Page 16 - Bulletin Fall 2024

A Call for Change
The Hidden Dangers of Freestanding Emergency Departments
Neil Manimala, MD nmanimal@gmail.com
As a urologist in our county, I have witnessed how freestanding emergency departments (FEDs) can harmfully affect patient care. Despite their promise of convenience, the reality often falls quite short, with patients frequently shocked to find themselves transferred far from their communities for critical care. This relatively unregulated practice has garnered national attention, high-
lighting the urgent need for legislative reforms to safeguard patients.
FEDs are defined by Florida Statute as hospital-based off-campus emergency department facilities that provide emergency services and care, are owned and operated by a licensed hospital, operate under the license of the hospital, and are located on separate premises from the hospital.
In Florida, the number of these facilities has ballooned in eight years, from 60 FEDs in 2016 to 127 FEDs in July 2024, driven by hospital systems’ financial incentives amid mini- mal state oversight. The 2021 state legislative session was the last time the topic was addressed by our representatives. At the time, a law had passed that only required FEDs to iden- tify themselves to patients with signs at the facilities so that patients who visited knew that they were emergency depart- ments charging hospital rates, as opposed to the urgent care centers they had tried to masquerade as being. Unfortunate- ly, patients who are brought into an FED for emergency care often do not have much choice to leave the facility in matters of life-and-death.
We as physicians understand that patient care truly is a matter of life-and-death. When patients are seen at an FED located 30 to 50 miles away from the “mothership” hospital, but need hospital care, they are forced to get in an ambu- lance to drive to the mothership hospital. We know in these cases that their outcomes can be negatively impacted by the delay in treatment.
Imagine this very real scenario: a patient with a septic kidney stone arrives at her local FED in Lakeland. Instead of receiving immediate clinically appropriate care with a
ureteral stent to relieve the renal obstruction, the patient is transferred across county lines to Brandon for inpatient treatment, bypassing several fully equipped hospitals along the way. Under current state regulations, that FED in Lake- land is considered part of the main hospital hub in Brandon, leading to unnecessary delays and thereby potential harm.
The hospital system responsible for this transfer might argue that their hands are tied by federal regulations, spe- cifically the Emergency Medical Treatment and Labor Act (EMTALA). They claim that sending the patient to an out- of-network hospital would violate EMTALA because the FED is considered the same entity as the mothership hos- pital. Per their interpretation, even if the FED does not have the capacity to care for the patient, the mothership hospital does, and it would be a violation to deny the patient care that is located within their campuses.
Moreover, although Florida Statute section 395.1041(3) (e) requires that patients’ medically necessary transfers be made to the geographically closest hospital, there is a loop- hole in state law that permits hospitals that have a “prior ar- rangement” to bypass the closest hospitals. Hospital systems exploit this language to justify this business practice, but pa- tient care suffers.
This scenario is a direct result of hospital systems prolif- erating FEDs in areas already served by other hospitals in an effort to increase their inpatient catchment area. Hospital systems often justify the establishment of FEDs by claiming they are expanding access to care in rural and underserved areas. Yet, easily accessible information on the addresses of these FEDs tells a different story. Most of the FEDs in Flori- da are located in well-served urban and suburban areas, not in the rural regions they claim to support. This misrepresen- tation is not only disingenuous but also dangerous.
I recall a disturbing case of a man with Fournier’s gan- grene who came into an FED septic, with necrotic scrotal skin. As physicians, we understand this scenario to be an ab- solute medical emergency, with life-and-death determined sometimes by a matter of minutes. However, hospital admin- istrators sometimes lack the same understanding. Instead of the patient being transferred to the nearest capable hos- pital, he was sent to the distant mothership hospital many
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HCMA BULLETIN, Vol 70, No. 2 – Fall 2024