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Freestanding EDs Growing in Number; Tend to Serve Privately Insured

BOSTON – The number of freestanding emergency departments (EDs) has increased rapidly during the past few years, according to a study seeking to better understand the phenomenon and what patients are being served.

The report, which looked at EDs physically separate from acute care hospitals but available 24/7 for emergency care, was published recently in the Annals of Emergency Medicine.

For the study, Brigham and Women's Hospital researchers created a national inventory of freestanding EDs, identifying 360 in 30 states as of March 31, 2015, a sharp increase from 222 in 2009.

Conducting ZIP code level geographic analysis in the three states with the highest number of freestanding EDs — Texas, Ohio, and Colorado — the study team found that the facilities tend to be 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, interestingly, in locations with a greater number of 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," explained corresponding author Jeremiah Schuur, MD, MHS, vice chair of Clinical Affairs, Department of Emergency Medicine at Brigham and Women's. "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.”

In Texas and Ohio, for example, freestanding EDs were located in ZIP codes with a higher proportion of privately insured residents. In Texas, with nearly 200 freestanding EDs, 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.

Nationally, 54.2% of freestanding EDs were owned by, or affiliated with, hospitals, and 36.6% were independently run by physician groups or other entrepreneurs. In addition, 45.3% of freestanding EDs were for-profit and 43.9% were non-profit.

The percentage of freestanding EDs associated with hospitals was lower in Texas (22.1%), while the percentage of those with for-profit status was higher (71.3%). The for-profit facilities were more likely to be located in ZIP codes with existing hospital EDs, according to study authors.

In Ohio, with 34 freestanding EDs, however, 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. Of Colorado’s 24 freestanding EDs, 45.8% were affiliated with hospitals, and 61.9% 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,” Schuur said in a Brigham and Women’s press release. “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.”