Freestanding ERs on rise across region
Providers tout access; critics claim profit rules.
The freestanding emergency center under construction at Austin Boulevard just off Interstate 75 is the latest in a surge of new satellite ERs built in recent years.
While freestanding emergency departments have been growing around the U.S., Ohio had the second-highest number of freestanding ERs in the country as of 2015.
The region is about to gain three more emergency departments that are under construction: Premier Health’s Austin Boulevard emergency center and Kettering Health Network’s new Troy hospital and Middletown emergency center, which will share a building with other Kettering Health medical services.
There are now 28 ERs in the region, eight of which opened
in the last five years. Even with Good Sam’s ER about to close and Atrium Medical Center Mason about to convert its ER to an urgent care, the region has seen significant growth in emergency services in recent years.
These freestanding ERs have the ability to provide crucial care in areas that don’t have full-service hospitals and might otherwise not have immediate access to these health services.
Freestanding ERs also play a business role, referring patients to hospitals under the same ownership for higher revenue services like operations or admissions.
Insurance companies have criticized the growth of these ERs as business tools, not health care access tools. Insurers say they are located to encourage patients to use an ER out of convenience and are built in wealthier areas that will attract more patients with private insurance, which pay hospitals more per service than Medicaid and Medicare.
About 79 percent of patients in the Dayton region pay with Medicare or Medicaid — which hospitals say pay less than the cost of health services — leaving health networks scrambling to attract the small pool of local patients paying with employer-sponsored insurance.
Michael Maigberger, Premier executive vice president, said they are always looking at both the health access needs of residents and the business case for the health system’s locations.
“Our mission depends on us being successful in both arenas,” Maiberger said.
Emergency rooms are one of the most expensive places that patients can be treated. The 24-hour facilities are costly to operate, and ER bills now typically come with “facility fees,” which are a baseline charge on the bill intended to cover the facility operating costs.
Both government and private insurers have tried different tactics to keep patients out of the ER when they could be treated in cheaper settings like urgent care centers or at their primary care doctor’s office.
Freestanding emergency rooms are often mistaken for an urgent care as their locations encourage patients to use them for convenience reasons and nonemergencies, according to the Ohio Association of Health Plans, a lobbying group that represents health insurance companies.
“We believe and know that there’s a lot of consumer confusion about these types of facilities,” said Miranda Motter, president and CEO of Ohio Association of Health Plans.
When patients go to an ER when they could have been in a cheaper setting, they face unnecessary out-ofpocket and insurance costs, she said.
But while ERs are expensive, patients can’t always tell the difference between a real medical emergency and a benign symptom that seems like an emergency but could have waited until the morning.
Dr. Darin Pangalangan, chairman of the Premier Health Emergency and Trauma Institute, said insurance companies have also tried to stop patients from inappropriately using hospital-attached ERs but have run into obstacles. Patients who sincerely believe they have an emergency will find an ER and sometimes medical issues happen in the middle of the night and patients have no other place to go.
“It’s almost like they are saying if freestandings didn’t exist, the patient wouldn’t go to the emergency department. That’s just not true, they would just drive to another emergency department,” he said.
While Premier is building a new Miamisburg freestanding emergency department to open later this year, the health network also has an extensive primary care network and has been rapidly adding urgent care centers for lower level medical needs.
And while there are patients who go to the ER who don’t need to, there are also patients who go to an urgent care with an emergency and then need transferred, Panglangan said.
Emergency departments also need to get patients in front of a doctor quickly after they walk in the door. Freestanding ERs help relieve overcrowding, especially in areas with fast-growing populations, said Panglangan.
Emergency rooms are the one place where patients are legally entitled to health care. Even if an ER physician thinks a patient could be appropriately treated in an urgent care or primary care office, they aren’t allowed to tell patients to leave and go to a lower care setting, he said.
Insurance companies have been pushing back against what they see as unnecessary ER use. Anthem in some cases has been denying emergency room cases if the patient is diagnosed with something that’s not an emergency.
Medicare, which covers about 53 percent of local patients, could be cutting back payments for some stand-alone ERs that are close to a full-service hospital.
The commission that advises Congress on Medicare payments submitted a report in April that questioned why stand-alone ERs get paid the same as hospital-attached ERs when they have lower standby costs since they don’t typically have operating rooms, 24-7 on-call specialists or trauma teams. The commission, MedPAC, unanimously recommended payment cuts.
In Ohio there were 34 freestanding emergency departments as of 2015, according to a study published in 2016 in the Annals of Emergency Medicine. The freestanding ER model could help bring care to areas with long wait times or limited access to health care, wrote one of the authors of the study, Jeremiah Schuur, with the Department of Emergency Medicine at Brigham and Women’s Hospital and Harvard Medical School.
“But in the states with the most freestanding EDs, it seems less likely that they will expand access to underserved populations as they are preferentially located in areas where people had more available health services, higher rates of private health insurance, lower rates of Medicaid and higher median incomes,” Shuur stated.
In Texas and Ohio, the study found freestanding ERs were located in ZIP codes with population growth, higher incomes, a higher proportion of the population with private insurance, a lower proportion of the population with Medicaid and more existing hospital ERs.
Shuur recommended policymakers review state regulations and payment policies to encourage the expansion of freestanding ERs in ways that will improve access and reduce cost, not duplicate services.
Motter, with the Ohio Association of Health Plans, also said these types of ERs are most likely to be built in areas with attractive payer mixes, drawing in privately insured patients with better reimbursements and more ability to pay out-of-network rates and facility fees.
“In Ohio, these types of freestanding ERs are intentionally situated in suburban, affluent neighborhoods rather than areas of the state where there might be a true access to care issue,” Motter said. Several satellite emergency rooms in the region brought health care access to rural areas with limited other options.
When Premier Health’s Jamestown emergency center opened five years ago, the company was praised for improving health care access in rural Greene County.
When Kettering Health Network’s Preble County emergency center opened three years ago, it brought emergency care to a county that had never had a hospital.
“It was actually the last county in the state to get emergency services,” said John Weimer, vice president of emergency and trauma services for Kettering Health Network.
Weimer said their expanded network of emergency care has made a difference when minutes matter, such as in the case of a stroke or heart attack, and even helped with emergency deliveries of babies. And while Kettering Health has ERs that are not attached to hospitals, they are built as part of a health center with other services.
Freestanding ERs have been criticized for charging the same rates as full hospitals when they don’t offer the same services, but Weimer noted that it’s common for hospitals to not have a full team of specialists at every location 24 hours a day.
“With our complex network of transportation, with our infrastructure and how we collaborate, we can get them stabilized and get them where they need to go wherever we have those critical care specialty physicians that we need,” Weimer said.