In the 1970s, the freestanding emergency department (FSED) emerged in rural areas to provide access to emergency care for residents living without a nearby acute care hospital. FSEDs offer emergency medical care at locations independent from hospitals. Growth in the number of FSEDs and the services rendered by these facilities varies widely from state to state, largely mirroring the regulatory structure in those locales.
This study identified twenty-one states that had regulations allowing FSEDs and twenty-nine states that had no specific policy toward these facilities. Of the states with policies specific to FSEDs, the study found significantly differing policies pertaining to permitted geographic locations for the facilities, required services, mandated equipment, staffing requirements, hospital affiliation, and whether a certificate of need was necessary for the creation of the facility. Unsurprisingly, states with stringent requirements regarding the creation, staffing, and activities of FSEDs saw dramatically less growth of these facilities. California, for instance, requires that surgical services be available immediately at all FSEDs. Alabama requires a certificate of need from the state to establish a FSED and requires all FSEDs to have a helipad. The statutes in these states are strict enough to largely or completely prohibit the creation of FSEDs.
Given the recent national trend of rural hospital closure, FSEDs remain a viable method of providing access to care in medically underserved areas. Further, FSEDs could also play an important role in reducing ED overcrowding in urban areas.
Conversely, increased availability of FSEDs could increase utilization of emergency care in circumstances that are non-emergent, increase health care costs, and siphon insured patients away from larger hospital systems who largely bear the financial burden of caring for the uninsured.
Moving forward, it would be prudent of policy makers to structure FSED regulatory policy to appropriately strike a balance between access to care and fiscally sustainable healthcare cost growth. For example, a state may implement statutes that curb the growth of emergency care facilities based on the per capita availability of emergency department beds. A rule of this nature would allow for free market innovation to accommodate demand while inhibiting over-expansion and the associated danger of increased healthcare costs.
This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. It is written by Nathan Vafaie. He is chair of the EMRA Health Policy Committee and a third year emergency medicine resident at Baylor College of Medicine.
Freestanding emergency departments (EDs), which offer emergency medical care at sites separate from hospitals, are a rapidly growing alternative to traditional hospital-based EDs. We evaluated state regulations of freestanding EDs and describe their effect on the EDs’ location, staffing, and services. As of December 2015, thirty-two states collectively had 400 freestanding EDs. Twenty-one states had regulations that allowed freestanding EDs, and twenty-nine states did not have regulations that applied specifically to such EDs (one state had hospital regulations that precluded them). State policies regarding freestanding EDs varied widely, with no standard requirements for location, staffing patterns, or clinical capabilities. States requiring freestanding EDs to have a certificate of need had fewer of such EDs per capita than states without such a requirement. For patients to better understand the capabilities and costs of freestanding EDs and to be able to choose the most appropriate site of emergency care, consistent state regulation of freestanding EDs is needed.