Baylor Scott & White Health officials indicate there were 150 million visits to hospital-based emergency rooms nationwide last year. In response to demand for ERs and changing legislature, emergency options have increased in recent years in Grapevine, Colleyville and Southlake. One option is freestanding ERs.
Freestanding ERs, like hospital emergency rooms, are required by the state to handle most emergency situations. They are licensed by the state of Texas; operate 24 hours a day, seven days a week; and are staffed by board-certified emergency physicians and nurses.
“These freestanding emergency centers are just like an emergency room—they’re just outside the walls of a hospital, and that seems to be the concept that everyone has a hard time understanding,” said Brad Shields, executive director of the Texas Association of Freestanding Emergency Centers. “In many ways what you see in a freestanding emergency room is very similar to what you would see in an emergency department within a hospital.”
The rise of freestanding ERs
In 2010, Texas became the first state to allow freestanding ERs to operate without hospital affiliation.
FirstChoice Emergency Room spokesperson Warren White said according to the American College of Emergency Physicians’ 2014 National Report Card, Texas received an F in access to emergency health care, which speaks to the need for additional access to such care.[polldaddy poll=9445841]
In May, officials at Texas Health Resources announced a partnership with FCER’s parent company that will bring several more FCER locations online by the end of the year. FCER has 27 locations in four North Texas counties, including one in Colleyville.
THR officials said the partnership is a response to changing consumer demands as the North Texas population continues to increase.
FCER is only one of many freestanding ER chains that are spreading throughout the state.
A recent ACEP survey stated the nationwide shortage in access to emergency care is driven by regulatory changes and evolving medical care habits, including fewer people having a primary care physician, White said.
Freestanding ERs are becoming more popular because many times they are located within the patient’s neighborhood, have reduced wait times and physicians are able to spend more one-on-one time with patients, he said.
“I think it has a lot to do with convenience,” Southlake EMS Battalion Chief Ryan Arthur said. “Also with the health care increases there are a lot of people using an ER or an ER physician as their primary care physician, and that’s the only health care they have access to. They may or may not have insurance, and they just use the emergency department as their health care.”
Arthur said the rise of freestanding ERs can help with alleviating long wait times at hospital-based ERs.
“It will definitely cut down on the number of patients that are seen in a hospital-based ER,” he said. “So I think it’s [good when considering] convenience for the consumer and how it will alleviate some of the pressure on some of those hospital-based ERs. However, the freestanding ERs should not replace the 911 system.”
How do they compare?
Hospital-based emergency room operators agree that there are many similarities between freestanding emergency rooms and hospital emergency rooms.
Hospital-based ERs and freestanding ERs are both required to remain open 24 hours daily and have ER physicians on-site at all times.
Robert Risch, medical director in chief of the emergency medicine department at Baylor Scott & White Medical Center-Grapevine, said a major difference between the two types of ERs is freestanding ERs have limitations to the care they can provide, but a hospital-based emergency room can handle severe cases such as a stroke or traumatic injuries.
“Freestanding ERs are generally smaller and have some ability to do diagnostic testing like CT scans and ultrasounds, but [they] don’t have the inpatient part of the hospital,” he said. “Many of them can do short stays for like six to 12 hours, but they aren’t set up to do long-term admission.”
According to TAFEC, freestanding ERs charge equal to or less than hospital ERs for emergency care, and both are federally mandated to treat everyone, regardless of their ability to pay.
According to www.healthcare.gov, the Affordable Care Act rates emergency services as one of the 10 “essential health benefits” that health insurance plans must cover. Coverage for emergency services cannot require pre-authorization or limit a patient to an in-network facility. Patients cannot be penalized for going out of network or for not having prior authorization, and one’s insurance company must pay for ER services at an in-network rate.
Risch said freestanding ERs have proven to be beneficial to hospital-based ERs.
“Most of the physicians in the community have a good idea if you go to [a freestanding ER] they might not be able to solve your problem, but they can help you figure out if you need the next level of care,” he said. “And that’s a lot of what we do in emergency medicine; we try to sort patients and decide whether they are severely sick and need a lot of care or not as sick. Freestanding ERs are an integral part in our system in helping us do that.”
Know where to go
Freestanding ERs can accept patients from an ambulance in an emergency situation.
“State law requires all freestanding ERs to have an ambulance bay dedicated to dropping patients off or picking patients up,” Shields said. “The law also requires that freestanding ERs participate in the [emergency medical service] system, which means we are required to take patients who are brought to us by 911 or EMS. On the flip side, the EMS or 911 services are not required to bring patients to freestanding ERs.”
Of the five hospitals in the Grapevine, Colleyville and Southlake area with emergency rooms, two accept emergency patients transported by ambulance in their ERs, but the other three hospitals only take patients who come to the emergency room separate from an ambulance.
Methodist Southlake Hospital and Texas Health Harris Methodist Hospital Southlake have emergency rooms, but they do not accept emergency patients transported by ambulance.
The ERs at Baylor Scott & White Medical Center-Grapevine and Texas Health Harris Methodist Hospital Hurst-Euless-Bedford accept ambulance patients.
Shields said the decision to take a patient to a hospital-based ER or a freestanding ER depends upon the request of the patient or knowledge of the EMS crew.
“Many freestanding ERs in Texas do receive patients via ambulance, but it is a community-by-community situation,” he said. “If the EMS director in that community knows the freestanding ER and how they operate, they might be more open to taking patients there. If the director is uncertain of who that facility is, then they may bypass it to go to an emergency room at a hospital.”
Emergency medical services in Grapevine and Southlake have policies against taking patients to freestanding ERs, but Colleyville’s EMS does not.
Grapevine EMS Battalion Chief Brent Irving said the department will not transport to a freestanding ER even if the patient requests it because freestanding ERs do not offer the same emergency services as a hospital.
“We cannot transport to a lesser level of care; it has to be equal to or greater than the level of care that we provide,” he said. “When [he or she] calls 911 within the Grapevine Fire Department, they get an MICU, which stands for mobile intensive care unit, and it’s basically a rolling intensive care unit. We can paralyze and intubate patients, transmit the patient’s EKG to a hospital-based ER; we can’t transmit [an EKG] to freestanding ERs.”
Arthur said Southlake EMS will only transport a patient to a hospital-based emergency department.
“We haven’t [run] into the problem yet where folks call 911 and say they want to go to a freestanding ER,” he said. “If it became a problem where a lot of people wanted to go to a freestanding ER, we might have to look at that, but right now it’s not an issue.”
However, in Colleyville, Fire Chief Brian Riley said the city’s EMS has taken patients to freestanding ERs.
“Any patient that we pick up, we give them the ability to make the decision on what hospital or freestanding facility they want to go to, and then that is based also upon the injury or illness that they have,” he said.
Irving said where the difference becomes apparent is that hospital-based ERs have more availability of next-step resources than freestanding ERs.
“Multiple times a day we go to the freestanding ERs to pick up patients because [what the patient needs is] above [the freestanding ER’s] care level,” Irving said. “They don’t have nearly as much equipment and specialty teams that a hospital-based emergency room has.”
Typically, Shields said, freestanding ERs will have transfer agreements with area hospitals to transfer patients who need to be admitted for trauma care—more acute care than what a traditional ER offers—or extended stays. That is the case with Baylor Emerus Emergency Medical Center in Colleyville and Baylor Scott & White Medical Center-Grapevine.
“Those type of situations—when you have a network of both freestanding ERs and full-service hospitals providing a combination of services—I think, is when freestanding ERs work best,” Risch said.
