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Ann Emerg Med. 2017 Dec;70(6):846-857.e3. doi: 10.1016/j.annemergmed.2016.12.006. Epub 2017 Feb 15.

Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers.

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Rice University's Baker Institute for Public Policy and the Department of Economics, Rice University, Houston, TX; Department of Medicine, Baylor College of Medicine, Houston, TX. Electronic address:
Blue Cross Blue Shield of Texas, Richardson, TX.
Baylor College of Medicine, Houston, TX.
Division of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX.
Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX; Medical Care Service Line, Michael E. DeBakey VA Medical Center, and Harris Health System, Houston, TX.
Health Care Service Corporation, Chicago, IL.



We compare utilization, price per visit, and the types of care delivered across freestanding emergency departments (EDs), hospital-based EDs, and urgent care centers in Texas.


We analyzed insurance claims processed by Blue Cross Blue Shield of Texas from 2012 to 2015 for patient visits to freestanding EDs, hospital-based EDs, or urgent care centers in 16 Texas metropolitan statistical areas containing 84.1% of the state's population. We calculated the aggregate number of visits, average price per visit, proportion of price attributable to facility and physician services, and proportion of price billed to Blue Cross Blue Shield of Texas versus out of pocket, by facility type. Prices for the top 20 diagnoses and procedures by facility type are compared.


Texans use hospital-based EDs and urgent care centers much more than freestanding EDs, but freestanding ED utilization increased 236% between 2012 and 2015. The average price per visit was lower for freestanding EDs versus hospital-based EDs in 2012 ($1,431 versus $1,842), but prices in 2015 were comparable ($2,199 versus $2,259). Prices for urgent care centers were only $164 and $168 in 2012 and 2015. Out-of-pocket liability for consumers for all these facilities increased slightly from 2012 to 2015. There was 75% overlap in the 20 most common diagnoses at freestanding EDs versus urgent care centers and 60% overlap for hospital-based EDs and urgent care centers. However, prices for patients with the same diagnosis were on average almost 10 times higher at freestanding and hospital-based EDs relative to urgent care centers.


Utilization of freestanding EDs is rapidly expanding in Texas. Higher prices at freestanding and hospital-based EDs relative to urgent care centers, despite substantial overlap in services delivered, imply potential inefficient use of emergency facilities.

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