Boom in free-standing emergency centers raises questions about regulation

CAL/AAEM News Service at
Mon Oct 17 21:46:34 PDT 2016



October 4, 2016


Boom in free-standing emergency centers raises questions about regulation 



mpaign=financedaily> Modern Healthcare



By Harris Meyer

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

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

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

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."




Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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