The growth of free-standing emergency departments has raised concerns about the impact of these new facilities on healthcare costs, access, and quality of care. One fear is that free-standing EDs—unlike hospital EDs—may turn away uninsured patients in emergency situations because they are not required by federal law to accept all patients for emergency screening and stabilizing treatment regardless of ability to pay.
A new study in Health Affairs found a large increase in recent years in the number of free-standing EDs. The authors counted 400 free-standing EDs in 32 states, some operated by hospital systems and others by non-hospital companies such as Adeptus Health, sometimes in partnership with hospital systems. They projected that there could be 800 to 1,600 more free-standing EDs in the future.
But of the 32 states with such facilities, only 17 have established specific policy requirements for them. Only 15 of the 32 states require a physician to be on-site during all hours of operation, and only 11 require certified emergency physicians to be on-site at all times. That raises eyebrows among some emergency medicine groups.
And just 18 states have rules comparable to the federal Emergency Medical Treatment and Labor Act, or EMTALA, requiring the facilities to accept all patients for treatment and stabilization regardless of insurance status.
Even in states with EMTALA-like rules, such as Texas, there are doubts about whether those rules are as effective as the federal law, which is enforced relatively aggressively. “EMTALA carries a very big stick, with a large fine and potential loss of Medicare certification,” said Dr. Jeremiah Schuur, an assistant professor of emergency medicine at Harvard Medical School who co-authored the Health Affairs report. “It's not clear that state laws will be as effective.”
To maintain good community relations, most operators of free-standing EDs have a policy of accepting all emergency patients for screening and stabilizing treatment, said Dr. Marc Futernick, immediate past president of the California chapter of the American College of Emergency Physicians. Hospital-owned free-standing EDs must have such policies because they come under the federal EMTALA law.
Still, Futernick thinks states should establish their own EMTALA-like rules for free-standing EDs. “Having to see everyone who comes to your door should be the price you pay to hold yourself out as an emergency provider,” he said.
There are no studies looking at how free-standing EDs handle uninsured patients. But there have been scattered reports of problems. An August article in Cosmopolitan found that a young woman named Dinisha Ball was turned away at a free-standing ED operated by a non-hospital company when she arrived reporting she had been raped and needed treatment and a rape kit. According to the article, the receptionist turned her away because she was uninsured—even though Texas administrative rules require screening and stabilizing treatment regardless of insurance status.
But Maureen Fuhrmann, chief business development officer of Houston-based Neighbors Emergency Centers, said her company's centers operate just like hospital EDs, with licensed emergency physicians who provide screening exams and arrange appropriate transfers for all patients regardless of ability to pay.
She said the Texas Association of Freestanding Emergency Centers, of which she's vice president, would like to see all states adopt EMTALA-like rules, as Texas has.
Of course, even the federal EMTALA law is no guarantee of appropriate emergency care. From 2002 to 2015, the CMS conducted 6,035 investigations of EMTALA complaints against hospitals and physicians, according to a recent study in the Western Journal of Emergency Medicine. The CMS found violations in 2,436 of the complaint cases it surveyed in conjunction with state agencies.
Of the cases where HHS' Office of Inspector General imposed civil monetary penalty settlements, the most common citations were for failure to screen and stabilize for emergency conditions. Patients were turned away from hospitals for financial reasons in 15.6% of cases.
“If the law went away and there were no penalties, given human nature and financial pressures, the attitude would be, 'Who cares if the patient is unstable, get 'em out of here,' ” Dr. Mark Langdorf, a professor of clinical emergency medicine at the University of California at Irvine who co-authored that study, said in an interview earlier this year.
But operators of free-standing EDs tend to locate them where they face less risk of drawing uninsured patients. In a previous study, Schuur and his colleagues found that free-standing EDs in Colorado, Ohio and Texas were more likely to be located in ZIP codes with existing hospital EDs and with wealthier, better-insured populations. “That's not surprising because these are business entities,” Schuur said.
Advocates of free-standing EDs argue these facilities expand access to speedy, high-quality and conveniently located emergency care. But Schuur said that's questionable if these facilities are being built largely in areas that already have hospital emergency rooms, rather than in rural and underserved communities.
Fuhrmann said, however, that her company has located centers in rural Texas towns such as Orange, Crosby and Wichita Falls and provides a significant amount of uncompensated care, since Medicare and Medicaid generally won't pay for care at free-standing centers. "We can't serve the underserved because (the CMS) won't allow us reimbursement," she said. "If we could get (CMS) recognition, we could certainly expand into more rural areas."
Still, critics say strong, enforceable rules requiring all free-standing EDs to provide stabilizing treatment regardless of ability to pay are needed to level the playing field with hospital emergency departments. The lack of such requirements “allows free-standing EDs another financial advantage that absolves them of the obligation to provide emergent and urgent care to those who can't pay,” Langdorf said Tuesday.
The Health Affairs authors also raised concerns that consumers may not understand that free-standing EDs generally don't offer the same scope and intensity of services provided by hospital EDs or urgent-care centers. They also may not know that free-standing EDs that aren't affiliated with a hospital don't participate in Medicare, which means patients may face large out-of-pocket costs.
The authors concluded that efforts to standardize requirements for free-standing EDs nationally may help patients choose the most appropriate acute-care site and avoid unnecessary costs and treatment delays.
“The widespread growth of free-standing EDs has the potential to create a parallel system of emergency care that operates under different rules or has different capabilities,” Schuur said. “There's a role for state regulation so the public knows what type of care they'll get at a free-standing ED.”