State Regs Rule Freestanding EDs; Regs Are All Over the Place

HealthLeaders Media News, July 18, 2016

The proliferation of freestanding emergency departments is marked by the duplication of services and little improvement in access for the underserved, research shows.

Vast differences in the composition, location, and patient mix of freestanding emergency departments are the result of a patchwork of state regulations governing such facilities, researchers have discovered.

A study conducted by Brigham and Women's Hospital researchers and published in the Annals of Emergency Medicine shows that nationwide:

  • 54.2% of freestanding EDs are owned by or affiliated with hospitals
  • 36.6% are independently run by physician groups or other entrepreneurs
  • 45.3% of freestanding EDs were for-profit entities, and
  • 43.9% non-profit entities

Researchers conducted ZIP code-level geographic analyses on the three states with the highest number of freestanding EDs: Texas, Ohio, and Colorado.

They found 360 freestanding EDs nationwide, up sharply from 222 in 2009—a 62% increase during the study period.  


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Generally, freestanding EDs are located in areas with population growth, higher incomes and a higher proportion of the population with private insurance.

That's not surprising—businesses go where the money is—but could also be skewed by the fact that many hospital-based EDs are already in areas with higher proportion of the population on Medicaid or uninsured.

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.

  • In Texas, only 22.1% were owned by, or affiliated with hospitals, 71.3% 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% 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% were affiliated with hospitals, and 61.9% were for-profit.

Researchers say their findings should help inform states on the effects their regulations have on the development of such facilities.

"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, said Jeremiah Schuur, MD, MHS, vice chair, Clinical Affairs at the Department of Emergency Medicine at Brigham and Women's Hospital, and corresponding author of the study. His remarks were in a press release accompanying the report's publication.

"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."

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