Examine the Impact of Independent Freestanding Emergency Departments in Texas on Rural and Underserved Health Workforce
Authors: Luo Q. , Chong N. , Chen C. 
Published: August 2020

Research ObjectiveIn recent years, more and more emergency departments (EDs) are located and operated away from hospital campuses. A MedPAC report found at least 556 stand‐alone EDs around the country, comprising of 363 hospital‐affiliated off‐campus emergency departments and 203 independent freestanding emergency departments (IFEDs) in 2017. Five Metropolitan Statistical Areas (MSAs) in Texas accounted for over 72 percent of all IFEDs in the country. The rapid proliferation of IFEDs brings into question, who and where are the workforce coming from for these IFEDs. This study explores the origin and composition of health workforce of IFEDs in Texas and the implications of IFEDs on rural and underserved workforce.Study DesignWe compiled a list of current IFED physicians using the freestanding emergency department list released by Texas Department of State Health Services (July 2019 version) in conjunction with a search of Texas Medical Board Licensing and IFED organization web searches. We identified 545 physicians from 211 IFEDs. We were not able to find staffing information for 11 IFEDs (5.2% of IFEDs). We tracked the IFED physicians prior practice locations using the Medicare Physician Shared Patient Patterns data (2009‐2013) and CareSet DocGraph Hop Teaming data (2014‐2017). We identified those physician’s self‐reported specialty in National Provider and Plan Enumeration System (NPPES) and Medicare Provider Enrollment, Chain, and Ownership System (PECOS). We further examined the historical volume of Medicare services provided by these IFED physicians over time using Medicare Part B Public Use Files (2012‐2017).Population StudiedAll 545 physicians who we can identify worked at Texas IFEDs at the time of data collection (September 2019).Principal FindingsOf the 545 IFED physicians, NPPES data indicate 481 physicians are Emergency Medicine physicians, 38 Family Medicine, 11 Internal Medicine and 15 other. PECOS data differed slightly. We were able to identify at least 1 previous practice location for 533 of the 545 physicians currently working at IFEDs. In any year, physicians may have practiced in up to seven hospitals. In 2012, we can identify the practice hospitals for 442 IFED physicians, of whom 95 practiced at rural hospitals and 417 practiced at Disproportionate Share Hospitals (hospitals may be both rural and DSH). In 2017, we can identify the practice hospitals for 267 IFED physicians, of whom 48 practiced at rural hospitals and 207 practiced at Disproportionate Share Hospitals. The reduction of IFED physicians who we can identify from Medicare databases represented the movement of physicians from hospital EDs to IFEDs. We observed a 64.7% decline in total volume of Medicare services provided by this cohort of physicians from 2012 to 2017.ConclusionsOur findings suggest IFEDs are recruiting physicians largely from rural and underserved settings.Implications for Policy or PracticeThe recruitment of IFED physicians from rural and underserved settings taken in combination with evidence that freestanding emergency departments locate in areas with higher incomes and lower proportions of Medicaid patients; our findings raise concerns about the potential negative workforce and access side effects of these newer, entrepreneurial health care organization models.Primary Funding SourceHealth Resources and Services Administration.