The Wave of the Future

The wave of the future is the free-standing Emergency Department.

By requiring insurance coverage or full payment at time of presentation, these facilities are able to offer reduced waiting times, concierge-style amenities, and a full array of emergency diagnostic and therapeutic services. And if they refuse to accept Medicare or Medicaid, then they are not forced to follow the restrictive rules of EMTALA.

EMTALA applies only to "participating hospitals" -- i.e., to hospitals which have entered into "provider agreements" under which they will accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program for services provided to beneficiaries of that program.

So these "free-market" emergency facilities can not only refuse treatment of patients who are unwilling or unable to pay, but they can also transfer patients at will without negotiating with a receiving hospital or jumping through a lot of regulatory hoops. Realistically, however, hospitals love receiving transfers from these types of facilities because they know they are getting fully-paying patients. Do you think that a hospital might accept an otherwise healthy well-insured young woman with a gallstone attack in transfer, perhaps causing the cirrhotic Medicaid patient to wait a few more hours in their own ER? I think they just might. The bottom line is a powerful incentive.

As this business model becomes more widespread, hospital-based emergency departments will be faced with an increasingly problematic payer mix, because the higher-paying patients will be siphoned off the top, leaving only the most undesirable trauma and Medicare/Medicaid populations to fill their overcrowded waiting rooms. And when emergency physicians have a broader selection of practice environments to choose from, I suspect the hospital-based ERs will soon have some difficulty filling their schedules as well, thereby compounding their problems even further.

Guess what?

Healthcare isn't a right after all.

Labels: Analysis, Insurance, Medicaid, Medicare

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