Freestanding ER trend hitting Tyler

Published on Sunday, 11 October 2015 05:34 - Written by Coshandra Dillard,

Emergency medical centers have been a hot trend sprouting around the state the past few years, typically in large urban areas such as Houston or Dallas.

But Tyler residents soon will have several options for emergency medical care as at least four freestanding emergency centers are planned.

One has opened, two are under construction and another facility is under transition from urgent care to an emergency center.

Excel ER opened last week at 6718 S. Broadway Ave. It’s one of 13 Texas locations, along with Longview, Nacogdoches and Texarkana, where Excel ER is opening centers. Neighbors ER is scheduled to open this month and crews are in the groundbreaking phase for Patients ER. Meanwhile, Tyler Urgent Care is preparing to merge with Complete Care to become a licensed freestanding emergency center early next year.

In Texas, the emergence of such centers followed the Texas Freestanding Emergency Medical Care Facility Licensing Act in 2009, which allowed for emergency centers providing medical care 24 hours a day to operate independently of hospitals.

There are 168 licensed in Texas so far, according to the most current data from the Texas Department of State Health Services. This does not include the four coming to Tyler, or others that have not opened their doors yet.

Most centers are part of a chain of facilities and are physician-owned, while investment groups own a minority.

Dr. Christopher Kwon, president and chief operating officer of Excel ER, explained why the company chose Tyler.

“Tyler is a growing, vibrant city, but we believe there is a need that only a freestanding ER can fill,” Kwon said in an email. “In cities such as Dallas and Houston, freestanding ERs are well-established, offering convenient and accessible ER care to residents. It is only natural that this type of care would come to cities like Tyler, and Excel ER is excited to bring freestanding ER care here.”

Kwon said they hope to redefine how patients receive emergency care. To begin, there is no triage process as experienced at hospitals.

“The main difference between our new facility and a hospital ER is that our patients are seen by a board-certified emergency doctor within minutes of coming through our doors, while it may take a much longer period of time for that same patient at a hospital ER,” Kwon said.

He also noted that freestanding emergency centers are equipped with CT scanners, digital X-ray, EKG, ultrasound and labs and can handle more complex medical problems than urgent care centers.

“Urgent cares are not able to see very sick patients, where Excel ER can see any emergencies that walk through our doors,” Kwon said. “Urgent cares are often staffed by ‘mid-levels,’ such as physician assistants and nurse practitioners, as opposed to physicians.”

Kwon also touts that Excel ER’s environment feels “more like a four-star hotel.”

Dr. Bill Wallace, along with Dr. Brad Robertson and Dr. Jeff Leach, opened Tyler Urgent Care in 2007. Like other urgent care centers, their doors close early - at 6 p.m. It was a chief complaint among patients needing less acute care at night.

“For us, it seems like a natural progression, given the fact we’d gotten out here and done this sort of thing for a long time,” Wallace said of the merger with Complete Care, which has 12 locations across the state. “It seemed like the next logical step.”



There has been confusion about the difference between the freestanding emergency centers, hospital emergency centers and urgent care centers.

Urgent centers are used for less complex problems, such as lacerations and sprains. Hours are usually limited to business hours.

A freestanding emergency center is open 24 hours, has equipment and capabilities similar to a hospital emergency department and treats issues such as cardiac, respiratory and abdominal problems.

However, these centers do not have inpatient beds. Patients with the most complex problems or trauma are transferred to a hospital.

A criticism of such emergency centers is they are more costly than a traditional emergency department or urgent care center, although some officials contend that the costs aren’t much different from traditional emergency rooms.

“Excel ER offers virtually the same rates as traditional hospital-based ERs,” Kwon said. “Urgent care centers do not treat the same level of emergencies as a hospital ER and freestanding ER’s, so their costs would naturally be different.”

Patients could be billed for what an insurer doesn’t pay.

“That’s still sort of a controversial area, because as it stands right now, most freestanding emergency rooms will charge a facility fee in addition to the physician’s fee, and that’s a big part of what makes it more expensive than just a doctor’s office or urgent care,” Wallace said. “Some insurers pay for that, and some insurers will deny a claim like that, depending on the emergency.”

He added, “Our plan is not to do any balance billing for the patient and try to price things a lot like an urgent care. They’re going to be a little more than our current prices, because there’s other overhead we’re going to have to cover, but not through the roof as far as out-of-pocket billing for patients.”

The Centers for Medicare and Medicaid Services does not recognize freestanding emergency centers and therefore does not reimburse them for services.

It’s why patients typically will find these facilities in more affluent areas rather than low-income areas where patients are more likely to receive Medicaid or Medicare.

From a business standpoint, it wouldn’t be sustainable.

A Texas Tribune ZIP code analysis this summer found that the neighborhoods where the facilities are found earned 49 percent more income than the state average. 

However, freestanding emergency centers, such as traditional emergency rooms, are required to treat anyone needing emergency care.

Advocates of this emergency care model believe Centers for Medicare and Medicaid Services eventually will recognize freestanding emergency care centers.

Not everyone is excited about the outlook of the growth of these centers. Hospital officials worry they could have a negative impact on the medical community.

“Venture capital is seeking to get involved in as much of the health care space as much as possible,” said Lance Lunceford, vice president of strategic communication at the Texas Hospital Association, in a previous interview with the Tyler Morning Telegraph.

“That’s presenting a significant problem for our hospitals primarily due to the fact that we have an extremely high rate of uninsured that hospitals do have to provide care. Texas has the highest rate of uninsured in the U.S. Groups that come in and develop the freestanding (emergency departments) that aren’t associated with hospitals aren’t taking the uninsured that the hospitals are required to take on. It takes that part of the market that does have people who are able and willing to pay through their health insurance and it cuts off access to the hospital. … It means they are getting fewer (patients) who have coverage.”

Lunceford said freestanding emergency centers also operate at a lower cost, since they don’t have some of the regulatory requirements of hospitals.

“To be a Level 1, Level 2 or even a Level 3 trauma center, you’ve got certain requirements that you have to meet, certain staffing levels that you have to hit, and there are significant costs with those that freestanding (emergency departments) do not have to afford,” he said.  


The Texas Association of Freestanding Emergency Centers is looking to expand opportunities for these facilities across the state and around the country.

The Texas association is spearheading a national organization - the National Association of Freestanding Emergency Centers - which formed this summer. These associations work with physicians and physician groups and lobby for laws to ensure the centers aren’t too restricted.

The national association will host its first membership meeting this month and will be electing its board of directors.

Officials with the Texas association said there is interest nationally, but some states’ laws do not allow freestanding emergency centers. Some states require a certificate of need, others require that a center be affiliated with a hospital and some simply won’t allow the freestanding model at all.

Officials with the centers don’t see themselves as competition for hospitals or urgent care centers, but rather options for patients, and a way to relieve congestion in traditional emergency departments.

“Even as new places are opening, you can still go to almost any emergency room and find people waiting there three hours, four hours or longer if it’s busy,” Wallace said. “That’s just a super-common scenario. As long as you’re still hearing people waiting hours, then I think there is still going to be room for other places to help offload patients from the ER.”

But even with the growth of freestanding emergency centers in Tyler, Wallace said he expects that trend to be short-lived - at least for now.

“It is kind of surprising how they took off all of a sudden,” he said. “The market this year is up in the air. The dust will need to settle for a little bit as far as supply and demand for ER services before you have much in the way of other places wanting to open. That would be my guess.”

TWITTER: @cdillard_TMT