UnitedHealthcare Guided Yale’s Groundbreaking Surprise Billing Study

From The Intercept:

In 2016, an academic study from some of the most respected scholars in health care economics prompted a national outcry. The study, published in the New England Journal of Medicine by Yale University researchers, found that 22 percent of the time someone goes to an emergency room in a hospital covered by their insurance, they still receive costly bills after being treated by an out-of-network doctor. The practice, known as “surprise billing,” saddles Americans with thousands of dollars in debt per year.

The researchers went on to find that surprise billing was not only relatively common, but also a tactic that private equity-owned hospital staffing companies had employed to increase revenue. According to their findings, when either of the country’s two largest staffing companies took over a hospital’s emergency department, out-of-network charges soared.

The research was based on data from more than 2 million claims provided by UnitedHealthcare, the largest private health insurance company in the United States, under a data sharing agreement with Yale. As stipulated in contracts between the two entities, United was not named in the study. In the Yale paper and its subsequent media coverage — by the New York Times, the Wall Street Journal, and the Washington Post, among others — the data is attributed to an unnamed insurance company.

But internal emails between executives at UnitedHealthcare provided to The Intercept reveal that the insurance giant provided its data while working behind the scenes to influence the paper and a 2017 follow-up — not necessarily their statistical conclusions, but their narrative framing. The latter paper portrays private equity-run hospital staffing companies, which are perpetually at odds with insurers over physician compensation, in a negative light for using surprise billing as a negotiating tool to hike up in-network rates.

TeamHealth, one of the two staffing agencies named in the study, alleges in a civil lawsuit that the insurer and its subsidiaries had lowered out-of-network reimbursement rates for their own benefit, forcing staffing companies to hike their own rates to make up the difference. Arguing that this practice qualifies as racketeering, the staffing company filed a civil suit against United in May 2020 on behalf of three emergency departments, and a Nevada district court compelled United to turn over its executives’ emails with the Yale researchers during discovery. After months of litigation, the court held that the communications could be released to the public. TeamHealth representatives sent them to The Intercept.

The emails do not invalidate the Yale study’s conclusions. Since its publication, other research has replicated its findings using different datasets, and TeamHealth admitted to saddling patients with unexpected bills in 2017. But the emails do show frequent contact between United officials and the researchers over a period of nearly two years. They offer an instructive look into the ways corporations can shape the framing and media coverage of academic research.

“As a researcher, it is ideal to have a data use agreement that has no restriction on what you write or what you find,” said Genevieve Kanter, an assistant professor of medical ethics and health policy at the University of Pennsylvania. But in a field like health care economics, where most of the data belongs to private organizations, a company’s data cache becomes its leverage. Even agreements that give a company the power to veto a study’s publication or sway its media spin aren’t unheard of, Kanter said.

“If this is the only way to get this kind of data, researchers feel they are not in a strong enough bargaining position to push back on these restrictions.”