Health Policy Journal Club, Health Policy

Health Policy Journal Club: Better for Business

Freestanding emergency departments locate based on payer mix, not community need

The number of freestanding emergency departments (FSED) have been increasing in the past decade. A recent study published in Annals of Emergency Medicine evaluated the geographical and socioeconomic factors of communities where Freestanding emergency departments locate. The authors compiled a national inventory of freestanding emergency departments and then categorized them based on the respective demographic, insurance, and health utilization characteristics of the zip code where each FSED was located.

There exist 360 freestanding emergency departments in 310 different zip codes across the United States. Texas, Colorado, and Ohio have the highest concentration of freestanding EDs. Nationwide, over half of the freestanding emergency departments were associated with a hospital. Over a third were independently owned, and freestanding emergency departments were nearly equally divided between for-profit and non-profit status.

Focusing on Texas, Ohio, and Colorado for further analysis, the study found that freestanding emergency departments tend to locate near urban areas with higher population densities. The demographics of the zip codes in all three states demonstrated that the freestanding emergency departments are located in areas with  fewer minorities and lower percentages of Medicaid beneficiaries. In contrast, the communities where freestanding EDs located had overall higher household incomes and private health insurance beneficiaries. Freestanding EDs in Texas tended to be in areas where there was higher utilization of health care services, however, this difference was not appreciated in Ohio and Colorado.

This study demonstrates that freestanding emergency departments may choose to locate in areas that will be financially beneficial, including communities with a better payer mix and higher overall incomes. While freestanding emergency departments have been established to increase access to emergency medical care, it is unknown whether the quality provided at these facilities are comparable to those at a hospital, how often patients require transfer to higher levels of care, cost of care compared to those at a traditional ED, or whether the presence of a freestanding emergency department in a community decompresses traditional hospital-based EDs or simply encourages new patients to seek emergency care due to convenience. Regardless, this study illustrates that the current locations of freestanding emergency departments do not provide for equitable access to emergency care for minorities and lower socioeconomic groups.

Abstract: Schuur JD, Baker O, Freshman J, Wilson M, Cutler DM. Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States. Ann Emerg Med. 2016 Jul 12. pii:S0196-0644(16)30199-8. doi: 10.1016/j.annemergmed.2016.05.019. [Epub ahead of print]

Study objective: We determine the number and location of freestanding emergency departments (EDs) across the United States and determine the population characteristics of areas where freestanding EDs are located.

Methods: We conducted a systematic inventory of US freestanding EDs. For the 3 states with the highest number of freestanding EDs, we linked demographic, insurance, and health services data, using the 5-digit ZIP code corresponding to the freestanding ED's location. To create a comparison non-freestanding ED group, we matched 187 freestanding EDs to 1,048 non-freestanding ED ZIP codes on land and population within state. We compared differences in demographic, insurance, and health services factors between matched ZIP codes with and without freestanding EDs, using univariate regressions with weights.

Results: We identified 360 freestanding EDs located in 30 states; 54.2% of freestanding EDs were hospital satellites, 36.6% were independent, and 9.2% were not classifiable. The 3 states with the highest number of freestanding EDs accounted for 66% of all freestanding EDs: Texas (181), Ohio (34), and Colorado (24). Across all 3 states, freestanding EDs were located in ZIP codes that had higher incomes and a lower proportion of the population with Medicaid. In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population with private insurance. In Texas, freestanding EDs were located in ZIP codes that had fewer Hispanics, had a greater number of hospital-based EDs and physician offices, and had more physician visits and medical spending per year than ZIP codes without a freestanding ED. In Ohio, freestanding EDs were located in ZIP codes with fewer hospital-based EDs.

Conclusion: In Texas, Ohio, and Colorado, freestanding EDs were located in areas with a better payer mix. The location of freestanding EDs in relation to other health care facilities and use and spending on health care varied between states. PMID: 27421814

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.