Driving in and around the cities that make up the Dallas–Fort Worth (DFW) metroplex, I get the sense that something is in process that could have dire consequences for our specialty. Freestanding “emergency rooms,” both hospital- and physician/investor-owned, are multiplying at an alarming rate, and this is happening all over the state. Texas is, of course, the first state to legitimize and regulate physician/investor-owned freestanding emergency facilities, and there is a good chance this phenomenon will spread nationally. Certainly, the number of hospital-owned freestandings is increasing in other states, but thus far, physician/investor development has dominated the market only in Texas. Is the proliferation of physician/investor-owned freestanding emergency facilities good or bad for emergency medicine?
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ACEP Now: Vol 34 – No 02 – February 2015There is a certain irony in my sense of alarm about this because I was, at one time, considered a pioneer in the development of freestanding “minor emergency centers” in DFW in the late 1970s and throughout the 1980s. Though I sold these facilities long ago, those same 17 practices, now referred to as “convenience care clinics,” are still in business and have since been joined by dozens of others, mostly physician/investor owned. While operating these clinics, I simultaneously staffed several hospital-based emergency departments in the same catchment areas and was able to conclusively prove that the presence of convenience clinics has no impact on either ED volume or payer mix—but I suspect not so for these freestanding emergency rooms. These facilities take paying emergency patients out of the hospital-based ED, and this logically has to have a negative impact on volume and payer mix. This, in turn, has to make it harder for both the hospital-based facility and its emergency physician staff to meet their unfunded EMTALA mandate. In addition, these aren’t the only potential negative impacts on the EMTALA-bound hospital-based ED safety net.
Physician/investor-owned freestanding emergency facilities typically involve an investment of $1.5 million to $3 million. The facilities’ ability to charge and collect a hospital-level facility fee as well as use the 992_ _ CPT emergency department professional service codes enables them to break even at about a dozen patients per day. They are required to see all comers, but they are disproportionately located in areas of the metroplex unlikely to have significant numbers of underinsured or uninsured people. To use the word “emergency” in their name, these facilities must operate 24-7 to comply with Texas law. Twelve patients a day is one every two hours. Given the sheer number of these facilities being built, I suspect that many of them may not reach or far exceed this number of visits. From a health care system perspective, this seems an extremely inefficient use of capital, expensive and rapidly obsolescent equipment, and emergency physician manpower. In addition, these facilities can’t but worsen the already near-critical emergency physician shortage.
What alarms me is that, at a time when the health care system is crying out for less duplication of services and greater efficiency in the use of expensive resources, the boom in physician/investor-owned freestandings appears to be moving the needle the other way.
There is a kind of “tragedy of the commons” at work here, where everyone is acting logically and according to their own self-interest but the end result is likely to be detrimental to all. Hospitals do only that which is in their strategic interest, but physicians/investors are free to plunk one of these down at every major intersection in the nicer parts of town. What alarms me is that, at a time when the health care system is crying out for less duplication of services and greater efficiency in the use of expensive resources, the boom in physician/investor-owned freestandings appears to be moving the needle the other way. So it would be helpful to know what factors are driving this phenomenon.
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24 Responses to “Opinion: Why Freestanding, Physician- or Investor-Owned Emergency Departments May Be Bad for Emergency Medicine”
February 18, 2015
Michael J. Sarabia, MD, FACEPIt is remarkable that opinion (admitted by the author) is used to inflict injury on the interests (admitted by the author) of the dues-paying membership of ACEP, and in our own newsletter of all places. ACEP Now claims to be “the Official Voice of Emergency Medicine,” and is an “official publication of ACEP.” Why did the editor dissallow the chairman of our section the ability to preview and refute the article this month?
Michael Sarabia, MD, FACEP
Counsilor
Section for Freestanding Emergency Centers of ACEP
February 23, 2015
RonI regret that my op-ed piece caused Dr. Sarabiia such anguish. After reading what I wrote again I do think it can be interpreted as being anti-FSED and for that I apologize, but that was not my intention. I do not have a dog in this hunt as they say in Texas. Being semi-retired my practice is limited to medical group management consulting. Rather than passing judgment I was attempting to frame a series of questions regarding the possible impact of FSEDs that I think the College will have to address sooner rather than later. I would be happy to speak with Dr. Sarabia off-line about his concerns about my concerns if he wishes. My e-mail is rahellstern@ gmail.com.
March 20, 2015
Kevin M. Klauer, DO, EJD, FACEPACEP does proudly promote ACEP Now as “The Official Voice of Emergency Medicine,” and takes that responsibility seriously and in the most literal sense. Our vision is to offer the most appropriate, unbiased forum possible for the discussion, deliberation, and airing of any issues impacting our specialty, especially the most complex and controversial of those issues. In doing so, we must allow diversity of opinion to be heard and, from a specialty society perspective and journalistic perspective, it would be inappropriate to avoid difficult topics and more importantly, it would be inappropriate, and even unethical, to censor valid opinions, whether or not they support ACEP policy or not. Our belief is that ACEP cannot be a credible leader in our specialty or in the house of medicine without such integrity. Interestingly, and historically, ACEP and ACEP News were formally criticized for the perception of such censorship.
Kevin M. Klauer, DO, EJD, FACEP
Medical Editor-in-Chief
February 22, 2015
Henry Higgins MDI would have thought that a senior consultant would realize that patients come first and that our duty is to do what is right for the patient. From his “Ivory Tower Comments” it is obvious that Ron has very little knowledge of what actually is going on in emergency departments across America. It has become obvious too many of us who actually practice emergency medicine that hospital based emergency rooms are not always able to provide the best and timely care. There is no reason that people should be forced to wait in pain for timely care! Free Standing Emergency Centers make sense to the public and staff who provide the care. If CMS were to begin to recognize and fund this service then you would see a plethora of FSED development in every Ghetto and underserved area. We are all physicians trying to create the best circumstance to render the best care possible to our patients. We are not economists (like Ron) who try to force “free labor” unto our duties. We provide this “free labor” already in FSEDs as well as Hospital EDs.
Privately owned and operated Free Standing Emergency Centers offer emergency physicians the ability to control the Emergency Medicine practiced in their area. This scares the “Ivory Tower” of hospital monopolies so they hire the likes of Ron Hellstern to write articles like this. Shame on you Ron Hellstern. You are an idiot with a platform. You failed to mention that many FSED’s like mine gave away nearly $500,000 in free healthcare to people who needed help in my community. Shame on you for not understanding that 99.99% of physicians become physicians so that they can care for others. Yes we hope to make a comfortable living and pay off medical school debt but at the end of the day we simply enjoy helping others irrespective of the profit or loss involved. Emergency Medicine Physicians are by far the most the most “giving” of indigent care. What type of physician is better suited to go out into the community and set up an ER business. Who amongst the specialties of medicine is most apt to provide “free care” when appropriate? Unfortunately I know Ron Hellstern as he was hired by my democratic group in Abilene to help us debate our contract renewal. He ended up being bought off by the hospital and we ended up with a very bad deal after paying him very handsomely (in addition to whatever he was paid by the hospital). Proof in the pudding as that previous democratic group is now owned by EMCARE. EMCARE bought the group out shortly there after Ron Hellstern’s consulting job.
So ACEP Members need to evaluate the “stuff” they are subject to. I find it very interesting that ACEP would allow the likes of Ron Hellstern to provide commentary on FSEDs. It makes me wonder if ACEP is truly the voice of Emergency Physicians or instead simply another layer of people collecting “cream off of the top” of ER Docs trying to treat patients.
February 26, 2015
Ron HellsternDr. Higgins: I respectfully disagree with your characterization of my role in advising both your hospital and group. I would be happy to discuss your concerns about the outcome of my consulting engagement off-line. My e-mail is rahellstern@gmail.com. I wrote about my observations in the spirit of initiating a discussion about the possible impact of FSEDs on the hospital-based ED safety net. No one paid me to post these observations. I, like you, am dedicated to the welfare of EM and the EPs that make it work despite a very dysfunctional “system.”
February 28, 2015
A Antoine Kazzi, MD, MAEM, FAAEMDear Dr Higgins,
I want to congratulate you on an excellent reply. History indeed repeats itself, and it does not surprise me that those who called us, emergency physicians, ambulance-chasers have not changed.
FYI, I own my own free-standing facility in Damour, Lebanon – in an under-served location with lot of poverty all around.
And yes, few know or can sense what it feels like to carry the burden of clinical, financial and administrative responsibilities associated with owning such a practice, including how we face daily demands for free-care.
Few will ever understand how heavy of an overhead we have to pay for, and how large is the uncompensated service we provide…
Yes, physician ownership is part of why I did this in Lebanon.
You raise excellent valid points.
As you may know, I served as President for AAEM, and a number of years on the ACEP Council or California ACEP Board of Directors.
I am heading to Austin for the AAEM Scientific Assembly, and will propose the establishment of an Interest Group for Free Standing EDs. We need it.
I congratulate you and your section for what you have done, and send you respect and appreciation, to all of the members of your section.
Antoine Kazzi
February 22, 2015
Sam MoraleI believe this article allowed ACEP to be used to further one persons agenda…..
February 22, 2015
Gregory West, MDiv, MD,PhD,FAAP, FAAEMThis is not a new conflict of interest for ACEP, it has existed from it’s founding. The author might explore membership in the American Academy of Emergency Medicine.
February 22, 2015
John JohnsonMichael – relax ! 6 of us started the first (and only) ER residency in IN. I practiced EM for 35 years. The group also recognized the problems in ERs for ERs and their patients alike with episodic minor care. Costs, excessive lab & imaging, excessive delays – to name a few. We started urgent cares in the 80s and they continue to thrive. Should drugstores be in the business ? I have my opinion, but the fact is – patients no longer want nor need (in most cases) long term relationships with a physician in this mobile society. The current corporate practices of medicine don’t allow that one physician concept – its a gang, see who you can. Alexandria, VA, had one of the 1st Freestanding ERs that I recall. They made geographic sense given the driving times in the area, esp. in rush hours. They also fed patients to the “mother ship” out of perhaps another hospital’s catchment area. Now physicians, I talked to several from AZ at the ACEP meeting, are tired of being disrespected slaves to a broken hospital ER system and are doing their own freestanding ERs and doing them right for the physicians and the patients. Hospitals need to learn from these new entrepreneurs on how to create a wholesome environment for patients, physicians and staff. Patients are generally smart enough to self-select the appropriate location – urgent care, freestanding and ER. The “injury” as you call it being inflicted as you opine on emergency physicians is being done by hospitals that treat ER docs as commodities, by medical staffs that disrespect the ER as an intrusion on their life, and by terrible systems of care within the hospitals that fail to analyze and correct the problems. Aren’t you tired of your new name “No No Bad Dog” and the phrase, spoken or implied “Shut up and do your job!”. Until ER docs get involved (a dying breed), take responsibility (not merely a paycheck)and become leaders in their own “homes” it is not going to get better. Large physician groups are beholding to the “mother ship” for their contract and are loathe to rock the boat, so they are not much help. The smaller groups or one-horse contract groups that were the backbone of emergency medicine years ago have been usurped by hospitals hiring their own staff or big groups that ease the hospital’s burden of management. The status quo prevails. I applaud the entrepreneurs who see and know how to do it right and risk their own capital to make it happen. Its the American way. I only hope that hospitals will either learn from these adventurers’ experiences or lease the square footage to them and let them open their boutique unencumbered by the hospital bureaucracy and a disrespectful medical staff. [Reference: I started in ERs in 1974, the residency was at Methodist now, IU Health – largest in US), was the “ego maniac of EMS” within the College according to Ron Krome, 20th President of ACEP, group had up to 10 urgent cares, retired from ER in ’09 and own an urgent care now 12 years old.]
February 22, 2015
R Joe Ybarra MDACEP members who work at hospital based EDs also work at hospital based freestandings(HOPDs),Hospital licensed Freestandings(ie Emerus), and both licenced (and in States that don’t have restrictions, CON states) independently owned freestanding emergency centers…they also work in Urgent Cares and the back of ambulances, disaster Tents, etc.
The ACEP Board embraced a Resolution in 2012, and subsequently allowed a freestanding emergency center Section to be formed(2014) with objectives and membership following all criteria. The ACEP White Paper on Freestanding EDs, the Policy Statement on Freestanding EDs, and the FEC Section website (with objectives and membership info) are all easily accessible through the ACEP website, and I invite all to read to understand a balanced understanding.
We, the Leadership of the Section, invite a multi-perspectival dialogue to occur on this issue in a profession, and scientific process.
Although the Opinion of Dr Hellstern is interesting, and it raises valid issues, concerns, pro or against the concept, there is a healthy(ier), more complete story to be told to the ACEP readership.
We invite all to join the dialogue through our open FEC Section meeting(s) and on our e-list as a Section member.
R Joe Ybarra MD
ACEP FEC Section Chair
February 22, 2015
Rick BukataI have known Ron Hellstern for over 25 years and have considered him, without doubt, one of the finest intellects in emergency medicine when it comes to operational and organizational knowledge.
Ron has been “calling them as he sees them” his entire career and I consider his view on freestandings EDs to be tempered and fair. Does not a red flag go up when an entity with a CT scan in it can break even on a handful of patients a day? Does not a red flag go up when a patient with a minor illness stumbles into a freestanding ED and gets hit up with a nasty facility fee as well as a service charge (when they should have gone to an urgent care clinic for a fraction of the charge).
Emergency physicians used to pride themselves regarding wearing the “white hat” in medicine — talking on all comers 24/7. And yes, we heavily cost-shifted to get the job done. If a freestanding ED only takes patients with “good” insurance (both Medicaid and even Medicare excluded), what is left for the ED — we have our brothers and sisters skimming off the cream because the ROI is so compelling.
Hospitals to a large extent deserve what they have let happen — their EDs are notorious for making patients wait for care (despite the concierge level charges), have been inept at providing a consistent level of quality, have their halls littered with admitted patients, have been unable to assure specialist coverage and on and on. But when emergency physicians choose to take away the “good” patients from the community hospital, it seriously undermines the tenuous system that we all will need.
Ron hellstern is right on.
May 12, 2015
Dr. Joseph L McDanielDr. Bukata,
I appreciate your defense of your colleague’s approach and experience. Difference of opinions spur healthy discussions that do bring red flags to light that may have not been fully considered. I would like to offer an alternative opinion to the items you suggest.
CT’s do go down whether at FCERs or hospitals. I cant tell you how many times over my 18 year career that our hospital scanners have been down for various reasons. We would be forced to send a patient, by ambulance, to a sister hospital for a needed scan. This would take hours. This has also occurred at my free standing facility on occasion. Likewise, I was forced to send a patient to one of our sister facilities to complete the scan. The difference however is that my turn around time is 30-40 min tops as compared to 2-3 hours at best. These facilities are much more efficient in that the radiology side only serves our patients and is not split among all the hospital services. In most instances, I can get a scan done and read at another facility faster than a hospital can accomplish if their scanner is functioning within its own facility.
Second, I’ve delt with far more minor illnesses in a hospital based ED than I do at any free standing ED. Patients are given extensive information, up front, regarding our facility being an emergency department and not an acute care center. Patients are more informed and make better decisions based on the amount of time and information we are able to give them. There are far more patients being hit “with a nasty facility fee as well as a service charge” from hospital ED’s because no front desk staff have time to explain any options due to the overcrowding and extensive patient load that now inflict this failing system of care. There is no ED doc in existence that will deny that patients use ED’s for minor problems regardless of cost. Its the McDonalds mentality that is so prevalent in our society. Its a attitude and mind set problem that is not going away any time soon.
Quite frankly, this model is a godsend that saves practices. Emergency trained physicians are happier, patients are happier and care is far more efficient and carries with it a high level of satisfaction both for the practitioner and patient which is why we went into the profession to begin with.
Its interesting that when the specialty of emergency medicine was being built back in the 70’s, these same statements were being yielded by doctors against the change. This is just another catalist for the improvement of the specialty as a whole
Dr. J
December 30, 2015
Patrick J. McHugh, DO, FACEPDr. McDaniel,
Well said, sir.
Unlike some others who commented above I do not interpret Dr. Hellstern’s words as anti-FSED. I consider his opinion intelligently written, thoughtful, impartial, and fair. He makes some excellent points re FSED’s and the threat they pose to hospitals. His figures on break-even volumes would benefit from supporting data and I disagree with some of his conclusions. But he never masks the fact that this is an opinion piece – just look at the first word of its title.
I worked many shifts during my six years with Mary Washington Healthcare at its FSED in Fredericksburg, VA. Our wait times were better than that of our two, hospital-based ED’s and our processes were just as efficient/tight. Communication with patients by both front desk staff and clinical personnel was less impacted by patient volume and the associated pressure to empty an overcrowded waiting area. And our volumes were a far cry from 12 patients per day. With the exception of the 11p-7a shift we usually treated more patients per shift due to our ability to work more efficiently than we could at our hospital-based ED’s. I must admit, however, that the acuity of our FSED was lower than our hospital-based ED’s. But on days with higher acuity we still outperformed them.
Dr. Bukata implies that FSED’s are at greater risk for CT malfunction and that FSED’s only take patients who can pay. I respectfully disagree. The risk of malfunction is identical at both. And FSED’s are held to the same standards as hospital-based ED’s (i.e. treat everyone regardless of ability or intent to pay). His goes on to portray hospital-based EP’s as having superior character and pathos. The imagery of white-hatted EP’s working in hospital-based ED’s unfairly paints FSED-based EP’s as uncaring mercenaries. The issue of minor illnesses getting hit with expensive fees is also no different at FSED’s versus hospital-based ED’s despite his implications otherwise. I believe his words of opposition directed towards some of the dissenting opinions above are nothing more than a straw man. Please excuse me, Dr. Bukata, if I am paraphrasing you incorrectly. I take issue with your words but respect the man.
The market will decide if Dr. Hellstern in saying the explosion of FSED’s is an extremely inefficient use of capital. Supply will eventually exceed demand and the market will self-correct. Until emergency physicians are truly valued by hospitals and healthcare systems our collective pursuit of better working conditions is anything but a waste of emergency physician manpower. I argue that the increased professional satisfaction experienced by many of us at FSED’s will decrease burnout rates and strengthen our numbers. And I suspect that the care provided by happier, healthier, and less-stressed emergency physicians will better serve our collective patient population.
My past decade of full-time clinical practice took its toll. I recently made the decision to accept a full-time administrative role and work clinically on a part-time basis in order to preserve my passion for emergency medicine and patient care. Ownership interest in an FSED may have kept me as a full-time clinical EP. There are days that I miss the grind. But I now eat dinner with my family every night, help get my children ready for school most mornings, sleep better, and take solace knowing the time I spend with my family is of higher quality than ever before. Life is good despite my going over to the dark side.
Perhaps FSED’s will be, as Dr. McDaniel so eloquently suggests, the catalyst that moves our amazing specialty and the emergency healthcare system at large towards improvement.
PJM
February 22, 2015
Chris K. MDHospitals be damned! This is the very thing that surgeons, radiologists, sleep study physicians, anesthesiologists, and many others have been doing for years. Free standing centers of excellence to care for insured patients in a bontique setting. Finally, emergency medicine gets in on the action. Let the hospitals compete for ED physicians and watch our pay increase. We will not solve this trend anymore than its been solved in all the other specialties. When the government gets serious about mandated care, EMTALA funding, and covering the uninsured then and only then will this practice start to be addressed. In the mean time, let emergency medicine thrive where its profitable. Game on!
February 23, 2015
Howard Haysom, MDInteresting perspective, however if hospitals operate these freestanding ER’s, revenues could be used to offset the deteriorating payer mix in the hospital based ER. My concerns are 1. The quality of medical practice reflected by available equipment (example 16 MSCT versus 64 MSCT in most hospitals), available studies (ultrasound for DVT, Ectopics), availability of specialists at bedside. 2. Violation of the “self-referral” Stark law. 3. The cursory attention to preventative care, immunizations and disease management for Diabetes, Asthma, Hypertension to name but a few.
February 26, 2015
Ron HellsternDr. Haysom: I agree with your concern about quality of ancillary support but the combined hospital-freestanding unit has to be less efficient and less profitable overall because the medical care infrastructure is being duplicated with neither location at optimum utilization.
February 28, 2015
Henry Higgins MDDr Haysom please consider the following in regard to your concerns
1. In Texas the state has mandated very stringent requirements for the operation of free standing emergency centers. At our free standing centers we decided to far exceed these requirements and offer our community the highest quality of care possible. We use a 64 slice Ct Scan and employ a radiology tech staff that are highly experienced in all forms of ct angiography including coronary ct angiography-CCTA (non invasive cardiac heart caths). Every February (for fun) we offer the community free heart screening. By removing any cost barrier and time concern as entry for screening we typically have gotten a very large number of volunteers from the community to under go free heart screening via calcium scoring and or CCTA (only when indicated via strict protocol). We have been absolutely amazed at how many folks that we have found that have silent/hidden but significant coronary artery stenosis. We have sent these free volunteers to cardiologists and cardiothoracic surgeons for stents, medical therapy and CABG. We also have this technology available for our emergency patients patients who may benefit from it. We use onsite Ultrasound, X-ray and lab 24/7. We only employ Physicians and Nurses with 5+ years of experience in “High Impact” emergency medicine. We have even helped the Hospital out by doing CT Scans on their ER patients when the Hospitals CT scanner goes down.
2. We do not refer any patients to our emergency centers. Instead, we treat anyone who presents to our facility. We are very upfront regarding our costs with patients. We refer nonemergency cases to Urgent Care whenever they could be cared for more cost effectively and do not require an ER visit. We work with these Urgent Cares and they often send patients to us when their patients require an Emergency Medicine workup. This is “Best Practice” for our patients and our “Best Practice” for operation. In no way could this ever be construed as a Stark Law concern. In effect we are saving our potential patients cost by turning them away to Urgent Cares when it is medically appropriate. This is actually greatly supports the intent behind the Stark Law and helps our community keep their healthcare costs down.
3. We offer preventive medicine to all emergency patients via immunizations, disease management and etc. The State of Texas will not allow free standing emergency centers to involve themselves in any “non emergency” business activities unless this is done “pro bono”. We routinely do pro bono health screening and sports physicals for area athletes. We did have an arrangement with the police department where we charged $20 to do blood alcohol blood draws for suspect DUI. After conferring with the state we were forced to discontinue this practice. I am aware of other free standing emergency centers being fined for giving immunizations to non emergency patients and charging a fee for this. For this reason when we do immunizations to non emergency patients we give these in our parking lot and do not charge the patients anything (free drive thru flu shots). The reality is that patients adore the free standing emergency center model for its convenience and high quality care. This has many medical monopoly systems very concerned. As a result of these concerns many barriers to free standing emergency centers have been developed by these Medical Monopoly Systems. We follow these rules and simply use creativity and probono work to offer our community health maintenance when they are not emergency patients. Meanwhile those of us with boots on the ground are simply having a blast becoming highly involved with our community and offering extremely high quality care to our patients.
4. Employing High quality Emergency Physicians and Nurses is very expensive. Having a 64 slice CT scanner with a highly tuned radiology tech staff is also expensive. Giving away heart screening & flu shots also costs money. Not being reimbursed for the care we render to medicaid, medicare and tricare patients is also very expensive. Emergency Medicine is very costly to provide. The vast majority of us in this industry have been able to provide this high quality care without “balance billing” our patients. “balance billing” is the routine practice of all hospital based emergency departments. So free standing emergency centers are actually cheaper than hospital based emergency departments for patients who use them.
5. The free standing emergency center model has been shown to increase the access that patients have to high quality care, be cheaper than hospital based emergency care, and de-monopolize healthcare and the “ownership” of emergency physicians. This model is good for patients, emergency physicians and nurses and drives down the cost of care for patients.
February 25, 2015
Michael J. Sarabia, MD, FACEPThank you, Dr. Hellstern, for your response and encouraging healthy discussion. I will contact you privately as you requested, along with our chairman. In the meantime, readers should understand:
1) FECs are accused of being able to break even on too few patients. Hospital-owned FECs have and take the same opportunity. FECs aren’t charging more than hospitals, so why aren’t hospitals providing the same access and service with far more paying patients and revenue? The FEC model will compel hospitals to better fund ED care, which is long overdue.
2) Most opponents to FECs (Hellstern and Bukata included, I am sure) have never set foot in an FEC. If they have, they have not taken a family member there for care. They fail to see our perspective in which we and our patients understand the value of access.
3) Diplomacy is important, but sometimes the facts are so blaringly clear that they should be spoken firmly.
Keeping it real: Here is a personal story to illustrate #2. My brother-in-law sat in the hospital ED waiting room, where I was working and on duty, for 8 hours with meningitis. He did not want to cut the line, so he did not tell me that he was there. He should have gone to an FEC. These instances occur every hour in overcrowded urban environments. I am big fan of Dr. Bukata’s CME. He knows all about the casualties of the status quo in Southern California, where I understand wait times can be more than 24 hours.
My father, conversely, DID call me when he was having stroke-like symptoms. He never would have waited in the hospital ED for 8 hours, so I sent him to a hospital-owned FEC near his home and in the same hospital system as above. He was evaluated expeditiously without cutting the line, CT results were back in less than 60 minutes from him leaving his house, and he was admitted and properly evaluated.
Bukata and Hellstern’s poor understanding of the FEC model take focus away from the patients. This stance, and offering no alternative which has not already been attempted, will lead to ACEP continuing to give the U.S. a grade of D- for access on its report card for emergency care. This stance is “doing harm,” and is against the Hippocratic Oath. These are firm words, but the facts in Houston are too blaringly clear. Gentlemen, please join our section and become informed.
If you join our section, you will receive informative newsletters with articles like:
“FEC Physician Careers Survey, The Perspective of Hundreds.” (This should trump the opinion of one, or just a few.)
and,
“The Tale of Two Cities – A Comparison of Emergency Healthcare in Houston, the “Epicenter” of FECs, Versus Los Angeles, Where There are None.”
Yes, I am the author of these. The second, however, is still in creation. I invite Dr. Bukata to co-author with me. Let’s find the truth together!
Respectfully,
Mike (speaking for myself, not necessarily the section. I will speak without delay when the wellbeing of patients is at stake.)
Michael Sarabia, MD, FACEP
Councilor
Section for FECs, ACEP
March 6, 2015
Juan Nieto, MD, FACEPDr. Hellstern has opened quite a dialogue! Ron I remember your
Entrepreneur days well and other EM physicians especially those of us who were residency trained saw your facilities as taking paying patients away from hospitals. I wonder if you would not have taken advantage of the FSED model instead of all your UC
Facilities.
I don’t believe this is a black and white issue that you bring up. The number of patients that will be so call taken away from hospital emergency departments will probably not change The volume of patients seen. We know that most emergency departments are overcrowded and unable to provide the services that many people want or deserve. The volume will only continue to increase with the increase in “insured “patients.
I find it interesting that it is usually the people who have no direct experience or contact with the freestanding model that are the ones who most criticize it.
Like you I have had a long career in emergency medicine and I can tell you Ron that this model has allowed me to practice the type of medicine that I would’ve considered ideal for my specialty. The ability to communicate with patients and to make sure that they were adequately informed of everything that was done to them and to make sure that all issues are addressed. As a matter of fact many patients have remarked that I have been able to spend more time andt show more interest in them than their primary care physician. After a long and very diversified career in emergency medicine of which half was spend in an academic setting, It is good to find satisfaction in the practice of emergency medicine and not have to deal with hospital issues. Nor do I miss the abuse by CMGs of physicians. There are few democratic groups and emergency medicine has been taken over by groups that are so large and even funneled their way into Wall Street. Is this what you support? Perhaps you support the corporate takeover of hospitals as they also attempt to employ emergency physicians.
I remember the days when you used to speak out for emergency physicians. But you also learned very early how easy it was to make money from emergency physicians in the business of emergency medicine.
I am glad that you are well and I am not sure exactly what type of consulting you do but I think that you are a decent person. I would not consider any of my remarks personally. They are the same remarks used by others who are unexperienced and do not have firsthand knowledge of freestanding emergency
departments.
With that said I must say that it is good to hear all sides. I have supported this model for years. Recently however I have seen how investor groups have taken over some of them.
I have also seen some of the flaws in freestanding ED’s. Any board-certified physician from any specialty can own and work in one of these facilities. I believe that emergency medicine can best be practiced by emergency residency trained physicians. And I will always support that. And I do question the intrusion of other specialties into this model. all it takes is someone who is board certified in any specialty to build a facility and practice emergency medicine which is my specialty.
I think that if this model is to be a long-term success it must police itself and agree to stand up for the rights of our specialty.
Can you imagine yourself building A facility and practicing another specialty?
Bottom line Ron Some of the responses have been spot on and I understand what you were trying to say. Now that you consult for hospitals perhaps you were mostly interested in defending their interests. I’m not sure.
Just remember the early days of emergency medicine and how difficult it was to fight the battles. All these battles were not fought by hospitals nor CMG’s. But by strong-willed independent emergency physicians who believed in our specialty. Dr. Rosen has taught me well!
The success of this model will depend on how well our specialty and our specialty trained physicians control the quality and the regulations.
There are two sides to almost all issues involving emergency medicine except one : to provide the most compassionate care to all utilizing all of the expertise of our training and experience.
When all is said and done it is about business and there’s nothing wrong with emergency physicians becoming independent dictating how emergency medicine should be practiced.
Ps. Have you also noticed the rapid expansion of urgent care centers? You were an owner once.!
Best regards
http://my.nd.edu/redirect.aspx?linkID=132488&eid=167424
May 31, 2015
Randall B Case, MD, MBA, MSE, FACEPI’m shocked, as I read this thread – to my amazement, laced with name calling and ad hominem attacks. If we don’t treat one another respectfully – whether discussing controversies, or otherwise – by what entitlement do we expect others to respect emergency physicians?
May 31, 2015
Ron Hellstern“Ad hominem is an argument of the weak and insecure.”
― Princess Maleiha Bajunaid Candao
What is it about emergency physicians that makes them so predisposed to getting lost in the trees and to failing to address the the points made about the state of the forest?
Ron
June 24, 2015
Keith A. Lepak MD FACEPLast week in Irving, the National Association of Free Standing EDs (NAFEC) received its inaugural framework. The event was quite exiting to witness, and the energy in the room was palpable. Quality and uniformity of care seemed to be the dominant theme. Wonderful.
When all facts are considered, each argument against the concept of ER physicians owning their own practice ‘in toto’ fades. As to the ‘forest’: Consumer demand will dictate the economics. FSEDs, coming to a state near you!
K Lepak MD
Director, ERCA Little Elm, TX
October 28, 2015
Susan EMBE, Consultant for more cost effective healthcare delivery.All good conversation – some interesting perspectives. FEC’s, when hospital-owned allow the hospital to target better payer class patients for referral into their system. Especially if the hospital is located in a poor payer class area. Other choice, close the hospital and move it to where their “suburban” competitor with a better payer class is located. Perhaps we are over-bedded? When physicians owned FEC, it may be somewhat of a “practice” quality of life, but it’s also about revenues and profits, as it is for hospitals. The first time I heard of the concept of an FEC, was in 2001, when Dr. Scott of Coastal Healthcare (PhyAmerica) was considering moving forward with developing. Back then, it was about profits and patient control for EM Physicians – no longer viewing hospitals as their partners. Note, he didn’t move forward – instead retired. Today, with escalating healthcare cost, to the CONSUMER – either “free market’ and/or “payer push back” will occur when the future of FEC’s comes to pass. Payers aren’t happy about paying a facility fee for urgent care, in either the attached ED or in an FEC. It’s my opinion, EM physicians need to figure out how to make a good living while assisting in the reduction of overall healthcare expenditures, not escalating them. Perhaps some should consider “concierge medicine” for those patients, who can afford to pay above Medicare, Medicaid, and/or negotiated private payer rates; or cut the significant profit line from some of those large EM management groups and/or WallStreet Health Insurance companies. (See article on 5.7 BILLION offered to Team Health for acquisition). We already have a 3-4 tiered system. Many Medicaid patients end up in the ED, due to primary care docs not accepting Medicaid. Not so much Medicare, due to the aging of our population. I agree, in suburban area’s generally – FEC’s are the hospital’s and EM physicians way to “cherry pick” treating good payer class patients, some… potentially out of institutional survival. One other comment, EM physicians should also look ahead at the path of Telehealth’s role in triaging patients to the appropriate venue for care. (See article re: Jefferson Hospital in Philadelphia). The attached hospital ED will and should always provide high acuity care and operate as a safety net for many… as well as being the decision influencers on admissions.
February 2, 2016
Henry Higgins MDSusan,
Excellent comments. “We all want the same thing here”. The reality is that payers are absolutely driven by profits. The whole thing reminds me of some of my colleagues who own and operate urgent cares in LA and others in NM. These colleagues essentially perform emergency care in their urgent cares for the benefit of their patients. These colleagues independently have met personally with the 5 major insurers in the US to discuss some type of minor increased payment for providing EM in an UC setting. They were each essentially laughed at by all of the payers.
From the EM Doc standpoint the insurance companies have set the stage for reimbursement to be more about facility type than quality of care provided. For this reason I encourage every UC and physician office in the US to become “facility based”. Hopefully they might associate with physician owned facilities that have the ability to lesson patient’s out of pocket expenses and not balance bill as the hospitals all do.
Not only are the insurer’s inability to consider options but also the past hospital experiences of EM Docs are encouraging the FEC revolution but also the patients. Why wait in a hospital based ER for hours for care when you may simply visit a nearby and convenient FEC and be treated with the dignity/respect you deserve and be properly diagnosed and treated? It is absolutely exciting knowing that you will not be balance billed.