118 The Freestanding Emergency Department: Economic Burden or Benefit? Preliminary Insights Using Disposition as a Surrogate Index of Visit Acuity

Abstract

This study analyzes trends in freestanding ED (FSED) use and billing as a function of visit acuity using patient disposition as a surrogate for ESI level. ED visit data for 2014-2016 was retrieved via the ED Query Tool on FloridaHealthFinder.gov; data was obtained for 213 HEDs and 28 FSEDs & stratified by patient disposition, which serves as a surrogate for visit acuity. Dispositions listed as transferred to a “short-term general hospital for inpatient care,” “psychiatric hospital,” “designated cancer center or childrens hospital,” “Critical Access Hospital,” and “Expired” were assigned to a surrogacy class for ESI levels 1 & 2; Dispositions reported as “Discharged to home or self-care” were assigned to a surrogacy class for ESI levels 3-5. This data was stratified into selected principal payer groups and charges to each payer group within either surrogacy class were averaged for total visits in their respective surrogacy classes. The number of FSEDs in FL has grown from 15 in 2014 to 28 in 2016. FSED visits have increased from 265,363 in 2014 to 540,179 in 2016, corresponding to 3.3% and 6.1% of total ED visits in FL, respectively. Total ED visits in FL increased by 406,741 (5.05%) from 2014 to 2015 with 28.6% seen in FSEDs and 71.4% seen in HEDs; total ED visits in FL increased by 394,647 (4.66%) from 2015 to 2016, with 40.2% seen in FSEDs and 59.8% seen in HEDs. In 2016, Florida FSEDs billed approximately $2.19B, or 4.58% of all 2016 ED billing in FL. For the ESI 1-2 surrogacy class, charges to principal payer averaged $10,740 for FSED visits and $9,629 for HED visits. For the ESI 3-5 surrogacy class, principal payer charges averaged $3,973 for FSED visits and $5,489 for HED visits. We conclude that, for severely ill or injured patients (ESI 1-2 surrogacy class), FSEDs may strain the cost to the principal payer, with a higher average charge per visit than for HEDs. Conversely, those visits assigned to ESI 3-5 surrogacy class benefit from a lower cost to principal payer when seen in FSED, with a lower average charge than when seen in HEDs. It is also observed that, while ED use in FL has increased from 2014 to 2016, this increase is not attributable solely to an increase in FSEDs, as HEDs are observed to see a greater proportion of annual visit growth than FSEDs, though it shall be noted that the proportion of total annual visit growth seen in FSEDs is increasing. Finally, we observe that while FSEDs have demonstrated an increase in annual visit and annual billing, FSED billing growth is outpaced by FSED annual visit growth. We conclude that FSEDs may afford payer groups a lower cost burden for emergent, low-acuity visits than HEDs, but advise that emergent, high-acuity visits be deferred to HEDs given the higher cost burden seen in FSEDs. Further, we conclude that the increasing proportion of annual ED visit growth seen in FSEDs suggests their proliferation in FL may help to alleviate HED crowding.