This thread wasnt about a hospital's revenue stream. Its why ERs/EDs/ECs are structured the way the way they are.

Stagecoach said:

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I'm told by some experts that the Texas/Colorado markets are a disaster and that other states have and will continue to avoid that model.

The Wonderer, what is your background on this subject?

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I do not have any experience in the Colorado markets other than know that some Texas companies are expanding into it.


Can you describe "disaster"?

Gladly

Seven Costanza said:

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In 2009,Texas became the first state to allow free-standing ERs.

They offer nice, clean, efficient facilities that can take care of your problem with little wait time 24/7.

They charge "ER prices". Many patients don't understand the difference between an ER and an urgent care facility, so they are surprised to see that the fever they went in for winds up costing them $1500 when they get a bill a few weeks later.

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This is true and there has been some proposed state legislative action to remedy the confusion between ER and urgent care

Regardless, I don't know much about the ER P&L but the Urgent Care model is very lucrative. I'd imagine the ER model to be attractive as well but more capital intensive

from a non-business perspective skip the urgent care clinic and see your GP if at all possible

I feel like FSEDs have a bad reputation because it has been fairly new and there have been some shady corporate establishments who have blurred the line between an ER and Urgent Care. So I do understand why people would be upset when they go to an ER, get an ER bill when they assumed that they were going to an Urgent Care. IMO, the fault lies with the FSED that did not educate the patient when they walked in. If you go to a FSED, the doctor or staff should have told the patient that it was an ER, staffed by ER docs/nurses, and you will be getting an ER bill and paying the ER copay. And if all they had was minor and did not need to be in an ER, then they should have been told at check in that they would be better served going to an Urgent care across the street.

I have worked at FSEDs and the confusion usually comes from establishments that are somewhat shady. They are usually corporate owned and have little regard for patient care, appropriateness of service, or what the FSED model should be. They just want volume and squeezing out every little bit of profit.

That is why you are seeing FSEDs opening up with family practice/Internal medicine docs who should be in urgent cares and not ERs. You are seeing places hire any nurses without any ER experience. Again, it comes down making money at the cost of patient care. I suspect the Neighbors and Signature ERs near the university are not staffed with boarded Emergency medicine doctors.

A bunch of ER docs and I are opening a site in Bryan soon and have a hiring post on the Jobs network board. If anyone is interested please contact me because we want to make the quality of care in the Bryan site just as good as a hospital with a much better patient experience at the same or lower costs.


Our mission is to have an ER where you are seeing only ER docs, have experienced ER nurses, experienced ER techs/radiology/lab. We will only have ER docs with years of experience working and the ER is totally owned by these same doctors without any corporate overlord telling us what to do. The same care you would get at any Hospital based ER anywhere in the country but with a better experience.

I relate this to choosing to get the same product from Amazon vs having to go to Walmart. We will deliver the same quality of care without the long ER waits, sitting in a dirty/overcrowded ER with other sick patients, having to be seen in the hallway and with better after care.

We will talk to you after you leave the ER if you have any questions, Call in your prescription to the Pharmacy if you like so you can pick it up after leaving, Send the records to your primary care doctor in order to keep everyone informed for follow up, give you all of your labs/radiology images.

But the bottom line is we don't want to be your urgent care and will tell you that you will be better off going to an Urgent care when something is minor. We absolutely want to make money, but only if its medically proper. Because we are totally owned by ER docs, we can sacrifice profit for doing what is right. There are very few FSEDs anymore that is owned only by the doctors that work there.

out of curiosity, who will be the person to tell the incoming customer "you dont need us, go to an urgent care place down the road"?

This hit my inbox last week and reminded me of this thread; I know folks with both imaging and urgent care (not ER clinics) and from what I've seen, I think urgent care is the better investment but it depends on location.

I do think urgent care can improve on quality of care overall though

Topic is Consolidation in free-standing ER's:

http://www.bizjournals.com/dallas/news/2017/02/14/boom-in-dallas-freestanding-emergency-rooms.html?ana=e_mc_prem&s=scroll&ed=2017-02-15&u=DxUSE8CmZJVJzRiMqzSTFw0884198d&t=1487603675&j=77391831

aggiesq said:

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out of curiosity, who will be the person to tell the incoming customer "you dont need us, go to an urgent care place down the road"?

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In the Early days, FSEDs were similar to the wild west. People put it up, made alot of money, didn't care about customer service or quality of care. They knew people would come b/c the only other choices were Hospital Based ERs. As this model and competition has evolved, you have to distinguish yourself from First Choice type corporate models if you want to be successful.

In our FSED, we care about pt care and satisfaction as much as profit which is not true with the corporate model which will cut any corners to squeeze out more profit for the owners.

So if a pt comes in to our FSED and its something minor like a cold, I would tell them that I do not believe this to be a true emergency and they are better served going to their PCP/Urgent care at a lower price. Some people with insurance that has a $100 ER copay without any other costs may chose to be seen by me in the ER. They have to make that choice but I want them to make an educated one. For some, it may be worth paying extra to see me b/c its a One stop shop. If they go to their PCP and get a CXR ordered or some other testing done, they may have to go to another place or wait for results. If they see me, they will get everything back in less than an hour and have all of their results. The time may be worth the money for them.
I know I would rather pay an extra $100 to get everything done in an hour, get any prescription needed, and pick it up on the way home rather than having to make an appointment, take off work, and then have to take off for Labs/xrays at a later time, and then make another appointment for results.

Anyone coming to our ER will be clear that they are getting an ER bill and charges typical of a full service ER (which is what we do). We make all signs obvious right when you walk in because I rather lose a patient who doesn't Need ER care than an unhappy patient who gets an ER bill when they expected an Urgent care.

texrover91 said:

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This hit my inbox last week and reminded me of this thread; I know folks with both imaging and urgent care (not ER clinics) and from what I've seen, I think urgent care is the better investment but it depends on location.

I do think urgent care can improve on quality of care overall though

Topic is Consolidation in free-standing ER's:

http://www.bizjournals.com/dallas/news/2017/02/14/boom-in-dallas-freestanding-emergency-rooms.html?ana=e_mc_prem&s=scroll&ed=2017-02-15&u=DxUSE8CmZJVJzRiMqzSTFw0884198d&t=1487603675&j=77391831

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Consolidation and closures of FSED are happening b/c the old days of just open and they will come doesn't work anymore in our current environment. This is why First choice is pushing towards bankruptcy.

Physician staffing costs are the highest carrying cost of any FSED, which is close to 50% of the operating costs. Corporate FSEDs have a choice of paying high ER Physician salaries or hiring a Family practice doctor sacrificing quality of care. Our FSED in Bryan (Physicians PremiER ) have the advantage where we can set our pay as low as we need to keep the doors open without sacrificing quality of care. We are committed to keeping the doors open even if we don't get a salary.

Why do FSEDs have ambulances outside of them. Do they send patients to real hospitals in them?

Good insight Med - what type of imaging equipment do y'all have onsite? Looking at an imaging related investment at the moment and curious

FSEDs will have xray, CT, and sono on site per state regs.

Duncan Idaho 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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The fact that these are two different questions is complete bull*****

Quote:

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1. Is your facility in my network?
2. Are all of your doctors in my network?

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I can't imagine any other service where I have to ask if everyone one affiliated with the delivery is actually an employee or an independent contractor that would bill me separately.

The only people that don't think the medical billing system is complete bull****, are the people that haven't gone through it.

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Way back when we were still in BCS, wife had her appendix removed. Involved a night visit to the ER at the in network hospital after a call to the phone nurse.

Got a call from the insurance questioning why we choose an out of network doc.

That particular issue existed long before FSEDs.

Gracias -

The Wonderer said:

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FSEDs will have xray, CT, and sono on site per state regs.

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Do FSEDs typically purchase or lease the imaging equipment?

texrover91 said:

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Good insight Med - what type of imaging equipment do y'all have onsite? Looking at an imaging related investment at the moment and curious

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FSEDs have everything but an MRI which does not have a place in 99.99% of the ED visits.

jac4 said:

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The Wonderer said:

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FSEDs will have xray, CT, and sono on site per state regs.

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Do FSEDs typically purchase or lease the imaging equipment?

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I've seen both.

Thx -

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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The ones in our area are glorified urgent care centers that charge like an ER. Worst of both worlds.

They do have imaging equipment but if you have any injury that requires an ER they will normally transfer you to an ER and you get billed again. Like if you have a broken bone they will xray it tell you it is broken then send you to an ER where they will xray it again because they can't access the xray from the other ER (even if they can).

I would avoid them and go to an urgent care or clinic attached to my docs office or go straight to the ER if necessary.

These places advertising as FSEDs creates confusion and mistrust in what a FSED should be. There are Family practice offices and urgent cares that change to a FSED eventhough they are no better than an urgent care staffed by Primary care physicians who do not have the ability to care for true emergencies.

Our FSED will have the same doctors you get at high volume/high acuity hospital based ERs.

What happened to you should never have happened. If you came to our FSED with a fracture/dislocation that needs reduction, everything will be done in our FSED and you would be sent home. We have the capacity to put you to sleep/monitor you during sedation, reduce the fracture, splint you up, and set up follow up. During business hours, we could even call to set up an appointment for you with the orthopedic surgeon before you leave.

We would never send you to another hospital unless you require a specialists that is not on our call list or require admission. And if you require admission, we would work to get you directly admitted to the hospital.