Welcome to the thirty-second episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

DISCUSSING (CLICK ON TITLE FOR FULL TEXT, OPEN ACCESS THROUGH NOVEMBER 30):

Freestanding Emergency Department Entry and Market-level Spending on Emergency Care. Vivian Ho, PhD, Yingying Xu, MA, Murtaza Akhter, MD

**See also the accompanying commentary Maybe It’s Time to Rethink Freestanding Emergency Departments by Jesse M. Pines, MD, MBA, MSCE

LISTEN NOW: INTERVIEW WITH FIRST AUTHOR VIVIAN HO, PHD

ABSTRACT

Background

Freestanding emergency departments (FrEDs) could reduce wait times in overcrowded emergency departments, but they might also increase usage and overall spending for emergency care. We investigate the relationship between the number of FrEDs entering a local market and overall spending on emergency care.

Methods

We accessed data from Arizona, Florida, North Carolina, and Texas in Blue Cross Blue Shield Axis®, a limited data set of de-identified insurance data claims that we linked to Public Use Microdata Area (PUMA) data from the American Community Survey, and lists of licensed FrEDs from state agencies. Regression analysis was used to estimate the association between changes in the number of FrEDs in 495 Public Use Microdata Areas (PUMAs) and total spending on emergency care, out-of-pocket spending, utilization, and price per visit from January 2013 to December 2017. Final estimates came from a PUMA-level fixed-effects model, with controls for state, quarter, and PUMA-level demographics.

Results

Entry of an additional FrED in a PUMA was associated with a 3.6 percentage point (pp) (CI 2.4 to 4.9) increase in emergency provider reimbursement per insured beneficiary in Texas, Florida, and North Carolina. There was no change in spending (2.6 pp; CI -8.2 to 3.1) associated with a FrED’s entry in Arizona. Entry of an additional FrED was associated with a 0.18 (CI 0.12 to 0.23) increase in the number of emergency care visits per 100 enrollees in Texas, Florida, and Arizona. In contrast, entry of another FrED was not associated with a change in utilization (-0.03; CI -0.09 to 0.02) in North Carolina. Estimated out-of-pocket payments for emergency care increased 3.6 pp (CI 2.4 to 4.8) with the entry of a FrED in Texas, Florida, and Arizona; but declined by 15.3 pp (CI -26.8 to -3.7) in North Carolina.

Conclusions and Relevance

Rather than functioning as substitutes for hospital-based emergency departments, FrEDs have increased local market spending on emergency care in 3 of 4 states markets where they have entered. State policy makers and researchers should carefully track spending and utilization of emergency care as FrEDs disseminate, to better understand their potential health benefits and cost implications for patients.