Proliferation of for-profit, freestanding emergency departments

Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States

By Jeremiah D. Schuur, Olesya Baker, Jaclyn Freshman, Michael Wilson, David M. Cutler
Annals of Emergency Medicine, July 12, 2016 (online)

Study objective

We determine the number and location of freestanding emergency departments (EDs) across the United States and determine the population characteristics of areas where freestanding EDs are located.


We conducted a systematic inventory of US freestanding EDs. For the 3 states with the highest number of freestanding EDs, we linked demographic, insurance, and health services data, using the 5-digit ZIP code corresponding to the freestanding ED’s location. To create a comparison nonfreestanding ED group, we matched 187 freestanding EDs to 1,048 nonfreestanding ED ZIP codes on land and population within state. We compared differences in demographic, insurance, and health services factors between matched ZIP codes with and without freestanding EDs, using univariate regressions with weights.


We identified 360 freestanding EDs located in 30 states; 54.2% of freestanding EDs were hospital satellites, 36.6% were independent, and 9.2% were not classifiable. The 3 states with the highest number of freestanding EDs accounted for 66% of all freestanding EDs: Texas (181), Ohio (34), and Colorado (24). Across all 3 states, freestanding EDs were located in ZIP codes that had higher incomes and a lower proportion of the population with Medicaid. In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population with private insurance. In Texas, freestanding EDs were located in ZIP codes that had fewer Hispanics, had a greater number of hospital-based EDs and physician offices, and had more physician visits and medical spending per year than ZIP codes without a freestanding ED. In Ohio, freestanding EDs were located in ZIP codes with fewer hospital-based EDs.


In Texas, Ohio, and Colorado, freestanding EDs were located in areas with a better payer mix. The location of freestanding EDs in relation to other health care facilities and use and spending on health care varied between states.


Are free-standing emergency rooms helping only the wealthy?

By Sabriya Rice
The Dallas Morning News, August 3, 2016

Business is booming in Texas for free-standing emergency departments. The centers are emerging in wealthier neighborhoods, where patients are privately insured and are less likely to have Medicaid or Medicare, finds a study published in July in the Annals of Emergency Medicine.

That's concerning for some health policy researchers. Emergency services in the U.S. have historically been provided by hospitals, and therefore must adhere to federal regulations that protect patients from being denied care if they cannot afford it.

"It's the one part of health care where there is some expectation that everyone can have access," said Dr. Jeremiah Schuur, lead author of the study. "That might not be the case in a parallel emergency system, one that is not regulated by the same standard that has prevented hospitals from dumping patients."

They are also worried that the proliferation is not helping improve access to emergency care, for which Texas got an "F" in a 2014 report card from the American College of Emergency Physicians.

In 2009, Texas became the first state to make it legal for emergency services to be provided by private for-profit companies, not just hospitals. The number of stand-alone emergency departments jumped from 19 in 2010 to just over 200 to date, according to Texas Department of State Health Services data.



By Don McCanne, M.D.

Texas is leading the nation in establishing for-profit, freestanding emergency departments. And what has that brought them? An “F” from the American College of Emergency Physicians.

Physicians for a National Health Program not only supports coverage of all essential health benefits for everyone, but we also support regional planning and separate budgeting of capital improvements within a non-profit health care delivery system. Texas shows us why.

Texas entrepreneurs are placing their new, for-profit emergency departments in locations that provide the greatest income potential - areas with higher incomes, greater prevalence of insurance, fewer patients with Medicaid, and lower concentration of Hispanics, even though these areas were already better served by existing hospitals and emergency departments. They go for the buck, but ignore the need.

The longer we wait to enact an equitable, efficient, and more effective health care financing system, the greater will be the cumulative losses from greed and inefficiency, and the greater will be the cumulative suffering and deaths due to our inaction.

No more “let’s wait and see how the Affordable Care Act is working.” The establishment of these freestanding departments coincided with implementation of the Affordable Care Act. Our health policies are designed to benefit the health care industry, and patients have been included only because they are the necessary coal to stoke their ovens. We need to change that. Now!