To Serve Vulnerable Patients and Relieve Hospital Bed Shortage
In a letter to U.S. Department of Health and Human Services (HHS) Secretary Alex Azar, the National Association of Freestanding Emergency Centers (NAFEC) offered the full resources its 200 FECs have to assist with the COVID crisis and also requested that the Centers for Medicare and Medicaid Services (CMS) utilize its authority to provide Medicare and Medicaid reimbursement to freestanding emergency centers (FECs) for Medicare and Medicaid patients during the Covid-19 pandemic.
FECs’ recognition as Medicare and Medicaid-approved healthcare facilities would alleviate hospital overflow during the expected surge of COVID patients, provide rural and underserved patients with more and easier access to care and help leverage untapped resources, including hundreds of ER physicians and more than 1,500 hospital beds, in the nation’s response to the pandemic.
Currently, the more than 200 FECs across the nation are not eligible for Medicare or Medicaid reimbursement because the Medicare statute has lagged the relatively new form of health care delivery and only recognizes centers owned by hospitals. This cuts off many vulnerable and older patients dependent on Medicare and Medicaid who are at greatest risk during this healthcare crisis from critical medical resources. In order to facilitate recognition of FECs by CMS, HHS must modify its current CMS regulatory interpretation.
“The COVID-19 outbreak demands that health resources across America be fully available to treat a patient population that could overwhelm hospital-based emergency rooms,” said Brad Shields, Executive Director of the National Association of Freestanding Emergency Centers. “During this healthcare crisis, patients’ needs should take precedence over facility ownership in determining where they can seek medical care. The nation’s freestanding ER’s are ready, willing and able to serve Medicare and Medicaid patients and relieve the pressure on the hospital system as soon as the federal government is able to give them the green light.”
The nation’s more than 200 FECs are fully equipped emergency rooms staffed by emergency physicians, nurses and support staff and are required to provide 24/7 access to emergency health care under the same quality standards that apply to hospital emergency rooms. FECs possess key healthcare resources such as ventilators and isolation rooms that are badly needed during the pandemic. Across the state of Texas alone there are more than 1,550 patient beds in freestanding emergency centers ready to relieve the burden on hospitals.
In its letter, NAFEC further offered a range of suggested services FECs could perform, if authorized, that would relieve the strain on hospitals, including
- Serving as Covid-19 testing sites
- Offering inpatient or ICU services
- Providing outpatient services
- Caring for patients longer than 23 hours
- Serving as a dedicated facility for hospital ERs
- Offering post-op treatment for emergency surgery patients
SEE LETTER BELOW
March 26th, 2020
The Honorable Alex M. Azar II
Secretary of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
As the COVID crisis has deepened in Texas and across the country, it has become
clear that no resources should be left on the sidelines and all providers must do
what they can to assist hospitals as they prepare for the expected surge of patients.
On behalf of the more than 200 freestanding emergency centers (FECs) in the
country, we wanted to reach out to let you know that we stand ready to work with
you and the providers in our communities to assist in this fight to ensure that
patients in our communities get the care they need. Like many others, these FECs
are on the frontline of this fight and have seen thousands of COVID-19 symptomatic
patients with a growing number of positive cases.
We are, therefore, writing to request that the Centers for Medicare and Medicaid
Services (CMS) utilize its authority under the recent 1135 waiver to provide
Medicare and Medicaid reimbursement to FECs that are able to serve Medicare
and Medicaid patients during this pandemic.
While FECs have the capabilities of an off-campus emergency department of a
hospital, because they are not owned by a hospital, they are not recognized by CMS
as facilities eligible for payment under Medicare or Medicaid. FECs have only been
in existence for 10 years and have been working with Congress and the American
College of Emergency Physicians (ACEP) and Emergency Department Practice
Management Association (EDPMA) to obtain Medicare and Medicaid recognition1,
but the statute has, unfortunately, lagged behind our delivery model.
FECs are fully equipped emergency departments, possess around the clock lab and
advanced imaging services and are staffed by Emergency Medicine trained
physicians who are on-site 24 hours a day, seven days a week. They are regulated
and licensed by states and subject to state EMTALA laws and a panoply of other
health and safety regulations that equal or exceed emergency departments
operated by hospitals. During this time, all resources should be available to
patients, including FECs, especially given that many of those facilities may have key
healthcare resources (e.g., respirators, isolation rooms) to assist in caring for the
patient overflow from hospital emergency departments.
Across the state of Texas alone, there are more than 1,550 beds in 200 freestanding
emergency centers that stand ready to relieve the burden on hospitals. There are
FECs in small rural towns and rural counties as well as large, urban and suburban
areas. FEC physicians and staff can provide much needed support in the large cities,
which will most likely be hit the hardest with COVID-19. As a point of context,
budgets for major hospital construction allocate between $1 million and $1.5
million per inpatient bed planned, which includes everything else that goes into a
hospital, (operating rooms, cafeteria, physical plant) most of which isn't needed
during this pandemic. As such, the cost to build three major 500 bed hospitals,
FECs can add an inpatient construction value of $1.5 billion overnight by simply
making our more than 1,500 beds accessible to Medicare and Medicaid patients. In
addition, FECs small size is strategically perfect to keep patients in smaller groups
and minimizes COVID spread to other patients.
But we cannot do that if we do not have the resources to provide care to these
patients. Due to CMS’s current regulatory interpretation of FEC eligibility for
disaster funding, the resources freestanding emergency centers can offer are not
being fully utilized.
Based on our legal analysis (attached), we believe CMS has the current waiver
authority under the Section 1135 of the Social Security Act to provide Medicare
funding for FECs that are providing care to Medicare beneficiaries during the
COVID-19 pandemic. This waiver authority under Section 1135 expressly states that
it should be construed, “to ensure, to the maximum extent feasible,” that sufficient
health care items and services are available to meet the needs of beneficiaries
during an emergency and in an emergency area. Id. 1135(a), 42 U.S.C 1230B-5(a).
Further, Section 1135 provides that the “term health care provider means any
entity that furnishes health care items or services, and includes a hospital or other
provider of services, a physician or other health care practitioner or professional, a
health care facility, or a supplier of health care items or services.” (Emphasis
added). Id.1135(g)(2), 42 U.S.C 1320b-5(g)(2).
The definition of “health care provider” is sufficiently broad to include FECs. The
waiver authority extends to conditions of participation, certification, program
participation and similar requirements, for not only individual providers but also
types of providers. Furthermore, nothing in Section 1135 suggests the waiver
authority does not extend to payment. The contrary suggestion is without merit as
it implies the Secretary could waive program participation, but not be empowered
to pay for items or services then furnished.
Section 1135 of the Social Security Act empowers the Secretary to waive
participation with respect to FECs providing care during this national disaster and
to pay dedicated Medicare emergency facility rates to those centers.
A provider’s ownership status should not determine whether they are eligible to
serve patients during this national crisis, and all resources must be marshaled and
brought to bear.
Enclosed with this letter is a matrix to help demonstrate our current capabilities
and a variety of options on how FECs can be fully utilized. We would like to discuss
these options with you and collaborate how we can assist immediately and in the
longer term based on developments on the ground and where resources are
needed. Below are the concepts you can find in our matrix.
- Option 1. Extend CMS emergency care coverage to FECs
- Option 2. FECs to offer outpatient services
- Option 3. Observations of patients for over 23 hours
- Option 4. FECs to offer inpatient or ICU services
- Option 5. FECs to be included as COVID-19 testing centers
- Option 6. FECs to be a dedicated facility for Hospitals EDs
- Option 7. FECs offering Post-Op for emergency surgery patients
We look forward to working with you to ensure that Medicare and Medicaid
beneficiaries are getting the emergency care they need and require during these
Brad Shields, Executive Director
National Association of Freestanding Emergency Centers (NAFEC)