Free-standing emergency room operators are exploring how to win state regulatory approval to expand their facilities nationwide despite opposition from hospitals.
The biggest operator is Lewisville, Texas-based Adeptus Health, which owns the First Choice chain of free-standing emergency rooms. Since going public in June 2014, Adeptus stock has tripled. The company opened seven new ERs in the first quarter of this year, bringing its total to 63 centers. Most are in Texas, which in 2010 became the first state to allow ERs to operate without a hospital affiliation. Adeptus also has centers in Arizona and Colorado, though it partners with full-service hospitals in those states.
“They're sprouting up like Texas wildflowers,” said Vivian Ho, a health economist at Rice University in Houston. “Everywhere you drive in upper-middle-income Houston, you're seeing emergency rooms on every block.”
Adeptus has hired lobbyists in Ohio and Washington, but it's been quiet about specifics. Many states only allow free-standing emergency rooms that are operated by hospitals. Others, including California, don't allow them at all.
Some experts say free-standing ERs could help solve the growing problem of healthcare access as hospitals in rural and underserved areas close. But the recent surge in free-standing ERs has not occurred in rural, underserved or low-income communities. Beset by hospital closings, Georgia last year changed state rules to allow hospitals to create rural free-standing emergency rooms. But by the end of 2014, no free-standing ER operators had plans to build centers.
Critics say free-standing ER operators' business strategy is to cherry-pick privately insured patients in more affluent suburban and exurban communities who want care access closer to their homes, while steering sicker and lower-income patients to traditional hospital emergency departments. “They're very good at targeting areas with people with higher incomes, with good insurance,” Ho said.
Independent free-standing ERs rely on reimbursement from private insurance, although they have had a sometimes-rocky relationship with health plans. Some plans have argued that the facility fees charged by free-standing ERs are not justified. But so far, the major insurers are paying those fees.
Hospitals generally oppose free-standing emergency centers that are not tied to health systems, particularly in areas where providers serve large low-income and uninsured populations.
“These free-standing (ERs) do not have to meet the rigorous requirements of our hospital facilities, such as staffing issues that significantly affect costs,” said Lance Lunsford, vice president of advocacy communications with the Texas Hospital Association. “It's a frightening disadvantage as our hospitals invest heavily in equipment, technology and clinical talent, while these other facilities are able to service only patients who have an ability to pay, and provide only a fraction of the services to remain financially viable.”