Freestanding Emergency Departments: C A L I FOR N I A Do They Have a Role in California? H EALTH C ARE F OU NDATION Introduction The California HealthCare Foundation retained The past decade has witnessed a growing trend The Abaris Group to research the extent of FEDs in the operation of freestanding emergency in the United States, inventory their practices, and departments in the United States. The Centers describe California’s experience with FEDs. for Disease Control and Prevention has Issue Brief reported that the number of visits to emergency This issue brief provides an overview of FEDs and departments has increased by 32 percent in the their regulation by federal and state governments. last decade, while the total number of emergency It also presents a short discussion of the environ- departments has decreased by 4.6 percent.1 In a ment for FEDs in California. 2007 American Hospital Association survey, 48 percent of hospitals reported that their emergency History and Overview of department was functioning at capacity or over Freestanding Emergency Departments capacity. The increased utilization of emergency FEDs have existed for almost 40 years, yet these departments, coupled with a decrease in the overall facilities have remained largely unknown to the number of them, and a heightened government public and many in the health care industry. and public focus on quality and performance The concept of a freestanding emergency standards have put great pressure on hospital department emerged in the early 1970s as a systems to change their approach to providing result of the need for emergency care in rural or episodic health care. other underserved regions of the eastern United States. In some cases, non-hospital-affiliated The growth of freestanding emergency FEDs were constructed to fill the need for local departments (FEDs) has provided both emergency care. In other cases, health care opportunities and challenges for health care organizations could not justify the construction of providers, legislators, and payers, which has a full hospital, so they instead built freestanding prompted discussions regarding their regulation emergency facilities. Some of the first FEDs and effect on the health care system. In some have now expanded to full hospitals, while others states, organizations have concluded that opening have remained freestanding facilities. urgent care centers and/or FEDs will alleviate emergency department (ED) overcrowding, There is no strict definition for FEDs, although increase patient access to emergency services, there has been much consideration by many provide a needed public service, and create a regarding what they look like, the services they source of improved patient flow. offer, and even their hours of operation. An FED is generally a facility that provides emergency J uly 2009 care but is separate from an acute care hospital. This The State of FEDs Today relationship exists in a number of forms: An estimated 222 FEDs were operating in at least 16 n The FED may be owned and run by a hospital, but states in the United States at the end of 2008. The situated in a separate location. American Hospital Association estimates there are 191 hospital-affiliated freestanding EDs, the majority of which n The FED may be located near an acute care hospital, are affiliated with regional hospitals or large health care but is a distinct legal entity operating under different organizations3 (see Appendix A for a listing of the 16 management. states). In addition, there are approximately 31 FEDs that n The FED may be a fully isolated facility that is not are owned and managed by physicians or other private co-located with an acute care hospital and is under groups, located mostly in Texas. At the time of this report, separate ownership. the only FED that is not hospital-affiliated or physician- owned is the Newark Emergency Center in Delaware. These facilities differ from urgent care centers in that Some states require special licensing for FEDs or allow they can accommodate additional procedures such as them to operate under the parent hospital’s license. Some defibrillation, intubation, and conscious sedation. In FEDs have also received accreditation from The Joint addition, unlike urgent care centers, most FEDs are Commission through their affiliated hospitals (174 FEDs) open 24 hours a day, 7 days a week, and are staffed by or as an ambulatory care facility (24 FEDs). experienced and trained emergency physicians and nurses. Some FEDs also have been permitted by local emergency While there is some variation among facilities, most FEDs medical service agencies to receive ambulance patients. offer the following: n Urgent and emergency care; In 1978, there were approximately 55 FEDs in the United States, although most of these facilities could n Laboratories—lab service with the capability to have been classified as urgent care centers.2 The conduct the type of rapid tests that are necessary in number of FEDs grew only slightly in subsequent years, emergency care; until approximately 10 years ago when health care n Common radiology services, such as x-rays, organizations began demonstrating a renewed interest computed tomography (CT), and ultrasound; and in them. n Staffed by emergency medicine physicians and nurses. The motivations for constructing FEDs most commonly According to the American Hospital Association, include the following: approximately 70 percent of FEDs are open 24/7; n Provide enhanced access to care and meet an however, there has been a push by the industry and state increasing demand for emergency services; policymakers for all of them to be open 24 hours a day.4 n Develop sites and services that differentiate the This move is part of a trend in which FEDs are further organization from its competitors; distinguishing themselves from urgent care centers, thereby looking and acting more like hospital EDs. n Gain increased market share; Table 1 lists some of the characteristics of FEDs. n Provide a referral source for affiliated physicians; n Increase the potential for referring patients to hospital-based services; and n Increase the potential for mitigating competitive threats. 2  |  California HealthCare Foundation Table 1. Characteristics of FEDs in the United States* is stabilized at the FED and transferred to the nearest Characteristic Description hospital. FEDs transfer patients in one of three ways: FEDs 222 n Provide a transport service via FED-owned States with FEDs At least 16 ambulance; Hospital-Affiliated FEDs 191 (86.0%) n Contract with a local ambulance service; or Average Size Approx. 14,000 sq. ft. n Call an ambulance provider for transport. Staff Emergency MDs, PAs, NPs, RNs Hours of Operation Approx. 91.2% are open 24/7 FEDs are typically within 15 to 20 miles of a hospital, Services Offered Urgent/emergency care, lab, x-ray, CT which helps ensure prompt transport for patients who must be admitted. The Joint Commission Hospital = 174 Accreditation Ambulatory Care = 24 Regulation† CMS, EMTALA, state licensing The Role of FEDs in Health Care Billing‡ Type A/B dedicated ED or outpatient The Centers for Disease Control and Prevention has clinic reported that 32.1 percent of ED visits are non-urgent *Due to the lack of research/data on FEDs, most numbers are estimated. or semi-urgent, 36.6 percent are urgent, and 15.9 † Some FEDs are not Medicare or Medicaid providers and are not restricted by the Emergency percent are emergency or immediate. This implies that Medical Treatment and Active Labor Act (EMTALA). ‡ DED: Dedicated Emergency Department, as defined by Centers for Medicare & Medicaid 68.7 percent of ED visits could be adequately cared for Services (CMS) at some outpatient non-emergency facilities or FEDs. Sources: American Hospital Association, 2009 Survey of Hospital Leaders; CDC, National Center for Health Statistics (NCHS), National Hospital Ambulatory Medical Care Survey: 2006 Table 2 shows the varying acuity levels of patients visiting Emergency Department Summary; The Joint Commission, Quality Check, 2009; The Abaris Group estimates emergency departments. Additional services at some facilities include the Table 2. Patient Acuity Levels accommodation of: Triage Acuity Percentage n Some 9-1-1 transports; Immediate 5.1% n Observation beds (for up to 48 hours); Emergency 10.8% n Pediatric care beds; Urgent 36.6% Semi-Urgent 22.0% n Helipad; and Non-Urgent 12.1% n Co-location with primary care and specialty physician Source: CDC, NCHS, National Hospital Ambulatory Medical Care Survey: 2006 Emergency offices, imaging centers, and/or surgery centers. Department Summary. No FEDs to date offer trauma services to severely injured For a number of reasons, FEDs have the potential to fill patients (e.g., severe head trauma). These trauma cases are a pubic need in underserved regions and form part of the typically directed by Emergency Medical Service (EMS) solution to overcrowding in hospital EDs. An explanation authorities to the nearest trauma center. of some of these reasons follows. While not all FEDs receive 9-1-1 ambulance patients, many have interfacility transport services and contracts for patient transfers. In the event an FED receives an acute care patient who requires hospital admission, the patient Freestanding Emergency Departments: Do They Have a Role in California?  |  3 Easier Access Issues for Lawmakers and FEDs historically have filled a need in rural or underserved Health Care Providers regions where EDs or general acute care hospitals were The introduction of FEDs in the health care system can separated by long distances. More recently, many FEDs are present some challenges for lawmakers and health care open 24/7 and are located in suburban areas that are 15 to providers. Details of these challenges follow. 20 miles from the nearest hospital ED. Both the proximity and the hours of operation for FEDs provide the potential Licensing for patients to receive prompt care. Some states directly or indirectly prevent the operation of FEDs through legislation (see “Legal Considerations” later Fast Throughput in this report for more information). Because many FEDs do not receive EMS 9-1-1 transports, the majority of their patients “walk” into the Billing FED and thus are lower-acuity patients. In regions where Only FEDs that comply with the Centers for Medicare FEDs do receive 9-1-1 calls, the local EMS agencies have & Medicaid Services (CMS) and Emergency Medical created policies that prevent higher-acuity patients who Treatment and Active Labor Act (EMTALA) regulations might require admission from being transported to FEDs. can bill as a dedicated emergency department. All other Because FED patients’ conditions are generally of lower FEDs bill as an outpatient clinic, which tends to yield a acuity and they are not waiting for inpatient beds, FEDs much lower reimbursement amount (see the “Billing and have the potential to operate with faster throughput. Reimbursement” section for more information). Some FEDs report a door-to-doctor time of 30 minutes or less, compared with hospital ED door-to-doctor times, Admissions which average 55.8 minutes. In addition, FEDs report Despite the low average admission rate of most FEDs, door-to-discharge times of less than 90 minutes, in a few FEDs have reported admission rates similar to contrast to 180 minutes for hospital EDs.1, 5-7 hospital EDs, at 10 and 11 percent.13 The Bardmoor FED in Largo, Florida, reports a 14 percent admit rate, Expedient Admissions which is slightly above the hospital ED average. Many FEDs have reported an average hospital admission rate of 5 percent, which is much lower than the average High admission rates at FEDs have the potential to create hospital ED admission rate of 12.8 percent.1, 8-12 challenges in several ways. First, they can create patient In addition, FEDs have the potential to reduce the time safety issues if the facility is not equipped to stabilize the it takes for patients to be placed in inpatient beds for two patient. Second, the time it takes for the patient to arrive reasons: Because FEDs presumably have a faster average at the FED, have the doctor authorize admission, and for door-to-doctor times, patients potentially can be then transport the patient to a qualified hospital may triaged and stabilized more promptly than if they were unnecessarily put the patient at risk. Finally, the necessity being treated in a hospital ED. In addition, multiple for FEDs to transport all patients requiring admission hospital transfer agreements allow an FED to select may unnecessarily increase 9-1-1 transports. hospitals with available inpatient beds, compared with hospital EDs, which typically board a patient until an Transport inpatient bed is available at the same hospital. Some FEDs, either through billing or licensing requirements, are required to arrange interfacility transport services when necessary. This includes potential transfer agreements with nearby hospitals and possibly 4  |  California HealthCare Foundation agreements with local ambulance providers. As a result, “Dedicated emergency department means any patients may experience higher costs because of the department or facility of the hospital, regardless of transport billing, whereas if they had walked into a whether it is located on or off the main hospital hospital ED, this expense would not have been incurred. campus, that meets at least one of the following requirements: Public and Political Pressure 1. It is licensed by the state in which it is located Legislators and health care providers’ perceptions of under applicable state law as an emergency room FEDs at times have created challenges for those intending or emergency department; to operate such a center in the community. Concerns 2. It is held out to the public (by name, posted have ranged from FEDs’ scope of services and potential signs, advertising, or other means) as a place that confusion with hospital EDs to unnecessary competitive provides care for emergency medical conditions advantages and regulatory issues. on an urgent basis without requiring a previously scheduled appointment; or In Texas, for example, lawmakers’ perceptions of FEDs have affected licensing criteria. And in Florida, lawmakers’ 3. During the calendar year immediately preceding perceptions have affected not only licensing criteria, but the calendar year in which a determination certificate-of-need requirements as well. Some hospital under this section is being made, based on systems have lobbied to prevent FED construction a representative sample of patient visits that near their facilities because they are concerned about occurred during that calendar year, it provides competition. It can also be difficult to convince both at least one-third of all of its outpatient visits for state and local stakeholders that a FED can care for some the treatment of emergency medical conditions higher-acuity patients and are capable of accepting some on an urgent basis without requiring a previously 9-1-1 transports. scheduled appointment.”14 In the 2008 Federal Register, CMS divided the billing While not required to do so, many FEDs have obtained category for dedicated EDs into Type A and Type B. The Joint Commission accreditation to demonstrate their Within these categories, any facility that meets the compliance with accepted standards of care. Current Procedural Terminology (CPT) definition of an ED, and meets the requirements set by the Emergency On-Call Physician Specialists Medical Treatment and Active Labor Act can bill as a Hospital EDs rely on on-call physician specialists, but Type A dedicated ED. The CPT definition of an ED is most FEDs do not have on-call specialists. In the event “an organized hospital-based facility for the provision of that a patient arrives at an FED and requires a specialist, unscheduled episodic services to patients who present for the FED must stabilize the patient and arrange for immediate medical attention. The facility must be open prompt transport to a hospital or refer the patient for an 24 hours a day.”15 appointment with the specialist. ED facilities that incur EMTALA obligations, but do not Billing and Reimbursement meet Type A regulations (those that are not open 24/7) FEDs did not receive recognition from the Centers for are considered Type B. Type A dedicated EDs must fulfill Medicare & Medicaid Services until 2004, despite the one or both of the first two requirements (1 and 2) of the fact that they have existed for 40 years. In January 2004, dedicated ED definition, while Type B dedicated EDs CMS published new regulations, which provide the must fulfill at least one of the three requirements. (See following definition of a dedicated ED: Appendix B for the CMS excerpt on dedicated EDs.) Freestanding Emergency Departments: Findings and Recommendations for California  |  5 The 2004 Federal Register permitted freestanding Other states have passed legislation specifically emergency departments to bill as a dedicated ED; the defining FEDs and their licensing requirements. These more recent CMS regulations further specify the billing requirements are typically similar to hospital ED practices by dividing them into Type A and Type B. requirements, including acceptance of all patients arriving This new rule establishes a significant difference in at the facility, stabilization, and provision for transport billing and reimbursement between FEDs and urgent when necessary. Delaware and Illinois have implemented care centers. By allowing FEDs to bill as dedicated EDs, similar policies. (See Appendix C for a Comparison they are able to receive a higher reimbursement from of Type A/B Dedicated Emergency Departments Medicare than an urgent care center. Despite the fact and Outpatient Clinics, and Appendix D for more that some urgent care centers provide services for urgent/ information about Delaware State Regulations). emergency patients, they still must bill as outpatient clinics. Appendix C provides a comparison of the CMS In at least one other state, licensing and regulatory billing for Type A dedicated EDs and urgent care centers requirements have not been established for FEDs. Texas, (outpatient clinics). Per patient visit, dedicated EDs which has seen a significant increase in FEDs in the past are reimbursed between 25 percent and 100 percent decade, does not currently have licensing requirements more than outpatient clinics, not considering additional for FEDs. In 2007, a bill was introduced to the Texas procedural or other miscellaneous charges. state legislature providing a set of criteria for FEDs, but the legislation has not been approved because of a dispute Two types of FEDs do not bill as a dedicated ED. FEDs about whether to require FEDs to operate 24 hours a day. that do not operate under the same provider number as their parent hospital and thus are not required to The result of no regulation in Texas has led to somewhat comply with EMTALA must bill as an outpatient clinic. of a boom in FED construction. The Houston area A number of other non-hospital-affiliated facilities call now has an estimated 19 FEDs, and the Dallas-Fort themselves “emergency centers,” but are not Medicare Worth area has approximately 11 FEDs. Only five of or Medicaid providers. These facilities either bill the Houston FEDs and two of the Dallas FEDs are the patient or the patient’s private insurer. However, hospital-affiliated, but most are accredited by The Joint with reimbursement criteria for FEDs having been Commission either through their parent hospital or as an implemented by Blue Cross Blue Shield in Texas, and ambulatory care center. with other insurers likely to follow, these types of facilities may soon need to alter their billing and operational Most states that do not have operating FEDs have practices. (See Appendix F for Blue Cross Blue Shield not passed laws to explicitly prevent them. However, Texas criteria.) California law indirectly prevents FED construction through a strict definition of an “emergency department” Legal Considerations and the requirements associated with the use of the term Federal regulations permit the operation of FEDs “emergency.” Table 3 on the following page lists some but leave licensing and regulation to the states. State examples of FED regulation. regulation of FEDs varies in a number of ways. Some states allow FEDs to operate as an offsite facility under the same license as the parent hospital. After an initial pilot program, Florida chose to require FEDs to meet the same criteria as onsite EDs and allows them to operate under their parent-hospital state license. 6  |  California HealthCare Foundation Table 3. A Sample of State Regulation of FEDs The California Landscape State The California Health and Safety Code does not explicitly Examples Description allow or disallow the operation of FEDs. However, it does FED and Parent Hospital Florida The FED is permitted to operate state that any facility using the term “emergency” and Under Same License as an offsite outpatient facility under the same state license as claiming to provide “emergency medical services” must the parent hospital that owns comply with specific regulations for Standby, Basic, or the FED. Comprehensive services of permitted EDs (see Appendix FED-Specific License Illinois, The FED must be licensed by Delaware the state as a “Freestanding G).18 (The State of California uses the term “emergency Emergency Center” and comply medical services” to identify licensed hospital ED services.) with associated state regulations. No License Texas An FED is permitted to operate To be licensed in California for Standby, Basic, or Requirement without a license. Comprehensive emergency medical services, the facility Indirect Prohibition of California Because of strict requirements must provide the following services onsite:19 FED Operation in the Health and Safety Code for emergency facilities, FEDs n Intensive care service with adequate monitoring and are indirectly prohibited from operating.* therapeutic equipment; *California law provides an exception for the operation of a potential look-alike FED for n Laboratory service; urgent/emergency care in rural areas when the local EMS agency has given approval for such operation (see Appendix H). n Radiology service; Sources: Delaware Administrative Code, 4404; Illinois Register Title 77, Chapter IIa, Section 1110.3230; Florida Agency for Health Care Administration, December 2004; California n Surgical services that are immediately available for Health and Safety Code 1798.175. life-threatening situations (Basic and Comprehensive);20 As of mid-2008, 36 states have some form of Certificate n Post-anesthesia recovery; and of Need (CON) law in place.16 CON laws address a range of health care facilities and procedures and vary n Blood bank. by state. CON laws vary for FEDs as well. In Texas and Florida, there are no CON laws that address FEDs. But Any facility that provides all of these necessary services Illinois requires a CON prior to the construction and under state law will essentially be a full-fledged hospital operation of an FED and Delaware requires a Certificate and thus not operate like an FED. In addition, California of Public Review, similar to a CON. Health and Safety Code Section 128700 (c) states that “emergency department” means “in a hospital licensed to In 1987, Florida removed review of outpatient services provide emergency medical services, the location in which from the state CON requirement. In 2002, when Florida those services are provided.”21 began its pilot FED program, it was determined that hospitals could have multiple inpatient premises on one There have been at least two bills introduced in the license, and specific offsite outpatient facilities could be past five years to modify California law to allow FEDs listed on the hospital license.17 This new requirement to operate in the state. In 2003, AB 835 would have allows FEDs to operate on the same license as the required the State Department of Health Services to grant parent hospital and have virtually no regulations on new licenses to specific urgent care centers that would be construction. In 2003, the Florida state legislature passed standalone EDs. In 2005, AB 1050 would have allowed a bill that placed a moratorium on construction of new up to four hospitals to establish emergency receiving FEDs in the state. The moratorium was lifted in 2007 centers that could be in a separate freestanding facility, for when a bill to extend the moratorium was vetoed by the testing/demonstration purposes. In both bills, the FEDs state’s governor. Freestanding Emergency Departments: Do They Have a Role in California?  |  7 would have had to comply with the same regulations If FEDs were permitted to operate in California, a as hospital EDs. Neither of the bills passed out of determination would need to be made regarding whether committee. staffing ratios would also apply to them. In the event that an FED opens, the staffing ratios might apply for an FED State Law Exceptions that operates under the hospital license; is owned by the California state law provides an exception for the hospital, but licensed separately; or is not owned by or operation of a potential look-alike FED for urgent/ licensed through a hospital. emergency care in rural areas when the local EMS agency has given approval for such operation (see Appendix H). Past Efforts at Operating FEDs in California There are four facilities in the state known to have been Centinela Medical Center reached an agreement with approved as an FED under this exception: the County of Los Angeles in 2006 to upgrade its Los n Western Sierra Medical Clinic in Downieville; Angeles International Airport urgent care center to an urgent/emergency facility that receives Basic Life Support n Community Medical Center-Oakhurst; ambulances. The California EMS Authority declared that n Redwood Coast Medical Services in Gualala; and current state law did not permit the operation of such a n Naval Hospital Lemoore in Lemoore. facility and intended to force the closure of the facility. Los Angeles County disagreed that the state had any authority These facilities are essentially urgent care centers that over Basic Life Support ambulance patients. The pilot (because of their distance from a hospital) are permitted project was intended to last two years; however, the FED to accept emergency and ambulance patients if they are closed after one year as a result of standards imposed by presented at the facilities. None of the clinics advertise the County of Los Angeles and low volume that resulted themselves as “emergency centers” and none are open from the restrictive county ambulance triage policy. 24/7. They provide basic urgent/emergency care only to stabilize the patient for transport. The California The University of California, San Diego Medical Center Health and Safety Code requires only that the clinic announced its plans in 2005 to downsize its Hillcrest and local EMS agency “take into account, but not be inpatient campus near downtown San Diego. The initial limited to” having appropriate staff and equipment to plan was to transfer all inpatient beds to the La Jolla care for emergency patients. The specific requirements campus and convert the Hillcrest campus into an FED. of the urgent/emergency facilities are determined by the The plan drew a great deal of criticism from local public local EMS agency. All of these clinics currently bill the figures and the community, which led the medical center emergency visits as outpatient clinic visits. to abandon the plan in 2007. Staffing Challenges Characteristics of Successful FEDs In 2005, California initiated a state-mandated nurse-to- Organizations in other states attempting to construct an patient ratio for hospitals and EDs. The mandate requires FED have encountered resistance from political leaders, that hospitals with a Basic or Comprehensive ED have a local EMS agencies, competing hospital systems, and 1:4 or fewer nurse-to-patient ratio at all times. The law sometimes the community. A large number of these does not apply to Standby hospitals or outpatient services, attempts have succeeded in complying with regulations, even if they fall under the same license as the hospital. and some are well accepted by their communities. This section details common characteristics of the implementation and operations of successful FEDs across the nation. 8  |  California HealthCare Foundation The Proper Location Services Offered The location of an FED can be the most important Most FEDs offer 24-hour lab service and have radiology factor in determining its success. First and foremost, services, including x-ray and collocated computed there should be an establishment of public need. Most tomography (CT), and sometimes magnetic resonance FEDs are located within 15 to 20 miles of a hospital; imaging (MRI) and mammography. Additional however, in some urban/suburban regions, they are closer. nonemergency services are sometimes offered at FEDs Proximity to a hospital should be evaluated by the public that are co-located with other outpatient facilities. need for additional emergency services, as well as the This can include surgery centers, rehabilitation centers, timeliness of interfacility transfers that will be executed specialty clinics, and physical therapy. from the FED. Second, successful FEDs are located in an area that is currently or is projected to have substantial Staffing population growth and a low percentage of Medicaid or Staffing, especially initially, is a vital component of any self-insured payers for any given FED. successful health care facility, but particularly with FEDs. By equipping the FED with experienced ED clinicians, Open Communication and Collaboration the facility can ensure quality of care and build public The establishment of many successful FEDs has often confidence in the abilities of the FED. Having the been preceded by open communication and collaboration proper staffing ratio can be just as important as having with local EMS agencies, their medical directors, and state experienced staff. A recent survey at an academic and local officials. Clear descriptions of the operations and hospital on patient expectations in FEDs found that dedication to quality should be conveyed to stakeholders. 93 percent of patients prefer to see a staff physician, And effective marketing and facilitated community rather than a resident physician or a physician assistant. gatherings can help ensure that the public has a clear A higher proportion of respondents also felt it was understanding of the services that the FED will offer. “extremely important” to be seen by a “competent physician” rather than a “caring physician” (94.4 EMS Transport percent vs. 82.1 percent).22 Many FEDs have an ambulance entrance and provide their own transport service or call local ambulance Other Factors providers when transport is needed. Other FEDs engage Other factors that can help an FED be successful include in contractual agreements with the local EMS agency the following: to revise paramedic triage criteria that allow for selected n The Joint Commission and/or other accreditation. EMS transport to FEDs. The criteria will vary depending n Co-location with specialists, surgery centers, and on the services offered at the FED. There should also be rehabilitation centers, which provide the potential an agreement with the local EMS agency and regional for specialty consultative services nearby. Having all hospitals for arrangement of interfacility transport. the additional outpatient facilities in the “mediplex” owned by the same organization yields increased revenues. Freestanding Emergency Departments: Do They Have a Role in California?  |  9 Conclusion FEDs have existed in the United States for decades; however, following a recent resurgence, FEDs are now under more scrutiny. FEDs vary widely in their services offered, and the states vary in their regulation of the facilities. As such, there is no current standard or benchmark for data on quality and performance. Little academic research has been published on the quality and effectiveness of these facilities and whether their use in fact reduces hospital ED visits, lowers health care costs, or fills a public need. Without sufficient data, it is difficult to determine the true effectiveness and public benefit of FEDs, especially for the long term. FEDs have the potential to meet community need when a community faces the loss of emergency services upon closure of an acute care hospital or when there is an established need in a community that does not have a hospital emergency service. However, developing an FED in order to gain competitive advantage when services are already available may not be an appropriate use of limited health care resources. Despite these considerations, the number of FEDs has continued to expand in both rural and suburban regions, and the FED model appears to be successful for many organizations. FEDs’ potential to provide greater access and faster throughput continues to attract those in the health care industry. As the number of ED visits continues to increase in the United States, those in health care are forced to confront ED overcrowding and patient care issues. In some states, FEDs have been utilized to assist in mitigating such hospital ED issues. 10  |  California HealthCare Foundation Authors 10.Appleby J. “More Emergency Rooms Open Away From Hospitals.” USA Today, April 24, 2008. http://www.usatoday.com/ The Abaris Group news/health/2008-04-24-emergency-rooms-stand-alone_N.htm (last accessed March 19, 2009). Mike Williams, MPA/HSA, president 11.Meyer-Reed EJ, Reeve KR, Wadman MC, Muelleman RL, Michael Pfeffer, MPH, research assistant Tran TP. “Patient Expectation in a Freestanding Emergency Department.” Annals of Emergency Medicine, Research Forum Abstracts, 52(4):October 2008. About the F o u n d at i o n 12.Arevalo JD. “Freestanding Emergency Departments on the Rise.” AMN Healthcare News, 2008. http://www.amnhealthcare.com/ The California HealthCare Foundation is an independent News/news-details.aspx?Id=3916 (last accessed March 19, 2009). philanthropy committed to improving the way health 13.Inova Healthplex and Swedish/Issaquah. care is delivered and financed in California. By promoting 14.Code of Federal Regulations, Title 42, Parts 413, 482, and 489. innovations in care and broader access to information, our 15.Code of Federal Regulations, Title 42, Parts 410, 416, and 419, goal is to ensure that all Californians can get the care they p.704. need, when they need it, at a price they can afford. For 16.“Certificate of Need: State Health Laws and Programs.” National Conference of State Legislatures, August 21, 2008. http://www. more information about CHCF, visit www.chcf.org. ncsl.org/programs/health/cert-need.htm#Facilities. 17.Freestanding Emergency Department Report. Florida Agency for Health Care Administration, December 2004. 18.California Health and Safety code 1798.175. 19.California Code of Regulations Title 22, Division 5, Chapter 1, Endnotes Article 6, Section 1798.101. 20. In regard to on-call services, the common interpretation of 1.Pitts SR, Niska RW, Xu J, Burt CW. National Hospital “immediate” is “prompt,” which is generally defined as having an Ambulatory Medical Care Survey: 2006 Emergency Department on-call physician who can be available within 30 minutes. Summary. National Health Statistics Reports; No. 7. Hyattsville, MD: National Center for Health Statistics, 2008. 21.California Health and Safety code 128700(c). 2.Preliminary Survey of Freestanding Emergency Centers. Silver 22.Meyer-Reed EJ, Reeve KR, Wadman MC, Muelleman RL, Spring Md.: Orkand Corporation, February 1979. Tran TP. “Patient Expectation in a Freestanding Emergency Department.” Annals of Emergency Medicine, Research Forum 3.The 2009 Survey of Hospital Leaders. American Hospital Abstracts, 52(4): October 2008. Association, 2009. 4.Preliminary Survey (Short Title). Orkand Corporation, February 1979. 5.Larkin, Kelly, MD, FACEP. St. Luke’s Episcopal Health System— Emergency Services. Telephone interview. February 9, 2009. 6.E-Care Emergency Center. http://e-carecenters.com/about.htm (last accessed February 26, 2009). 7.Emergency Health Centre at Willowbrook. http://www. emergencyhealthcentre.com/about/facility_what.php (last accessed February 26, 2009). 8.Press Release: Emergency Center in Germantown Treats More, Sicker Patients than Anticipated During First Year. Shady Grove Adventist Emergency Center, August 7, 2007. http://www. adventisthealthcare.com/about/news/2007/emergency-center-in- germantown.aspx (last accessed January 6, 2009). 9.Hill RF, Steelman A. “Freestanding Emergency Centers: A Win-Win for Providers and Patients.” Managing the Margin, Healthcare Financial Management Association, April 2008. http:// www.healthstrategiesandsolutions.com/documents/0408MTM.pdf (last accessed December 30, 2008). Freestanding Emergency Departments: Do They Have a Role in California?  |  11 Appendix A UCSD Medical Center­ Hillcrest — Case Studies • Location: San Diego, CA Many states have allowed the construction of FEDs, • UCSD attempted to close its Hillcrest inpatient and a number of organizations have been successful in campus and replace it with an FED and 23 implementing them over the years. Examples of both observation beds. successes and failures in the implementation of FEDs • The plan was halted as a result of community and follow. This list is not exhaustive; it is merely a set of political pressure. examples of FED characteristics in different states. Rural Emergency Centers The following four rural community clinics have taken Arizona advantage of the “rural emergency center” exception to West Valley Emergency Center the California Health and Safety Code. None are open • Location: Goodyear, AZ 24/7, but some do provide 24-hour on-call services: • 1986–2004 • Closed when parent organization opened a hospital • Western Sierra Medical Clinic in Downieville two miles away • Community Medical Center–Oakhurst • Redwood Coast Medical Services in Gualala Gilbert Emergency Department • Location: Gilbert, AZ • Naval Hospital Lemoore in Lemoore • Opened in 2006 as an FED advertising door-to- Colorado doctor times of less than 30 minutes. The facility has since grown and is now licensed as a general Swedish Southwest Emergency Center acute care hospital. (Swedish Medical Center) • Location: Littleton, CO Sedona Medical Center • Open 24/7 (Verde Valley Medical Center) • 18 rooms, including five 24-hour observation rooms • Location: Sedona, AZ • Lab, CT, x-ray, ultrasound • Open 24/7 • X-ray, CT, mammography • The Joint Commission accredited • Lab only Mon.–Fri. (7:00 a.m.–5:00 p.m.) Connecticut • Cancer center, two primary care offices Middlesex Hospital Shoreline Medical Center • Location: Essex, CT California • Open 24/7 Centinela Airport Medical Clinic • Location: Los Angeles, CA • Lab, CT, x-ray, ultrasound, mammography • In 2006, Centinela Medical Center reached an • Receives ambulance patients agreement with the County of Los Angeles and Middlesex Hospital Marlborough Medical Center its local EMS agency to upgrade the Los Angeles • Location: Marlborough, CT International Airport urgent care center into an urgent/emergency facility that receives ambulance • Open 24/7 traffic. • 12 treatment rooms, two of which are dedicated to • A limited transport procedure (FED accepted Basic critical patients Life Support only), extensive staffing rules, and a • Lab, CT, x-ray, ultrasound, mammography, bone generally low patient volume prompted the facility densitometry to close. • Receives ambulance patients 12  |  California HealthCare Foundation Delaware Indiana Newark Emergency Center St. Vincent Medical Center Northeast— • Location: Newark, DE Fishers Emergency Center • Opened in 1973 • Location: Fishers, IN • No hospital affiliation • Opened in 2008 • Open 24/7 • “Non-life-threatening emergencies only” • Lab, CT, x-ray, MRI, ultrasound Florida • Co-located with a mediplex Emergency Center at TimberRidge • The Joint Commission accredited • Location: Aventura, FL • Opened in 2002 Iowa • Co-located with a mediplex Trinity Iowa Health System—7th Street Emergency Center • 12 miles from the hospital • Location: Moline, IA • Transport provided by the hospital • Opened in 1997 • Obtained state and county approval prior to • Open 24/7 construction • Eight exam rooms • After success of program, Florida Agency for Health • Lab, x-ray, CT, MRI Care Administration set criteria for FEDs • Accepts nontrauma ambulance patients • The Joint Commission accredited • Co-located with a cancer center, birthing facility, Bardmoor Emergency Center post-surgical inpatient rooms (Morton Plant Mease) • The Joint Commission accredited • Location: Largo, FL • Opened in 2008 Maryland • 15,000 square-foot facility Shady Grove Adventist Emergency Center • 15 beds, three of which are 23-hour observation • Location: Germantown, MD beds • Opened in 2006 • CT, lab, x-ray, pharmacy • 17,000 square-foot facility • The Joint Commission accredited • Co-located with a 96,000 square-foot medical building North Port Emergency Center & Outpatient Care • 21 emergency beds Center (Sarasota Memorial) • Location: North Port, FL • Five inpatient beds for low acuity patients, maximum 48-hour stay • Planned opening, summer 2009 • 10 miles from parent hospital • 25,000 square-foot facility • The Joint Commission accredited • 24-hour observation unit • 18 treatment rooms, some of which are specialized Dimensions Healthcare FED— for obstetrics, trauma, and psych Bowie Health Center • Location: Bowie, MD • CT, MRI, x-ray, ultrasound, mammography, bone density • Co-located with 60-acre health campus • Night-Light Program: after hours pediatric ED and urgent care • The Joint Commission accredited Freestanding Emergency Departments: Do They Have a Role in California?  |  13 Michigan Minden Medical Center Canton Emergency Department • Location: Minden, NV (Oakwood Healthcare) • Open 8:00 a.m.–8:00 p.m., 7 days • Location: Canton, MI • Dexa scan, CT, ultrasound, mammography, MRI • Opened in 1988 as urgent care/emergency facility (Tues. only), x-ray, • Since 2006, known as “Emergency Care” • Full lab • Co-located with outpatient medical campus • Co-located with physician offices (general and • 25 miles from hospital specialty) • The Joint Commission accredited • The Joint Commission accredited Henry Ford Medical Center—Sterling Heights North Carolina • Location: Sterling Heights, MI WakeMed North Healthplex—Raleigh • Open 8:00 a.m.–5:00 p.m. • Location: Raleigh, NC • Ultrasound • Seven private rooms • The Joint Commission accredited • Two pediatric-ready rooms Henry Ford Medical Center—Fairlane • 23-hour observation beds • Location: Dearborn, MI • Co-located with a mediplex • Open Mon., Tues., 8:00 a.m.–8:00 p.m.; Wed., • “Superclinic” offers full imaging, lab, outpatient Thurs., Fri., 8:00 a.m.–5:00 p.m.; Sat. 8:00 a.m.– clinics, surgery, rehab, endoscopy, and physician 12:00 p.m. offices • Ultrasound • The Joint Commission accredited • The Joint Commission accredited Ohio West Bloomfield (Henry Ford Health System) Avon Emergency Department • Location: West Bloomfield, MI (EMH Regional Hospital) • Opened in 1975 • Location: Avon, OH • Ultrasound • Open 24/7 • Opened as a full hospital in March 2009 • Helipad Brownstown Township (Henry Ford Health System) Solon Medical Campus ED • Location: Brownstone Township, MI (St. Vincent Charity Hospital) • Location: Solon, OH • Opened in 2006 Co-located with physician offices, same-day surgery center, and medical imaging • Open 24/7 offices • Lab, x-ray • The Joint Commission accredited • Ground/air transport • Observation beds and critical care beds Nevada • The Joint Commission accredited Carson Valley Medical Center • Location: Carson Valley, NV • Operated from 1996–2006 • Full hospital built onsite in 2006 14  |  California HealthCare Foundation South Carolina E-Care Emergency Center—Frisco Roper St. Francis Medical Center—Berkeley • Locations: Frisco and McKinney, TX (Roper St. Francis Healthcare) • Physician-owned • Location: Moncks Corner, SC • Hours: Mon.–Sat., 10:00 a.m.–10:00 p.m.; Sun, • Opened in 1991 1:00 p.m.–10:00 p.m. • Open 24/7 • Charge $100 for urgent visit, $200 for emergency • 24-hour lab/radiology services visit • Co-located with outpatient surgery center, cancer Virginia therapy, wound care Inova Emergency Care Center—Fairfax • CT, mammography, ultrasound, bone density, • Location: Fairfax, VA X-ray, MRI (Wed. only) • Opened in 1987 • The Joint Commission accredited • Open 24/7 Roper Medical Center—Northwoods • The Joint Commission accredited (Roper St. Francis Healthcare) • Location: Northwoods, SC Inova Emergency Care Center—Leesburg • Location: Leesburg, VA • Opened in 1997 • Open 24/7 • Open 24/7 • Adjacent to Loudon Hospital • 24-hour lab/radiology services • Lab, x-ray • The Joint Commission accredited • The Joint Commission accredited Texas Inova Emergency Care Center—Reston/Herndon Community Emergency Center—Woodlands • Location: Reston, VA (St. Luke’s Episcopal Health Services) • Locations: The Woodlands, Pearland, Houston, TX • Open 24/7 (The Vintage, Holcomb, San Felipe centers are in • The Joint Commission accredited Houston) Inova HealthPlex Emergency Care Center • Open 24/7 • Location: Alexandria, VA • 14,000 square-foot facility • Open 24/7 • Lab, x-ray, CT • Co-located with HealthPlex • Does not accept transport, but provides interfacility • The Joint Commission accredited transport • The Joint Commission accredited Washington East Texas Medical Center, Emergency Centers Swedish/Issaquah Emergency Room • Locations: Gun Barrel City, Rusk, and Tyler, TX • Location: Issaquah, WA • Staffed by “trauma care specialists” • Opened in 2005 • Open 24/7 • 14 exam rooms • “Complete radiology and lab services” • X-ray, CT, ultrasound, MRI • The Joint Commission accredited • Lab • Plans for a full hospital to open 3 miles away (opening set for 2012) • The Joint Commission accredited Freestanding Emergency Departments: Do They Have a Role in California?  |  15 Appendix B EMTALA obligations with respect to an individual who Centers for Medicare and Medicaid presents to the department and requests, or has requested Services, “Hospital Outpatient on his or her behalf, examination or treatment for an Prospective Payment System, Final emergency medical condition. However, because they did Rule.” Federal Register 73, Number 223 not meet the CPT requirements for reporting emergency (18 November 2008): p. 68680 visit E/M codes, prior to CY 2007, these facilities were required to bill clinic visit codes for the services they Dedicated Emergency Department furnished under the OPPS. We had no way to distinguish Section 489.24 of the EMTALA regulations defines in our hospital claims data the costs of visits provided in “dedicated emergency department” as any department or dedicated emergency departments that did not meet the facility of the hospital, regardless of whether it is located CPT definition of emergency department from the costs on or off the main hospital campus, that meets at least of clinic visits… one of the following requirements: (1) It is licensed by the State in which it is located under applicable State …In the CY 2007 OPPS/ASC final rule with comment law as an emergency room or emergency department; period (71 FR 68132), we finalized the definition of (2) It is held out to the public (by name, posted signs, Type A emergency departments to distinguish them from advertising, or other means) as a place that provides care Type B emergency departments. A Type A emergency for emergency medical conditions on an urgent basis department must be available to provide services 24 without requiring a previously scheduled appointment; hours a day, 7 days a week, and meet one or both of the or (3) During the calendar year immediately preceding following requirements related to the EMTALA definition the calendar year in which a determination under the of a dedicated emergency department, specifically: (1) It regulations is being made, based on a representative is licensed by the State in which it is located under the sample of patient visits that occurred during that calendar applicable state law as an emergency room or emergency year, it provides at least one-third of all of its outpatient department; or (2) It is held out to the public (by name, visits for the treatment of emergency medical conditions posted signs, advertising, or other means) as a place that on an urgent basis without requiring a previously provides care for emergency medical conditions on an scheduled appointment. urgent basis without requiring a previously scheduled appointment… We defined a Type B emergency In the CY 2008 OPPS/ASC proposed rule (72 FR department as any dedicated emergency department that 42756), we reiterated our belief that every emergency incurred EMTALA obligations under §489.24 of the department that meets the CPT definition of emergency EMTALA regulations but that did not meet the Type A department also qualifies as a dedicated emergency emergency department definition. department under EMTALA. However, we indicated that we were aware that there are some departments or facilities of hospitals that meet the definition of a dedicated emergency department under the EMTALA regulations, but that do not meet the more restrictive CPT definition of an emergency department. For example, a hospital department or facility that meets the definition of a dedicated emergency department may not be available 24 hours a day, 7 days a week. Nevertheless, hospitals with such departments or facilities incur 16  |  California HealthCare Foundation Appendix C CMS OPPS Comparison of Type A/B Dedicated Emergency Departments and Outpatient Clinics Table A. Comparison of Type A and Type B Dedicated EDs in November 2008 Type A Type B Description CPT RVU Payment RVU Payment Payment Difference Percent Difference Level 1 Visit 99281 0.7972 $52.66 0.6840 $45.18 -$7.48 -14.21% Level 2 Visit 99282 1.3040 $86.14 0.9302 $61.45 -$24.69 -28.66% Level 3 Visit 99283 2.0694 $136.70 1.3418 $88.64 -$48.06 -35.16% Level 4 Visit 99284 3.2987 $217.91 2.4093 $159.16 -$58.75 -26.96% Level 5 Visit 99285 4.9032 $323.90 4.9032 $323.90 $0.00 0.00% Critical Care 99291 7.3479 $485.39 – – – – Source: Centers for Medicare and Medicaid Services (CMS), Outpatient Prospective Payment System (OPPS), November 2008 Table B. Comparison of Dedicated EDs and Outpatient Clinics in November 2008 Type A Dedicated ED Outpatient Clinic Description CPT RVU Payment CPT RVU Payment Payment Difference Percent Difference Level 1 Visit 99281 0.7972 $52.66 99201 0.8277 $54.68 $2.02 3.69% Level 2 Visit 99282 1.3040 $86.14 99202 1.0439 $68.96 -$17.18 -24.91% Level 3 Visit 99283 2.0694 $136.70 99203 1.3585 $89.74 -$46.96 -52.33% Level 4 Visit 99284 3.2987 $217.91 99204 1.7192 $113.57 -$104.34 -91.87% Level 5 Visit 99285 4.9032 $323.90 99205 2.4477 $161.69 -$162.21 -100.32% Critical Care 99291 7.3479 $485.39 – – – – – Source: Centers for Medicare and Medicaid Services (CMS), Outpatient Prospective Payment System (OPPS), November 2008 What does this mean? The payment difference and payment percent are for Dedicated ED—Outpatient. Therefore, the payment difference is the revenue saved by operating as a Dedicated ED vs. an outpatient clinic. The percent difference is the proportion of the amount saved. This means that FEDs can receive anywhere from 25 percent to 100 percent more revenue per visit by billing as an ED, not counting any additional procedure or other charges. Freestanding Emergency Departments: Do They Have a Role in California?  |  17 Appendix D 3.0 Application for License and Ownership Delaware State Regulations, 4404 3.1 Application for license to establish, maintain or Free Standing Emergency Centers, operate a Free Standing Emergency Center shall be made Sections 1.0 to 3.1 to the Division of Public Health stating the location 1.0 Definitions thereof, the name of the person in charge and all other “Free Standing Emergency Center” means a facility information necessary to determine the qualifications of physically separate from a hospital, which uses in the applicant. its title or in its advertising, the words “emergency,” “urgent care,” or parts of those words or other language or symbols which imply or indicate to the public that immediate medical treatment is available to individuals suffering from a life-threatening medical condition. The facility rendering such care is capable of treating all medical emergencies that have life-threatening potential. 2.0 License Requirement 2.1 No person shall establish, conduct or maintain in this State any Free Standing Emergency Center without first obtaining a license from the Division of Public Health. 2.2 Existing Institutions 2.2.1 No person shall continue to operate an existing Free Standing Emergency Center unless such facility is approved and regularly licensed by the State Board of Health as provided in this chapter. 2.3 Trailblazing Signs 2.3.1 No Free Standing Emergency Center, treatment facility, office or station shall be authorized to exhibit any Trailblazing signs, symbols, or directional signs by the State Highway Department unless such facility has been duly licensed under the provisions of this chapter. 2.4 Transfer Agreement 2.4.1 The Free Standing Emergency Center shall have a written transfer agreement with one or more hospitals, which provides the basis for effective working arrangements in which inpatient hospital care or other hospital services are available promptly to the facility’s patients when needed. 18  |  California HealthCare Foundation Appendix E 2)If the proposed project involves the replacement of Illinois State Regulations, an FEC facility on site, the applicant shall comply Section 1110.3230 with the requirements listed in subsection (a)(1) for Category of Service Modernization. Freestanding Emergency Center Medical Services, Excerpt 3)If the proposed project involves the replacement of a) Introduction the FEC facility on a new site, the applicant shall comply with the requirements listed in subsection 1)These criteria are applicable only to those (a)(1) for Establishment of Service. projects or components of projects involving the freestanding emergency center (FEC) medical 4)All projects shall meet or exceed the utilization services (FECMS) category of service. In addition, standards for the service, as specified in 77 Ill. the applicant shall address other applicable Adm. Code 1100. requirements in this Part, as well as those in 77 Ill. 5)All projects for an FEC must comply with Adm. Code 1100 and 1130. Applicants proposing the licensing requirements established in the to establish, expand or modernize an FECMS Emergency Medical Services (EMS) Systems Act category of service shall comply with the applicable [210 ILCS 50/32.5], including the requirements subsections of this Section, as follows: that the proposed FEC is located: A) in a municipality with a population of 75,000 or Project Type Required Review Criteria fewer inhabitants; Establishment of Service (b)(1)— Planning Area Need—77 Ill. Adm. B) within 20 miles of the hospital that owns or Code 1100 Formula Calculation controls the FEC; and C) within 20 miles of the Resource Hospital affiliated (b)(2)—Service to Area Residents with the FEC as part of the EMS system (Section (b)(3)—Service Demand for 32.5(a) of the Emergency Medical Services Establishment (EMS) Systems Act). (b)(4)—Service Accessibility 6)The applicant shall certify that it has reviewed, (c)(1)—Unnecessary Duplication of Services understands and plans to comply with all of the following requirements: (c)(2)—Maldistribution (c)(3)—Impact on Other Providers A) The requirements of becoming a Medicare provider of freestanding emergency services; (c)(4)—Request for Data from Other Providers and (e)—Staffing Availability B) The requirements of becoming licensed under Expansion of Existing Service (b)(2)—Service to Area Residents the Emergency Medical Services Systems Act [210 ILCS 50]. (e)—Staffing Availability Category of Service Modernization (d)(1)—Deteriorated Facilities (d)(2)—Documentation (d)(3) − Additional Documentation Freestanding Emergency Departments: Do They Have a Role in California?  |  19 Appendix F Blue Cross Blue Shield Texas FED Reimbursement Criteria The following is a summary of the BCBSTX criteria for a facility to be a free standing emergency care (FED) facility. Currently there are no free standing emergency facilities in Texas that meet these criteria. 1. The Facility complies with Emergency Medical Treatment and Active Labor Act (EMTALA) applicable requirements (whether or not it is subject to EMTALA). 2. The Facility must have and maintain appropriate standing arrangements for the transfer of the member to an acute care hospital with an emergency department if medically necessary. 3. Physicians performing services at the Facility must have additional training in Emergency Medicine and/or be board certified in Emergency Medicine. 4. The Facility must be open 24 hours a day, 7 days a week, with at least one emergency care qualified physician and one licensed nurse on duty at all times. 5. The Facility must have and maintain equipment and supplies suitable for provision of emergency care services. 6. The Facility must be accredited by one of the following programs: •The Joint Commission on the Accreditation of Healthcare Organizations •Accreditation Association for Ambulatory Health Care This information is available at http://www.bcbstx.com/ hs/freestandingcriteria.htm. 20  |  California HealthCare Foundation Appendix G (H)The quality and appropriateness of emergency California Health & Safety Code 1798.175 services are evaluated at least annually as part of a quality assurance program. Definition of “Emergency” No person or public agency shall advertise itself as, or (I) Provide information to the public that hold itself out as, providing emergency medical services, describes the capabilities of the facility, by using in its name or advertising the word “emergency” including the scope of services provided, the or any derivation thereof, or any words which suggest that manner in which the facility complies with the it is staffed and equipped to provide emergency medical requirements of this section pertaining to the services, unless the person or public agency satisfies one of availability and qualifications of personnel or the following requirements: services, and the manner in which the facility cooperates with the patient’s primary care (1)Is a general acute care hospital providing approved physician in followup care. standby, basic, or comprehensive emergency medical services regulated by this chapter (J) Clearly identifies the responsible professional or professionals and the legal owner or owners (2)Meets all of the following minimum standards: of the facility in its promotion, advertising, (A) Emergency services are available in the facility and solicitations. seven days a week, 24 hours a day. (K)Transfer agreements are in effect at all (B) Has equipment, medication, and personnel times with one or more general acute care experienced in the provision of services needed hospitals that provide basic or comprehensive to treat, life-, limb-, or function-threatening emergency medical services wherein conditions. patients requiring more definitive care will (C)Diagnostic radiology and clinical laboratory be expeditiously transferred and receive services are provided by persons on duty or on prompt hospital care. Reasonable care call and available when needed. shall be exercised to determine whether an (D)At least one physician who is trained and emergency requiring more definitive care experienced in the provision of emergency exists and the person seeking emergency care medical care who is on duty or on call so as to shall be assisted in obtaining these services, be immediately available to the facility. including transportation services, in every way reasonable under the circumstances. (E) Medical records document the name of each patient who seeks care, as well as the disposition of each patient upon discharge. (F) A roster of specialty physicians who are available for referral, consultation, and specialty services is maintained and available. (G)Policies and procedures define the scope and conduct of treatment provided, including procedures for the management of specific types of emergencies. Freestanding Emergency Departments: Do They Have a Role in California?  |  21 Appendix H Appendix I California Health & Safety Code 1798.101 (b) California Health & Safety Code Section 1797.221 Exception for Emergency Services in Rural Areas “In rural areas, as determined by the authority, when Local EMS Agency Authority to Approve the use of a hospital having a basic emergency medical Scientific or Trial Studies service special permit is precluded because of geographic The medical director of the local EMS agency may or other extenuating circumstances, as determined by the approve or conduct any scientific or trial study of the authority, the medical director of the local EMS agency efficacy of the prehospital emergency use of any drug, may authorize another facility which does not have this device, or treatment procedure within the local EMS special permit to receive patients requiring emergency system, utilizing any level of prehospital emergency medical services if the facility has adequate staff and medical care personnel. The study shall be consistent equipment to provide these services, as determined by the with any requirements established by the authority for medical director of the local EMS agency.” scientific or trial studies conducted within the prehospital emergency medical care system, and, where applicable, with Article 5 (commencing with Section 111550) of Chapter 6 of Part 5 of Division 104. No drug, device, or treatment procedure which has been specifically excluded by the authority from usage in the EMS system shall be included in such a study. [Added by AB 3119 (CH 299) 1988. Urgency statute: Provisions became effective July 8, 1988. Amended by SB 1497 (CH 1023) 1996.] 22  |  California HealthCare Foundation References Larkin K, Scott MK. “Retail Healthcare: Freestanding EDs and Retail Centers.” The Abaris Group Webinar Andrews M. “Need the Emergency Room? Skip the Series. January 16, 2008. Wait.” US News, September 17, 2008. 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Hamilton TE. “Requirements for Provider-based Off- campus Emergency Departments and Hospitals that Specialize in the Provision of Emergency Services.” Centers for Medicare and Medicaid Services, Center for Medicaid and State Operations, Survey and Certification Group, 2008. Ref: S&C-0808. Hill RF, Steelman A. “Freestanding Emergency Centers: A Win-Win for Providers and Patients.” Healthcare Financial Management, May 2008. Freestanding Emergency Departments: Do They Have a Role in California?  |  23