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Breaking News: Washington Legislator Seeks to Stall Freestanding ERs

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000413876.89680.d3

    Washington State Sen. Cheryl Pflug has filed bill after bill since 2008 asking for a moratorium on freestanding emergency centers until their affect on the health care system can be assessed. All her efforts have been to no avail, but now she and her colleagues are taking a new tack to persuade hospital officials to look at the proliferation of the centers.

    The growth of freestanding ERs, as they are often called, has been extensive in Washington. Seattle's Swedish Medical Center opened the state's first freestanding emergency center and ambulatory care center in Issaquah in March 2005, but closed it when Swedish's new hospital opened there. It opened a second one in Redmond in December 2010 and a third in Mill Creek two months later. Evergreen Hospital Medical Center answered with its own freestanding center in March 2011, in the Bella Bottega Shopping Center in Redmond. MultiCare Tacoma General Hospital in Covington is expected to open a freestanding ER this spring, with a hospital to follow, and Valley Medical Center is planning a medical mall in Covington, with a freestanding ER, professional offices, and retail stores.

    “This is a market domination issue,” said Sen. Pflug, who sits on the state senate's Health and Long-Term Care Committee. “We are being told that one reason they are building these freestanding centers is to prepare for the Medicaid expansion.”

    But the locations chosen for the centers, she said, indicated that Medicaid growth is going to occur in the city's wealthier suburbs, and “apparently, we plan to treat them all in the emergency room,” she said.

    Sen. Pflug is no stranger to health care. A registered nurse who worked in a variety of settings, she said many of the freestanding centers are well staffed and well designed.

    “They are going into areas that are already pretty well served,” she said. “A well equipped freestanding emergency center staffed by physicians who do a lot of emergency care may provide good emergency care. However, I am concerned that the well-insured patients get sent to the mother ship hospital in central Seattle and the others go to the nearest hospital. That could undercut the existing hospital, which may be part of a public hospital district.”

    Sen. Pflug said the proliferation of these emergency rooms goes against everything that is known and hoped for in quality care and cost control. “Quality care needs to be coordinated by a good medical home. If it's an emergency, you should go to the nearest hospital. Emergency rooms — and their attendant costs — should not be used for convenience care. You will end up spending an extraordinary amount of money that is needed to enhance primary care. It's harder when we are bleeding money into the care we don't want to deliver — high cost care in the wrong location or wrong model of care.”

    The freestanding emergency centers do abide by the federal Emergency Medical Treatment and Active Labor Act (EMTALA), she said, but under-the-table discrimination does seem to exist. “Insured patients are often talked into going farther to the parent hospital rather than the closer community hospital. They end up downtown at the parent hospital, which only grants privileges to their own physicians, which means an even further disruption of continuity of care. The biggest problem, though, is the cost of care — period. It's $800 for a UTI and $400 for a respiratory infection.”

    Renee Hsia, MD, an assistant professor of emergency medicine at the University of California-San Francisco, has examined hospital-based emergency centers that closed in her own state, and said it is difficult to predict the effect of freestanding emergency departments. “It may take up some of the slack. You have a certain demand, and this means there's more supply,” she said. Even if they are not located in poor areas, those emergency departments in the poor areas will be less crowded because wealthier people will be seen elsewhere.”

    Freestanding centers also make it more difficult for inner city EDs to attract providers, Dr. Hsia said. “We already have a system where people on private insurance don't get as much access to care. If we entrench this two-tier system, eventually we may not be able to fund the public system. It can seem like a short-term solution, but in the long-term, I fear that any provider will say, ‘Why would I want to work in an environment like that of the public system, and they will opt out.”

    Freestanding emergency rooms initially stabilized patients with true medical emergencies for transport from a remote geographic area, said Alwyn Cassil, a spokesperson for the Center for Studying Health System Change, a Washington, D.C., think tank that is monitoring them across the nation.

    The movement is part of an attempt to gobble up more market share, Ms. Cassil said. “Historically, in metropolitan areas, the market has been geographically segmented. One hospital had this quadrant, another hospital had another. Now they are competing in each other's backyards.” And that rivalry, she said, is not limited to emergency departments.

    Sen. Pflug admitted that her attempt to impose a legislative moratorium on building freestanding ERs is not going to be enough, and she is looking at other tactics, such as limiting hospitals' access to small cap bonds for building these facilities. She said she is also proposing legislation to examine the tax breaks nonprofit hospitals receive and whether they provide the community any advantages.

    “Tax preferences should be given for providing a community benefit — meeting an unmet need in the community as opposed to colonizing the suburbs,” she said. “Clearly, we have some issues. We still have an inadequate mental health network and not enough inpatient beds for mental health.”

    “States and political leaders will have to develop the backbone to say we have to find ways to pay for what the people need and ensure adequate capacity for the care people need,” Sen. Pflug said. “We need to do a better job of primary care. That means the states will have to take an active role in designing the system that uses our power of the dollar.”

    That may mean that entities seeking to build freestanding emergency rooms will not be able to fund them with low rate bonds, she said, and they might not be reimbursed at the same levels or receive a property tax exemption if they build something that is not needed.

    Those are the kinds of tough system tactics the nation is facing, she said. “We are not on the verge of spending less for health care. We have an aging population moving into the expensive years of health care, and we are facing an obesity epidemic. We need to spend more efficiently and increase productivity,” Sen. Pflug said.

    Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app, both available at


    • Read Dr. Renee Hsia's JAMA study on ED closures at
    • The Scalpel or Sword blog, written by an anonymous emergency physician in Texas, weighed in on freestanding ERs:
    • Access the New York Times article, “Fewer Emergency Rooms Available as Need Rises,” which includes a link to an article about a freestanding ER in Manhattan, at
    • The Seattle Times article, “ER Building Boom is Wrong Prescription, Critics Say,” with a list of expansions, new construction, and freestanding ERs around Puget Sound, is available at
    • Read this article in EMN's new app for the iPad! Download it for free on our website,, or through iTunes at EMNiPadApp.
    • Comments about this article? Write to EMN at [email protected]
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