Innovating and Disrupting Emergency Care

Freestanding emergency departments (FSEDs) have seen rapid growth in the United States in recent years, with their number increasing to 360 in 2015. This growth, however, has not been evenly distributed. Three states (Texas, Colorado, and Ohio) account for two-thirds of all FSEDs, with Texas alone being home to half. This study used a ZIP code-level analysis to understand the characteristics of areas in which FSEDs chose to locate in order to investigate how FSEDs affect access to emergency care.

Source: Pixabay (Public Domain)

Source: Pixabay (Public Domain)

In short, FSEDs are unlikely to increase access to emergency care for disadvantaged populations, as they tend to locate in ZIP codes that have higher incomes and greater rates of private insurance coverage. The picture is slightly more complicated with regard to medically underserved areas, though.

In Texas, ZIP codes with FSEDs have more hospital EDs, physician visits, and higher medical spending than those without but in Ohio, FSEDs are usually located in ZIP codes with fewer hospital EDs. This distinction may emerge from differences in ownership of FSEDs between Texas and Ohio, as nearly all FSEDs in Ohio are hospital affiliated while most FSEDs in Texas are not. The article suggests that since Ohio’s FSEDs are satellite EDs of acute care hospitals, their business model may involve locating in areas that have less access to health services in order to draw in additional business for the hospital, perhaps even at the expense of being a loss-leader.

Although this study was limited to ZIP code-level analysis and would benefit from looking at patient-level factors, it still offers some potential lessons for policymakers. If policymakers are concerned that FSEDs are not adequately improving access to emergency care, one option could be requiring new FSEDs to have hospital affiliation, which may serve to decrease their concentration around existing hospital EDs. Another approach would be to follow the example of several states that require evidence of need for health care services in a market before permitting a freestanding emergency department to open.

This Policy Prescriptions® review is written by Matthew Stampfl, a medical student at Baylor College of Medicine, as part of our Health Policy Journal Club Series.

Abstract

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 nonfreestanding ED group, we matched 187 freestanding EDs to 1,048 nonfreestanding 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 Schuur, JD, et al. Ann Emerg Med. 2016 Jul 12; Epub ahead of print.