Freestanding emergency departments expanding rapidly but access questions remain

Freestanding Emergency Departments (EDs) are a rapidly increasing source of emergency care in the United States. Physically separate from acute care hospitals but available 24/7 for emergency care, freestanding EDs offer many of the same services as traditional EDs, such as on-site advanced diagnostic imaging, laboratory testing and quick delivery of care for patients.

In a new study published in Annals of Emergency Medicine on July 12, 2016, Brigham and Women's Hospital researchers set out to describe the location and distribution of freestanding EDs and identify what populations they serve. Researchers created a national inventory of freestanding EDs, identifying 360 in 30 states as of March 31, 2015, a rapid increase from 222 in 2009. Researchers conducted ZIP code level geographic analysis in the three states with the highest number of freestanding EDs: Texas, Ohio and Colorado, and found that freestanding EDs were located in areas with population growth, higher incomes, a higher proportion of the population with private insurance, a lower proportion of the population with Medicaid, and more hospital EDs.

"Freestanding EDs are an innovative model of acute care delivery with the potential to reshape the market for emergency care. As many EDs nationwide experience crowding and long wait times, especially those in urban areas, freestanding EDs offer the potential to improve access to emergency care," said Jeremiah Schuur, MD, MHS, vice chair, Clinical Affairs, Department of Emergency Medicine, Brigham and Women's Hospital, and corresponding author of the study. "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," Schuur added.

In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population carrying private insurance. Of the almost 200 freestanding EDs in Texas, most were highly concentrated around several metropolitan areas and were located in ZIP codes that had fewer Hispanics, a greater number of hospital-based EDs and physician offices, and more physician visits and medical spending per year than ZIP codes without a freestanding ED.

Researchers found that, nationwide, 54.2 percent of freestanding EDs are owned by, or affiliated with, hospitals, while 36.6 percent are independently run by physician groups or other entrepreneurs; 45.3% of freestanding EDs were for-profit, and 43.9% non-profit.

In Texas, only 22.1 percent were owned by, or affiliated with hospitals, 71.3 percent of freestanding EDs were for-profit, and they are more likely to be located in ZIP codes with existing hospital EDs. In Ohio, with 34 freestanding EDs, all but one were affiliated with hospitals, while only 5.8 percent were for-profit, and they were more likely to be located in areas without hospital EDs. In Colorado, which had 24 freestanding EDs, 45.8 percent were affiliated with hospitals, and 61.9 percent were for-profit.

"Our findings, which addressed the distribution of freestanding EDs in relation to underserved populations and populations with fewer health services, can help inform ongoing policy discussions on how to regulate and pay freestanding EDs. Policymakers should review state regulations and payment policies to encourage the expansion of freestanding EDs in ways that will improve access and reduce cost not duplicate services," Schuur said.

Researchers say additional research is needed to study how the expansion of freestanding EDs impacts local health care needs, access to care, and health spending and outcomes.