The Texas Freestanding ER Act
Last week Governor Rick Perry signed C.S.H.B. (Committee Substitute House Bill) No. 1357 which regulates and defines freestanding emergency facilities.
A "freestanding emergency medical care facility" means a facility, structurally separate and distinct from a hospital and not affiliated with a hospital licensed under Chapter 241, that receives an individual and provides medical treatment or stabilization to the individual in an emergency or for a condition that requires immediate medical care.
C.S.H.B. 1357 establishes procedures for license application, issuance, denial, suspension, probation, and revocation. The bill provides for the emergency suspension of a license and injunction for a violation of licensing requirements. The bill provides for facility inspection, fees, and the freestanding emergency medical care facility licensing fund.
The bill prohibits the minimum operating hours of such a licensed facility from being less than 7 days each week and 12 hours each day. There will be separate licensing for 12 hour and 24 hour facilities, perhaps opening the door to insurers to pay the 12 hour facilities less. Facilities open less than 24 hours per day will not be able to use the word "emergency" in their advertising, but that restriction will not be enforced for 2 years.
C.S.H.B. 1357 requires a facility "to provide to each facility patient, without regard to the individual's ability to pay, an appropriate medical screening examination within the facility's capability, including ancillary services routinely available to the facility, to determine whether an emergency medical condition exists." The bill does not specify that these patients must be stabilized as with the EMTALA law, and since these facilities are not required to follow EMTALA anyway, perhaps a medical screening exam followed by a 911 call would suffice for uninsured patients. That remains to be seen.
Perhaps the most important section deals with insurance reimbursement. The bill requires insurers to provide coverage and reimbursement for services originating in a freestanding emergency medical care facility. Formerly, some insurers would refuse to pay the facility fee for emergency care not obtained in a "hospital's" emergency department. Not anymore.
C.S.H.B. 1357 requires a freestanding emergency medical care facility to obtain a license not later than September 1, 2010.
A "freestanding emergency medical care facility" means a facility, structurally separate and distinct from a hospital and not affiliated with a hospital licensed under Chapter 241, that receives an individual and provides medical treatment or stabilization to the individual in an emergency or for a condition that requires immediate medical care.
C.S.H.B. 1357 establishes procedures for license application, issuance, denial, suspension, probation, and revocation. The bill provides for the emergency suspension of a license and injunction for a violation of licensing requirements. The bill provides for facility inspection, fees, and the freestanding emergency medical care facility licensing fund.
The bill prohibits the minimum operating hours of such a licensed facility from being less than 7 days each week and 12 hours each day. There will be separate licensing for 12 hour and 24 hour facilities, perhaps opening the door to insurers to pay the 12 hour facilities less. Facilities open less than 24 hours per day will not be able to use the word "emergency" in their advertising, but that restriction will not be enforced for 2 years.
C.S.H.B. 1357 requires a facility "to provide to each facility patient, without regard to the individual's ability to pay, an appropriate medical screening examination within the facility's capability, including ancillary services routinely available to the facility, to determine whether an emergency medical condition exists." The bill does not specify that these patients must be stabilized as with the EMTALA law, and since these facilities are not required to follow EMTALA anyway, perhaps a medical screening exam followed by a 911 call would suffice for uninsured patients. That remains to be seen.
Perhaps the most important section deals with insurance reimbursement. The bill requires insurers to provide coverage and reimbursement for services originating in a freestanding emergency medical care facility. Formerly, some insurers would refuse to pay the facility fee for emergency care not obtained in a "hospital's" emergency department. Not anymore.
C.S.H.B. 1357 requires a freestanding emergency medical care facility to obtain a license not later than September 1, 2010.
Labels: ER, health care crisis
posted by scalpel at 1:36 AM
35 Comments:
You must be devastated.
Why? There's nothing in there that hurts me, and much that helps me.
I'm totally psyched about it.
You have to give a "medical screening exam" to non-paying patients! You just defined what an emergency was to you to include everything up to and including colds, so have fun with those MSEs and the liability that comes with them.
No big deal, we do that anyway.
Oh come on...you said you were going to turn away non-paying patients, even with potentially serious emergencies (other than the arrest patient which you'd have your ACLS-trained staff do 'first aid' on). Whatever, dood. :)
The law doesn't require stabilization or treatment, only examination.
In practice, we will only turn away frequent flyers or previous nonpayers. I'll give anyone the benefit of the doubt once.
When you have an exceedingly high percentage of privately insured clientele, arrangements can be made with local specialists to take the rare nonpaying patient in return for the numerous well-paying referrals we give them.
It really isn't that complicated or as evil as you try to make it out to be. Location is critical though, and my location is outstanding.
I'm confused. How can you turn away a frequent flyer or non-payers when the bill states screening exams are mandatory? You're not required to stabilize only to screen but there has got to be a cost to screening people or are you just hoping these people won't utilize your facility?
The main costs of doing business are rent, salaries, and operational expenses. The cost for screening a given patient is minimal if you're already open anyway.
Nonpaying patients can either be turned away after screening (if stable), referred or transferred to an EMTALA-compliant hospital (if they do have an emergency) or evaluated and treated (at our discretion).
And by choosing the location of a freestanding ER carefully, one can indeed minimize the likelihood of nonpaying patients.
The definition of a "freestanding emergency medical care facility" is overbroad.
A facility that "receives an individual and provides medical treatment or stabilization to the individual in an emergency or for a condition that requires immediate medical care" could be any doctor's office in the state.
A patient walks into the doctor's office (consider him "received"), complains of chest pain (a condition that "requires immediate medical care") and the doctor gives him an aspirin (the "treatment") before sending him to the hospital. Before this law, that treatment was OK, now the doctor is breaking the law unless he uses all the ancillary testing available in the office before he sends the patient - potentially delaying care of a time critical medical problem.
Same for an orthopedist's office that sets a broken leg.
So now all doctor's offices have to be open at least 12 hours a day, 7 days a week and provide medical screening examinations? I'd tell Governor Perry to get a clue.
And if a freestanding ER wants to comply, it can be open from 7AM to 7:00:01 PM or it can just call itself a freestanding "ER" or "ED" without using the term "emergency." I'd even throw it back in the governor's face and call my facility a "really really urgent medical care facility."
I can see how it helps true freestanding EDs in fights with insurance companies, but it wasn't wordsmithed very well at all.
One of my clinical sites resides in an extremely wealthy old money enclave, polo pony original. Nobody, I mean nobody with money who lives there goes to that hospital if at all possible. They go to the "real" hospital in the next town, or into the city. Funny this site in big money land gets the uninsured in big numbers simply because they "believe" that it's locale must mean it is where the rich go. This hospital is not a bad hospital and, sure if you looked up staff, that site has a few good names, but you'll never see 'em there...
Have you got enuf parking for transport?
-SCNS
Whitecoat the law specifically excludes doctors' offices and similar facilities from licensing. It's actually very specific, I only hit the main points.
I think it starts getting dicey when the law says you don't have to stabilize but "real" ERs always stabilize (due to EMTALA and/or ethics). I could see court cases coming up which try to hold your facility to a "real" ER's standard, especially regarding stabilizing enough to transfer to another facility. I'm hoping you'd at least IV and fluid bolus the GI bleedeur and do some ABCs. Yah know? Is saying, "Yep, it's an emergency, his BP is low and he has rectal bleeding; I'm gonna call 9-1-1" really enough?
If a patient is unstable and we transfer him to a hospital by ambulance, it isn't a violation of EMTALA because we are not subject to EMTALA. It isn't a violation of the state law as written either.
Nor is it any sort of ethical violation, because I'm not ethically required to provide uncompensated care.
You just can't handle this whole concept, and I find it hilarious. I'm pretty sure they have IV fluids on most ambulances these days.
I'm talking about civil lawsuits, dork. Sure, you don't violate EMTALA nor state law, but 99.5/100 ER docs would stabilize the patient before a transfer; that's what they're used to doing and that's how they'd testify. No c-collar on that trauma patient? No IVFs for that bleeding out GI bleeder? You don't think EMTALA care is the "standard" by which all other care will be judged whether or not the law supports your hands-offiness?
Also, maybe it's not the same there, but here, if you transfer to another facility, the 2nd facility doesn't get paid for the ER visit. So you could do a medical screening exam (ie vital signs and "yep, sounds serious"), collect your facility fee and doctor exam fee, call 9-1-1 and cockblock Facility #2 from getting paid. Kinda of assholical.
There are some conditions for which every second spent on "stabilization" (or transfer paperwork or phone calls,etc) only delays needed care and worsens outcomes. We aren't hospital facilities and we don't have cath labs or surgical suites, so all of our admissions must be transferred anyway.
The sickest patients need immediate transfer, and the less sick patients are unlikely to deteriorate en route.
Interesting.
If the law doesn't require you to do anything if you discover an emergency, it's kind of toothless. That's a good thing for you.
Nurse K, civil suits can only succeed if there is some duty to a patient. Walk into a doctor's office whom you've never seen before with an MI and the doctor has no duty to treat you. They may call 911, but there is no law saying the doctor even has to do that.
If freestanding EDs have no duty to treat under the law, then no civil duty can follow. That's a matter of law, not something to be decided by an expert.
Scalpel,
You get a bad night where you get several in an hour or two, who are real sick and require immediate care. These are a mix of pts some who meet your TOS guidelines and some who don't. That's gonna get wierd for your staff. I imagine the (small) waiting room where one family gets their sick family member ushered in, and the other is told, yes your family member is real sick, but he doesn't meet our TOS. Say, both families live in that little wealthy area, word spreads. Everyone is gonna think that you suck, just say'in.
Also how many ALS ambulances do you think can respond to just your site at one time, say you got like 5 that gotta go? Are you gonna make the paramedics come in and take the patient out of your triage, off premises, into the ambulance before allowing them to initiate tx?
I imagine watching some guy sitting in one of your triage chairs, vomiting blood from his GI bleed in a plastic bag, waiting for an ambulance to come get him. Paramedics come in, you say, "Take this guy to real ER, BTW he's bleeding out, and ya might wanna get a line in fast... justa tip"
Scalpel, please tell me I have you figured all wrong?!
-SCNS
SCNS, are you for real?
SCNS, you have the wrong impression of the type and number of patients that come to these facilities. GI bleeder guy should have called the ambulance to begin with. I'm not taking anything away from the uninsured that they had before...I'm simply offering a better option to those who can pay.
The reason wealthy families come to these places is so they don't have to wait hours in the "regular ER" behind the hordes of uninsured, Medicare, and Medicaid patients. Our door to doctor time is faster than it takes to get a cup of coffee from Starbucks. Our patients aren't going to be too upset if we turn away a few folks - that's why they come to us in the first place! And if we see 30 patients in 24 hours, I'll be ecstatic and wildly successful. That's 1.25 patients per hour - it's not likely we'll have five crashing patients all week, much less simultaneously.
Scalpel,
I wish you the best, I do. Heck I had my own business at one time as well. You should always plan to handle wildly successful. Also, I have Texas connections...(Hook 'em)
Anon, yeah I'm really real.
The purpose of my example was to set a ridiculous scenario, one you would think would not happen ever. Doesn't matter how sci-fi you get with it. It is supposed to open your mind up to things you hadn't considered before. Anything. Maybe it spurs another question. You are supposed to be able to say, no, truthfully this would never happen, or, should pigs fly, this is what I would do in response so my whole deal doesn't fall through. FYI.
-SCNS
Awesome. Do you need an ER tech?
-ee
Hmmm. Lets see how things pan out. In a few years someone will get sued in all likelihood (not necessarily at your place but at some similar facility) and we will see how this law and the concept of a freestanding ER works out in court.
Personally however, I still would call such a place an upscale "Urgicare" if it is not bound by EMTALA.
That's kind of a long commute, Em.
And you can call it whatever you want, erp, but the sign says "emergency" and the reimbursement is the same as any other ER, so you're in the minority whether referring to your opinion or to your collections.
"The reason wealthy families come to these places is so they don't have to wait hours in the "regular ER" behind the hordes of uninsured, Medicare, and Medicaid patients."
I'm in the Houston area and by no means are we wealthy, but we do have private insurance. There are three freestanding ERs within a few minutes of my house. I have used them so that I could get immediate care for a kid ...broken finger, split lip, fever & dehydration, streaking infection on a weekend. The one time I thought that a problem of my own might actually result in me being admitted I had some friends drive me to Memorial Hermann downtown 45 min away, where in fact I was admitted. I plan to avoid both Tomball and Methodist Willowbrook(10 min from where I live)if at all possible, the two hospitals nearest me. If I don't get satisfactory service as an outpatient there I surely won't risk being a captive audience.
"Our door to doctor time is faster than it takes to get a cup of coffee from Starbucks." Bingo. I showed my insurance card and go straight back, never got a chance to sit down in the completely empty waiting room. If it costs the same, why wouldn't I?
"urgent cares" are just docs with extended office hours, can't sew up a lip or do x-rays.
Ann
My son had his foot sewed up at an Urgent Care. Made an appointment and came in an hour later. Saved the health care system some money avoiding all types of real or fake ERs. Urgent Cares can do XRs, set broken bones, sew lacs, and the one I go to even has an on-site CT scanner. Extended office hours (which are also a good thing) are not the same as an urgent care.
Is that sort of like the "Fake Track," where patients pay for an MD visit but have to settle for an NP?
True, but your part of the state has a lot more to offer for my family. I'd move. You could even get a Doc of PT out of the deal, LOL.
-ee
I gotta be honest, Scalpel, I don't think giving a GI bleeder a once-over and saying "yep, he looks like he's dying, call an ambulance" would count in my book as an appropriate medical screening exam.
Apparently the bill doesn't require you to stabilize them... that being said, I think you'd get your ass handed to you in court trying to explain to a jury why you let him bleed out in your waiting room. And I think you'd have a hard time finding an expert witness sympathetic to your cause.
Plus, I agree with Nurse K. The hospitals you refer to are going to hate you in a matter of weeks.
If someone is vomiting significant quantities of blood, they by definition have a condition that will require admission and so they should be taken to a hospital as soon as possible.
There really isn't much I can offer such a patient. I don't have a blood bank, and I'm not planning on asking any Gastroenterologists to perform emergent endoscopies on site. So they must go, and the sooner the better. We can start an IV and hang a bag of fluid while waiting for the ambulance, no big deal.
The bill has passed but the rules and regulations are still being finalized. I'm reading through them now and making suggestions. These facilities are badly needed in rural areas that have no care and in urban areas where ER overcrowding is a huge problem. And despite what you hear: the genuine free standing Emergency Rooms do not turn away any patients with an emergency. But getting them transfered, without financial resources, is nearly impossible because hospitals won't "recognize" us as an ER and therefore won't accept transfers. This bill will formalize what it is that the Free Standing ER's do.
Yes, the new proposed (draft) regulations are very restrictive. But I would disagree with you on one point - freestanding ERs are much more likely to follow a stricter interpretation of medical screening than most hospital-based ERs. Not that that's a bad thing.
Seems pretty reasonable to me, Scalpel. I'm a radiologist in East Texas, none of my partners are neurointerventionalists so if there is something that needs to be glued or coiled you bet we tell the patient "We don't do that." We can't offer the service, so we refer the patient to the appropriate level of service.
Got a call today about an MRI I read on a young woman with what looks to me and all my partners like a large cerebral AVM. The referring doc said, "Don't we do angiography here?" I replied, "Yes we do, but why would we do an arteriogram that is sure to be repeated (at additional and likely unreimbursed cost) at a tertiary facility? Let's get her to someone who has a chance of fixing her before we start poking holes in this nice lady."
When I was in residency at S&W, we didn't refer anything out. I had assumed this was the way things were until I started practice and found out that in Paris, Texas, small bowel GI bleeders didn't require intestinal angiography and gelfoam in the mesenteric arcades. They required a helicopter and doctors in Dallas.
In Paris, it worked like this: people went to the hospital in Broken Bow, OK, and if they were too sick for Broken Bow they were sent to Paris. If they were too sick for Paris, they were sent to Dallas. Your freestanding ER is basically Broken Bow -- you fix what you have the facilities to fix, and refer the rest up the food chain. From the sounds of things, you lack the facilities to fix a GI bleeder -- so off they go.
People objecting to your service model should consider what's best for the patient, seat of the pants stabilization in a building without subspecialty support, RT support, blood bank, endoscopy or an OR, or referral to a place with all of those. The answer is pretty clear, he doesn't belong in your facility any more than he belongs in Target.
Good luck!
Which agency is doing the site survey for these facilites? The Texas Department of State Health Services?
Does anyone know which Texas Agency will be responsible for conducting the certifying site surveys for these faciites?
Yes, the DSHS licenses and surveys these facilities.
- scalpel
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