New freestanding ERs: faster care, but it can cost you
By Michelle Crouch
Co-published with The Charlotte Ledger
From SouthPark to Steele Creek, Mountain Island Lake to Waxhaw, sleek and efficient freestanding emergency rooms are springing up across the Charlotte region to serve patients, no hospital required.
Since 2010, Atrium Health has opened eight standalone emergency rooms in the Charlotte metro area, part of a nationwide building boom. Two more are on the way, with openings planned in Ballantyne later this year and in Concord in 2025. Also in the region, CaroMont Regional Medical Center operates a freestanding ER in Mount Holly.
The trend is playing out in other parts of the state, too, with new freestanding ERs in the Triangle and in Greensboro, and others coming to the Asheville area.
For patients, the facilities are more convenient and typically have shorter wait times compared with hospital-based ERs, which are often more crowded. Patients visiting one for the first time are often astounded at how quickly they can get in and out.
But weeks later, they may be astounded again when they get the bill — with hospital-like charges that can total thousands of dollars for an hour-long visit.
As more freestanding ERs open in North Carolina and nationwide, some health care researchers are raising questions about whether the convenience is worth the escalating costs and confusion they can create for patients.
And then there are questions about access.
Although hospitals say standalone facilities boost access to care, they tend to be mostly in affluent suburbs and not rural or low-income areas.
“You hear the argument that they are serving rural areas, but that’s not the case,” said Daniel Marthey, a researcher at Texas A&M who studies freestanding ERs. “Where they locate tends to be in suburban areas. They are targeting privately insured patients who are paying more, and that’s raising the price of care for all of us.”
Studies show many patients go to standalone ERs for problems that could be treated at a lower-cost urgent care center, while others go in with conditions that need a higher level of care, so they have to wait for (and pay for) an ambulance transfer to a hospital.
The rise of hospital-free ERs
In 2001, freestanding ERs accounted for just 1 percent of all emergency departments nationwide. By 2016, that proportion had risen to 11 percent, according to Becker’s Hospital Review. More recent numbers are hard to come by, but experts said the trend has accelerated.
In some states, such as Texas, hundreds of standalone facilities have opened, including many not linked to a larger health system.
The trend has unfolded more slowly in North Carolina, mostly because freestanding emergency departments (EDs) are regulated through the state’s Certificate of Need approval process. The state requires them to be affiliated with a hospital.
Atrium, which operates almost half of the state’s 16 freestanding ERs, chooses locations “with expansion and ease of access in mind,” according to an email from Jennifer Sullivan, an emergency medicine physician and Atrium’s senior vice president of strategic operations.
“This has become an easier option for patients, because they can drive themselves or a family member, as opposed to an ambulance perhaps bringing them,” she said.
The centers allow the system to manage infrastructure costs, since it can serve an area without building an additional full hospital, Sullivan said, adding that Atrium uses them to “service rural areas better — like Waxhaw, Kannapolis and in rural Georgia.”
In addition, she said, freestanding ERs “take some of the patient pressure off of the hospital-based ERs.”
Other N.C. hospitals are also ramping up construction of the facilities.
In the Triangle area, WakeMed Health & Hospitals opened its fifth standalone ER in early 2024. In a recent podcast, WakeMed’s senior vice president for strategic ventures and ambulatory operations, Carolyn Knaup, touted WakeMed’s success with the facilities.
“We feel that health care is truly local,” Knaup said on an April 2024 podcast produced by the architectural firm that designed the facilities. “When you look at our geography, and you see our three hospitals, our standalones are strategically placed around those three hospitals. The thought process is that the standalones would feed the hospitals, if the patients at the standalones would need to be admitted or need a higher level of care.”
Nashville-based HCA Healthcare, which owns Mission Health in Asheville, has also been aggressively building freestanding facilities across the country. It already has approval to build its first two N.C. facilities in Arden and Candler, which are outside of Asheville.
Winston-Salem-based Novant Health has two freestanding EDs. One is in Bluffton, a fast-growing community outside Hilton Head, S.C., and the other is in the Scotts Hill area of Wilmington, on a site where Novant said it plans to open a full-scale hospital in 2026.
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