New law seeks to prevent surprise medical bills from freestanding ERs

Patients who visit freestanding emergency rooms in Texas should now have a better idea of whether their health insurance will cover the bill.

A new state law that took effect Sept. 1 requires the facilities — which resemble urgent care clinics but often charge hospital emergency room prices — to post notice of what, if any, insurance networks they’re in.

The new law is about “protecting consumers,” said Jamie Dudensing, chief executive officer of the Texas Association of Health Plans. Meant to prevent patients from surprising — and often debilitating — medical bills, freestanding ERs can comply with the new rules by posting the insurance information on their websites, as long as written confirmation is also provided to patients.

“We take educating patients very seriously,” said Brad Shields, executive director of the Texas Association of Freestanding Emergency Centers, which represents such facilities in Texas.

In 2009, Texas became the first state to permit freestanding ERs, facilities independent of hospitals that provide acute care around the clock — and frequently aren’t in insurance networks. They have spread quickly across the state, profiting, their critics argue, by charging up to ten times more than urgent care centers to treat ailments like a fever or sore throat. These prices have blindsided unsuspecting consumers who realize too late that they were treated by an out-of-network provider.

Christopher Spector was startled to receive an $1,100 bill after visiting a freestanding ER in North Richland Hills for an eye injury. In a letter he wrote to contest the charge, Spector says he went to the facility after being hit in the right eye with a tennis ball and, after a series of tests, was told to see a nearby ophthalmologist for further treatment. He doesn’t remember asking if the freestanding ER was in or out of his health insurance network.

“For doing essentially nothing but giving me the name of an ophthalmologist,” he wrote in the letter, “First Choice billed my insurance (United Healthcare) an outrageous amount of $6,111. UH paid $4,400.10 (which is still a ludicrous amount) but First Choice isn’t satisfied. They say I’m responsible for $1,100.03 of the remaining amount.”

He called the charges “unreasonable, uncustomary and even predatory,” and described how the ophthalmology center he visited the next day provided him more comprehensive care at a fraction of the price.

“I wasn’t surprised to receive a bill,” he said, but freestanding ERs need to be more upfront about what care they provide and at what cost.

The new law aims to clarify a process all sides agree can be confusing.

State Rep. Tom Oliverson, R-Cypress, who authored the legislation, said it prevents Texans from being deceived. For the “90 percent of freestanding ERs that aren’t in the business of intentionally misleading people,” he said, “if it helps patients be less confused, they’re good with it.”

Shields said his group supported the bill through the legislative process. Most facilities are good actors, he said, that strive to inform consumers about what their insurance plan covers. The websites of some freestanding ERs in Texas, for example, advise that the facility may not be in-network and may charge rates comparable to a hospital ER. Some even suggest patients visit an urgent care clinic instead.

Shields said the benefit of freestanding ERs is that they provide more timely and convenient access to medical care. “Waiting in the hospital waiting room for five hours,” he says, “that doesn’t have to be the norm.”

The new law was one of several bills filed during the 85th Texas legislative session that took aim at freestanding ERs. Another that passed, authored by state Sen. Kelly Hancock, R-North Richland Hills, allows more patients to use a mediation system to dispute surprise medical bills, including those incurred at freestanding ERs.

Together, Dudensing said, the new laws provide better protection for consumers, who will have more information before making decisions about their treatment.

“We’re not trying to disrupt any business model,” she said.

Source: New law seeks to prevent surprise medical bills from freestanding ERs | The Texas Tribune

Posted in Freestanding ER, Government Regulations, Industry Updates, TX Hospitals

How to Fix the Emergency Room – WSJ

How to Fix the Emergency Room

ERs are notorious for long waits, endless forms and inconsistent care. Now researchers and hospitals are rethinking the ways they work—with impressive results.

Long wait times in the emergency room have bad effects for patient outcomes and satisfaction. 

Hospitals are making a push to fix one of the most irritating issues in health care: the emergency room.

Armed with new research and strategies borrowed from the business world, some facilities are trying to ease the frustrating experience of waiting, filling out forms, explaining a problem—and then waiting some more.


Explore ER times in a searchable database of 4,800 hospitals around the country

These pioneering hospitals model different ways for hospitals throughout the country to rethink the way they handle emergency care.

“There’s a lot hospitals can do that they haven’t done yet,” says Jesse Pines, professor of emergency medicine at George Washington University, whose research published in the journal Health Affairs in 2015 shows that on average hospitals have adopted less than half of the proven interventions they were surveyed about.

Adding urgency to the search for solutions: Not only are wait times dauntingly long, but they’re not improving at the national level. The median length of stay for patients treated in the ER and then discharged was 138 minutes, according to data for October 2015 to September 2016 submitted to the U.S. Centers for Medicare and Medicaid Services. Researchers analyzing wait times in 2006 found virtually the same median.

Long waits don’t just bring patient frustration. Crowded ERs and long wait times have bad effects for patient outcomes and satisfaction, research shows. For instance, it takes longer for patients to get pain medications, antibiotics or the care they need if they’re having a heart attack.

The overall evidence “paints a pretty clear picture that under more crowded conditions, quality of care declines,” says Benjamin Sun, an emergency-medicine physician at Oregon Health and Science University, who was involved in a study on ER wait times and strategies recently published in the journal Annals of Emergency Medicine.

Improving conditions on a wide scale won’t be easy. Researchers say there must be sustained management support to make changes stick. And many of these solutions don’t just mean reorganizing the way things get done—they also mean taking on additional staff, which can be a hard sell.

That said, many hospitals are seeing strong results from their efforts, and the movement is spreading. Here’s a look at some of the interventions that are helping make things smoother for patients.

Rethink (or eliminate) triage. One of the biggest frustrations people encounter in the ER is one of the first things they have to put up with: registration and triage. After signing in and giving information, patients see a nurse who asks questions to judge how urgently they need care and the amount they’ll need, on a five-point scale. Then patients wait to see a doctor who may ask them the same things all over again.

With the traditional triage and registration, “there’s no way a patient can get to a physician in less than 30 minutes, even if there’s nobody in the ER,” says Assaad Sayah, senior vice president and chief medical officer of Cambridge Health Alliance, a hospital system with many uninsured and Medicaid patients.

In 2006, Cambridge Health Alliance set up a system where arriving patients give their name, Social Security number or birth date, and chief complaint. They are then brought to a treatment area so a provider can start caring for them right away, and don’t have to complete registration until they’ve gotten that initial help.

Patients in the Cambridge Health system waited to see a provider for a median of 10 minutes, compared with a national median of 29 minutes for other ERs seeing a comparable number of patients, government data show.

Rich Petrik, the ER physician director for Ocala Regional Medical Center in Ocala, Fla., has adopted another strategy to cut repetition: having a doctor listen to the patient during triage and begin to formulate and execute a plan of care. After Ocala Regional Medical Center put that change in place last year, as well as other fixes, patients were treated and sent home a half-hour faster than before. (The results don’t include patients who were admitted to the hospital.) Other facilities have gotten similar results from rethinking triage, according to researchers.

Eliminate details that waste time. Another approach to streamlining emergency rooms comes from the world of business—the “lean” management system where an organization looks at every step in its processes and figures out how to improve them, cutting out as much waste as possible.

As part of the Canadian province of Labrador’s efforts to reduce ER wait times, the staff at Labrador Health Centre in Happy Valley-Goose Bay went through lean training last April with consulting company X32 Healthcare. Looking at their operations through the lean lens, the staff noticed that “supplies were kind of everywhere,” says Donnie Sampson, co-chairwoman of the regional steering committee for emergency-department improvement, who oversaw the hospital’s work.

So the staff collected the supplies in one room, giving the nurses only one place to keep stocked—instead of the previous five carts—and look for the items they needed. The staff also noticed nurses were taking time to escort patients to other areas of the hospital for testing such as X-rays, so they put up colored tape that patients could follow to where they needed to go.

Another big change involved how doctors and nurses communicate. The hospital set up whiteboards for nurses and doctors to write up the most current patient information for other staff to see, such as the status of test completion. Instead of walking around the ER to find another staff member to ask, the boards “allowed people to see flow without actually having to talk to another provider,” says Ms. Sampson.

Help patients with minor complaints quickly… One of the most widely adopted fixes to emergency rooms has to do with patients who have minor issues. How to make sure that they don’t face endless waits—and crowd ERs—while doctors are dealing with seriously injured patients?

Some 40% of hospitals in the U.S. are giving the people with small complaints their own spot in the ER. Labrador Health Centre’s redesign included an area where patients in need of a medication refill or with mild complaints like a sore throat could be seen right away by a nurse practitioner or physician dedicated to seeing only such patients. Seeing the low-acuity patients quickly means there’s “not a huge pileup of people in the waiting area,” says Wanda Slade, Ms. Sampson’s co-chairwoman, who oversaw similar changes at another hospital in Labrador.

Labrador Health Centre measured its average wait time to see a doctor for a representative week before the change for low-acuity patients and found wait times ran to nearly 3½ hours, Ms. Sampson says. In a representative week afterward, that average had been cut in half.

According to the research Dr. Pines published in Health Affairs, about 40% of hospitals had similar fast-track areas for minor ailments by 2010—and other research finds hospitals with these treatment spaces decreased patient wait times and overall length of stay.

…And those who probably just need tests. In addition to creating specialized areas to care for low-acuity patients, some ERs have begun to separate out patients who require diagnostic testing but appear well otherwise. In the old system, those patients get put in a bed—but that takes space from sicker patients, and involves a lot of cleanup to make the bed ready for the next person. So Kaiser South Sacramento has patients wait for tests in chairs or wheelchairs.

Having these patients lie down on a gurney would have “no real benefit,” says Karen Murrell, Kaiser South Sacramento’s assistant physician in chief for the emergency department and hospital operations.

Schedule elective surgeries evenly. A big cause of snarls in emergency rooms doesn’t have anything to do with emergency-room patients at all. It is patients elsewhere in the hospital undergoing elective surgeries such as knee replacements.

Doctors often schedule those surgeries early in the week so that patients will recover by the weekend (and doctors won’t need to look in on them past Friday). The result: Early in the week, elective patients take up a lot of hospital beds, and there’s no room for ER patients who have been admitted. So these patients must stay—or “board”—in the ER instead, reducing its capacity and bringing longer wait times.

The uneven surgery scheduling “creates a very unbalanced demand for inpatient beds,” says Dr. Pines. Boarding is “the elephant in the room when it comes to crowding.”

In a study of one emergency room, researchers from Boston University calculated what happened on days when the hospital had a typical number of elective-surgery patients and the maximum number of ER patients. They found that elective admissions added 35 hours to the total time all patients spent in the ER, in their findings published in 2007 in Annals of Emergency Medicine.

Some hospitals have chosen to schedule elective surgeries evenly throughout the week to avoid buildups. The strategy “sounds great in theory and has been proven to work,” says Dr. Sun, “but is very difficult to do because of physician preferences and culture.” Dr. Pines’s research showed that in 2010 less than 5% of hospitals had smoothed their surgery schedules.

Another way hospitals can release pressure from boarding is through rules dictating that boarding patients must be taken from the ER to inpatient floors to wait for a bed when the ER is out of space. That makes room for new arrivals and patients waiting to be seen.

After the Canadian province of Alberta instituted full-capacity protocols for its hospitals in December of 2010, boarding decreased by nearly half. What’s more, the time admitted patients spent in the ER decreased to about 11½ hours from an average of 17, according to research led by the University of Calgary and presented at the 2012 Society for Academic Emergency Medicine Annual Meeting. Although the admitted patients still wait for open beds, moving them to wait in another part of the hospital allows other patients to move through the ER more quickly.

Ease admissions from the ER to the hospital. When emergency-room patients are admitted to the upper floors of the hospital, getting them from the care of one medical team to another can be complex. Especially in a teaching hospital, the process can involve multiple conversations between ER staff and a medical student, resident and then the attending physician on the upper hospital floor.

Beginning in 2006, Dr. Sayah at Cambridge Health Alliance oversaw changes to get the ER and inpatient floors working together better. They cut the handoff down to one phone call to discuss the patient’s care. The handoff between nurses was also simplified down to a single phone call between secretaries for the ER and inpatient floor.

Meanwhile, even before the phone call is made, a nurse upstairs has seen a brief page of information about the patient and, barring any concerns that would keep the person in the ER longer, the patient will be moved in 10 minutes after the call. The system’s hospital in Cambridge, Mass., cut the average total length of stay in the emergency room for all patients to about 2¼ hours from nearly 3½ hours, according to research Dr. Sayah published in 2014 in Emergency Medicine International.

Anticipate backups with software. It can be daunting for harried staffers to keep track of how many patients are in the emergency room and how long they’ve been waiting. So some hospitals are using software to deliver real-time data on patient numbers—and advice on how to shorten waits as they’re happening.

Mercy, a 44-hospital health system in Arkansas, Kansas, Missouri and Oklahoma, is using data collection and analysis software from health-care analytics company Qventus in nine of its ERs, and plans to roll out the program in another. The system monitors data including how many patients are in the ER, how urgently they need care, and how many patients are waiting to be seen or to go to a bed in the hospital. It also takes into account expected patient volume from historical data, as well as possible upward spikes from factors such as weather.

With all that information in hand, the system can predict when the ER will run out of capacity and alerts staff a few hours in advance, via text or another messaging mode. Staff members have specific tasks to do after they’re alerted, like accelerating the completion of lab and imaging tests and getting patients who have been either discharged or admitted where they need to go.

Qventus doesn’t direct treatment decisions, but it can recognize patients who have been waiting a long time and are likely to leave, then nudge staff to check in. The system can also recognize when lab tests or imaging studies for a patient haven’t been completed in a timely manner and alert the doctor or charge nurse before the patient has been waiting for two or three hours.

Mercy’s emergency room in Fort Smith, Ark., its first to adopt Qventus, in the summer of 2015, has reduced the average time patients wait to see a doctor by 15%, to about 60 minutes from the previous 70. The hospital also cut the average time patients spent in the ER before being discharged by about 23 minutes, to just under three hours.

Source: How to Fix the Emergency Room – WSJ

Posted in Industry Updates, Satisfaction Surveys

Dr. Overachiever: Award to honor Ovalo physician

Kyle Sheets jokingly calls himself an overachiever “in a bad way.”

Others probably say his overachieving is a great thing, considering all he’s done and is doing. Friends and associates call him “special,” “entrepreneurial,” “amazing.”

Patients call him “Dr. Sheets.” This week, however, everyone can add “Humanitarian of the Year” to the list.

That honor will be awarded Sheets during the annual conference of the American Academy of Family Physicians in San Antonio.

Sheets, a modest man, acknowledges that he’s proud to be receiving the award, but what led to it makes him even prouder. Several doctors who know him nominated Sheets through the Texas Academy of Family Physicians, the state chapter of the American academy.

“That’s pretty special to me,” Sheets said.

And pretty amazing for a man who didn’t enroll in medical school until he was 42. And that was after dropping out of Abilene Christian University halfway through his senior year in 1973.

“My parents nearly killed me,” he recalled.

Twenty years later, after starting, building and selling a number of businesses, Sheets re-enrolled at ACU, earning a degree in biology in 1993. Four years later, he had a medical degree and began serving a residency at Via Christi Family Medicine Residency Program in Wichita, Kansas.

It was an experience during that residency that led to the Humanitarian of the Year Award.

Family adventure

The primary reason that Sheets, who lives with his wife, Bernita, on a ranch near Ovalo in south Taylor County, was nominated for and won the honor was for his establishing Physicians Aiding Physicians Abroad (PAPA Missions) in 2003.

The organization provides practical help to other physicians who want to serve medical missions. The vision began in Zimbabwe and has expanded globally.

The seed for PAPA was planted in 1999, when Sheets was serving his residency in Kansas. Residents could spend one month in Zimbabwe helping at a hospital and receive credit toward completing their residency.

So, Kyle and Bernita and their 10 young children all headed to that African country for a month.

Aat their own expense.

“We’re still paying for that trip,” Sheets joked.

Several of the children live in or near Abilene, including the youngest, Cori, a student at ACU. One son, Tyler, was killed in a car wreck in 2006. He was 19. The ranch the couple lives on near Ovalo is the “Flying T Ranch,” named for Tyler. His mother recalled that as a child, Tyler dreamed of riding on a flying horse.

Whatever the cost of the Zimbabwe trip, it was a priceless experience for the entire family, Kyle and Bernita agreed. Their first impression, Sheets said, was that if the Americans could just help those extremely poor people make money, they would be happy.

But it didn’t take long to see that a mistaken view, Sheets said.

“They are so much happier than we are now,” he said. “All they have is ‘right now.’”
They don’t waste time storing up material goods or worrying about tomorrow. All they are concerned about is “today.”

That experience never left Kyle and Bernita and when the time was right, they started PAPA. The purpose is to help other physicians who have a desire to serve but not the experience to make a mission trip of that magnitude happen.

Larry Anderson, a physician in Wellington, Kansas, was one such doctor. He had heard of Sheets because the clinic where he practices is affiliated with the residency program in Wichita, where Sheets served his residency.

In 2006, Anderson went on a PAPA mission trip to Zimbabwe and recalled that it was “quite an education.” He has since done mission work in Mexico. Anderson, a former member of the board of directors of the American Academy of Family Physicians, put the bug in the ear of a colleague in Texas to nominate Sheets for the humanitarian award. No one is more deserving than Sheets and his wife, in Anderson’s mind.

“They’re special people,” he said, “and have been doing this a long, long time.”

A restless soul

If Kyle Sheets hadn’t been an overachiever, he most likely wouldn’t be getting the honor. In the 20 years between dropping out of ACU and returning to graduate, Sheets “overachieved” by starting, building and then selling business of all sorts from a fish farm to landscaping.

Joining him on that journey was his Bernita, a former ACU student. They didn’t know each other in school but were introduced by a friend. They married in December 1976.

“We kind of had a knack of starting and growing businesses,” Sheets said.

But always restless, Sheets began thinking about medical school, something he first considered as a biology major at ACU. He wasn’t ready then and dropped out instead. But the thought never completely left him.

So, at 42, he was accepted to the University of Texas Medical Branch in Galveston. The couple at that time had eight children, and two more were born there. After graduating, Sheets was accepted into the family practice residency program in Kansas, which suited him well.

He had grown up in Farwell and was recruited to join a practice in Muleshoe, just 20 miles from his hometown.

“Small town practice is what I was cut out for,” he said.

Today, in addition to flying to Muleshoe or Zimbabwe or Guatemala, Sheets oversees the company he founded in 2001, Concord Medical Group. It is a physician-owned and operated organization that assists with staffing rural hospitals in West Texas and in three states besides Texas.

Even while raising the family in Muleshoe, and loving the small town life, Sheets kept thinking about that trip to Zimbabwe, which eventually led him to start PAPA.

Other doctors involved

Not even a close call in 2010 keeps him away.

He was operating on an AIDS patient when he cut his hand.

A daughter, Heather Sample, an anesthesiologist who lives in Houston, was assisting.
Immediately after the surgery, Sheets began a regimen of drugs to ward off the disease.
He suffered severe reactions to the drugs, which attacked his liver, and had to be flown back to the United States for treatment.

On the flight, Sheets started failing quickly and his daughter began sobbing.

“It was terrifying,” Sheets said. “I was sure I was dying.”

Two men asked if they could help. They were doctors–in fact, the plane was carrying 100 doctors who were returning from a conference on infectious diseases. Sheets eventually recovered fully and HIV tests were negative.

The story was included in one of Max Lucado’s books on grace. Sheets and Lucado, a prolific writer on spiritual topics, a pastor, and fellow ACU graduate, are friends. When Lucado learned what had happened, he immediately recognized an amazing story of grace.

Despite that close encounter, Kyle and Bernita Sheets return to Africa about once a year to the 150-bed hospital they serve. When they go, they take teams of physicians, medical students, some family members, and people who just want to help, all recruited through PAPA Missions.

“”I’m the cook,” Bernita chimed in, a job she is well equipped to handle.

Not only did she raise a family of 10 children, she still is the primary mover and shaker behind an annual Thanksgiving feast at the ranch, attended by their children and families, and occasionally, friends. In all, 45 or so spend the Thanksgiving holiday at the ranch, with everyone divided into teams for cooking and cleaning.

After purchasing the ranch, which included a sprawling, four-bedroom house and two-bedroom guest house, the Sheets built a bunkhouse which sleeps 22. And the barn sleeps another 12.

Nothing seems too big for Kyle and Bernita Sheets to conquer — not starting multiple businesses, raising 10 children, serving medical missions all over the globe, flying back and forth to see patients in Muleshoe while running a multi-state hospital staffing business, or hosting 45 people for a long holiday.

Some would say that’s overachieving in “a good way.”

Humanitarian Award

According to the website for the American Academy of Family Physicians, the Humanitarian of the Year award created in 1997 “honors extraordinary and enduring humanitarian efforts both within and beyond the borders of the United States.”

Sheets had a family practice in Muleshoe for17 years and still flies there every couple of weeks in his own plane to see patients. In 1999, Kyle and his wife, Bernita, and their 10 children went to Zimbabwe for a month as part of the residency he was serving at Via Christi Family Medicine Residency Program in Wichita, Kansas. They were hooked immediately on medical missions.

In 2003, Sheets started Physicians Aiding Physicians Abroad (PAPA Missions) to provide practical help to other physicians who had a desire for medical missions. The vision began in Zimbabwe but since 2003, PAPA has sent hundreds of volunteers to six different countries and has shipped medical supplies worth millions to needy medical facilities around the world. 

In addition to operating PAPA and practicing medicine, Sheets started Concord Medical Group in 2001. Concord is a physician-owned and operated organization that assists with staffing in rural hospitals in West Texas and in three states besides Texas. 

Source: Dr. Overachiever: Award to honor Ovalo physician

Posted in Industry Updates, Providers Perspective, TX Hospitals

Journal republishes withdrawn paper on emergency care prices, amid controversy

The Annals of Emergency Medicine has republished a controversial paper it withdrew earlier this year which compared the cost of emergency care at different types of facilities.

Because the paper drew heavy criticism when it was originally released, the journal has published a revised version, along with several editorials and discussions between the authors and critics. One point of contention: The analysis stems from data provided by an insurance company — Blue Cross Blue Shield — which it declined to share.

The paper — originally published in February —  caught national attention (and raised concerns among some emergency care providers) when it reported the cost of treatment in emergency departments can be significantly higher than at urgent care centers, even for the same conditions. The journal withdrew the paper in spring, and re-published it Tuesday, with minor changes.

First author Vivian Ho at Rice University told us she made “slight changes”  to some headings, phrases, and the appendix, but:

the main results stay the same…I’m very happy the article has been re-released.

However, Ho added that she was “disappointed” the journal felt it had to publish so much extra “wording, and verbiage, and various editorials.”

Journal editor Michael Callaham at the University of California, San Francisco, told us:

We decided not to retract, and instead address and share the issues directly…We could not conclusively validate or exclude all the findings.

The findings have not been independently validated because the paper is based on data provided by health insurer Blue Cross Blue Shield, which it declined to share. Callaham told us:

…the entire analysis is still based on that data. We received an attestation of sorts from the Texas branch that they “stood behind the data”, but our efforts to find out if [Blue Cross Blue Shield] would allow impartial third party review of the data, went unanswered. And it certainly concerns me, but as you can see our efforts to resolve it, although very labor intensive, were unsuccessful.

Ho told us she has no doubts about the data:

I’m not at all concerned about the validity of Blue Cross Blue Shield’s data. I’ve seen their code, I’ve discussed the results extensively.

Both she and Callaham noted that other studies have relied on commercial insurance data to arrive at conclusions about clinical care; Callaham told us:

As far as I know, that data was not reviewed by anyone else either. This issue is a concern in our research community and has been discussed a good deal in our last several editorial board retreats, without arriving at any practical and moderately efficient solution.

Ho said insurers often can’t share the raw data due to issues with patient consent. It’s also an economic problem, she added, since insurers don’t want individual treatment centers to be able to compare reimbursements, which can vary significantly.

Conflicting reports

Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers” reviewed insurance data from places that offer emergency care in Texas: hospitals, freestanding emergency departments, and urgent care centers. It found emergency departments charge sometimes 10 times more to treat the same conditions as urgent care centers. (Texas has the most freestanding emergency departments of any state.)

The original article quickly raised concerns — for instance, some argued costs can vary depending on patient severity. Ho said some values could be influenced by patient care, but one table in the paper compares procedures, which are not influenced by patient severity; that table shows a routine urinalysis cost $51 in a freestanding emergency department, and $3 at an urgent care clinic.

Ho told us she believes some of the criticisms have been politically motivated — specifically, that some critics “worked really hard to make this article withdrawn” while the Texas legislature (which meets only a few months every two years) was considering legislation around emergency care. Ultimately, the governor signed a bill that makes it easier for patients to challenge their bills following emergency care, and expands requirements to disclose if facilities are out of a patient’s insurance network.

One major critic of the paper has been Paul Kivella, president-elect of the American College of Emergency Physicians, which owns the journal. In one of his letters asking to retract the paper, he writes:

…we have grave concerns about the study’s methodology, the integrity of the data, the potential conflicts of interest on the part of the authors, and the possible serious consequences that the report’s flawed conclusions and recommendations could have in terms of supporting policy changes that could jeopardize access to emergency care and undermine the “prudent layperson” standard.

Before republishing the paper (a decision already reported by Health Data Buzz), it underwent extensive review, according to Callaham’s editorial:

This unusually extensive review took the energies and expertise of 4 peer reviewers, 1 regular editor, and 4 expert editorialists. Additionally, the editor in chief and 4 deputy editors, who have a collective total of more than 86 years of experience in high-level editorial decisionmaking, were engaged in many hours of discussion…After digesting all the assessments and arguments, we concluded the article had some original and important data to report (on a topic with a paucity of such information) and believed it should be published. But because the concerns were also important and could not be conclusively resolved, they should be published too.

Callaham’s editorial acknowledges that some critics had a range of conflicts of interest (in addition, some of the co-authors on the paper itself are based at Blue Cross Blue Shield):

These potential conflicts of interest included those of some individuals who had financial interest in freestanding EDs, and of others who participated in insurance company marketing campaigns to the public to limit freestanding ED use. These campaigns have led to the announcement in some states that Blue Cross Blue Shield will deny claims after the fact for ED visits that in their judgment could have equally well been cared for in an urgent care center. Obviously, this insurer could benefit directly in instructing patients to use less expensive care, so the integrity of the raw data used in this analysis may be more crucial than the analysis itself.

Kivella, for instance, reports that he is an investor in a facility that operates four freestanding emergency centers, and lectured at the National Association of Freestanding Emergency Centers conference last year.

Here are links to the other documents published alongside the revised paper and editorial:

Source: Journal republishes withdrawn paper on emergency care prices, amid controversy – Retraction Watch at Retraction Watch

Posted in ER Billing, Freestanding ER, Industry Updates, TX Hospitals

Comparing Utilization and Costs of 20 most common procedures by facility type – Annals of Emergency Medicine

Table 2 lists the 20 most common procedures by facility type for the study period 2012 to 2015. The prices in Table 2 include both the facility and professional component of each procedure’s price.

Rank by frequency, percentage of all visits, and mean prices of the most common procedures by provider type (2012 to 2015).
Rank % Price, $ Rank % Price, $ Rank % Price, $
Bacterial culture, urine 19 6.1 83
Blood cell count, automated 5 22.8 109 3 39.7 67 10 4.7 7
Blood test: prothrombin time 17 7.2 48
CT scan, abdomen/pelvis 17 7.1 1,560 13 8.6 1,625
CT scan, head and neck 20 4.9 1,210 15 8.0 957
ECG 16 7.5 155 9 17.9 235 19 1.1 23
ED visits 1 98.3 1,049 1 97.1 937
Observation care 16 7.3 541
Immunology tests 15 1.7 7
Injections: immunizations 13 2.2 31
Injections: therapeutic/intravenous 3 37.6 123 2 41.7 111 4 20.6 17
Laboratory tests, organ/disease panel 6 22.1 198 4 38.8 149
Medical supplies and devices 2 38.0 46 12 9.0 145 8 5.6 13
Office visits, emergency 9 5.2 65
Office visits, established patient 1 53.1 130
Office visits, new patient 2 43.3 149
Office visits, other 5 9.4 21
Other chemistry tests 12 11.4 111 5 30.6 86 20 1.0 6
Other injections/noninjectables 13 10.2 47
Other microbiology tests 8 14.0 150 14 8.3 93 3 22.6 18
Other minor skin and breast surgery 19 4.9 393 17 1.4 141
Other nonsurgical pulmonary services 4 30.2 81 16 1.7 4
Other urinalysis 15 9.1 64 18 6.4 70 18 1.2 6
Respiratory therapy 14 1.9 22
Routine urinalysis 7 18.7 51 6 27.1 49 6 6.7 3
Specialty drugs 14 10.0 109 10 13.2 58
Transportation services 18 5.6 171 20 5.4 456
Venipuncture (draw blood) 10 12.4 19 7 21.0 12 12 3.0 3
Radiograph, chest 11 12.0 267 8 19.7 194 11 4.7 25
Radiograph, extremities 9 13.2 266 11 11.4 216 7 6.4 27

View Table in HTML

Source: Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers – Annals of Emergency Medicine

Posted in ER Billing, Freestanding ER, Industry Updates, TX Hospitals

Comparing Utilization and Costs of Care in FSED, HED, and UC


Main Results


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Figure 1

Visits by Blue Cross Blue Shield customers in Texas by provider type and year.

The plotted values reflect increases of 10%, 24%, and 236% in visits between 2012 and 2015 respectively, for hospital-based emergency departments, urgent care centers and freestanding emergency departments.

Figure 2 graphs the average price paid for care by facility type and year. Between 2012 and 2015, the average price per visit at freestanding EDs increased 54%, from $1,431 to $2,199. During this same period, the average price per visit at hospital-based EDs increased 23%, from $1,842 to $2,259. Prices at urgent care centers were substantially lower and increased only 2% (from $164 to $168) between 2012 and 2015. As prices increased, the amount patients were liable for out of pocket also increased. Freestanding ED patients were liable for 32% out of pocket in 2012 ($462/$1,431) but 35% ($763/$2,199) in 2015. Patients treated in hospital-based EDs were liable for 29% out of pocket in 2012 ($541/$1,842) but 33% ($749/$2,259) in 2015. Even urgent care center patients were liable for more out of pocket over time: 36% in 2012 ($58/$164) versus 38% in 2015 ($63/$168). Median prices by provider type and year are reported in Table E1 (available online at The median prices are lower than mean prices for freestanding and hospital-based EDs, suggesting that payments to these providers are skewed to the right. Changes in mean prices paid out of pocket for freestanding ED patients are greater than the change in median prices, indicating that freestanding ED patients with the highest out-of-pocket costs fared the worst over time.


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Figure 2

Mean total price per visit and mean amounts paid by insurance versus out of pocket by provider type and year.*

*Number of visits in 2012 versus 2015 equals 54,696 versus 183,971 for freestanding EDs, 954,548 versus 1,046,545 for hospital-based EDs, and 748,213 versus 926,933 for urgent care centers.

At urgent care centers, the insurer-paid amount was $106 in 2012 and $104 in 2015. The amount paid out of pocket was $58 in 2012 and $63 in 2015.

Source: Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers – Annals of Emergency Medicine

Posted in ER Billing, Freestanding ER, Industry Updates, TX Hospitals

Forum Raises Question: Can EMS Providers Help Treat Addiction Before An Overdose?

One hundred health care and first-response experts will convene to share ideas, strategies, and specific tools for fighting Connecticut’s opioid epidemic in a first-of-its-kind conference at UConn Health in Farmington on Wednesday. Focused on pre-hospital preventative care, the forum, co-hosted by UConn Health and the state Department of Public Health, will also feature the release of a free online training programfor emergency medical services (EMS) providers.

“EMS providers are absolutely on the front line of a lot of the treatment and interaction with the folks who are suffering opioid abuse and addiction,” said Dr. Richard Kamin, the EMS program director at UConn Health. “They are in a phenomenal position to treat [them] … from a better understanding and raising awareness and possibly even preventing [overdoses].”

Connecticut Ranks High In Opioid-Related Hospital Visits »

The conference, featuring speakers ranging from overdose survivors to psychiatrists to paramedics to medical examiners, is organized in response to the statewide strategy for combating the opioid crisis announced by Gov. Dannel P. Malloy in October 2016. Connecticut is the 4th highest among 30 states in terms of opioid-related emergency room visits, a report by the Agency for Healthcare Research and Quality found in June.

Editorial: Worsening Opioid Crisis Demands Action »

By equipping EMS providers — essentially, first responders of any sort with up-to-date medical training — with greater context of the opioid crisis, conference organizers Kamin and Peter Canning, a practicing paramedic and the EMS coordinator for UConn’s John Dempsey Hospital, hope their online training will enable them to better fight the disease when they confront it in the field.

Their goal is for EMS providers to treat opioid addiction beyond just administering the overdose-counteracting drug naloxone once an overdose has already happened. “That is often a very teachable time because the awareness and importance of understanding this is probably never greater than when you have just been resuscitated from an overdose and when your loved ones are watching you go through this,” Kamin said.

“The problem [of opioid addiction and overdose] in and of itself is clinically fairly well-described. People are not breathing because they use too much of an opiate. The interventions that we provide historically have always focused on getting people to breathe again,” he said. “This educational emphasis takes a broader look at hoping to make our interventions more efficient and prevent the need to ‘get there once folks stop breathing’.”

The training, available at, is free and open to anyone, though Kamin said it is geared toward medical professionals and first responders. Registration for the conference is full.



Posted in Industry Updates, Opioid Epidemic

UMC at Capacity, ER Wait Up to Eight Hours 

LUBBOCK, TX – University Medical Center started turning non-emergency patients away Tuesday morning after the hospital reached capacity. This is not the first time this happened and in fact, UMC said this happens often.

The hospital being at capacity affects nurses, resources and wait times. Recently, wait times for the ER lasted for more than six hours in some cases. The wait times are longer because the ER is full with patients from other areas of the hospital.

“Unfortunately, we have to hold patients in the ER,” said marketing director at UMC, Eric Finley. “That means is that we keep a patient in the ER until a bed is available for them in the hospital. Sometimes that’s 12 hours, sometimes that’s 24 hours.”

This causes the ER to operate differently and drains ER nurses who are not trained to work with these kinds of patients.

“It does wear on staff, we’re trying to listen to their needs because they are fully taxed every moment they are here,” said Finley.

A new facility with eight beds opened on Monday, but those beds are already full. As of this morning, they started having to turn away patients.

“This morning until about 9:30, we were on diversion for adult medical patients,” said Finley. “We’d take trauma or some type of bad car wreck but if your doctor said ‘Hey, I want to put you in the hospital for some testing,’ we wouldn’t accept that patient.”

Finley said a big part of the problem is people coming to the ER when they should be going somewhere else for their medical services, which adds to the wait time.

“One thing that we see at any given time is only about 30 percent of patients who are in the ER actually need to be there,” said Finley.

UMC is asking the community to avoid coming to the ER for symptoms like the flu or a bad cold and instead utilize the clinics around town. If it’s something more serious, the ER is the correct setting.

By spring, UMC hopes to add 45 more beds to their facilities. Currently, UMC is recruiting nurses to man those beds.

Source: UMC at Capacity, ER Wait Up to Eight Hours – Story

Posted in Industry Updates, TX Hospitals

Closing of freestanding ER in Amarillo may signal industry trend

The shuttering of what had been Amarillo’s fifth freestanding emergency room less than four months after opening may signal market saturation, according to those in the industry locally and statewide.

Neighbors Emergency Center at 4121 S. Georgia St. closed its doors on Sept. 8 after opening on May 27 — a move caused by low patient numbers and a reassessment of the Amarillo market, according to a company spokeswoman.

“This is more of a reset for the Amarillo market for Neighbors Emergency Center,” said Denise Hahn, NEC public relations specialist. “The numbers weren’t as high as we anticipated so it was just best to consolidate the staff and pull everybody into the first location on Western.”

Hahn didn’t provide specific numbers for how many people were seen at each facility.

She estimated all but 10 employees with varying titles were able to transfer to the location at 2105 S. Western St., and “at least 30” people are now employed there.

“We don’t go into any of our markets with a set goal,” she said. “So many factors are involved —population, the existing medical services … there’s a magic formula (and) those are done about 24 months in advance.

“We go in just with the forethought of truly trying to have more access to emergency medical care in a community that needs it.”

NEC operates 28 freestanding emergency rooms throughout Texas. Their operation began with a Houston location in November 2008. They opened their first location in Amarillo Feb. 5, 2016, on Western St.

The market in Texas for freestanding emergency rooms expanded rapidly after 2009 when the Texas Legislature approved House Bill 1357, the Texas Freestanding Emergency Medical Care Facility Licensing Act, which essentially legitimized the industry.

“The freestanding industry kind of took off … word got out to patients that there was an alternative to sitting in an ER waiting hours and hours to be seen so you did have a huge saturation of the market throughout the state of Texas,” Hahn said.

Hahn said they’ve seen the most success operating in rural Texas communities such as Kerrville and Paris.

“We have a high patient satisfaction (rate) because a lot of people don’t want to wait and there’s absolutely no reason for people to wait for hours and hours on end while a hospital is backlogged and just kind of herding them through,” Hahn said.

Hahn said that, on average, patients at NEC locations have a five-minute wait before being checked into an exam room, are seeing a board-certified doctor and ER nurse within 10 minutes and discharged within about three hours.

Despite the quick service, the freestanding ER market may be depleting.

“We have seen a big compression of the freestanding market just since the first of the year. Competitors have closed centers as well so this is just what’s happening across the state in this industry as we continue to fight for recognition from the federal government and going toe-to-toe with insurance companies,” Hahn said.

Though Hahn was clear that closing of the Georgia Street location was not due to billing issues or insurance reimbursement, she said those factors have contributed to the closing of some other locations. This year they have shut the doors to three locations in Texas — Austin, Longview and Lufkin — as well as locations in Rhode Island and Colorado.

Hahn said the industry has banded together to form organizations like the Texas Association of Freestanding Emergency Centers to tackle the hurdles they face.

While Hahn does not expect the industry-wide closings to continue — NEC is set to open a new location this fall in Lake Jackson — Jack Hooper, founder and CEO of Dallas-based company Take Command Health, a licensed health insurance agency, said he thinks more freestanding rooms will close.

“I think the trend is going to reverse in the next few years as consumers get wise,” he said. “It’s not all bad. I had a director here tell me that the average freestanding ER needs to (only) see six patients a day to be profitable.”

‘One too many’

Dr. Gerad Troutman, physician and founder of ER Now said they see anywhere from 10 to 50 patients daily at either of their locations at 2101 S. Coulter St. and 5800 S. Coulter St. and are in no danger of closing.

“Amarillo is going to support local and we are the local guys,” he said. “We’re not in danger of closing. We’re all local, we’re owned by seven local physicians that are part of the Amarillo community; we’re not going anywhere.”

While Troutman said there are no current plans for expansion at ER Now, he doesn’t think the industry is shuttering.

“Overall, the industry is absolutely growing,” he said. “The vast majority of patients that seek emergency care at a freestanding emergency center say they would come back.”

In addition to NEC and the two ER Now locations, Amarillo is also home to the ER on Soncy, which is a part of the BSA provider network.

Troutman said there are 215 independent freestanding licensed ERs in Texas.

“Every market can potentially become saturated and in Amarillo, I think that’s what happened. When you look at other markets we’re probably about where we should be. I think the one extra (ER) we had probably put it over the hump.”

Billing issues

Hooper’s company also helps patients with their bills when they feel they’ve been overcharged.

“If (someone) has a question about their bill they can snap a photo … we have a team that will review it … and get it straightened out,” Hooper said. “Turns out a lot of medical bills are wrong and usually not in the patient’s favor.”

Hooper said there’s no standardized or regulated price list hospitals, emergency rooms and urgent care centers must charge. However, he said there is a list of Usual and Customary (UC) charges, which they use as a guide.

“It’s a list of generally accepted charges,” he said. “It’s kind of unwritten rules, as long as bills are underneath that amount the bills aren’t under scrutiny. If bills are above that … you can threaten with reporting them to the insurance board and things like that.

“We’ve found a lot of them are willing to negotiate especially when they realize they can get a cash payment out of a client and not have to go through insurance or battle back and forth.”

Hooper said patients often complain about facility fees, for which emergency rooms charge the highest amount, and also redundant charges from the freestanding ER and then the hospital if the patient is transported. Hooper said he sees billing discrepancies in all levels of medical providers but “it’s most apparent in the ER because the bill is so much larger.”

Hahn said NEC works hard to ensure patients are not overcharged.

“Our charge master is often reviewed to make sure we stay in line with local market costs and charges,” Hahn said. “Our charge master has continually been at the same level as a hospital’s cost or in many cases, cheaper because we don’t have the massive overhead that a hospital has.

“Insurance obviously helps a great deal because that’s just the world that we are in. We do offer free medical screenings to anybody that comes in and we need to — we want to make sure that there’s not an emergent situation with somebody’s health or their life is on the line. We do a fair amount of what would be called charity care in that sense of Medicare patients … we don’t get any sort of reimbursement for that because freestanding emergencies are not recognized by the federal government.”

Troutman said ER Now’s prices are comparable to what a patient will be charged at a hospital.

“We are not out there to price gouge anybody. We trying to charge what’s fair and the industry standard and we do it in a better environment,” said Troutman, who is also the president-elect of Texas College of Emergency Physicians.

“In the state of Texas, as well as under federal law, under the current ACA, anytime a patient seeks emergency care the insurance company must pay for that emergency care at — it’s called the greater of three — the in-network benefit, the Medicare rate or the Usual and Customary (rate) and they’re supposed for to pay for every emergency at the greater of any of those three numbers.

“A lot of freestanding ERs are not in-network technically with any insurance company because there really hasn’t been a need to because they have to pay us the in-network rate and the vast majority accept that as final payment.”

He added they have also negotiated prices with uninsured patients to make sure they receive the care they need.

Freestanding ERs in Amarillo

ER Now, 2101 S. Coulter St. Opened Sept. 4, 2015

Neighbors Emergency Center, 2105 S. Western St. Opened Feb. 5, 2016

ER Now, 5800 S. Coulter St. Opened Oct. 13, 2016

ER on Soncy, 3530 S. Soncy Road. Opened Nov. 25, 2016

Freestanding ER vs. urgent care

Urgent care centers:

Not open usually open 24/7

Typically staffed by family practitioners, nurse practitioners and physician’s assistants

Not mandated to have x-ray equipment, don’t have CAT scan machine and have limited laboratory capabilities.

Can turn away patients with no ability to pay.

Typical bill costs $200-300

Freestanding emergency rooms:

Open 24/7

Typically staffed by emergency physicians

Have EKG, X-ray and CAT scan equipment as well as a full laboratory

It’s against the law for an ER to turn away patients

Source: Closing of freestanding ER in Amarillo may signal industry trend |

Posted in Freestanding ER, Industry Updates

Britain begging US physician assistants to fill staff

Britain is offering US physician assistants cash and long vacations in Europe if they relocate to fill desperate staff shortage

  • Physician assistants (also known as physician associates) train for two years, roughly a quarter of the time a doctor trains
  • It means they can do many of the same things but under supervision
  • Given staff shortages in the US, they are being given more autonomy to prescribe and operate
  • Now the UK is looking to recruit from the 115,000 US physician assistants
  • The NHS is offering $1,000 to relocate, 41 days’ holiday and free flights home
  • While they will not be intended to replace doctors, they will be allowed to perform the same tasks
  • Patient groups warn it could trigger a slippery slope to relying on under-qualified staff 

Physician associates, medical professionals who assist doctors in making a diagnosis and analyzing test results, train for two years, roughly a quarter of the training of a doctor.

It means that while they are qualified to prescribe and diagnose, it must all be done under supervision.

But that is changing in both the US and the UK as both nations struggle with demand for medics.

The NHS plans to recruit up to 3,200 PAs to perform minor operations and monitor wards - primarily from the US, which has more than 115,000 of them (file image)

The NHS plans to recruit up to 3,200 PAs to perform minor operations and monitor wards – primarily from the US, which has more than 115,000 of them (file image)

Given staff shortages in the US, they are being given more autonomy to prescribe and operate. Now the UK is looking to recruit from the 115,000 US physician assistants.

The National Health Service (NHS) is offering £1,000 ($1,350) to cover their relocation, 41 days paid vacation a year, and free flights home during holidays.

Ultimately, officials say the plan is to recruit up to 3,200 PAs to perform minor operations and monitor wards.

The move has sparked outrage, with senior medics and patient groups warning it could trigger a slippery slope towards relying on under-qualified transplants to perform essential duties.

British health officials insist the PAs would not be replacing doctors, though they would be allowed to perform the same tasks.

The pamphlet continues: ‘This means that you will have ample time to explore the rest of the UK where there are many fascinating and historic sites and exciting cities and towns.

‘The UK is also perfectly placed for taking trips short trips overseas to other countries.

‘You can reach most European destinations in just a few hours from London which makes the UK a fantastic travel hub from which to explore Europe and even further afield.’

The plans come amid similar moves in the US to give PAs more autonomy.

As of this year, there were 115,000 trained physician associates in America, up almost six-fold since 1990, when there were 20,000.

States are increasingly easing restrictions on PAs, primarily allowing them to prescribe almost anything.

Last year, every state made at least one change to legislation that allowed PAs to have more power.

Doctors who supported the bills insist physician assistants should be allowed more scope as clinicians, since they are already trained to operate, diagnose, prescribe and work with patients.

Source: Britain begging US physician assistants to fill staff | Daily Mail Online

Posted in Industry Updates, Physician Encounters