, New York ACEP, today took issue with a report about emergency patients in New York, released by Univera Healthcare, saying it is based on a flawed methodology developed by the New York University’s Center for Health and Public Service Research, which does not capture all the data necessary to analyze whether emergency visits are appropriate, leading to false conclusions.

“There are several significant flaws in the original analysis that lead to incorrect conclusions,” said Dr. David Seaberg, president of ACEP. “First, the study makes the determination of the need for emergency care based on patient’s final discharge diagnosis, which is only determined after a full evaluation, rather than on the patient’s symptoms at the time of arrival. It is also based on a non-peer reviewed study using a small sample from a New York inner city population that is not representative of patients who are treated in other emergency departments. In addition, the algorithm used for the analysis was never intended to be used to determine whether emergency visits are appropriate.”

Dr. Seaberg said previous research has examined why low acuity emergency patients seek care in emergency departments, and nearly two-thirds believe they are having medical emergencies. In addition, up to 30 percent of low acuity patients are sent by their primary care physicians.

ACEP’s New York Chapter previously asked the state to correct the inaccuracies in the methodology that generated results that conflict with scientifically valid research from the Centers for Disease Control and Prevention (CDC), along with data from other recognized institutions, such as the Institute of Medicine and JCAHO, which have determined that less than 8 percent of the nearly 136 million emergency visits nationwide are for non-urgent reasons.

“Nonurgent is what an emergency physician determines after a medical exam,” said Dr. Seaberg. “Health plans historically have denied coverage for emergency care, based on the final diagnosis. But patients with the symptoms of a medical emergency should seek emergency care. If it turns out their chest pain was not a heart attack, it still was appropriate for them to come. There is a national prudent layperson standard that says health plans should cover emergency visits, based on a patient’s presenting symptoms, not final diagnosis. Doing otherwise may save money for health plans, but it’s bad for patient health and potentially life threatening. It also does not make sense from a national standpoint since emergency care represents less than 2 percent of the nation’s health care expenditures.”

The nation’s emergency physicians have fought hard for many years to make sure health plans do not deny coverage for emergency care, for example, when they have the symptoms of a medical emergency, such as chest pain, but after examination, it is determined they have a hiatal hernia (nonurgent medical condition) and not a heart attack. Emergency physicians have always advocated that nothing should prevent patients who believe they are experiencing a medical emergency from seeking immediate care at an emergency department, whether or not the ultimate diagnosis and treatment is for a non-life-threatening condition.

The flawed New York report also defines nonurgent care as any patient who could wait at least 12 hours for treatment — unlike the CDC, which defines nonurgent care as anyone who could wait 24 hours for treatment.

“Patients should not be in the position of diagnosing their own medical conditions,” said Dr. Seaberg.

ACEP is a national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

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