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The Lines Are Blurred Between Freestanding ERs and Urgent Care Centers

The vague distinction between the two may be misleading—and costing—unsuspecting patients in North Texas.
By Olivia Nguyen |

Last November in Frisco, Candie and Dustin Sandlin entered a Legacy ER & Urgent Care center—a walk-in clinic that also operates as a freestanding emergency center—because the couple’s primary-care physician was unavailable. Candie, experiencing symptoms of a migraine headache, was told by the on-site doctor that a CAT scan was needed to rule out any serious diagnoses.

Candie was reluctant, but agreed to the procedure. Afterward, Dustin says the doctor diagnosed his wife with a headache. The Sandlins returned to Legacy ER & Urgent Care five days later, with Candie still in pain. This time, Dustin says, another doctor suggested she may have vertigo, and ran a blood test to confirm the hunch. Once the diagnosis was confirmed, he says, the doctor could only provide “over-the-counter motion-sickness medicine, because the facility did not have medicine to specifically treat vertigo.” The total bill for the two visits? “$7,000,” Dustin says.

When asked by Dustin in a formal complaint why the bill was so high, he says the facility replied it was because Candie had received a CAT scan and a blood test and that these services were categorized as “emergent,” allowing Legacy to charge freestanding ER prices, without verbally notifying the patient. (Emergent care typically is required in case of a threat of grave disability, or an immediate threat to a patient’s life.)

Later, the Sandlins did recall seeing, in fine print, a reference in Candie’s paperwork to the possibility of some services being “emergent,” which for them meant out-of-network insurance care, carrying a higher price tag. For Dustin, though, a bigger question arose: “Why weren’t patients being notified which medical procedures are classified as urgent care—or emergency services—so they knew the difference?” Legacy didn’t return our calls seeking comment.

“There should be a list of services that is distinctly offered, so people are aware. But that list doesn’t exist.”

Dustin Sandlin, husband of patient

The Sandlins aren’t alone in their experience, or in their question. In Frisco alone, freestanding emergency centers owned by Legacy, Code 3 ER & Urgent Care, and other independent operators have attracted more than 10 pages of website reviews. There, patients have complained variously about exorbitant, hidden costs for the treatment of problems ranging from minor injuries to colds.

This is mostly because independently owned urgent care or freestanding emergency centers in general are able to “bait and switch consumers,” Dustin Sandlin alleges. “People are coming in for urgent care—it’s not our goal to go to the ER,” he says. “The transparency of what is and what isn’t considered an ‘emergent’ service determines the price point. There should be a list of services that is distinctly offered, so people are aware. But that list doesn’t exist.”

In Dallas-Fort Worth, according to a national urgent care database, there are at least 45 urgent care centers—26 of which operate as both urgent cares and freestanding ERs. There are more than 490 urgent care centers total in Texas. In addition, there are at least 40 freestanding ERs in North Texas, mostly in middle-to-high income areas, according to the Texas Association of Freestanding Emergency Centers (or TAFEC), and 325 such facilities statewide. Two-thirds of these ERs are independent, while the rest are hospital-operated.

Of course, not everyone believes like the Sandlins that independently operated, freestanding medical facilities are misleading patients. One who doesn’t is Dr. Carrie de Moor, president and CEO of Frisco-based Code 3 Emergency Physicians, and chairman of the American College of Emergency Physicians’ Freestanding Emergency Centers Section. She believes a lack of cooperation between insurance providers and the facilities is what leads to higher-than-expected, out-of-network bills.

In an April commentary for D CEO Healthcare titled “Willing healthcare providers seek fair in-network contracts,” de Moor wrote about the resistance by insurance companies to accepting these facilities as healthcare providers. She describes the facilities as providing expeditious, cost-effective emergency services in a transparent manner.

In an interview, de Moor adds, “I believe having a dual model—both an urgent care and a freestanding emergency center—actually helps us be transparent. We can distinguish if a patient has an emergency or not, and diagnose them on how to treat it.” According to TAFEC, urgent care facilities serve as alternative care options for patients with non-life-threatening injuries or illnesses. Meanwhile, freestanding emergency centers serve as facilities—staffed with 24/7, ER-trained physicians—that treat cases requiring immediate attention.

But Stephen Mansfield, CEO of Dallas-based Methodist Health System, contends that, in reality, there is little difference between the two. Mansfield says he knows of a few facility owners who “basically turned an urgent care into a freestanding ER, by changing [their] operating hours to be open 24/7, 365 days. They didn’t really change the staffing model, clinics, or equipment. They may add a CAT scan and a small lab. But the main difference is that the facility needed only four more visits a day [to stay in business], since the reimbursement is so much higher” for emergency centers.

With a highly profitable business model, and free rein to plant seeds in higher income areas following the passage of a 2010 Texas licensing law, it’s no wonder that freestanding ERs are proliferating here. “For a private entity investing in private money … there’s not any stipulation that you can’t set up a freestanding ER,” Mansfield says. “We don’t have [certificates-of-need] in Texas. … If you want to put one at an intersection or by a hospital, and you can get the land, you can do it. There is no regulatory body to tell you otherwise.”

While it may be relatively easy to set up shop, de Moor says independent freestanding centers face other obstacles. Her struggle working with insurance providers, for example, prevents her patients from being billed in-network, she says. “We’re trying to get patients to understand their healthcare plans better, and educate them so they know we’re trying our best to be in-network with them,” de Moor says. “ … We’re doing what we can.”

Kevin O’Donnell, managing partner at Dallas-based Healthcare Resources of America, believes patient safety is an additional concern with some of these facilities. “Urgent care centers and freestanding ERs have a lot of limitations on what medical services they can provide,” O’Donnell says. “In a serious emergency like a stroke or heart attack, [patients] won’t get the care they need there. They may be able to stabilize them for the next move—which is a hospital emergency room—but you’re putting their safety at risk, losing time.”

Says Mansfield: “Hospital systems pay millions of dollars every year for specialists to be on-call. If you go to an emergency room there, you’ll have a doctor that can cater to your problem well. At a freestanding ER, you’ll see a doctor with a limited skill set. What ends up happening is an ambulance will take you to a hospital ER. Then you have to pay for two visits, while putting your health at risk.”

Mansfield’s Methodist Health is one of the largest DFW healthcare systems that has yet to contract with any independently operated, freestanding ERs. Other systems have opted to open freestanding emergency centers, sometimes partnering with independent operations.

In a D CEO Healthcare article last year, Barclay Berdan, CEO of Texas Health Resources, said THR decided to partner with the First Choice Emergency Room chain, adding a number of freestanding emergency rooms in order to increase access to care.

As of now, Mansfield says, Methodist has no similar plans. “We believe everything we do either needs to improve quality of care for the patient or lower the cost,” he says. “So far, we’ve had a hard time convincing ourselves that freestanding ERs do that.” 

After this article went to press in D CEO’s July/August issue, Dustin Sandlin reported that his issues with Legacy ER & Urgent Care had finally been resolved.

Olivia Nguyen is the editor of D CEO Healthcare and a D CEO associate editor.

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