More emergency rooms open away from hospitals

GERMANTOWN, Md. -- This commuter suburb near Washington, D.C., boasts new homes, shopping centers, plenty of traffic — and a state-of the-art 21-room emergency department tucked into an office complex.

Unlike most emergency departments, however, there are no patients awaiting transfer upstairs to a medical ward, because there is no medical ward.

The nearest hospital is about 8 miles away.

"A lot of people were skeptical" about the idea at first, says Robert Jepson, associate vice president of Adventist HealthCare, which owns both the nearby hospital and the free-standing emergency center.

High-tech emergency departments such as this one — staffed with doctors and nurses but often miles from a hospital — are increasing rapidly nationwide. The centers offer convenience to patients and can ease overcrowding in nearby hospital ERs. Yet, they also have spurred questions about their limited services, their ability to decrease the overall burden for area hospitals and their impact on health care spending.

The number of such facilities owned by hospitals or entrepreneurial doctors grew 23% from 2005 to 2006, jumping from 146 to 179, according to an American Hospital Association survey. About a dozen more are opening or in the planning stages in states such as Florida, Minnesota and Texas.

In September, a group of Houston doctors opened one in a shopping center next to a popular Mexican restaurant. It boasts posh waiting areas, wireless access and free coffee.

Another, owned by Mount Sinai Medical Center in Aventura, Fla., opened in January about a mile from rival Aventura Hospital and Medical Center.

The growth of stand-alone emergency departments comes amid continued overcrowding in hospital ERs and stiff competition among hospitals to expand their business in fast-growing suburbs.

The free-standing centers, open around the clock, often offer shorter wait times than hospital-based departments and can treat a variety of illnesses and problems, such as fevers, broken bones and serious cuts.

Yet, some experts, such as health care consultant Jim Unland, say that stand-alone ERs also can siphon patients with minor ailments away from lower-cost urgent care centers or doctors' offices, increasing costs to insurers and consumers. Urgent care centers differ from free-standing ERs because they usually are not open 24 hours and don't have the same level of high-tech equipment.

Ambulances generally won't bring the most critically ill to the stand-alone centers, including trauma patients and those having strokes or heart attacks. In Miami, ambulances won't bring patients to stand-alone ERs at all.

Patients who arrive on their own — the majority at most ERs — and need surgery or cardiac procedures must be rushed by ambulance to hospitals, a potential delay in treatment that worries some emergency service providers.

"We only transport to hospitals," says Elizabeth Calzadilla-Fiallo, spokeswoman for the Miami-Dade County Fire Rescue Department, which refuses to take patients to a newly opened center there. "If we transport to a stand-alone, and the patient actually needs more than the stand-alone can provide, you're compromising care."

Jepson and others say the centers provide the same high-level care given at hospital-based ERs and can handle just about any emergency, rapidly stabilizing patients, then sending them to a hospital for further treatment.

Heart attack patients who walk into the Germantown facility, for example, can be assessed quickly and sent by ambulance to the center's parent hospital, Jepson says.

Maryland lawmakers allowed the new center, which opened in 2006, after much debate. They're studying it and one other pilot project before deciding whether to permit more. In Florida, where there are at least four stand-alone centers, lawmakers adopted a moratorium on new facilities in 2007. Gov. Charlie Crist then vetoed the legislation.

"A lot of states are looking at them, partly out of fear that there is something less safe about them," says Juliet Rogers of Karlsberger Health Care Consulting Group in Ann Arbor, Mich. "These actually fill a need, but they are definitely controversial."

What customers want …

Stand-alone emergency departments have their roots in a growing health care customer-service movement that also has spawned convenience clinics staffed by nurses in supermarkets and doctor-owned urgent care centers. Among reasons for building free-standing emergency departments: shortening travel times for suburban or rural residents; gaining a foothold in a growing suburb; and competing with a rival hospital, says consultant Rogers.

The construction of such centers comes as traditional emergency departments treat more patients. From 2001 to 2005, the number of ER visits rose from 101 million to 115 million, says Carlos Camargo, a Harvard Medical School professor who coordinates the National Emergency Department Inventory.

Stand-alone centers, especially those affiliated with hospitals, "can make sense," he says. "If you can build them in the suburbs, they could take care of a lot of visits quickly."

They also likely will drive up the total number of ER visits: "Like anything else in medicine, the more you make something available, the more it will be used," he says.

Insurance plans and Medicare generally pay for care in stand-alone emergency departments, just as they do for hospital-based ERs. Yet, care in an ER — whether free-standing or attached to a hospital — costs the patient and the insurance company substantially more than at doctor's offices or urgent care centers.

For the same type of outpatient visit, for example, Medicare reimburses medical providers $316 if a patient is treated in an emergency department, compared with $138 in an urgent care center. Emergency departments are open longer hours and generally have more staff, so overhead costs are higher.

Free-standing emergency departments also can draw the insured away from hospitals, which rely on paying patients to make up for money they lose treating the poor and uninsured, says Unland, president of the Health Capital Group, a health care consulting firm in Chicago.

Stephen Marshall, chief of staff at Overlake Hospital Medical Center in Bellevue, Wash., says no one has done a wide-ranging study of the quality of care that stand-alone emergency centers offer.

"We're building these things without proof that we're providing quality care," says Marshall, whose hospital has a nearby urgent care center but no stand-alone emergency department. A rival hospital, Swedish Medical Center, opened a stand-alone ER near Overlake in 2005.

Rules on such centers vary by state and region. Most states and local emergency service providers set guidelines on who can be taken by ambulance to the free-standing emergency departments.

In King County, Wash., which includes Seattle, ambulances can take willing patients to stand-alone centers if the patients don't need paramedic care and don't seem to be having a heart attack, stroke, abdominal aneurysm or trauma.

Still, 85% of all emergency patients arriving at hospital emergency departments don't come by ambulance, Centers for Disease Control and Prevention statistics show. Some health experts wonder if those patients understand the difference between stand-alone centers and full-scale hospitals.

"There's been a lack of education to consumers," Unland says. "It would not surprise me … to see some regulation that when hospitals advertise (free-standing centers), they have to be specific about what they can and can't do."

Choked highways to hospital

In Maryland, hospital and state officials agreed the growing Germantown area needed its own ER, mainly to save residents from the drive down congested highways to the closest hospital, Shady Grove Adventist in Rockville, Md.

Maryland lawmakers approved the project as a pilot — and directed the state health department to create licensing standards for such stand-alone facilities. Ambulance crews are instructed not to bring patients to the free-standing center if it seems likely they will need to be hospitalized.

In its first year, the new center treated 22,010 patients. Of those, about 7% were taken to a hospital, mainly by ambulance. A helicopter was used in seven cases, mostly trauma patients or children needing specialized care at a children's hospital.

That year, the stand-alone emergency department helped reduce visits to Shady Grove's hospital ER by about 10,000, says Michael McAdams, an assistant chief with the Montgomery County Fire & Rescue Service.

Taking patients to the stand-alone center also saves travel time for the rescue crews based around Germantown, increasing their availability to handle other emergencies, he says.

Yet, some health care experts, including Maryland's Emergency Medical Services Systems Director Robert Bass, say that although stand-alone centers might help their communities, they won't solve overcrowding that plagues many urban emergency centers.

The stand-alone center didn't reduce the amount of time that Shady Grove diverted ambulances to other hospitals because it was overloaded. In fact, state records show the diversion time more than doubled in the year after the free-standing ER opened.

That's because two emergency departments — the hospital's and the free-standing facility — are now sending patients who need a hospital bed to Shady Grove, says Bass.

"If you're seeing more patients and admitting more patients … those patients are competing for beds," he says.

Still, he approves of stand-alone ERs — when patients use them properly.

"If you have chest pain or signs of a stroke, call 911," he says. "On the other hand … if you fall and think you may have a broken arm … or feel ill and don't know if you have the flu, it is perfectly appropriate to go to a (stand-alone) center like that."