Free Standing ED's losing medicare reimbursement

[SangriaSalsa]

Medicare Advisers Recommend Payment Cuts To Many Free-Standing ERs

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[southerndoc]

I saw this a few weeks ago when MedPAC recommended it. Surprised it didn't become news sooner. There are some exclusions, but I think it might cause some FSER's to close.

 

[xaelia]

Was just a matter of time.

Probably only the beginning of the squeeze.

 

[The White Coat Investor]

Legislative/regulatory risk has always been the big concern with these cash cows. Funny how one little change can so dramatically change an industry and make it economically non-viable.

I couldn't believe how depressing the FSED section meeting was at ACEP last year. I mean, there were no tears but it was a far cry from the enthusiasm seen a couple of years before.

 

[miacomet]

Legislative/regulatory risk has always been the big concern with these cash cows. Funny how one little change can so dramatically change an industry and make it economically non-viable.

I couldn't believe how depressing the FSED section meeting was at ACEP last year. I mean, there were no tears but it was a far cry from the enthusiasm seen a couple of years before.

Regulators want to shut down anything where doctors can have freedom and make money. I know you are a proponent of SDGs, and I agree, but as a group you still have to put in unpaid time maintaining your contract, and while the docs individually may not be employed by the hospital, the group is, and groups lose their contracts all the time. FSEDs were the only way to escape the employer-employee relationship. Now that's going, too. UCs for all, I guess.

 

[deleted206819]

It is a squeeze for those accepting Medicare (especially those associated with a hospital) as it would be untenable for them to continue to see patients at 30% decreased reimbursements. This may have an impact on the private insurers as well but that remains to be seen.

 

[deleted109597]

It is a squeeze for those accepting Medicare (especially those associated with a hospital) as it would be untenable for them to continue to see patients at 30% decreased reimbursements. This may have an impact on the private insurers as well but that remains to be seen.

You realize only ones associated with a hospital do take Medicare, right? That independent freestandings aren't choosing not to do this, but have no actual ability to bill Medicare. There is no set place in the law to allow them to, as they aren't recognized by CMS. Yet state laws require them to see those patients, right?
No, you don't. Clearly.

ASCs have the same 30% cut. They're doing ok. Some will close, but mostly the stupid hospital competing ones that are across the street from their rivals.

 

[Arcan57]

You realize only ones associated with a hospital do take Medicare, right? That independent freestandings aren't choosing not to do this, but have no actual ability to bill Medicare. There is no set place in the law to allow them to, as they aren't recognized by CMS. Yet state laws require them to see those patients, right?
No, you don't. Clearly.

ASCs have the same 30% cut. They're doing ok. Some will close, but mostly the stupid hospital competing ones that are across the street from their rivals.

The concern is that private insurance follows suit and everyone takes the cut. A 30% cut needs to be compensated for by an increase in volume and some of the FSEDs are not going to have that increase available. Also as volume increases the things that make FSEDs attractive to consum... I mean patients start disappearing. Unless you figure out how to smooth our arrival times, the typical skeleton crew of MD, nurse, tech will be overwhelmed as all their patients come in within a couple of hours during the evening rush. If you’re now waiting a couple of hours to be seen, UCs or waiting to see the doc in the am start looking more attractive.

 

[deleted109597]

The concern is that private insurance follows suit and everyone takes the cut. A 30% cut needs to be compensated for by an increase in volume and some of the FSEDs are not going to have that increase available. Also as volume increases the things that make FSEDs attractive to consum... I mean patients start disappearing. Unless you figure out how to smooth our arrival times, the typical skeleton crew of MD, nurse, tech will be overwhelmed as all their patients come in within a couple of hours during the evening rush. If you’re now waiting a couple of hours to be seen, UCs or waiting to see the doc in the am start looking more attractive.

Private insurance doesn't follow the model at ASCs, mainly because they see the outcomes are better. I'm sure they will follow suit with FSEDs as well.
Also, remember this rule is only for FSEDs within 6 miles of a hospital. While this probably covers a majority, it's not all of them.
I'm not sweating, but I don't have 5 of these within 10 miles. I'm what this will actually do is drive the insured patients away from the Hospital owned entities as they try to increase their volumes. And that will make independent joints even better.

 

[Arcan57]

Private insurance doesn't follow the model at ASCs, mainly because they see the outcomes are better. I'm sure they will follow suit with FSEDs as well.
Also, remember this rule is only for FSEDs within 6 miles of a hospital. While this probably covers a majority, it's not all of them.
I'm not sweating, but I don't have 5 of these within 10 miles. I'm what this will actually do is drive the insured patients away from the Hospital owned entities as they try to increase their volumes. And that will make independent joints even better.

How do you show improved outcomes for URIs? I think studies would probably find increased utilization and cost without improvement in outcomes since most of what walks into a FSED is benign and self-limited.

 

[Vandalia]

There are two distinct yet separate issues. First, as mentioned, this does not directly effect the vast majority of physician-owned FSEDs. However, while that is true, it also clearly highlights the vulnerability of those facilities to destruction with one regulation or one insurance company decision. If you read the "research" coming out of insurance companies, it is clear they are building a factual base to limit FSED reimbursement to urgent care rates. Pay attention to what their "healthcare policy arms" are putting out; that is a sure guide of where they are heading.

ASCs are a different animal. Insurance companies like them since they end up being paid a fraction of the rate for similar in-hospital care. They make their money by efficiency and volume moving a ton of patients through. The insurance-backed healthcare policy analysts report that they bill insurance at 53% of the rate of in-hospital care. Exceptions have probably emerged, but the marketing to EM physicians was that FSED would get reimbursed the same as hospital care and would therefore be profitable '"only seeing 5 patients per day."

Arbitrage never works in medicine; at least for physicians. "Arbitrage" is basically a fancy Wall Street term that essentially means "making a lot of money without much work." The nature of healthcare reimbursement means that there is always another specialty or segment of the industry that is willing to pounce on inefficiencies. Primary care and even to a much lesser extent specialists have the ability to mobilize the public to put pressure on politicians, I don't know if that ability exists with FSEDs.

If you are billing a fraction of the hospital rate and seeing 4 pph, then there is a chance that might survive; however, if your business plan is to survive on reimbursement >> costs, then I would be very concerned with that dynamic. There are certainly some well-run, physician-owned FSEDs that could survive. However, there are also some where the physician-owners will lose their shirts.

 

[deleted109597]

How do you show improved outcomes for URIs? I think studies would probably find increased utilization and cost without improvement in outcomes since most of what walks into a FSED is benign and self-limited.

Most of what walks into some FSEDs is benign and self limited. But most of what walks into regular EDs is the same. So don't feed me that bull****. You know it as well as I do. Otherwise we wouldn't have scads of threads about people bitching about non-emergent complaints.
But yeah, the ****ty study that "proves" FSEDs were worse? It didn't. It showed for similar complaints, FSEDs had lower admission rates and lower prices.
If you really want to bitch about EDs that have terrible utility, look at pediatric EDs. I mean, their admission rates are terrible, and most of their complaints are UC complaints. But nobody cares, because they're hospital based. F that noise. Burn it all down.

 

[enalli]

If you really want to bitch about EDs that have terrible utility, look at pediatric EDs. I mean, their admission rates are terrible, and most of their complaints are UC complaints. But nobody cares, because they're hospital based. F that noise. Burn it all down.

Hold up. Are you really hating on pediatric EDs by comparing them to adult EDs?

 

[Arcan57]

Most of what walks into some FSEDs is benign and self limited. But most of what walks into regular EDs is the same. So don't feed me that bull****. You know it as well as I do. Otherwise we wouldn't have scads of threads about people bitching about non-emergent complaints.

Working in both settings for the last 4 years, the average acuity for FSEDs is markedly lower than the acuity of the hospital based EDs. If you're running fast track in a main ED, sure it's going to look pretty comparable. And the scads of threads isn't that we're overwhelmed with N.E.C.s, it's that our ego considers having to deal with such things beneath us and we feel like sharing our aggrievement.

I'm sure for similar complaints there are lower admission rates for FSEDs. The average FSED patient has private insurance and while the may never have seen their PCP there are a network of hungry specialists that would be all over providing timely outpatient follow up. There are feels like a higher rate of AMAs since if the patient was in the headspace of needing admission they would have gone to a "real" ED. But chest pain and surgical bellies aren't where FSEDs make their money. It's the fast track stuff that hospital based EDs would also be making money on if they had the FSED's payor mix.

But given the vehemence of your post, it feels like you think that I'm against FSEDs. I'm not, I just don't think the arguments are there to convince the insurance companies that FSEDs are better for their patients. The comparison to ASCs is mostly based on having the same ownership model, not the same measurable improvement in outcomes.

 

[deleted109597]

Hold up. Are you really hating on pediatric EDs by comparing them to adult EDs?

Not in the slightest.
I've worked peds EDs for years. 80% of the complaints are "fever" or "URI". It's basically urgent care. Admission rates in the low single digits. I mean, hell, look at the literature for procedures of peds EM fellows. It's atrocious.
But if the complaint against FSEDs is "they aren't sick enough", then you need to look at all the places where people aren't sick.

 

[miacomet]

But then there's this. This. This is genius. It's LICENSED AS AN URGENT CARE.

An E.R. That Treats You Like a V.I.P.

 

[deleted480308]

But then there's this. This. This is genius. It's LICENSED AS AN URGENT CARE.

An E.R. That Treats You Like a V.I.P.

From the article, “Paying more for better, faster care may not be fair, but the concept has been around for decades.”?!?!?!?!

It’s not fair to pay more for better...?

 

[Dr Mantis Toboggan]

He got the idea for a concierge emergency room after helping a patient, an actress, who had fallen off a horse. “I brought her to Mount Sinai,” Dr. Kruger said. “The head of the department came down. We still waited five hours for a CAT scan. I said something is wrong here.”

Lol.

 

[alpinism]

I'm going to go out on a limb and say that she probably didn't need that CAT scan.

 

[enalli]

I mean, hell, look at the literature for procedures of peds EM fellows. It's atrocious.

Atrocious compared to whom? I'm certain Pediatric EM attendings have more pediatric-specific procedures under their belt than EM attendings.

But then there's this. This. This is genius. It's LICENSED AS AN URGENT CARE.

An E.R. That Treats You Like a V.I.P.

They saved the very best part of that article for the end:

Mr. Wilson, who lives just a few blocks away, said he had awakened one morning with a pimple and wondered whether Priority Private Care could take care of it.

“It was really bothering me,” he said. “They said come on over.”

When the concierge E.R. is empty, a visit for any ailment is welcome.

I really want to know what they did for this man's pimple (I really hope it was just a pimple and not an abscess).

 

[Angry Birds]

From the article, “Paying more for better, faster care may not be fair, but the concept has been around for decades.”?!?!?!?!

It’s not fair to pay more for better...?

It’s says it MAY not be fair to pay more for better, FASTER care.

How is that in the least bit controversial? You get an uninsured young man who was shot in the chest who needs a CT scan and an A-list celebrity who comes in for a non-emergent complaint and wants to pay for a CT scan. Who gets the CT scanner first in your world and why?

 

[Hamhock]

Atrocious compared to whom? I'm certain Pediatric EM attendings have more pediatric-specific procedures under their belt than EM attendings.
.

I wouldn't be so certain.
I would bet 'EM to PedsEM' attendings have more peds procedures than your typical EM attending; but I would definitely not bet a 'Peds to PedsEM' attending has more pediatric procedures...and I would bet their overall procedural competence is much less.
HH

 

[deleted480308]

It’s says it MAY not be fair to pay more for better, FASTER care.

How is that in the least bit controversial? You get an uninsured young man who was shot in the chest who needs a CT scan and an A-list celebrity who comes in for a non-emergent complaint and wants to pay for a CT scan. Who gets the CT scanner first in your world and why?

In “my” world, whoever owns the scanner sets the rules. If they are a charity based location it’s fine to go by “most medically urgent “. If they are a profit center, it’s also fine to go by “who is willing to pay the most for next in line”. It’s not at all unfair sell better and faster as a commodity with a price tag attached.

(Full context, I also don’t think emtala should exist)

 

[Angry Birds]

In “my” world, whoever owns the scanner sets the rules. If they are a charity based location it’s fine to go by “most medically urgent “. If they are a profit center, it’s also fine to go by “who is willing to pay the most for next in line”. It’s not at all unfair sell better and faster as a commodity with a price tag attached.

(Full context, I also don’t think emtala should exist)

Full context, you’re nuts.

 

[deleted480308]

Full context, you’re nuts.

You are capable of crafting a more relevant response and if you choose to do so we can discuss it further

 

[emergentmd]

I wouldn't be so certain.
I would bet 'EM to PedsEM' attendings have more peds procedures than your typical EM attending; but I would definitely not bet a 'Peds to PedsEM' attending has more pediatric procedures...and I would bet their overall procedural competence is much less.
HH

Other than sutures, and the occasional fracture reduction the vast majority of my shifts in PedEM has no attached procedures. In my adult EM shifts, There are procedures all over the place but so happy our midlevels does all the abscesses, sutures, and even fracture reduction.

I stick with lines, intubation, bad fractures, sedation/reduction which I would be happy if this went down too

 

[Angry Birds]

You are capable of crafting a more relevant response and if you choose to do so we can discuss it further

I prefer childish name-calling and angry trolling.

 

[Southpaw]

You are capable of crafting a more relevant response and if you choose to do so we can discuss it further

Free market capitalism and deregulating health care is one argument, and what is reasonable in a life or death situation is another. I don’t think an obvious mixing of the two is well tolerated in a developed country such as ours.

 

[The White Coat Investor]

In “my” world, whoever owns the scanner sets the rules. If they are a charity based location it’s fine to go by “most medically urgent “. If they are a profit center, it’s also fine to go by “who is willing to pay the most for next in line”.

I'm pretty capitalistic, but I don't think I'd go that far. Medicine is still a profession even if it is a business too. Remember we're talking about a GSW chest here not just saying "this person needs it slightly more".

 

[TooMuchResearch]

Hmm, yeah I'm sending the trauma patient to CT though in my experience GSW to the chest doesn't typically need a CT.

 

[TooMuchResearch]

I guess the ones where it was really GSW to the belly but surprise it's in the chest

 

[deleted206819]

You realize only ones associated with a hospital do take Medicare, right? That independent freestandings aren't choosing not to do this, but have no actual ability to bill Medicare. There is no set place in the law to allow them to, as they aren't recognized by CMS. Yet state laws require them to see those patients, right?
No, you don't. Clearly.

ASCs have the same 30% cut. They're doing ok. Some will close, but mostly the stupid hospital competing ones that are across the street from their rivals.

I actually do. I am a partner in our freestanding company.

My post may have been incorrectly worded but your snarkiness is not warranted.

 

[GeneralVeers]

The person paying for the CT scan is subsidizing the scanner so that the person with no insurance can get a free scan.

I don't think EMTALA should exist in its current form. Rather every patient seen under EMTALA but who cannot pay should be paid for by the government, since they are the ones mandating we have to do this.

 

[deleted109597]

I actually do. I am a partner in our freestanding company.

My post may have been incorrectly worded but your snarkiness is not warranted.

Yeah it is. People who own FSEDs are constantly being told by "the real ER doctors" that we aren't taking care of emergencies. So I come out swinging.
If you're a partner, then it's appalling that you would have written what you did. It smacks of little basic understanding and the common complaint against independent freestandings. Since I don't know you from Adam, can only infer from what you write.

 

[deleted109597]

Atrocious compared to whom? I'm certain Pediatric EM attendings have more pediatric-specific procedures under their belt than EM attendings.

Nah, you'd be wrong statistically. There's plenty of data to that point. PedsEM simply doesn't do that many procedures. Is it possible that there are docs out there that have been doing it for 40 years who might have more than others? Sure. But that's not common, I promise.

 

[deleted206819]

Yeah it is. People who own FSEDs are constantly being told by "the real ER doctors" that we aren't taking care of emergencies. So I come out swinging.
If you're a partner, then it's appalling that you would have written what you did. It smacks of little basic understanding and the common complaint against independent freestandings. Since I don't know you from Adam, can only infer from what you write.

What did I write in this forum post that got you riled up? That a 30% decrease in reimbursement for those hospital-owned or hospital-affiliated freestandings would be detrimental? That's the truth. These facilities around where we are see gobs of these types of patients, are staffed by FP or IM physicians, cannot handle acute conditions, call 9-1-1 to help stabilize, and other shenanigans. They are the ones that will be in trouble.

The independent freestanding like ours are staffed by board certified emergency physicians who also practice in the hospital EDs. We don't take and can't bill for Medicare. We still see far more acuity than people think and transfer dozens a month.

Look back on the threads that I've posted about freestandings and see where I come from.

 

[Birdstrike]

How do you show improved outcomes for URIs?

By not treating them at all. Benign neglect.

But that clashes with "patient satisfaction."

God strike me down!⚡️

 

[emergentmd]

All EM docs should be thankful and grateful for FSEDs. There is Absolutely Nothing but positives from an EM profession/reimbursement standpoint.

If FSEDs were allowed in All states, which IMO it should then all of your Pay would go up an substantially. Everyone making $175/hr would automatically get a $50-100/hr bump. All docs would be fleeing to the FSEDs making 175/hr and would drive up your sought after skills.

We live in a capitalistic world, there is no reason a doctor can not open a legal office practice.

 

[Vandalia]

All EM docs should be thankful and grateful for FSEDs. There is Absolutely Nothing but positives from an EM profession/reimbursement standpoint.

Sure. In the same way it would be great for patients if every physician would agree to work for free. (There was one crackpot candidate for Governor about 20 years ago who said she would solve the state budget deficit without raising taxes by getting teachers and the state police to work for free.)

The problem with that analysis is that in a capitalistic (sic) world, everyone else gets to be capitalistic as well. That means insurance companies who will demand you significantly undercut the price of the competition to get their business, and in that scenario hospitals will also be able to refuse to accept transfers from FSEDs as well.

What really undercuts the job market is physicians who end up going bankrupt in bad ventures who are so desperate they are willing to work for $50/hour.

 

[enalli]

The problem with that analysis is that in a capitalistic (sic) world, everyone else gets to be capitalistic as well.

What's with the "sic"? It was spelled and used correctly.

 

[Siggy]

What's with the "sic"? It was spelled and used correctly.

Probably that the system is not a laissez faire capitalistic utopia with no government intervention.

 

[emergentmd]

Sure. In the same way it would be great for patients if every physician would agree to work for free. (There was one crackpot candidate for Governor about 20 years ago who said she would solve the state budget deficit without raising taxes by getting teachers and the state police to work for free.)

The problem with that analysis is that in a capitalistic (sic) world, everyone else gets to be capitalistic as well. That means insurance companies who will demand you significantly undercut the price of the competition to get their business, and in that scenario hospitals will also be able to refuse to accept transfers from FSEDs as well.

What really undercuts the job market is physicians who end up going bankrupt in bad ventures who are so desperate they are willing to work for $50/hour.

I find it impeding to our profession when other physicians and worse, other EM docs rail against FSEDs.

What other specialty is the medical field so negative about when it comes to physician ownership and control? Why are radiologists owning their own imagining center? Why are Gi docs owning their own outpt suites? Why are surgeons having their own surgery centers?

Why not cut their reimbursement compared to hospital reimbursement to run them out of business? Lets Pay the GI docs $200 for a colonsocopy and start to control their profession. Soon enough, we will have true Universally government controlled healthcare. And you know what will happen when the government controls anything. Welcome to the USPS of healthcare. I use Fedex and UPS and pay more but I guess I still enjoy good customer service and quality.

 

[dchristismi]

I worked at a FSED last night. Sweet gig. Might have been my best overnight shift ever, and I mean EVER.

Same place a couple weeks ago saw an imminently-rupturing AAA. And the shift before last night had a DKA/septic/acidotic/trop-that-went-to-30 ICU player.
But the majority? Ankle sprains that were actually ankle sprains (ie not tibiotalar dislocations), a few rashes, a kid with a buckle fracture, an appy, one little monkey jumping on the bed who needed a scalp staple... Some EM, some UC, but a very pleasant 12 hours.

 

[emergentmd]

I worked at a FSED last night. Sweet gig. Might have been my best overnight shift ever, and I mean EVER.

Same place a couple weeks ago saw an imminently-rupturing AAA. And the shift before last night had a DKA/septic/acidotic/trop-that-went-to-30 ICU player.
But the majority? Ankle sprains that were actually ankle sprains (ie not tibiotalar dislocations), a few rashes, a kid with a buckle fracture, an appy, one little monkey jumping on the bed who needed a scalp staple... Some EM, some UC, but a very pleasant 12 hours.

Wow.... you work at a very busy ER with high acuity.....

And Im not kidding.....

 

[VA Hopeful Dr]

I worked at a FSED last night. Sweet gig. Might have been my best overnight shift ever, and I mean EVER.

Same place a couple weeks ago saw an imminently-rupturing AAA. And the shift before last night had a DKA/septic/acidotic/trop-that-went-to-30 ICU player.
But the majority? Ankle sprains that were actually ankle sprains (ie not tibiotalar dislocations), a few rashes, a kid with a buckle fracture, an appy, one little monkey jumping on the bed who needed a scalp staple... Some EM, some UC, but a very pleasant 12 hours.

That book haunts my dreams...

 

[deleted109597]

Wow.... you work at a very busy ER with high acuity.....

And Im not kidding.....

We have a helipad at mine. STEMI, strokes inside the tPA window, head bleeds, major trauma, DKA, HHS, you name it. We admit ~10%.
Not all of them are glorified UC, but all the ivory tower guys like to pretend like they are.

 

[emergentmd]

We have a helipad at mine. STEMI, strokes inside the tPA window, head bleeds, major trauma, DKA, HHS, you name it. We admit ~10%.
Not all of them are glorified UC, but all the ivory tower guys like to pretend like they are.

What you are describing sounds like a hospital system FSED extension who takes all comers. Those places can be busy. I know some hitting 40-50/dy with single coverage. That essentially defeats the purpose of a relaxed environment.

 

[deleted109597]

What you are describing sounds like a hospital system FSED extension who takes all comers. Those places can be busy. I know some hitting 40-50/dy with single coverage. That essentially defeats the purpose of a relaxed environment.

Mine isn't hospital affiliated. We are just busy. Not 40-50/day, but busy enough. It just happens to be relatively high acuity.
1pph isn't that bad.

 

[enalli]

We have a helipad at mine. STEMI, strokes inside the tPA window, head bleeds, major trauma, DKA, HHS, you name it. We admit ~10%.
Not all of them are glorified UC, but all the ivory tower guys like to pretend like they are.

Are the strokes and STEMIs that you're seeing people who just walked in, or do you have ambulances bringing you some of these? If the latter, how far are you to the nearest tertiary center?

 

[deleted109597]

Are the strokes and STEMIs that you're seeing people who just walked in, or do you have ambulances bringing you some of these? If the latter, how far are you to the nearest tertiary center?

No EMS traffic.
32 miles.