Freestanding ERs confuse patients — especially when they get the bill

So, when you think of an emergency room, you probably picture the part of a hospital where ambulances bring people who need immediate, life-saving measures.

You probably don’t picture a small facility in a strip mall “next to a nail place.” That’s something altogether different, isn’t it? Like an urgent care, perhaps.

Not according to the bill.

Freestanding emergency rooms are popping up all over the country. While many of them are operated by hospitals, some are operated by independent companies, including the largest provider, Adeptus Health. Some sticker-shocked patients complained in a lawsuit.

The suit targets Adeptus Health, the largest provider of freestanding ERs in the country, claiming that Adeptus “actively conceals its billing practices” and operates a business model meant to “trick patients into believing that its centers are appropriate for non-emergent care for the purpose of extracting extravagant fees.”

NBC News, 4/25/2017

The lawsuit might be a moot point. According to The Dallas Morning News, Adeptus Health filed for bankruptcy in April. Even without Adeptus Health in the picture, many freestanding emergency rooms will continue to operate.

What about EMTALA?

There’s another significant way in which freestanding emergency rooms can differ from hospital emergency rooms. The federal Emergency Medical Treatment and Labor Act (EMTALA) does not apply to them, meaning federal law doesn’t require them to accept all patients regardless of ability to pay. Some states have passed EMTALA-like laws for freestanding emergency rooms, but some have not.

So, are these facilities really emergency rooms, or are they merely urgent care facilities gouging non-emergent patients with ER-like prices? It’s an important reminder to be really sure about the level of care you are seeking before you receive it…or else you could pay a hefty price.


Still think we can solve health care with free-market principles? Just go to the ER.

I’m going to share a Fox News story that has its roots in the federal government’s intrusion in health care and how it led to a man’s death because he had to wait too long to see a doctor.

But it’s not the government intrusion into health care you’re probably thinking of. What really killed John Verrier was not the Patient Protection and Affordable Care Act of 2009 (commonly dubbed Obamacare, but I’ll shorten it to PPACA), but the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA).

You see, this is a story about how the government intruding in health care led to the tragic death of 30-year-old ER patient John Verrier. Verrier died in the waiting room at St. Barnabas Hospital in the Bronx  more than eight hours after he checked in. Apparently the hospital did not have a policy in place to check on people in the waiting room at the ER to make sure they were still present or alive — even after they called his name to be seen and he did not answer.

A little background: EMTALA requires all hospitals that participate in Medicare (which is essentially all hospitals period) to evaluate and stabilize any patient who comes to the emergency room, regardless of ability to pay. Sounds like a good idea, right? I mean, who wants hospitals to turn people with emergency ailments away or dump them onto county hospitals without being stabilized just because they can’t pay the bill? Sadly, the law had to be written because that’s exactly what was happening in the 1980s at an alarming rate. People died. There have even been plenty of cases post-EMTALA where hospitals have dumped patients due to the inability to pay.

Why would hospitals continue to dump patients after EMTALA said they couldn’t? Because, as Avik Roy of Forbes wrote, EMTALA is “one of the great unfunded mandates in American history.”

So what does this have to do with John Verrier’s death? According to a report on the case in the New York Post, a hospital employee said, “He died because [there’s] not enough staff to take care of the number of patients we see each day. We need more staff at Saint Barnabas.”

It makes sense, doesn’t it? If the federal government requires hospitals to accept all patients regardless of their ability to pay, then you can expect two outcomes:

1) A lot of people will get care and not pay for it. In fact, according to the Centers for Medicare and Medicaid Services, 55 percent of emergency room care goes uncompensated.

2) A lot of those people who need care but cannot pay for it will end up in the emergency room because, unlike at a traditional physician practice or an urgent care, the ER has to evaluate and stabilize them BY LAW even if they can’t pay. So a lot of people who end up in the ER have non-emergent conditions and would be better off if treated at a lower level of care…that is, if the primary care or urgent care practice would actually treat them since they don’t have to. A study in Health Affairs revealed that:

Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. (emphasis added) Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7–27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually.

So, here’s the perfect storm that led to the death of John Verrier. The unfunded mandate of EMTALA has led to a lot of  uncompensated care at hospitals, so it’s not surprising that hospitals like St. Barnabas don’t dedicate enough staff to the ER — it’s a loss center for them.

From my years of graduate-level study in health administration, I have my suspicions that management best practices are to staff the ER just enough to not violate EMTALA…walk right up to the line, but don’t cross it. Here in Indianapolis, we have a county safety-net hospital called Eskenazi Health. The previous facility was called Wishard Memorial Hospital.

And, according to one of my professors who would be in a position to have firsthand knowledge, there was a common saying among staff and management at private hospitals in the area: “Tube ’em to the Wish,” which meant that the hospital’s policy was to evaluate and stabilize an indigent patient just enough to not violate EMTALA and then dump the patient at the county hospital.

So, back to the understaffed ER at St. Barnabas and John Verrier’s deadly wait, it’s certainly worth considering that EMTALA played a role in his death. He was complaining of a rash, which on its surface would not seem like a life-threatening medical condition, but he was waiting for hours and hours just to be evaluated.

But, of course, I’m not suggesting that we stop requiring hospital emergency rooms to treat everyone without regard to their ability to pay — I’m suggesting that if we mandate something, we need to pay for it. After all, I’m not sure whether John Verrier was insured or not…so simply repealing EMTALA might have killed him too.

And that’s where the other federal law in this story — PPACA — can make a real difference. By passing EMTALA in 1986, we as a country established the idea that health care is a right and not a privilege and not a commodity that can be allocated by Adam Smith’s invisible hand. We just refused to acknowledge the price of this belief because we didn’t want to pay it. But of course there is always a price — there is no free lunch. It comes up in higher hospital bills and higher health insurance premiums for the rest of us. It comes up in hospitals being declared tax exempt because of the amount of charity care they provide to indigent patients.

By addressing the problem of millions of Americans being uninsured, we can reduce the problem of uncompensated care for hospitals that leads to understaffing AND we can give people with non-emergent conditions more appropriate care alternatives where payment will not be a barrier to treatment. PPACA is certainly not a complete answer to the problem, but it’s a big step. Maybe if Ronald Reagan had extended insurance coverage to all Americans back in 1986 instead of just mandating that hospitals see everyone in the ER without regard to ability to pay, then John Verrier and so many others in his situation might have lived.