The Cleveland Clinic has developed a hub-and-spoke acute care model that, if applied more broadly, could address three emergency medicine priorities: increasing job availability for emergency physicians, providing improved experience of care to mid-acuity patients, and broadening access to emergency care in rural America.

The hubs are large traditional hospitals, including Cleveland Clinic Main Campus. The spokes are smaller community hospitals and freestanding emergency departments (ED) in surrounding communities. Harvard Business Review discussed this model in “The Strategy That Will Fix Health Care”.¹ Other health systems have opened freestanding EDs using similar strategies. This article focuses on Cleveland Clinic because they have published their outcomes in detail.

ACEP projected in “The Emergency Medicine Physician Workforce: Projections for 2030” that the “specialty of emergency medicine is facing the likely oversupply of emergency physicians.”² Supply-side solutions, such as decreasing the number of emergency medicine residency spots or entry into the specialty, are unlikely to occur at least in the near term.

Ways to increase demand for emergency physicians, while providing high value patient care, are worth considering. Expanding the hub-and-spoke approach to emergency care delivery is one such solution.

Opening more health system affiliated freestanding EDs increases demand for emergency physicians in three ways. First, in the United States, two percent of patients leave EDs prior to being seen by a clinician.³ At freestanding EDs affiliated with an academic institution, the leave without being seen (LWBS) rate is only 0.4 percent.⁴ As there are 130 million ED visits in the U.S. per year, a LWBS rate decrease of one percent would translate to 1.3 million more patients to be seen by emergency clinicians annually.^4,5

Second, health system-associated freestanding EDs increase demand for emergency medicine by providing mid-acuity patients with a better experience than they would otherwise receive in a larger hospital-based ED. Cleveland Clinic’s freestanding EDs see proportionally more ESI 3 and 4 patients (midacuity), while their hospital-based EDs see more triage level ESI 1, 2 and 5 (highest and lowest acuity) visits.⁶ Patients reported choosing the freestanding over a hospital-based emergency department because of better access to needed testing, convenience, and “ED does a better job diagnosing and treating me.”⁷ Discharged ED patients rate their experience more favorably at Cleveland Clinic’s freestanding EDs than at their hospital-based EDs.⁸

Third, emergency medicine training is essential for physicians hired to work at a health system affiliated freestanding ED. Most freestanding EDs do not have rapid access to consultants. Much like at rural EDs, a physician working at a freestanding must have expertise in airway management, critical procedures, and trauma stabilization.

The main objections to freestanding EDs are their cost equivalence and siphoning of well-insured patients away from hospital-based EDs.^9,10 The perceived low value of care resulted largely from non-health system affiliated freestanding EDs that were out of network with most insurers and did not accept Medicare or Medicaid. Some facilities looked like urgent cares, leading patients to receive large bills for what they thought was urgent-care level treatment.

Health system affiliated freestanding EDs, like Cleveland Clinic’s, do not suffer from the low-value stigma of independent freestanding EDs. Cleveland Clinic’s freestanding EDs are regulated in the same manner as their hospital based EDs and are in accordance with ACEP’s “Freestanding Emergency Departments” policy.¹¹ Those freestanding EDs participate in Medicare and Medicaid. The clinicians are consistent across sites, as are quality initiatives. Each ED has systems for rapidly managing and transferring critically ill patients to higher levels of care.^12,13 Cleveland Clinic’s freestanding EDs are not siphoning insured patients away from the health system, only changing the setting of care.

A remaining concern about Cleveland Clinic’s hub and spoke model is that it has preferentially placed its freestanding emergency departments in wealthier communities. This is a common practice for health systems.¹⁴ However, the economic incentives for where to locate freestanding EDs are changing. A COVID-era federal bill has created the Rural Emergency Hospital (REH) model, which will go live on January 1, 2023. The REH legislation increases Medicare reimbursement for health systems opening rural freestanding EDs if they follow the law’s guidelines.

Under the REH model, critical access hospitals and rural Prospective Payment Systems can convert to REH status. The REH requirements are similar to the Cleveland Clinic freestanding ED model, including:

• No provision of acute care inpatient services
• An average per patient length of stay not to exceed 24 hours
• Have a transfer agreement in place with a Level I or II trauma center
• Maintain a staffed emergency department, including staffing 24 hours a day, seven days a week by a physician, nurse practitioner, clinical nurse specialist, or physician assistant.¹⁵

According to a North Carolina Rural Health Research and Policy Analysis Center analysis, “The Rural Emergency Hospital could be an important step for preserving access to emergency and outpatient services in rural areas, particularly in communities that face the risk of rural hospital closures.” The authors predict 68 critical access hospitals will convert to REH freestanding EDs. County-level predictors of conversion to REH status include higher unemployment rates and lower population density.¹⁶

Health system freestanding ED expansion can help balance emergency physician supply with demand, deliver better experience of care to mid-acuity ED patients, while improving access to emergency medicine across the county.

Disclosures: None. Leon Adelman has no financial connection with Cleveland Clinic or freestanding EDs.

Dr. Adelman is an emergency physician in North Carolina and co-founder/CEO of Ivy Clinicians.

References

1. The Strategy That Will Fix Health Care. In: Harvard Business Review [Internet]. 1 Oct 2013 [cited 11 May 2022]. Available: https://hbr.org/2013/10/the-strategy-that-will-fix-health-care.
2. Marco CA, Courtney DM, Ling LJ, et al. The emergency medicine physician workforce: projections for 2030. Ann Emerg Med. 2021;78: 726–737.
3. Smalley CM, Meldon SW, Simon EL, Muir MR, Delgado F, Fertel BS. Emergency Department Patients Who Leave Before Treatment Is Complete. West J Emerg Med. 2021;22: 148–155.
4. Dayton JR, Dark CK, Cruzen ES, Simon EL. Acuity, treatment times, and patient experience in Freestanding Emergency Departments affiliated with academic institutions. Am J Emerg Med. 2018;36: 139–141.
5. Emergency Department Visits. 25 Mar 2022 [cited 11 May 2022]. Available: https://www.cdc.gov/nchs/fastats/emergency-department.htm.
6. Simon EL, Shakya S, Muir M, Fertel BS. Differences in patient population and length of stay between freestanding and hospital-based emergency departments. Am J Emerg Med. 2019;37: 1738–1742.
7. Burke RC, Simon EL, Kesav N, et al. Patient-reported reasons for seeking emergency care at a freestanding emergency department compared to a hospital-based ED. Am J Emerg Med. 2018;36(9):1702–1704.
8. Simon EL, Shakya S, Smalley CM, et al. Same provider, different location: Variation in patient satisfaction scores between freestanding and hospital-based emergency departments. Am J Emerg Med. 2020;38: 968–974.
9. Alexander AJ, Dark C. Freestanding emergency departments: What is their role in emergency care? Ann Emerg Med. 2019;74: 325–331.
10. Pines JM. Maybe it’s time to rethink freestanding emergency departments. Academic Emergency Medicine. 2019. pp. 1297–1299. doi:10.1111/acem.13862.
11. Freestanding Emergency Departments. [cited 11 May 2022]. Available: https://www.acep.org/patient-care/policy-statements/freestanding-emergency-departments/. Accessed August 27, 2022.
12. Simon EL, Shakya S, Liu L, et al. Comparison of critically ill patients from three freestanding ED’s compared to a tertiary care hospital based ED. Am J Emerg Med. 2019;37(7):1307-1312.
13. Griffin G, Smalley CM, Fertel BS, et al. Reduced mortality and faster treatment in sepsis seen at freestanding vs. hospital-based emergency departments. Am J Emerg Med. 2022;54: 249–252.
14. Dark C, Xu Y, Ho V. Freestanding emergency departments preferentially locate in areas with higher household income. Health Aff. 2017;36: 1712–1719.
15. [No title]. [cited 11 May 2022]. Available: https://www.ruralhealth.us/NRHA/media/Emerge_NRHA/Advocacy/Government%20affairs/2021/04-15-21-NRHA-Rural-Emergency-Hospital-overview.pdf. Accessed August 27, 2022.
16. How Many Hospitals Might Convert to a Rural Emergency Hospital (REH)? In: Sheps Center [Internet]. 7 Jul 2021 [cited 14 May 2022]. Available: https://www.shepscenter.unc.edu/product/how-many-hospitals-might-convert-to-a-rural-emergency-hospital-reh/. Accessed August 27, 2022.

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