Health Policy Journal Club, Health Policy

Health Policy Journal Club: Planes, Trains, and Ambulances

Get on the Bus: The Role of Freestanding Emergency Departments in Access to Care

Freestanding emergency departments (FSED) are defined as "facilities that are structurally separate and distinct from a hospital and provide emergency care." Over the past several years, the number of freestanding emergency departments has grown exponentially. With this growth come many questions surrounding the utility of FSEDs and their role in access to healthcare.

Recognizing that the emergency department plays a critical part in the health of underserved populations, researchers sought to analyze the role of FSEDs in access to care in this population. Carlson, et al. performed a geospatial analysis comparing FSEDs and hospital-based emergency departments (HBEDs) to public transportation across 3 major metropolitan areas. Utilizing U.S. Census data, public transportation maps, and HBED and FSED locations, they calculated the distance from each HBED and FSED to public transportation.

The analysis found that FSEDs are located farther from public transportation than HBEDs. The median distance from a FSED to public transit was greater compared to HBEDs across all 3 locations - by 0.2, 1.0, and 1.6 miles in Denver, Houston, and Cleveland, respectively.

It is unlikely that FSEDs increase access to care among underserved populations. Presuming that underserved patients are more likely to utilize public transportation to access medical care compared to people with their own vehicles, it is reasonable to further assume that the increased distance of FSED from public transportation limits access to care. Additionally, the authors note that many FSEDs operate independently from hospitals, are not strictly subject to the EMTALA mandate, and may not accept Medicare and Medicaid reimbursement, potentially exacerbating financial barriers for these patients. For those who elect care elsewhere after learning that their insurance is not accepted, delays in care may ensue.

Although many assert that FSEDs have the potential to decrease overcrowding at HBEDs by creating additional sources of emergency care, the evidence to date does not bear that out. Instead of decreasing overcrowding at HBEDs, FSEDs simply provide an additional access point to the healthcare system for those whose insurance is accepted.

Abstract: Carlson LC, Baker ON, Schuur JD. A Geospatial Analysis of Freestanding and Hospital Emergency Department Accessibility via Public Transit. West J Emerg Med. 2019;20(3):472-476.

INTRODUCTION: Emergency departments (ED) are an important source of care for underserved populations and represent a significant part of the social safety net. In order to explore the effect of freestanding emergency departments (FSED) on access to care for urban underserved populations, we performed a geospatial analysis comparing the proximity of FSEDs and hospital EDs to public transit lines in 3 U.S. metropolitan areas: Houston, Denver, and Cleveland.
METHODS: We used publicly available U.S. Census data, public transportation maps obtained from regional transit authorities, and geocoded FSED and hospital ED locations. Euclidean distance from each FSED and hospital ED to the nearest public transit line was calculated in ArcGIS. We calculated the odds ratio of an FSED, relative to a hospital ED, being located within 0.5 miles of a public transit line using logistic regression, adjusting for population density and median household income and with error clustered at the metropolitan statistical area (MSA) level.
RESULTS: The median distance from FSEDs to public transit lines was significantly greater than from hospital EDs across all 3 markets. In Houston, Denver, and Cleveland, the median distance between FSEDs and public transit lines was greater than from hospital EDs by 1.0 miles, 0.2 miles, and 1.6 miles, respectively. The odds ratio of a public transit line being located within 0.5 miles of an FSED, as compared with a hospital ED, across all 3 MSAs was 0.21 (95% confidence interval [CI], 0.13-0.34) unadjusted and 0.20 (95% CI, 0.11-0.40) adjusted for population density and median household income.
CONCLUSION: In comparison with hospital EDs, FSEDs are located farther from public transit lines and are less likely to be within walking distance of public transportation. These findings suggest that FSEDs are unlikely to directly increase access to care for patients without private means of transportation. Further research is necessary to explore both the direct and indirect impact of FSEDs on access to care, potentially through effects on hospital ED crowding and overall healthcare expenditures, as well as the ultimate role and responsibility of FSEDs in improving access to care for underserved populations.

PMID: 31123548

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.