Elsevier

Annals of Emergency Medicine

Volume 70, Issue 6, December 2017, Pages 846-857.e3
Annals of Emergency Medicine

Health policy/original research
Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers

https://doi.org/10.1016/j.annemergmed.2016.12.006Get rights and content
Under a Creative Commons license
open access

Study objective

We compare utilization, price per visit, and the types of care delivered across freestanding emergency departments (EDs), hospital-based EDs, and urgent care centers in Texas.

Methods

We analyzed insurance claims processed by Blue Cross Blue Shield of Texas from 2012 to 2015 for patient visits to freestanding EDs, hospital-based EDs, or urgent care centers in 16 Texas metropolitan statistical areas containing 84.1% of the state’s population. We calculated the aggregate number of visits, average price per visit, proportion of price attributable to facility and physician services, and proportion of price billed to Blue Cross Blue Shield of Texas versus out of pocket, by facility type. Prices for the top 20 diagnoses and procedures by facility type are compared.

Results

Texans use hospital-based EDs and urgent care centers much more than freestanding EDs, but freestanding ED utilization increased 236% between 2012 and 2015. The average price per visit was lower for freestanding EDs versus hospital-based EDs in 2012 ($1,431 versus $1,842), but prices in 2015 were comparable ($2,199 versus $2,259). Prices for urgent care centers were only $164 and $168 in 2012 and 2015. Out-of-pocket liability for consumers for all these facilities increased slightly from 2012 to 2015. There was 75% overlap in the 20 most common diagnoses at freestanding EDs versus urgent care centers and 60% overlap for hospital-based EDs and urgent care centers. However, prices for patients with the same diagnosis were on average almost 10 times higher at freestanding and hospital-based EDs relative to urgent care centers.

Conclusion

Utilization of freestanding EDs is rapidly expanding in Texas. Higher prices at freestanding and hospital-based EDs relative to urgent care centers, despite substantial overlap in services delivered, imply potential inefficient use of emergency facilities.

Cited by (0)

Please see page 847 for the Editor’s Capsule Summary of this article.

Supervising editor: Melissa L. McCarthy, ScD

Author contributions: VH, CD, EW, and GS conceived the study and obtained research funding. All authors provided statistical advice on study design, analyzed the data, and contributed substantially to article revision. VH drafted the article and takes responsibility for the paper as a whole.

All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This article was supported in part by the Health Policy Institute of the Texas Medical Center. Dr. Ho reports an appointment as an executive board member of Community Health Choice and has included the following statement: “This manuscript is the first study that I have conducted using BCBS data. I first met my coauthors Dr. Metcalfe, Ms. Vu, and Dr. Underwood when I was looking for someone at BCBSTX who had access to freestanding emergency claims in Texas. My coauthors played a crucial role in providing access to the BCBSTX claims and participating in the calculation of all of the statistics reported in the paper. I have never received financial or other support for my research from BCBSTX or any of the BCBS affiliates across the country. In the past 13 years at the Baker Institue, as far as I can recall, the Institute has not received a donation or other support from BCBS.” Dr. Dark reports support from Community Health Choice, HealthCorps, and Schumacher Clinical Partners. He is a member of the Emergency Care Committee of the Harris County Medical Society. Formerly, he was a member of the American College of Emergency Physicians, State Legislative and Regulatory Committee; a member and Chair of the Subcommittee on FSED Regulations; and the Communications Committee Chair for the Texas College of Emergency Physicians. He also reports owning 15 shares of Adeptus Healthcare. Drs. Metcalfe, Vu, and Underwood report employment at the Health Care Service Corporation and Blue Cross Blue Shield of Texas.

Representatives of BCBS were asked by the editor of Annals of Emergency Medicine to attest to the completeness and validity of the data they provided to Dr. Ho. The Senior Director for Media and Public Relations for BCBS Texas sent a description of the methods and the multiple academic organizations who supported the research and the following statement, which we interpreted as their attestation of the data:

“Blue Cross and Blue Shield of Texas firmly supports the work done by the non-biased researchers led by Dr. Vivian Ho at Rice University's Baker Institute. We stand by the accuracy of the data used in the study.”

Additionally two other separate requests were sent to executives of national BCBS asking if they would be willing to have the data reviewed for completeness and accuracy by an impartial third party (the only intervention that could convincingly confirm or rebut the concerns about data manipulation). Neither request received any reply from BCBS.

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; or decision to submit the article for publication.

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