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An emergency physician recently contacted me to tell me a story. It all started when her local hospital emergency department received notice that they were on an award list published by a well-known health care grading company. “Terrific!” she said.

Are “pay-to-play” emergency department awards eroding the integrity of our medical care system?


An emergency physician recently contacted me to tell me a story. It all started when her local hospital emergency department received notice that they were on an award list published by a well-known health care grading company. “Terrific!” she said.

She knew that her local hospital had a great ED – door to doctor times were fast, length-of-stay for discharged patients was short, patient satisfaction scores were high. They had virtually no law suits. You name it and the hospital by any measure had a great ED.

But then she began wondering. How did this company know about their door-to-doctor times or length-of-stay for admitted patients? For that matter, how did they know any of the metrics that would be used to designate an ED worthy of an award?


She put the thought out of her mind. To tell you the truth, she said later, it really didn’t matter – what mattered was that the hospital ED got the recognition. The ownership would be pleased as punch, the executive team and ED leadership would congratulate themselves. Joy would flow in all directions.

She knew this would be a great marketing opportunity – a chance to inform the community about the excellent emergency department in their midst. The hospital could put up big signs and the like and really celebrate a job well done.

Or so she thought until she read the fine print. At the very bottom of the pages that list the winners there appeared, in light grey type, the following words: “Distinction cannot be used without a Licensing Agreement from . . . ”

The emergency physician in question was confused as to what this could mean, so she e-mailed the company, who revealed that yes, in fact, the award could not be “used or reprinted or republished without an agreement in place.” And what would it take to get a licensing agreement in place? You guessed it – money.


The bottom line was that the emergency department won an award from a for-profit company, but they couldn’t tell anybody about the award unless they paid money to the company.

A closer look disappointed the physician even more. How was the award determined? Using publicly available data, the mortality of Medicare patients admitted through the country’s ED was ascertained and then the EDs associated with the lowest risk-adjusted mortality (apparently ascertained by the company) were given the award – 268 of them throughout the U.S.

This appeared to be the single determinant of who got the award. “What reasonable person,” asked the EP, “would think that a Medicare patient who is in the hospital for five or six or more days had their fate determined by the several hours they spent in the ED?  Do not the many doctors who attended the patient multiple times a day get any credit for the ‘save’ or the teams of nurses in the ICU or any of the other healthcare professionals involved in the patient’s care have anything to do with a outcome?” To add insult to injury, a quick scan of the company’s web site revealed that the company’s leadership team did not have one doctor on it, and there was no mention of a medical advisory board.  

“This is an embarrassment,” said the EP. “Every ED who got this award should hand it back – or at least refuse to purchase a license. It means nothing.” Not surprisingly, the company gives out a range of other “awards” as well, and, if you need help, their consulting division will come out and advise you so that you are more likely to qualify for the awards they give out – for a fee.


Pay-to-play awards are no new concept, of course. They exist in every industry and range greatly in quality. On one end you have the myriad “Who’s Who” books that assault your inbox and claim that you – yes you! – have been chosen to appear on an exclusive list of “distinguished individuals.” In most of these cases, it’s best to follow the advice of the venerable Groucho Marx and stay away from any club that seems overly eager to have you as a member.

The airline industry has gotten flack for this as well. According to a January article in the Wall Street Journal, some two dozen organizations hand out “best airline” awards, each with their own selection criteria and judging. “What do they have in common?” asks WSJ reporter Scott McCartney. “Money. Though most award programs say there is no connection between winning and paying, many ask airlines to buy advertising, survey results or tables at banquets, pay licensing fees to use award logos or results, purchase sponsorships or even provide free tickets.”

While dubious Who’s Who registries and “Best Airline” awards might be questionable – some even unethical – they are far, far less concerning than a company that claims to rate healthcare providers. The former may bilk you of $50 or encourage you to fly Cathay Pacific while the latter threatens the stability of the healthcare system.

“The primary issue is that we are leveraging one entity over another,” says Dr. Kevin Klauer, the CMO of Emergency Medicine Physicians. “It’s implying to the patient that they will get better, safer and more effective care. However, the award is based on nonsense metrics and can only be used for a fee. Thus, this is a grand marketing scheme, pulling the wool over the innocent and unsuspecting eyes of the patient.

“So, if the physician or hospital says ‘we are great come to us,’ the patient will think twice. However, if someone else is paid to say ‘they are great go to them,’ the patient won’t think twice. It’s almost like money laundering.”
Should we expect more from an agency that ostensibly encourages spending at one healthcare facility over another? Listen to a few of the hoops that Consumer Reports jumps through to review products like tires and televisions (taken from consumer  

  • Staff includes 20 highly trained social scientists, including 11 Ph.D.s
  • Conduct random surveys from the approximately 7 million readers
  • Consumer Report’s National Research Center is free of corporate advertising.
  • Surveys are not commissioned or financed by industry.

If this is what we can expect from a company that rates mattresses, it’s time that we expect more – much more – from companies that rate emergency departments.

“We need rating companies to do more than use publicly-available data, combine the information with a little propriety manipulation and develop questionable surrogates for quality,” says Dr. Richard Bukata, editor of Emergency Medical

Abstracts. “These companies are feeding on hospitals that are desperate to distinguish themselves from the pack and increase market share.

“What emergency medicine really needs is a recognition program developed by highly credible and respected professional societies that will truly reflect operational and clinical excellence. They need to use metrics that are meaningful and realistic and which have had careful input by clinicians and ED leaders.”

There have been steps in the right direction, such as emergency physician-led Emergency Excellence which rates emergency departments on 100 key performance indicators. But in the minds of many emergency physicians, even this doesn’t go far enough. Emergency medicine needs a central body, possibly governed by a national organization, which can perform the kinds of rigorous ratings and surveys which will benefit society in the long term.

We need to know which emergency departments are doing well, and which are failing. The viabilit
y of our healthcare system may even depend on it. But dubious award companies that give out distinctions for profit divert the discussion, mask the problem, and take the whole system a step backwards.

Logan Plaster is the managing editor of Emergency Physicians Monthly and the publisher of Emergency Physicians International []


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