Editor’s Note: This editorial from ACEP’s Freestanding Emergency Centers Section is a response to “Why Freestanding, Physician- or Investor-Owned Emergency Departments May Be Bad for Emergency Medicine” by Ronald A. Hellstern, MD.

During ACEP’s Scientific Assembly in 2014, the Freestanding Emergency Centers (FEC) Section became an official ACEP section.¹ The section was created to meet the needs of emergency physicians working in the more than 500 FECs operating throughout the United States. During the first FEC Section meeting, officers were elected, operational guidelines were created, and goals were set to conduct research on care provided in FECs and to educate both professional colleagues and patients on how FECs are benefitting communities and preventing emergency physician burnout.²

FECs currently operating represent a mix of emergency departments serving as satellite facilities for large health care corporations and academic institutions and also functioning as privately licensed facilities owned by the emergency physicians who work there. They have been created to meet a number of health care needs:

• Bring emergency care closer to patients in Accountable Care Organizations (ACOs)
• Alleviate crowding at nearby emergency departments
• Increase training sites for medical students and residents
• Present another free-market option for delivery of emergency care

Academic groups like Baylor Health Care System, the Cleveland Clinic, Akron General, and the University of Utah operate FECs. These emergency departments expand training options for medical students and residents, offer moonlighting options for fellows, and serve as centers for certificate training programs for advanced practice providers. Several other academic institutions are also planning to build FECs.

National corporations, like the Hospital Corporation of America, and regional groups, like North Carolina’s WakeMed and Colorado’s Swedish Medical Center, have also built FECs to meet the needs of patients in their ACO who do not live near one of their flagship facilities.

Independent FECs are currently operating in Texas, Colorado, Rhode Island, and Delaware. This model is also expanding to other states like Arizona. California and Georgia, where independent FECs had originally been banned, are now reevaluating this position. Recent legislation in Georgia has opened the door for independent FECs to take over failing rural critical access hospitals (CAHs). Similarly, the California state legislature is considering changing its licensing protocol to remove stringent requirements that had, basically, disallowed independent FECs so that FECs could serve patients in communities where traditional hospital-based emergency departments have closed.

Per the State Association of Freestanding ERs (SAFERTX), FECs offer patients increased access, quality, and efficiency.³ One criticism levied against independent FECs is that because they are not recognized by the Centers for Medicare & Medicaid Services (CMS), they do not treat Medicare and Medicaid patients and the uninsured. However, independent FECs are actively lobbying to be recognized nationally by CMS. Until then, they strive to live by the ethos of EMTALA, and independent FECs like Cedar Park Emergency Center in Texas not only donate a large amount of charity care every year but also are heavily involved in community health and screening projects.

Emergency department overcrowding, failing grades for “access to care,” physician burnout, and a future physician shortage are all problems we face as emergency physicians. FECs may represent part of the solution.

In additional to the initial ACEP White Paper, there are many emerging opportunities to research FEC care. Jeremiah Schuur, MD, MHS, an assistant professor at Harvard Medical School, is currently working on a $50,000 Emergency Medicine Foundation grant to do a nationwide inventory on FEC care, services provided, staffing and administration, and physical facilities.⁴ Erin Simon, DO, FACEP, from Akron General Medical Center, a Cleveland Clinic Affiliate, is a pioneer in FEC research, and her recent articles have demonstrated that FEC acute coronary sydrome care meets national standards, described FEC treatment for blunt trauma, and documented that a hospital network can increase overall ED volume by adding satellite FECs in addition to the flagship hospital.^5–7 Additionally, the FEC Section created an FEC research group during its first few months of existence and has applied for an ACEP Section Grant to investigate the role of FECs in meeting the first goal of the Institute for Healthcare Improvement (IHI) Triple Aim, which is improving the patient experience of care by increasing quality and improving patient satisfaction.

Other current and future research projects involve investigating whether working in a FEC can prevent physician burnout and whether converting critical access hospitals to FECs can help keep emergency care local when a community is losing its failing hospital. Michael Sarabia, MD, FACEP, Councilor for the ACEP FEC Section, has performed research (publication pending) showing that working in FECs not only could improve job satisfaction for emergency physicians but also could improve career longevity and prevent burnout. This may be especially true for owner/operators of independent FECs where they are not burdened with many of the common frustrations as they choose their own electronic health record system and hire and train their own support staff instead of having the inevitable frustration of having both chosen for them.

Emergency department overcrowding, failing grades for “access to care,” physician burnout, and a future physician shortage are all problems we face as emergency physicians.⁸ FECs may represent part of the solution, and the FEC Section invites anyone interested in the dialogue to join the conversation.

The FEC Section is actively working to address these concerns with research. The FEC model brings solutions, and enthusiastic ACEP members are dedicated to making emergency medicine better for our patients, our communities, and emergency physicians.

References

1. ACEP Freestanding Emergency Centers Section. Available at: http://www.acep.org/freestandingcenters. Accessed March 19, 2015.
2. FEC Section Operational Guidelines. Available at: http://www.acep.org/Content.aspx?id=99552. Accessed March 19, 2015.
3. State Association of Freestanding ERs. FAQs about freestanding EDs. Available at: http://www.safertx.org/faqs. Accessed March 19, 2015.
4. Wiler J, Fite DL, Freess D, et al. Freestanding emergency departments: an information paper. Available at: http://www.acep.org/uploadedFiles/ACEP/Practice_Resources/issues_by_category/administration/Freestanding Emergency Departments 0713.pdf. Accessed March 19, 2015.
5. Simon EL, Griffin P, Medepalli K, et al. Door-to-balloon times from freestanding emergency departments meet ST-segment elevation myocardial infarction reperfusion guidelines. J Emerg Med. 2014:46:734-40.
6. Simon EL, Medepalli K, Williams CJ, et al. Freestanding emergency departments and the trauma patient. J Emerg Med. 2015;48:152-157.
7. Simon EL. The impact of two freestanding emergency departments on a tertiary care center. J Emerg Med. 2012;43:1127-1131.
8. Goldberg R, Boss RW, Chan L, et al. Burnout and its correlates in emergency physicians: four years’ experience with a wellness booth. J Emerg Med. 1996;3:1156-1164.