Ark03 said:

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The Wonderer said:

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Good Bull Jones 17 said:

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Not sure if this is happening all over the country, but I've noticed in Houston, San Antonio, and College Station, in the nice parts of town especially, these "corner ER's" that are not attached to a full hospital or a strip center are popping up everywhere.

They are freestanding ERs and have been around since ~2010.

What's going on the business end of these?

They are identical to the ER you'd find attached to a hospital with onsite imaging, labs, and an ER or family medicine trained physician.

Are they just huge cash flow centers?

Depends on the volume and operations. Obviously, those seeing 30+ patients per day ("PPD") make a lot more than those that see 5 PPD.

Do they charge more for their services since they're convenient, or because they can?

Both.

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The only real difference between FSEDs and those attached to acute care hospitals is that FSEDs cannot accept Medicare/Medicaid/Tricare payments for services.

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I work in employer benefits, so I hear from a lot of people who go to FSEDs for whatever reason. If the only real difference is FSEDs can't accept Medicare, then why to FSEDs always tend to send their real emergency cases to the real ER attached to their hospital?

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Some are suped up overpriced urgent cares. A handful provide some real value.

I see their main value in

1. People who get emergencies after typical urgent hours, such as a laceration. Much better choice than the hospital.

2. Known recurrent conditions that require frequent emergency visits that are too much for your local urgent care to handle but rarely require hospitalization.

I work at a Freestanding ER affiliated with Memorial Hermann. We do accept all forms of insurance and Medicare/Medicaid and Tri-Care.

We operate under the same regulations as our parent hospital, ie Memorial Hermann Katy.

We are set up to handle anything the main ER is set up for. Trauma, STEMI, Stroke, etc.

However, we rarely have any wait times at all. That is the attraction.


Edit: Hermann has about 8 freestanding ER's in the Houston area

malenurse said:

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I work at a Freestanding ER affiliated with Memorial Hermann. We do accept all forms of insurance and Medicare/Medicaid and Tri-Care.

We operate under the same regulations as our parent hospital, ie Memorial Hermann Katy.

We are set up to handle anything the main ER is set up for. Trauma, STEMI, Stroke, etc.

However, we rarely have any wait times at all. That is the attraction.


Edit: Hermann has about 8 freestanding ER's in the Houston area

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That is because you are an HOPD operating under Memorial Hermann's hospital license. That allows you to collect for CMS patients.

Ark03 said:

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The Wonderer said:

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Good Bull Jones 17 said:

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Not sure if this is happening all over the country, but I've noticed in Houston, San Antonio, and College Station, in the nice parts of town especially, these "corner ER's" that are not attached to a full hospital or a strip center are popping up everywhere.

They are freestanding ERs and have been around since ~2010.

What's going on the business end of these?

They are identical to the ER you'd find attached to a hospital with onsite imaging, labs, and an ER or family medicine trained physician.

Are they just huge cash flow centers?

Depends on the volume and operations. Obviously, those seeing 30+ patients per day ("PPD") make a lot more than those that see 5 PPD.

Do they charge more for their services since they're convenient, or because they can?

Both.

---

The only real difference between FSEDs and those attached to acute care hospitals is that FSEDs cannot accept Medicare/Medicaid/Tricare payments for services.

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I work in employer benefits, so I hear from a lot of people who go to FSEDs for whatever reason. If the only real difference is FSEDs can't accept Medicare, then why to FSEDs always tend to send their real emergency cases to the real ER attached to their hospital?

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Because they are not a Level 1 trauma center, they don't have super advanced operating rooms (ORs) or specialized surgeons on call, or a cath lab necessary for heart attack patients, or hyperbaric chambers necessary for some specialized treatments, etc. If the patient is still critical, but stable, they transfer to the ER to continue emergent level services upon arrival while waiting to be sent to the necessary inpatient room/ICU/OR/lab. If it can be done, every effort is made to transfer directly into the awaiting specialty area and skip the ER all together. That is coordinated and determined by the receiving hospital and transferring hospital.

You know who else doesn't have these things a lot of things FSEDs don't? Damn near every rural hospital and most urban hospitals don't have all of them in a centralized location. Some might have all of them within a system of hospitals.

FSEDs are ERs that stabilize and/or diagnose the patient and then transfer via the best method (car/ambulance/air ambulance) to the appropriate facility for further specialized treatment.

Do you think that hospital based ERs don't transfer patients between them/hospitals?

You might confuse some people without that tidbit after reading some of the questions from earlier in the thread.

So as more FSEDs are built, do you think they will expand in size and services offered, and lower prices due to competition?

Good Bull Jones 17 said:

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So as more FSEDs are built, do you think they will expand in size and services offered, and lower prices due to competition?

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No. The first real transition/transformation that we saw with the combo FSED/UC model as a way to expand services and offer lower rates for low(er) acuity issues. Now, I think you'll see (already happening in some cases) some larger (square footage wise) FSEDs convert to micro-hospitals and move towards the hub-and-spoke model to allow HOPDs to branch off for the CMS payment recovery and some preexisting facilities joint venturing with hospitals similar to what Family ER did with Texas Health Resources (owner of multiple hospitals in DFW including Dallas Presby) at the end of 2016.

Texas is over-saturated right now in the major metro areas (San Antonio maybe not so much, but that is a large BCBS and Tricare market) and we are starting to see some of the larger enterprises close failing facilities as a money loss mitigation attempt. The thing to keep in mind about lower prices is that you have to become a "volume dealer" (i.e., a larger PPD average) to break even. At that point, wait times go up and you lose the major appeal you have over hospital based ERs.

I fully believe the future is in the micro-hospitals with associated HOPDs and joint ventures with smaller, established hospital systems that can't afford the upstart capital necessary to open a FSED on their own. The CMS market share is just too big to ignore from a money collection standpoint. We are now seeing the "Texas model" of FSEDs expand to other states. That is where a lot of the new expansion and building is occurring from established FSED market participants. That said, I think you will continue to see some facilities built that are not part of an established enterprise, but it's a much riskier move now than it was, say, four years ago due to the saturation of the three largest metro areas. Most expansion I am hearing of/seeing now is in smaller, regional hub-type cities in north, north central, and east Texas.

And in the mist of all of this, Adeptus Health (Family ER) saw their stock free fall as much as 80-90% during November and December of 2016. That alone caused a major reevaluation of expansions and acquisitions in Q4 last year by mid-major and major market participants, as well as private equity firms and very large health systems.

What kind of BCBS plan is it? If a high deductible health plan ("HDHP"), then your deductibles returned to $0 on Jan 1 and your insurance will not begin supplementing payments until your plan-specific deductible is met.


In the future, don't ask "if they take XXXX insurance," always ask if they are "in-network with XXXX insurance." Nine times out of ten, you will get different answers. They take all insurances, but that doesn't mean that you will get in-network rates if they are not in-network (remembering that ACA requires out-of-network emergency bills (true emergencies) to be paid at in-network prices regardless of plan participation).

The Wonderer said:

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What kind of BCBS plan is it? If a high deductible health plan ("HDHP"), then your deductibles returned to $0 on Jan 1 and your insurance will not begin supplementing payments until your plan-specific deductible is met.


In the future, don't ask "if they take XXXX insurance," always ask if they are "in-network with XXXX insurance." Nine times out of ten, you will get different answers. They take all insurances, but that doesn't mean that you will get in-network rates if they are not in-network (remembering that ACA requires out-of-network emergency bills (true emergencies) to be paid at in-network prices regardless of plan participation).

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It's a PPO, never thought about asking if they're in network as I've only paid a $400 deductible at the older one in my town. The new one was much closer to home so we went there thinking we were covered by the bcbs deductible. Being Jan 1, they were unable to confirm even my deductible amount at the counter that night.

Still outrageously expensive for the minimal services rendered.

aggieforester05 said:

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Still outrageously expensive for the minimal services rendered.

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Have to look at the breakdown of what the charges were. You should have a facility fee for the ER and a physician fee for the doc's time. Two separate bills.

One thing to consider, and I'm not trying to be critical or an ass here, but was it because of amount of time you were there or the actual services provided? One of the number one complaints we hear is that people were "only there for 30 minutes, how can it be so expensive?" Think about the last time you were in a hospital ER and the amount of total time you spent with a physician versus the amount of time you were physically in the ER from sign in to discharge. Again, not being critical at all, just a thought that many people, including me, sometimes forget about.

I don't have that yet, just what's in the bcbs website. Yes that amount included both charges. I don't have a problem with the short amount of time spent (I hate waiting hours at the county ER). It's just that it was a simple exam and two routine tests. I wasn't expecting it to be cheap, maybe $1,500, but not $3,200. Of course everything happens during a holiday or after hours of urgent care or the pediatrician.

aggieforester05 said:

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I don't have that yet, just what's in the bcbs website. Yes that amount included both charges. I don't have a problem with the short amount of time spent (I hate waiting hours at the county ER). It's just that it was a simple exam and two routine tests. I wasn't expecting it to be cheap, maybe $1,500, but not $3,200. Of course everything happens during a holiday or after hours of urgent care or the pediatrician.

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Those charges were set high as a means of transfer payments for uncompensated care. That's my only rub with FSED getting the same reimbursement.

aggieforester05 said:

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I live in a city with a population of 80k, we had two hospital ERs and one stand alone(3-4 years old) up until recently. In the last year three new stand alone ERs were built at the same time. We have one or two small urgent care places that are not 24 hour. Hard to see how all those stand alone ERs will survive charging out of network rates like that. Seems like most people will be scared away after one visit.

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The one with the most money and can outlast the other(s) shall be the victor. That's what FamilyER tries to do. Surround the competition and squeeze them out while bank rolling the losses until they are the only one left. I refer to it as the "vice" model. Of course, they are smart in that they usually stick to strip centers where large retailers have left (usually involuntarily) because they can get a lot of space cheaper than building up a medical building that is stand-alone. They just pay to build the space out to code.

aggieforester05 said:

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So in layman's terms, the county ERs set the rates high to cover the uncompensated services. The stand alone ERs take advantage of that by charging the same rates without the liability of uncompensated services. Sounds like they have a recipe for a gold mine if they can get enough fools to come through the doors.

I live in a city with a population of 80k, we had two hospital ERs and one stand alone(3-4 years old) up until recently. In the last year three new stand alone ERs were built at the same time. We have one or two small urgent care places that are not 24 hour. Hard to see how all those stand alone ERs will survive charging out of network rates like that. Seems like most people will be scared away after one visit.

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Private hospitals too as they all fall under EMTALA

but basically yes.

I have had occasion to utilize the services of two different ER's near my house; both were/are a joke. The quality of care was pathetic. Checked my insurance first then told me I had to pay the insurance allowed ER charge. After all that was squared, they then asked why I was there

The Wonderer said:

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Good Bull Jones 17 said:

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So as more FSEDs are built, do you think they will expand in size and services offered, and lower prices due to competition?

---

No. The first real transition/transformation that we saw with the combo FSED/UC model as a way to expand services and offer lower rates for low(er) acuity issues. Now, I think you'll see (already happening in some cases) some larger (square footage wise) FSEDs convert to micro-hospitals and move towards the hub-and-spoke model to allow HOPDs to branch off for the CMS payment recovery and some preexisting facilities joint venturing with hospitals similar to what Family ER did with Texas Health Resources (owner of multiple hospitals in DFW including Dallas Presby) at the end of 2016.

Texas is over-saturated right now in the major metro areas (San Antonio maybe not so much, but that is a large BCBS and Tricare market) and we are starting to see some of the larger enterprises close failing facilities as a money loss mitigation attempt. The thing to keep in mind about lower prices is that you have to become a "volume dealer" (i.e., a larger PPD average) to break even. At that point, wait times go up and you lose the major appeal you have over hospital based ERs.

I fully believe the future is in the micro-hospitals with associated HOPDs and joint ventures with smaller, established hospital systems that can't afford the upstart capital necessary to open a FSED on their own. The CMS market share is just too big to ignore from a money collection standpoint. We are now seeing the "Texas model" of FSEDs expand to other states. That is where a lot of the new expansion and building is occurring from established FSED market participants. That said, I think you will continue to see some facilities built that are not part of an established enterprise, but it's a much riskier move now than it was, say, four years ago due to the saturation of the three largest metro areas. Most expansion I am hearing of/seeing now is in smaller, regional hub-type cities in north, north central, and east Texas.

And in the mist of all of this, Adeptus Health (Family ER) saw their stock free fall as much as 80-90% during November and December of 2016. That alone caused a major reevaluation of expansions and acquisitions in Q4 last year by mid-major and major market participants, as well as private equity firms and very large health systems.

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Very interesting as, I just found out, our facility is hosting a tour of Emerus doctors this morning.

Something is afoot.

BTW, Wonderer, what is your background?

malenurse said:

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The Wonderer said:

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Good Bull Jones 17 said:

---

So as more FSEDs are built, do you think they will expand in size and services offered, and lower prices due to competition?

---

No. The first real transition/transformation that we saw with the combo FSED/UC model as a way to expand services and offer lower rates for low(er) acuity issues. Now, I think you'll see (already happening in some cases) some larger (square footage wise) FSEDs convert to micro-hospitals and move towards the hub-and-spoke model to allow HOPDs to branch off for the CMS payment recovery and some preexisting facilities joint venturing with hospitals similar to what Family ER did with Texas Health Resources (owner of multiple hospitals in DFW including Dallas Presby) at the end of 2016.

Texas is over-saturated right now in the major metro areas (San Antonio maybe not so much, but that is a large BCBS and Tricare market) and we are starting to see some of the larger enterprises close failing facilities as a money loss mitigation attempt. The thing to keep in mind about lower prices is that you have to become a "volume dealer" (i.e., a larger PPD average) to break even. At that point, wait times go up and you lose the major appeal you have over hospital based ERs.

I fully believe the future is in the micro-hospitals with associated HOPDs and joint ventures with smaller, established hospital systems that can't afford the upstart capital necessary to open a FSED on their own. The CMS market share is just too big to ignore from a money collection standpoint. We are now seeing the "Texas model" of FSEDs expand to other states. That is where a lot of the new expansion and building is occurring from established FSED market participants. That said, I think you will continue to see some facilities built that are not part of an established enterprise, but it's a much riskier move now than it was, say, four years ago due to the saturation of the three largest metro areas. Most expansion I am hearing of/seeing now is in smaller, regional hub-type cities in north, north central, and east Texas.

And in the mist of all of this, Adeptus Health (Family ER) saw their stock free fall as much as 80-90% during November and December of 2016. That alone caused a major reevaluation of expansions and acquisitions in Q4 last year by mid-major and major market participants, as well as private equity firms and very large health systems.

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Very interesting as, I just found out, our facility is hosting a tour of Emerus doctors this morning.

Something is afoot.

BTW, Wonderer, what is your background?

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That's interesting.




I have worked with staffing companies, billing companies and a FSED group since the earlier days of FSEDs in Texas as legal counsel and in strategic business operations.

DallasAggie0 said:

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Some regulations just passed last week that are basically going to drive all the freestanding ER's without hospital affiliation out of business

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Can you send me a link or direct me to these regulations. I cannot find anything online.

These stand alone ER's are great for broken bones etc., as we've gone to one a few times by our house here in Katy. They also do physicals for school sports. Like mentioned, the wait times are a lot shorter but I have found that the service is good.

aggieforester05 said:

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So in layman's terms, the county ERs set the rates high to cover the uncompensated services. The stand alone ERs take advantage of that by charging the same rates without the liability of uncompensated services. Sounds like they have a recipe for a gold mine if they can get enough fools to come through the doors.

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they're being built in better neighborhoods, not the places full of "uncompensated care" customers. pretty smart

nu awlins ag said:

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These stand alone ER's are great for broken bones etc., as we've gone to one a few times by our house here in Katy. They also do physicals for school sports. Like mentioned, the wait times are a lot shorter but I have found that the service is good.

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ER's do not do physicals for school sports. You are probably talking about the Convenient Care Center which has Dr's offices and a freestanding ER in the same facility.

BTW. That's the ER I work.

malenurse said:

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nu awlins ag said:

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These stand alone ER's are great for broken bones etc., as we've gone to one a few times by our house here in Katy. They also do physicals for school sports. Like mentioned, the wait times are a lot shorter but I have found that the service is good.

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ER's do not do physicals for school sports. You are probably talking about the Convenient Care Center which has Dr's offices and a freestanding ER in the same facility.

BTW. That's the ER I work.

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Incorrect. We do it as a free service for high schools in the areas surrounding our facilities. We also provide free concussion baseline testing for those in contact sports if they desire.

El Duke said:

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DallasAggie0 said:

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Some regulations just passed last week that are basically going to drive all the freestanding ER's without hospital affiliation out of business

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Can you send me a link or direct me to these regulations. I cannot find anything online.

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http://www.modernhealthcare.com/article/20170112/NEWS/170119951?utm_source=modernhealthcare&utm_medium=email&utm_content=20170112-NEWS-170119951&utm_campaign=financedaily

Sorry, no official regs yet, but basically MedPAC and CMS are honing on these exorbitant pricing models and are going to start looking at the numbers about who is charging for what.

Can these ER's stay open without charging 2k for burn treatment? We'll see I guess.

Nothing will come of it most likely.

And CMS' opinion is fairly moot on the matter since they don't recognize it for payment anyway.

malenurse said:

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nu awlins ag said:

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These stand alone ER's are great for broken bones etc., as we've gone to one a few times by our house here in Katy. They also do physicals for school sports. Like mentioned, the wait times are a lot shorter but I have found that the service is good.

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ER's do not do physicals for school sports. You are probably talking about the Convenient Care Center which has Dr's offices and a freestanding ER in the same facility.

BTW. That's the ER I work.

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The corner of 99 and 1093? My bad....I got them mixed up.

New developement

http://dfw.cbslocal.com/2017/01/18/i-team-first-ever-lawsuit-filed-against-freestanding-ers/

malenurse said:

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New developement

http://dfw.cbslocal.com/2017/01/18/i-team-first-ever-lawsuit-filed-against-freestanding-ers/

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Oh shiiiiiiiit....

The Wonderer said:

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malenurse said:

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New developement

http://dfw.cbslocal.com/2017/01/18/i-team-first-ever-lawsuit-filed-against-freestanding-ers/

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Oh shiiiiiiiit....

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It's about time!

The Wonderer said:

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Good Bull Jones 17 said:

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Not sure if this is happening all over the country, but I've noticed in Houston, San Antonio, and College Station, in the nice parts of town especially, these "corner ER's" that are not attached to a full hospital or a strip center are popping up everywhere.

They are freestanding ERs and have been around since ~2010.

What's going on the business end of these?

They are identical to the ER you'd find attached to a hospital with onsite imaging, labs, and an ER or family medicine trained physician.

Are they just huge cash flow centers?

Depends on the volume and operations. Obviously, those seeing 30+ patients per day ("PPD") make a lot more than those that see 5 PPD.

Do they charge more for their services since they're convenient, or because they can?

Both.

---

The only real difference between FSEDs and those attached to acute care hospitals is that FSEDs cannot accept Medicare/Medicaid/Tricare payments for services.

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And for anything serious- they will transfer you to a real ER.

These are just cash cows- much like the payday loan places.

If you have an emergency for the sake of your finances please go to a real ER that accepts your insurance in network for all facilities and doctors

Carnwellag2 said:

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The Wonderer said:

---

Good Bull Jones 17 said:

---

Not sure if this is happening all over the country, but I've noticed in Houston, San Antonio, and College Station, in the nice parts of town especially, these "corner ER's" that are not attached to a full hospital or a strip center are popping up everywhere.

They are freestanding ERs and have been around since ~2010.

What's going on the business end of these?

They are identical to the ER you'd find attached to a hospital with onsite imaging, labs, and an ER or family medicine trained physician.

Are they just huge cash flow centers?

Depends on the volume and operations. Obviously, those seeing 30+ patients per day ("PPD") make a lot more than those that see 5 PPD.

Do they charge more for their services since they're convenient, or because they can?

Both.

---

The only real difference between FSEDs and those attached to acute care hospitals is that FSEDs cannot accept Medicare/Medicaid/Tricare payments for services.

---

And for anything serious- they will transfer you to a real ER.

These are just cash cows- much like the payday loan places.

If you have an emergency for the sake of your finances please go to a real ER that accepts your insurance in network for all facilities and doctors

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Mine won't. We've treated gunshots, stabbings, heart attacks, delivered a few babies, infections, etc. You are correct in that we will transfer them once they are stable if they need to be admitted to a hospital for inpatient services, just like a real ER before they transfer to the inpatient side of the hospital.

It might behoove the general public to understand the medical industry a little bit more.

I'm not responding to the last two statements because they are bother false and do not warrant a response.