Explore This IssueACEP Now: Vol 34 – No 02 – February 2015
Angel investors learn early on that you can’t make a market for goods or services; you can only discern it and meet its needs. The two markets in play here would seem to be paying hospital-based ED emergency patients and hospital-based emergency physicians. My theory about why the number of physician/investor-owned freestanding facilities is exploding in Texas is that hospital-based EDs have done a poor job of serving their paying patients and their emergency physicians. By any parameter you can name—physical plant, ambience, convenience, parking, rapidity of care, speed of ancillary services, availability of specialty backup, etc.—the hospital-based ED is trumped by the freestanding. All too often, the hospital treats its emergency physicians as commodities and gives them no say in issues like nurse/tech staffing levels, which electronic health record (EHR) will be used, and most other aspects of the operation of their practice. The tensions and pathos of hospital-based emergency medicine practice are psychologically draining, and constantly having to beg for specialty backup is exhausting and degrading in the extreme. What emergency physician of an age wouldn’t prefer the kind of white-glove practice that goes on in the typical freestanding? The stress and workload are a fraction of that of hospital-based practice; the pay is equivalent; you get to choose how you will equip and staff your ED, which EHR best suits your practice, and everything else; and the specialists come running when you call. So while the proliferation of these facilities may not be good for the safety net, they are clearly good for ACEP members. This creates a significant dilemma for the ACEP leadership.
On the one hand, ACEP would like to avoid taking a position on the issue of physician/investor-owned freestandings because it has members on both sides of the question, but on the other hand, ACEP has a duty to adopt health care system policies that support the preservation of the safety net within the context of the current dysfunctional payment system. ACEP’s current position sidesteps the issue, but if this phenomenon goes national, it will be forced to address it.
As to the economic consequences of the physician/investor-owned facilities, the libertarian in me says let the invisible hand of the market separate the winners from the losers, and this would all be fine except that our government-designed health care “system” pays for indigent and much of entitlement emergency care (when it pays for these at all) through cost shifting. Obamacare, for however long it lasts, is of no help in the ED because it leaves many uninsured out of the program, and its deductibles are so high that its beneficiaries are effectively uninsured for all but a medical catastrophe. In most states, Medicaid pays less than the cost of the care of its beneficiaries, so Medicaid expansion will only further compromise the hospital-based ED. Underinsured and uninsured hospital-based ED volume will continue to grow, and losing paying patients to freestandings must inevitably erode the hospital-based ED’s payer mix.