Freestandings are Starting to Worry Me

[deleted128562]

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[The White Coat Investor]

I've got mixed feelings on them myself.

As an investment, they've been fantastic. Not hard to make money when you break even at 6-12 patients.

As to the ability for a doctor to control his work environment and not be subject to a hospital contract, they're awesome.

As to the ability of the doctor to get some of the 80% of ED cost that goes to the facility fee, I love it

As to the ability to provide top notch customer service to the well-heeled, they're very good.

For the medical system as a whole, I'm much less convinced of their merits. There are still plenty of patients who can't tell the difference between an urgent care and a FSED. At least in my town, we need fewer EDs, not more. By having more, you have more emergency docs sitting on their duff, more patients being seen in an ED without a full call panel, an MRI, or bread and butter EM lab tests. As people have found, concentrating pathology is useful. We have trauma centers, STEMI centers, stroke centers etc presumably because they provide better care, but somehow we think that having an ED every couple of miles in the nice parts of town is improving care? It's even better for emergency docs to be in triple coverage+ shops than single coverage shops. There's more surge capacity, and it's much easier to put an extra doc on. In a single doc shop, adding a second one is a big deal financially.

In short, I applaud the entrepreneurship, but I'm not sure it's the right thing for the system.

 

[deleted109597]

I'll probably going to get crucified for knocking freestandings, but oh well. I'm interested in starting the discussion.

It's a reasonable discussion

I work occasionally at a freestanding ED. Like the other freestandings in our town we bill ourselves as a fully capable emergency department.

How often is "occasionally", and is this a hospital outpatient department or an independent freestanding?

But the more I work there, the more I don't think that's the case. We have very limited testing. I can't get a lipase, lactate, APAP conc, salicylate conc, CSF studies, synovial fluid analysis, etc etc etc without a 2 or 3 hours sendout.

That's a systems problem. There should be a courier ready within 30 minutes. Now, if the referral lab takes 2 hours to get those results to you, that's actually pretty standard for most hospitals.
Lactates are commonplace on most Piccolo, iStat, or any other POC lab. Lipase requires a high complexity lab, so almost every FSED uses amylase as a less than stellar substitute. You can run CSF and synovial fluid on the CBC instrument and get cell counts. Salicylate and APAP aren't that big of a deal. You can give a dose of acetadote if you feel like it. A dying salicylate overdose knowing the number isn't that important.

We don't have multiple meds that I give regularly in the hospital ED setting.

Are there specific ones you want and are lacking? Talk to your medical director. Or expand your pharmacology. They've got almost every class, they just might not have the one you want. Ours has ketamine, tPA, levophed, etc...

The rate of sick patients is so low that when one does come in, no one knows where stuff is at and the nurse and tech freak out. Any true or semi-true emergency has to get transferred after arguing with 47 hospitalists. I'd chalk this up to my shop, but I've been talking with several friends about this who are having similar experiences in other places.

This is no different than working at any rural hospital. Except that nobody points this out during their "antiFSED" diatribe. I would argue that the doctor should be able to control the situation and calm the nurse and tech down. Unless they too aren't comfortable with sick patients.

How is any of this better for patients aside from the ones that could have gone to an urgent care in the first place? Anyone who's actually sick, might be sick, or is actually suffering is either going to wait around for hours while I send out labs, drive around at 1AM finding a 24 hour pharmacy because I couldn't give them a stinking dose of phenazopyridine, or get transferred to a hospital where they could have gone in the first place.

It sounds like you've got a different problem. I don't consider phenazopyridine to be emergent, and you could just give them IV lido if you thought their urethral pain was so bad they were dying. I'm not sure what your discharged ED patients do at night, I guess they wait until the pharmacy opens?
Yes, if they need to be admitted, they'll need a hospital. But the FSED workup->admission times are remarkably shorter than the standard ed wait then admission. And if you're having to call a million people, you have a terrible transfer setup. And the doctors working in that hospital ED have the same problems likely. I can get a bed faster from a FSED than from a hospital ED, because they hold beds for us. The hospitals want the insured patients.

I don't know what to tell you or your friends, but it sounds like you work at a terrible place. I have never heard of these problems. You must be at one of the first choice sites.

 

[GeneralVeers]

I love freestanding EDs...

For those of us who are hospital-based it has given us better pay, and created a shortage. Due to the shortage the CMGs are having to work harder to keep existing docs, giving us better schedules and more control over our work environment.

 

[deleted109597]

I've got mixed feelings on them myself.

As an investment, they've been fantastic. Not hard to make money when you break even at 6-12 patients.

As to the ability for a doctor to control his work environment and not be subject to a hospital contract, they're awesome.

As to the ability of the doctor to get some of the 80% of ED cost that goes to the facility fee, I love it

As to the ability to provide top notch customer service to the well-heeled, they're very good.

All of these are true

For the medical system as a whole, I'm much less convinced of their merits. There are still plenty of patients who can't tell the difference between an urgent care and a FSED. At least in my town, we need fewer EDs, not more.

You might, but my town doesn't.

By having more, you have more emergency docs sitting on their duff, more patients being seen in an ED without a full call panel, an MRI, or bread and butter EM lab tests. As people have found, concentrating pathology is useful. We have trauma centers, STEMI centers, stroke centers etc presumably because they provide better care, but somehow we think that having an ED every couple of miles in the nice parts of town is improving care? It's even better for emergency docs to be in triple coverage+ shops than single coverage shops. There's more surge capacity, and it's much easier to put an extra doc on. In a single doc shop, adding a second one is a big deal financially.

In short, I applaud the entrepreneurship, but I'm not sure it's the right thing for the system.

Concentrating pathology is useful. But there's something to be said for decreasing waits. Is it ok for nonemergencies to wait? Sure. But every single lobby death was because people aren't very good at picking the needles out of the haystack, and allowing a therapeutic wait is going to lead to that.
Do we need them on every corner? I'm not sure. Some places might. In Houston at the Texas Medical Center, there are two Level 1 trauma centers across the street from each other, and 7 other hospitals in ~.5 miles. So there are probably places that this would work. Just like places where there are 2 starbucks caddycorner to each other.

 

[Brahnold Bloodaxe]

Ha, who cares if it's good for "the system." The system doesn't care about you at all except when it comes to figuring out how to shortchange you at every opportunity. That alone is reason enough to void any and all concern about "the system."

Furthermore, that money is going to be spent, one way or another. The financial health and long-term sustainability of the system is not altered by the existence of freestanding EDs. The only part of the calculus that freestandings affect is the identity of those pocketing the money, not the amount of money being spent. It's a bit weird to see an EM doc complaining about, in effect, that some of the money generated from seeing patients is being diverted from the pockets of empty suits to the physicians actually doing the work.

 

[The White Coat Investor]

Ha, who cares if it's good for "the system." The system doesn't care about you at all except when it comes to figuring out how to shortchange you at every opportunity. That alone is reason enough to void any and all concern about "the system."

Furthermore, that money is going to be spent, one way or another. The financial health and long-term sustainability of the system is not altered by the existence of freestanding EDs. The only part of the calculus that freestandings affect is the identity of those pocketing the money, not the amount of money being spent. It's a bit weird to see an EM doc complaining about, in effect, that some of the money generated from seeing patients is being diverted from the pockets of empty suits to the physicians actually doing the work.

I would agree with that except it seems the suits own more and more of the FSEDs every year.

 

[deleted109597]

I would agree with that except it seems the suits own more and more of the FSEDs every year.

They're not taking over the independents though. They're just building their own. And the largest suit declared bankruptcy.

 

[bravotwozero]

Which one is that?


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[em1234]

first choice

 

[EctopicFetus]

I think it is hard to say that this is better for the system. That being said it is nearly impossible to think this hasnt improved conditions for BC ED docs. While stories of friends in texas and AZ of hours of no work at high pay seem wasteful the reality is when there is a glut of ED docs the hospitals and CMGs run our rates down, treat us like crap etc.

For patients it is bad.. Adeptus aka first choice grew too fast and ran uot of money. They have few repeat visitors as people get really pissed about huge bills for minor complaints.

On the other hand as the GI docs, ortho docs and other surgeons capitalized 20 years ago with independent Surgi centers this is our ability to free ourselves a little from our chains. There is no argument in my mind that this is worse for patients, the system etc. The reality is that EM moreso than any other hospital based specialty is screwed. We can go to surgi centers like anesthesia. We cant go to other non hospital based pathology shops,we dont have the luxury of our outptient rdiology services. We have nothing outside of the hospital based ED. Urgent care doesnt count as this is really a FP alternative.

In the end we should root for their success. We should take advantage of the resulting shortage and demand more control.

my 2 cents.

 

[bravotwozero]

Patients getting huge bills for freestanding ed visits is not the fault of the freestanding EDs, but rather insurance companies who have been increasingly shrinking their 'in networks' and not telling their clients up front they won't be covering freestanding ED visits - hence all the hoopla over 'surprise bills' etc.

this is also an issue at many hospitals EDs. I know of freestanding EDs that are upfront about this with their patients, who show up with minor complaints and tell them that although we're happy to suture up your laceration, you'll likely rack up a $500+ bill. If someone still chooses to use freestanding ED services at that point, then they're responsible for any financial consequences.


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[Dred Pirate]

We have several free standing ED"s in our town who are extensions of one of the big hospitals - (a competitor of ours) - Many times we have EMS bring a patient who was critical to us after driving by them. Once they had a code in their parking lot (a strip mall) and drove them 8 miles to us. Our Doc's asked them why - "They say they are a fully function ED" - our EMS "You know they cant handle this"

Not sure where the disconnect is - but obviously that is a problem if they are treated like a glorified urgent care

 

[mauricekenter]

Each freestanding varies on how much they can handle, just like all hospitals (if you have worked outside of an ivory tower you will understand). However, it doesn't vary depending on the equipment, it varies based upon the staff. There should be all the equipment necessary to handle intubations, chest tubes, crics, central lines, LPs, etc.

The nurses will always be uncomfortable with this because it's not as common as in the hospital, however it is your duty as a board certified ER doc to provide a calm environment and direct the staff in a manor appropriate to get the job done.

I see the same complaints and number of sick patients at the Freestandings compared to my hospital based job. Take away the EMS and it's the same patient population.

Now as far as the labs go, the lipase is the only thing I have found that is pretty annoying since we will never use it at a freestanding and it's commonplace in the hospital based ER.

 

[deleted109597]

HOPDs can accept EMS traffic. Independent can, but the EMS companies are the ones that won't. They don't get reimbursed for alternate transport.
It's really sad when EM has these misconceptions about FSEDs. I get the other specialties not understanding it, but still.
Did the surgeons get called "mediocre" or "subpar" when they made ASCs? Anesthesia and pain clinics? GI? Cards and outpatient caths?

Lipase measuring makes it a high complexity lab. The hoops to jump through to get that are immense.

 

[emergentmd]

Any EM doc who thinks FSEDs are a bad thing are misinformed IMO.
Does it cost more than hospital EDs? NO. And many times less
Are patients better off at hospital EDs? I would say yes 2% of the time, and No 90% of the time. Most complaints will be cared for faster and just as well at a FSED
Has it given EM docs a nice place to relax and work? Yes
Has it given EM docs control? Yes
Has it taken the metrics chain off EM docs? Yes
Has it increased EM docs incomes? Yes

I don't see an issue.

I send my grandmother to the FSEDs over the hospital based EDs for almost everything. She gets faster care, and gets directly admitted from the FSED. Cost is no different.

I don't see the issue.

But if you want the hospital to dictate your life and be a cog in the wheel, then go ahead and work at the hospital. Just remember that your cog is not very valuable and easily replaced.