May 21, 2024
New freestanding ERs: Faster care, but it can cost you

By Michelle Crouch

From SouthPark to Steele Creek, Mountain Island Lake to Waxhaw, sleek and efficient freestanding emergency rooms are springing up across the Charlotte region to serve patients, no hospital required.

Since 2010, Atrium Health has opened eight standalone emergency rooms in the Charlotte metro area, part of a nationwide building boom. Two more are on the way, with openings planned in Ballantyne later this year and in Concord in 2025. Also in the region, CaroMont Regional Medical Center operates a freestanding ER in Mount Holly.

The trend is playing out in other parts of the state, too, with new freestanding ERs in the Triangle and in Greensboro, and others coming to the Asheville area. 

For patients, the facilities are more convenient and typically have shorter wait times compared with hospital-based ERs, which are often more crowded. Patients visiting one for the first time are often astounded at how quickly they can get in and out.

But weeks later, they may be astounded again when they get the bill — with hospital-like charges that can total thousands of dollars for an hour-long visit.

As more freestanding ERs open in North Carolina and nationwide, some health care researchers are raising questions about whether the convenience is worth the escalating costs and confusion they can create for patients.

And then there are questions about access. 

Although hospitals say standalone facilities boost access to care, they tend to be mostly in affluent suburbs and not rural or low-income areas.

“You hear the argument that they are serving rural areas, but that’s not the case,” said Daniel Marthey, a researcher at Texas A&M who studies freestanding ERs. “Where they locate tends to be in suburban areas. They are targeting privately insured patients who are paying more, and that’s raising the price of care for all of us.”

Studies show many patients go to standalone ERs for problems that could be treated at a lower-cost urgent care center, while others go in with conditions that need a higher level of care, so they have to wait for (and pay for) an ambulance transfer to a hospital.

The rise of hospital-free ERs

In 2001, freestanding ERs accounted for just 1 percent of all emergency departments nationwide. By 2016, that proportion had risen to 11 percent, according to Becker’s Hospital Review. More recent numbers are hard to come by, but experts said the trend has accelerated.

In some states, such as Texas, hundreds of standalone facilities have opened, including many not linked to a larger health system.

The trend has unfolded more slowly in North Carolina, mostly because freestanding emergency departments (EDs) are regulated through the state’s Certificate of Need approval process. The state requires them to be affiliated with a hospital.

Atrium, which operates almost half of the state’s 16 freestanding ERs, chooses locations “with expansion and ease of access in mind,” according to an email from Jennifer Sullivan, an emergency medicine physician and Atrium’s senior vice president of strategic operations.

“This has become an easier option for patients, because they can drive themselves or a family member, as opposed to an ambulance perhaps bringing them,” she said. 

The centers allow the system to manage infrastructure costs, since it can serve an area without building an additional full hospital, Sullivan said, adding that Atrium uses them to “service rural areas better — like Waxhaw, Kannapolis and in rural Georgia.”  

In addition, she said, freestanding ERs “take some of the patient pressure off of the hospital-based ERs.” 

Other N.C. hospitals are also ramping up construction of the facilities. 

In the Triangle area, WakeMed Health & Hospitals opened its fifth standalone ER in early 2024. In a recent podcast, WakeMed’s senior vice president for strategic ventures and ambulatory operations, Carolyn Knaup, touted WakeMed’s success with the facilities. 

“We feel that health care is truly local,” Knaup said on an April 2024 podcast produced by the architectural firm that designed the facilities. “When you look at our geography, and you see our three hospitals, our standalones are strategically placed around those three hospitals. The thought process is that the standalones would feed the hospitals, if the patients at the standalones would need to be admitted or need a higher level of care.”

Nashville-based HCA Healthcare, which owns Mission Health in Asheville, has also been aggressively building freestanding facilities across the country. It already has approval to build its first two N.C. facilities in Arden and Candler, which are outside of Asheville.

Winston-Salem-based Novant Health has two freestanding EDs. One is in Bluffton, a fast-growing community outside Hilton Head, S.C., and the other is in the Scotts Hill area of Wilmington, on a site where Novant said it plans to open a full-scale hospital in 2026.

A strategy to capture affluent patients?

Nationally, research shows freestanding facilities generally cater to a higher income population that already has access to health care, with 76 percent located within six miles of the nearest hospital. Studies show they are also more likely to be located in ZIP codes with lower proportions of Medicaid patients.

That’s reflected in the Charlotte region, where most freestanding facilities are in more affluent suburbs.

Experts said the the centers are typically part of a hospital strategy to target higher income, privately insured patients and funnel them into their system instead of a competitor’s.

“It’s about blanketing your market space and increasing your share of the market,” said Tina Marsh Dalton, an economist at Wake Forest University who studies health policy.

Revenue from freestanding facilities can also help health systems subsidize their hospital-based emergency departments, which provide more discounted and free care, she said.  

Marthey and his colleagues found that patients who visit freestanding facilities are younger, healthier, more likely to be privately insured, and less likely to be identified as Black or Hispanic compared with those who go to traditional ERs.

In addition, a larger share of freestanding visits are due to issues that could have been managed in a less expensive setting, Marthey said.

“Basically, what we’re seeing is patients coming to these facilities for conditions that could be treated in an urgent care center for a 10 times lower cost,” Marthey said.

Better service, but at a price

Curt Warner, 66, of the Ballantyne area in Charlotte, said he had a great experience on Christmas Eve when he took his 22-year-old son to the Atrium freestanding emergency department in Waverly for stitches.

“It was a very smooth experience,” Warner said. “I was very happy with the service and the cleanliness, the level of care was excellent, and the wait time was reasonable, especially for Christmas Eve with nothing else open.”

But he said he was taken aback a few weeks later when he got the bill, which was more than $3,000. After insurance kicked in, Warner said he was on the hook for about $1,750.

“Almost $2,000 for a few stitches? That seems like a crazy high price,” he said.

Health insurers, faced with a growing number of claims from freestanding centers, are also concerned about cost. They have publicized price differences as a strategy for encouraging patients to choose lower cost options.

For example, UnitedHealth Group found that the average cost of treating common conditions at a freestanding ER facility ($3,217) is 22 times more than at a physician office ($146) and 19 times more than at an urgent care center ($167).

If you build it…

Do freestanding facilities help reduce crowding at hospital ERs? One study found that an Ohio hospital-based ER did see fewer patients after the system opened two freestanding ERs in the area.

However, the researchers also found that the system’s overall number of emergency visits surged, because many people went to the freestanding centers for care that could have been provided in lower cost settings.

Marsh Dalton said some patients may not understand the difference between an ER and an urgent care.

“Freestanding EDs are a new concept,” she said. “There’s also a question about whether patients really understand when to go to urgent care and when to go to the ED. It’s just not clear with so many choices.” 

Others may go to a freestanding facility for a condition that requires a higher level of care offered only at a hospital, risking a critical delay in getting the treatment they need. They may not realize that many freestanding EDs don’t have operating rooms, pediatric equipment or specialists on site the way hospitals do.

Some patients need a transfer

Emergency physician Tim Lietz, CEO and president of Mid-Atlantic Emergency Medical Associates in Charlotte, said if you are having a time-sensitive, life-threatening emergency, of course you want to go to the closest ER. 

But there are times when you would probably be better off going to one that is part of a hospital, he said. For example, if you are having pregnancy-related complications, if you think you might need surgery, or if you have a particularly complex condition and you think you may be admitted.

“In general, if someone is in their 70s and 80s and is having symptoms, there’s a good chance they’re going to be admitted,” he said. “You can still go to a freestanding emergency department  … but you need to understand you’re probably going to be transferred by ambulance to the hospital. There may be an added cost for that transfer.”  

Jennifer Casaletto, an emergency medicine physician who has worked in freestanding facilities, said you may also face a longer delay if you need a transfer.

“At least in this day and age (when hospital ERs are often at capacity), you could end up waiting in the freestanding ED for several days before a bed becomes available and you can be transferred,” she said.

Heart-breaking delay in care

In rare cases, that type of delay could be devastating — a fact that haunts Lacey Williams of south Charlotte.

In 2017, Williams took her wife, Laura Maschal, to the freestanding Atrium ER in SouthPark for an unrelenting headache.

Doctors initially couldn’t find anything wrong and discharged Maschal, 39. But before the couple got home, Maschal began vomiting uncontrollably and not making sense, so Williams rushed her back. New tests revealed that Maschal had a ruptured blood vessel in her brain. The doctor said she needed emergency surgery to stop the bleeding.  

But there was no surgeon at the freestanding facility — which would not have been the case at most hospital ERs — and no operating room on site.

The ER staff put in an order for Maschal to be transferred to Carolinas Medical Center, Atrium’s level 1 trauma center, but said they couldn’t transfer her until a bed opened up.

It took three hours for the ambulance to arrive, Williams said. By the time they got to CMC, Maschal was brain dead.

“Would there have been a different outcome if we had gone to CMC Main? I don’t know,” Williams said. “But not knowing sucks. And just being there for hours, knowing that your significant other is just bleeding out in her brain and it’s an emergency — but nothing can be done — that was excruciating. I just remember pacing and feeling so much rage.”

In an emailed response to questions about Maschal’s case, an Atrium spokesman said privacy law prevented him from discussing a patient situation without permission, but he emphasized that “safety is always the first consideration in every patient encounter.”

He noted that health care has changed significantly in the seven years since Maschal’s case and that bed capacity is a problem in freestanding and hospital-based facilities.  

“In emergency medicine, we prioritize the most urgent cases, and that includes assigning beds and managing patient transport between facilities,” he said. “There are occasions where we experience delays due to bed availability or transportation capacities. We have multiple processes and pathways in place to help mitigate the impact of this when it happens, with an eye toward being able to expedite care for those most in need.”

These days, Williams said she still feels guilty about not going straight to the hospital, and she shares her wife’s story as a cautionary tale.

“I’ve done a lot of therapy, a lot of making peace,” she said, “but unless it’s something really simple like a broken bone or you need care right away, I would not recommend taking your ill loved one to a freestanding ED.”

This article is part of a partnership between The Charlotte Ledger and North Carolina Health News to produce original health care reporting focused on the Charlotte area. Want more information? Read more here.

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New freestanding ERs: Faster care, but it can cost you

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