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Texarkana Emergency Center is out of network and real expensive. Is it worth the money?

Sep 28, 2022

Editor's note: The article below was published to mark the opening of Texarkana Emergency Center. But many of the issues raised are still valid today as Freestanding ERs initially multiplied beginning in 2015 and then dwindled in the Ark-La-Tex - as more people began to ask tough questions about costs and care. Texarkana Emergency Center has recently added a micro-hospital and now calls itself Texarkana Emergency Center and Hospital. And, according to its website, it is still out of network for all insurance.

The phrase "Real ER without the wait" has been heard constantly by people in Texarkana and the surrounding area in the last few weeks as the city's first freestanding ER opened with one of the grandest business launches of a new enterprise in recent memory for the Four States Area. Positive press flowed from virtually every local media outlet with widespread TV coverage, radio discussions, newspaper articles, magazine spreads, and online media.

Soon, Texarkana, Tyler, and Longview will have several freestanding ERs in each city, and people in the Ark-La-Tex are beginning to have some questions about the concept of freestanding ERs: Are freestanding ERs "real" emergency rooms? How much should emergency care cost outside of a hospital? Should you go to an urgent care facility, a freestanding emergency room, or a hospital-based ER? These are just a few of the questions many Ark-La-Tex residents ask themselves while waiting for doctor's appointments, at dinner, and online following a deluge of publicity about Northeast Texas' new freestanding emergency rooms: not operated in conjunction with a local hospital.

Multiplying like dandelions

In the past few months, the Northeast Texas portion of the Ark-La-Tex has seen a land and building boom for new 24/7, freestanding ERs. The first freestanding emergency room just opened in Texarkana, Texas, and at least two more are planned for the Texas side of the city in 2016. Excel ER is scheduled to open in 2016 at 4102 Gibson Lane, and Pearland, Texas-based Neighbors Emergency Center will also be opening its center in 2016 near Texarkana's famous Bryce's Cafeteria. In addition, other emergency centers are under consideration in the Texarkana area from other comers in the healthcare space.

Residents of Tyler, Texas, already have two freestanding ERs -  Excel ER at 6718 S. Broadway and Neighbors Emergency Center at 2222 E. Southeast Loop 32. In addition, a new Patients ER has broken ground in the city, and the merger between Tyler Urgent Care and Complete Care will result in a fourth freestanding ER for Tyler in early 2016. In Longview, Patients ER is being built next to Little Mexico restaurant on McCann Road, and Excel ER will open at 120 Clay St. in the city. Recently, Neighbors Emergency Center announced plans to build a new emergency center at the west corner of the Gilmer Road intersection with Loop 281 in Longview. Excel ER has also announced a 2016 opening for a freestanding ER in Nacogdoches at 1424 North Street, and Excel ER is planning for an expansion into Louisiana shortly.

A well-respected doctor opens freestanding ER

Texarkana Emergency Center is the first freestanding ER in Texarkana and officially opened on December 3, 2015. It is located across the street from Central Mall, adjacent to the Texarkana Convention Center, and very near Christus St Michael Health System's Emergency Room. The building, which used to be a bank, was purchased during the first half of 2015, and it was listed for sale at $3.4 million by Reynolds Realty Management. The building was constructed in 2007 and houses over 10,000 sq. ft. of space.

With 14 rooms for treatment (including two triage areas), the Texarkana Emergency Center promises a "Real ER without the wait." Five local emergency room doctors - Bo Kelly, Dallas Bailes, Erik Jacobsen, Kyle Groom, and Matthew Young - are on-call at the facility. In addition, local artists have adorned the walls with artistic works, and kids of all ages can enjoy the Netflix and Hulu-enabled televisions in each room. In short, Texarkana Emergency Center has a purposefully "cozy" vibe.

The Texarkana Emergency Center's greatest asset is Matthew Young, medical director. Young, who prefers to go by the name "Matt," is the literal "face" of the new center and is now a public figure. Young's slight, confident smile is front and center with mailers, videos, newspaper ads, online media, and TV reports. It is an excellent choice because Young fits virtually everyone's description of a kind and caring doctor, and he could easily play one on TV if it was not his profession in real life.

Young had an all-American childhood growing up with a large Catholic family in Texarkana's Highland Park area under the watchful eye of his beloved father, the late Dr. Mitchell Young, and Donna, his mother. Young was an Eagle Scout, attended the University of Arkansas main campus for his undergraduate work, and later attended medical school at UA Little Rock.

Walk around the hallways of local medical offices in Texarkana, where Young was well known as an emergency room physician at Christus St. Michael, and people will tell you that he is a "good doctor and fine person." High praise can also be heard for him around town, and people will often mention his well-respected father, Mitchell. Indeed, the medical tradition is so strong in his family that Young has seven brothers who are medical doctors and one who is a veterinarian. Young's mother, Donna, worked with his father in his medical office, and the tradition continues today. That's because Young's wife, Cindy, is an integral part of the new Texarkana Emergency Center's mechanics and is its operations director. We spoke briefly with Mrs. Young while she was at the center, but she preferred to let the center's marketing director and her husband do the talking about the business.

Medicare-free zones

Most freestanding emergency rooms that have become a trend in Texas and other states (like Arizona and Colorado) do not have federal recognition and are only recognized by the state. This means they do not accept Medicare or Medicaid. Even though many doctors, nurses, and administrators at freestanding ERs will say that they would like to one day accept Medicare and Medicaid, it would probably vastly decrease profitability and increase wait times. By taking Medicare, freestanding ERs would be subject to the Emergency Medical Treatment and Active Labor Act (EMTALA) which would require the centers to provide care to patients who could not afford care, and that would be in addition to the relatively low reimbursements they would receive for patients on Medicare. Hospitals, of course, are bound by these regulations. Some critics argue that freestanding ERs take away patients with private insurance and leave hospitals to care for society's indigent and elderly.

Matt Young of Texarkana Emergency Center said that he would like to accept Medicare, and he has gone online to tell commenters this as well. The non-acceptance of Medicare at the center is often mentioned on the center's Facebook page. In response to one comment, Young replied: "It is unfortunate that we are not allowed to participate in Medicare or Medicaid. Maybe the laws will change." While some owners and employees of freestanding ERs might not be sincere in this statement, the high opinions of Young in the Texarkana community would lead almost anyone to believe that he really does want this change to happen.

Nevertheless, centers like the one in Texarkana are required to provide medical screening examinations and stabilize any emergency patient - regardless of the ability to pay. However, some freestanding ERs might actively encourage indigent patients to go to nearby hospital emergency rooms instead of caring for them at their centers.

Removing a splinter costs what?

Texas and Colorado have had the most significant growth in freestanding ERs  - mainly due to favorable state laws. So we reached out to award-winning TV reporter Chris Vanderveen of Denver, Colorado's NBC Affiliate, KUSA-TV. Vanderveen spent several months researching Colorado's freestanding ERs, which have expanded exponentially in a short time.

Chris Vanderveen reports on freestanding emergency rooms
Chris Vanderveen, reporter
KUSA-TV, Denver, CO
Vanderveen, an investigative reporter who won a national Edward R. Murrow Award in 2011 and reported on the shootings at Columbine, said it is estimated that 50% of people entering a freestanding emergency room are not educated about the high costs.

The KUSA reporter, who has a brother who is an emergency room physician, said his interest in freestanding emergency rooms stemmed from an email from a deck builder who received a $3,690 bill for the removal of a splinter from his thumb. After his private insurance paid the limit for his emergency care, the deck builder still owed $2,301.60 for the removal of the splinter.

The reporter said some patients of freestanding ERs feel like they have been the victim of a scam. "I used the huge bill for the splinter as a jumping-off point to tell a bigger story," Vanderveer said. "Everything freestanding ERs are doing is within the law, but people are not aware how much it costs."

Vanderveer called on people across Denver and other areas of Colorado to send him their statements from freestanding ERs, and he said he was amazed. "We put out a request for people to send us bills from the freestanding ERs, and I was just shocked at how many were three, four, and five thousand dollars for minor things," he added.

One patient showed Vanderveen her bill for $6,237 when she went to a clinic complaining of shortness of breath. Some tests were run, and they eventually told her to go home and "relax."

Nevertheless, Vanderveer said that many people believe there is a place for freestanding emergency rooms in both Texas and Colorado when someone has a legitimate emergency. He added that many freestanding ERs have good medical doctors and staff.

However, the irony of a new, freestanding ER being housed in a former bank was not lost on the reporter. "The public has no idea what these places cost. A CT scan in one emergency room might cost $1,000 and $8,000 in another. It's a tremendous difference," he added.

Indeed, the reporter said that, in his opinion, the future of freestanding emergency rooms is unclear. "People aren't versed on how expensive these things are," Vanderveer said. "The real question they have to face is that once the public is educated about the cost, how many customers will be left for them to stay in operation."

Vanderveer said that in Colorado, former customers of freestanding ERs have eventually let their friends and neighbors know the costs associated with them. "So it's a real question in my mind whether these places will be open in four years," he said.

Why are there so many new freestanding ERs?

The quick rise of freestanding ERs has more to do with high profits based on large bills for service. For example, first Choice Emergency Room, which operates over 50 freestanding ERs, the company collected an average of $1,500 per patient according to the Star-Telegram based on a Securities and Exchange Commission prospectus it reported First Choice had filed in 2013. The problem with this is that in many cases, the medical issues are relatively minor problems that could often be treated equally well in urgent care or retail clinic settings for sometimes one-tenth of the cost.

The main culprit for the high costs in most for-profit, freestanding ERs are the "facility fees" that are allowed to be charged. These fees, which are assessed on a per-patient basis, can routinely be $800 or more at many freestanding emergency rooms, which drives up costs significantly for each patient. This fee is charged in addition to the bill for service at standard emergency room prices. In addition, many freestanding ERs also allow doctors to bill patients separately. So customers might face two large bills - often arriving in the mail on different days. And this has led to significant sticker shock for patients, according to Alan A. Ayers, associate editor of the Journal of Urgent Care Medicine.

Ayers said that many freestanding ERs believe they should be able to charge a facility fee because their capabilities are similar to a traditional hospital emergency room. Ayers wrote: "The facility fee [is] a fee historically charged by hospitals to cover the overhead of being prepared to handle any situation that presents - natural disaster, terrorist attack, ambulance diversion, etc., offset losses incurred in treating Medicaid populations and to subsidize charity care/sliding fee scales serving the poor and indigent," said Ayers in widely read paper titled "Dissecting the cost of a Freestanding Emergency Care Visit."

However, Ayers argues that the cost structure of freestanding ERs is different than hospital emergency rooms because they are not subject to the aforementioned Emergency Medical Treatment and Active Labor Act (EMTALA), do not accept Medicare and have a lower cost structure than hospital-based emergency rooms.

Patients without financial means

Some freestanding emergency centers may not tell you this. Still, they are required by the state of Texas to medically evaluate and stabilize any patient that comes to them regardless of their ability to pay. The Texas Administrative Code that governs freestanding ERs specifically states this.
A facility shall provide to each patient, without regard to the individual's ability to pay, an appropriate medical screening, examination, and stabilization within the facility's capability, including ancillary services routinely available to the facility, to determine whether an emergency medical condition exists and shall provide any necessary stabilizing treatment.  Texas Administrative Code
The problem with this is that some freestanding ERs do whatever they can to discourage people from coming to them without private insurance or the ability to self-pay. If that doesn't work, some freestanding ERs might try to have poor patients transported to a local hospital that must care for the patient due to EMTALA after the freestanding clinic has met the minimum state guidelines. In addition, many potential patients of freestanding ERs will be referred to a hospital-based emergency room before they even see a doctor or are told incorrectly that payment must be made in full for any visit to the facility.

We discovered some problems first-hand. Our reporter called Texarkana Emergency Center at approximately 3:35 a.m. in the morning after the center officially opened. The reporter asked what the cost would be for him to be seen for his knee injury without insurance. In a somewhat discouraging tone, an employee told him the entire visit would have to be paid for in full at the time of service with no billing option. The reporter asked how much it would cost, and he was not given an answer. Finally, the reporter asked if the center was required to treat him by law, and the woman paused and then gave a somewhat terse "yes." The call ended.

The surprised reporter then called back a few minutes later. He asked the same employee how he would know if he could "pay in full" without being given a price, and she offered a fee of $250.00 to be evaluated by the doctor. Then, she said, the reporter would be advised of the additional cost of treatment before care was given.

Around noon the next day, on Saturday, December 5, the same reporter called Texarkana Emergency Center again and asked a different employee about the cost of treating his knee. During this call, he was offered a free medical evaluation by a doctor, which would be followed by an estimate of the cost of treatment. It is unknown whether our multiple inquiries for this article about the center in the previous 24 hours had caused a policy change or if the discouraging employee had mistakenly provided incorrect information because the freestanding ER and the employees are all new.

For the record, the medical staff members of Texas freestanding ERs are required to medically evaluate any patients who present themselves with an emergency and stabilize their condition, regardless of whether they are rich, poor, or somewhere in between.

Wealthy zip-codes

Texas was the first state to allow freestanding ERs not attached to hospitals in 2009, but the Legislature meant for these facilities to be placed in rural areas needing emergency rooms. As a result, there were only about 20 Texas freestanding ERs in 2010, and the number is closer to 200 in Texas today. However, rural areas are not getting freestanding ERs because affluent Texas suburban communities are where you will find the majority of these facilities. Because wealthier areas of larger cities were home to most of the original group of freestanding ERs, now the freestanding ERs are branching out to higher-income neighborhoods in mid-size Texas cities, such as Tyler, Longview, and Texarkana.

study by the Texas Tribune in 2015 showed that the income level of the neighborhoods with freestanding ERs is 49% above the average state income. This is no surprise because freestanding ERs need patients with private insurance who are then able to afford the balance not covered by insurance.

Health economist, Vivian Ho of the Baker Institute for Public Policy at Rice University, said freestanding ERs will not be opening in lower-income neighborhoods anytime soon. She noted that patients in these communities would need to buy insurance and make sure it was in-network with the emergency center.

Insurance confusion

Because more and more freestanding ERs are being built in Texas, many of them are becoming more likely to be covered in-network by health insurance plans. However, most patients who arrive at freestanding ERs are out-of-network. Nevertheless, freestanding ERs have been helped by the "Prudent layperson standard," which was included in the "Patients Bill of Rights" of 1995. It allows a person to be medically evaluated if they believe they have an emergency medical condition, and this standard was adopted for Medicare patients in 1997. While healthcare companies and health insurance companies continue to debate the "Prudent layperson standard," freestanding ERs are using this standard to force health insurance companies to pay for emergency care - even though some people use freestanding ERs for minor issues such as mild nasal congestion.

Earlier this year, one woman complained to a Dallas Fort Worth TV news station about the cost of treatment for her runny nose. She just wanted some quick care for her nasal drip to resume regular activities with her family over a holiday weekend. Still, her bill was $73 from the doctor plus a $980 facility fee from the freestanding ER. This will seem excessive to almost everyone, but some freestanding ER advocates argue that higher charges are justified because all patients are seen by an emergency room doctor and emergency staff - not nurse practitioners, which is sometimes the case at urgent care centers.

But freestanding ERs estimated to break even with an average of only 35-40 patients a day - compared to 150 patients on average for most hospital-based ERs - are sometimes more than happy to treat a stuffy nose complaint. While some freestanding ERs will refer patients with this type of minor complaint to urgent care, others will treat them with emergency care and charge the total rate of service. However, the cost differential can be startling to consumers because care at freestanding ERs is covered under the emergency care provisions in private health insurance and not at the rates and co-pays assessed for doctor's visits or urgent care.

Many insurance companies make patients responsible for the first $500 - $1500 (or more) of emergency care to steer people away from seeking emergency care for inappropriate circumstances. While someone might have a $40 co-pay at an urgent care clinic, a patient might be responsible for a cost up to ten times at a freestanding ER. After insurance has paid part of a trip to a freestanding emergency center, some patients are shocked to get a bill for the remaining cost of care from the freestanding ER and usually a separate bill from the doctor as well.

Deciding where to get treatment

Knowing when to go to a freestanding ER is one of the hardest things for consumers to understand based on online discussions. We wanted to ask an industry spokesman directly, and we briefly spoke with Brad Shields, executive director of the Texas Association of Freestanding Emergency Centers (TAFEC). Unfortunately, it was a Friday afternoon, and Shields could not talk, but we were in touch with TAFEC board member Marysol Imler. She directs operations and planning at Five Star ER, which has several Texas locations.

Imler said the best times to go to a freestanding ER are when a patient can't wait for a doctor's visit. "Freestanding emergency rooms are great options for severe stomach aches, chest pain, and orthopedic injuries, to name a few," she said. "Such facilities are typically capable of handling most any condition for which you might otherwise visit a hospital-based ER."

Angela Evans, director of community education at Healthcare Express, said the new freestanding ERs are confusing to patients, and she has been trying to help educate consumers. "I do think it is confusing if you don't work in the industry," Evans said. "If you go to the Texarkana Emergency Center for a non-emergency, your co-pay will be much higher in most cases."

Evans said insurance carriers prefer urgent care over freestanding ERs. "A lot of people don't know this, but your insurance carrier wants you to go to an urgent care, and patients will be seen in the order they arrived at urgent care," Evans said. "With emergency care, the patients with the most serious issues will be seen first."

Healthcare Express is a growing, Texarkana-based company with several urgent care clinics in cities around the Ark-La-Tex. They also own pain management, imaging, and physical therapy clinics. Realizing the confusion, Angela Evans created an infographic for patients to use when deciding whether to utilize urgent care or emergency care. "If someone is suffering a major trauma, we will send them to local hospitals," she added. "But you will save time and money coming to us for most things."

Evans said Healthcare Express moved to a 24-hour service commitment in Texarkana at its Richmond Road clinic in January. "It was feedback from our patients that helped us decide to make this change," she said. "If your child is suffering a high fever in the middle of the night, there will now be a cost-effective place to go."

Tonya Dubois, a physician's assistant and owner of Exceed Urgent Care at 3725 Mall Drive in Texarkana, also said the opening of the Texarkana Emergency Center had created some confusion, and she said patients need to look at the huge difference in insurance co-pays when utilizing urgent care versus freestanding ERs.

"People I have talked to don't realize that you will be paying emergency room prices at freestanding ERs, and our co-pays are significantly less at an urgent care," Dubois said. "We have contracted with insurance, so we have to charge you what we have already agreed, and we accept Medicare. Since we have already negotiated with insurance companies, it protects the consumer from surprise medical bills for emergency care that insurance won't pay for."

With Excel ER moving into the Texarkana market soon, there is the possibility that some customers could confuse Excel ER with the urgent care center named "Exceed" that she owns. However, Dubois has a simple response to that. "If it's non-life-threatening, come to urgent care," she said.

Partnering with hospitals

Freestanding emergency rooms present a difficult conundrum for hospitals. On the one hand, the new, freestanding ERs provide competition to their hospital emergency rooms. On the other hand, however, the new facilities can also feed more patients to hospitals. Nevertheless, all of the new, area freestanding ERs must work with local hospitals to treat patients with problems outside their capabilities or patients in need of care for more than 23 hours. Local freestanding ERs can stabilize and observe patients for up to 23 hours, but a hospital stay is required for a longer time because it is considered in-patient care.

We spoke with representatives from both major hospitals in Texarkana about the confusion generated by the press coverage of the new Texarkana Emergency Center. Some citizens believed the new center was officially affiliated with at least one of the local hospitals because news reports discussed the cooperation between local hospitals and the new freestanding ER.

Shelby Brown, director of marketing at Wadley Regional Medical Center, said her hospital wants to work with all emergency services in the area, including ambulance services and the new Texarkana Emergency Center. "We want great relations with everyone in the healthcare market," she said. "If a freestanding ER has a patient that needs to be hospitalized, we want to care for them."

Brown also said patients should remember that Wadley was the Four States Area's first certified stroke center. "We want everyone to know that we offer stroke victims timely care to make sure they are taken care of with the best emergency care that results in the least amount of debilitation possible," she added.

Wadley Regional Medical Center recently purchased 55 acres near Gander Mountain and close to I-30. Still, the hospital is not commenting on plans for the acreage as it makes plans for future growth in Texarkana.

Francine Francis, director of marketing and community relations at Christus St. Michael Health System, said her hospital has good relations with the new Texarkana Emergency Center. She said the hospital had already received patients from Texarkana Emergency Center. "I can certainly confirm that they have admitted patients," Francis said. "Our relationship is that we are available for transfer for conditions that are more serious and when a patient needs to be admitted to the hospital."

The community relations director admitted it was difficult for prospective patients to know where to go for emergency care with the new options. "It is very dependent on the level of care that you need," Francis said. "But if you have something that is fairly serious like a heart attack or stroke, this is where a hospital emergency room can help. We have significant in-house resources and specialists - including surgical specialists - that can be available immediately because they are on call 24/7."

Hospitals are also moving into the freestanding ER space, and Francis said she "doesn't know if there is a possibility" that Christus St. Michael might one day open a freestanding ER. For example, the University of Colorado Health System purchased a majority stake in more than a dozen Colorado freestanding ERs owned by Lewisville, Texas-based Adeptus Health. Adeptus operates Flower Mound, Texas-based First Choice Emergency Rooms with over 50 freestanding ERs. Industry experts expect more health systems to branch out with freestanding emergency rooms if the trend proves financially lucrative and helpful to the community. Indeed, some of the new Ark-La-Tex-owned, for-profit ERs could be purchased by hospitals and healthcare centers in the coming years. For example, we reached out to the freestanding ERs purchased by UC Health System and were surprised to learn that they still do not accept Medicare and are still under the auspices of a corporate office in Texas, according to a person answering the phone at one of the freestanding ERs.

Legislative action 

In early 2015, State Sen. Charles Schwertner (R-Georgetown), an orthopedic surgeon, said he had grown tired of hearing about "sticker shock" for relatively minor medical problems from freestanding ERs.
state senator schwertner introduces bill providing patient notification for freestanding ERs
Charles Schwertner,
State Senator,
Orthopedic Surgeon

Schwertner said he was "regularly" hearing from constituents who were confused about whether a facility was an urgent care or a freestanding emergency room. The senator said that "confusion quickly turns to frustration and anger" when a large unexpected bill arrives from a freestanding ER.

To help alleviate at least some of the problems, Schwertner authored Texas Senate Bill 425 (SB425) in the 84th Legislature that required freestanding ERs to post important information about their services so Texas consumers would know that they would be paying for emergency services and not urgent care. The bill was passed by both the Texas Senate and Texas House and was signed by Governor Greg Abbott - effective September 1, 2015. The law requires freestanding ERs to place vital information prominently in their office and on their website no later than January 2, 2016. In addition, freestanding ERs must each post that:
  • The facility is an emergency room.
  • The facility charges rates comparable to a hospital emergency department, including a possible facility fee.
  • The physician may bill separately from the facility.
  • The facility and facility-based physicians may not be a participating provider in an individual's health plan network.
Gary VanDeaver is a Texarkana representative to the Texas House of Representatives
Gary VanDeaver,
State Representative,
R-New Boston
Gary VanDeaver, representing Texarkana in the Texas House of Representatives, voted for the provision. He said area families deserved consumer protection. "To me, it is just wise from a truth in advertising perspective that people know up-front what kind of service they will be getting and what they will be paying," VanDeaver said.

As previously mentioned, the state of Colorado has also seen massive growth in freestanding ERs, but legislation has been faster in Texas. Chris Vanderveen, a Denver area TV news reporter from station KUSA, said a move from legislators in his state might come about in the next year.

Irene Aguilar, a Colorado state senator (D-Denver), said her state had traditionally embraced healthcare and freestanding emergency rooms without added regulations since some facilities would open during busy tourist times - for instance, during ski season. However, she told the reporter that the rules intended for rural areas needing emergency care may have "played into the business model" of freestanding ERs opening in the wealthiest suburban areas of Colorado. Experts predict the state will have 35-40 freestanding ERs by the summer of 2016.

The benefits of freestanding emergency rooms

For all the talk about the cost of freestanding ERs, it is clear that they have saved lives and will continue to do so. While some freestanding emergency rooms might be confused by consumers as an urgent care center, it appears that Texarkana Emergency Center has gone out of its way to look like a "real" emergency room. Indeed, at night, the location could be easily confused as a hospital-based emergency room with its tall 40" illuminated letters that proclaim "ER" on three sides along with a large medical cross. Lit signs simply saying "Emergency" with arrows also direct potential patients into the parking lot. The location has a large ambulance entrance on the side of the building nearest the Texarkana Convention Center.

Besides being popular in the city of Texarkana, the medical director of the Texarkana Emergency Center, Matt Young, has an unmistakably friendly Texarkana drawl, which is somewhat reminiscent of Ross Perot, who also grew up in the Highland Park area of the city and was a boyhood friend of Young's late father, Mitchell.

Many people told us that seeing a well-respected and trusted doctor such as Young in an emergency is "worth every penny" - to quote one Texarkana citizen we spoke with at a local medical office. And even a few of the most vocal critics of freestanding ERs admit that there is a place in the healthcare marketplace for freestanding ERs for wealthier citizens.

"We are more patient-friendly, and you don't have to park in a remote parking lot," Young told us. "We can do as much as a hospital-based emergency room."

Young also pointed to his freestanding ER's waiting times of ten minutes or less as a significant point of difference in the local healthcare market. "The biggest reason for the rise in freestanding ERs is patient waiting times, and with Texarkana  Emergency Center, you are getting the cream of the crop in people and facilities," he said.

The slogan for the facility is "Real ER without the wait," and the medical director defended the use of the phrase. "We are a real ER without the wait up to the point of hospitalization," Young said.

With a trusted local doctor and shimmering new facilities, this particular freestanding ER could and should be a shining star for the industry in the state of Texas. With millions spent on the new facility (Young would not give exact figures), many customers in the Texarkana area say they know it is emergency care. They are willing to pay the price when it comes to an emergency with their friends or family.

"We made a huge investment in the healthcare of our community, and we are now part of the community's healthcare," Young said.

Marysol Imler, a board member of the Texas Association of Freestanding Emergency Centers, also pointed out the benefits of the Texas facilities. "Freestanding ERs are equipped to provide quick, convenient emergency medical care in a comfortable environment," Imler said. "The combination of in-house x-ray, ultrasound, CT imaging, and onsite laboratory services (not typically available in an urgent care setting) gives physicians in freestanding ERs the information they need to rapidly diagnose and treat a medical emergency. Like traditional emergency rooms, freestanding ERs are open 24/7."

Is there a place for freestanding emergency rooms?

As long as Ark-La-Tex consumers have the facts, freestanding ERs can make a positive impact in communities. However, the emergence of these facilities has led local healthcare industry officials to ask even more questions: Will there be enough emergency doctors? And, if so, where will they come from? Will more doctors leave hospital-based emergency rooms, or will emergency doctors from outside Texas fill the void?

If doctors leave hospitals, it is a serious public health matter because Texas citizens in the most need of care usually end up in hospital-based emergency rooms. And the exit of some doctors in hospital emergency rooms has already happened in Houston, Dallas, and Corpus Christi, where freestanding ERs have been present in the health marketplace for some time.

Nevertheless, patients walking out of Texarkana Emergency Center seem to be pleased with a high level of care. Medical director Matt Young's positive reviews might easily have patients clamoring for his attention at virtually any price with his admirable aim of concierge care for every patient. Moreover, price is not an object to many people when it comes to the sickness of a child or a grandmother who has a bad case of flu and needs intravenous hydration at a freestanding ER - especially since many Ark-La-Tex residents die every year from flu. However, potential patients should educate themselves at the start of each year about their own insurance costs for emergency care versus doctor visits or urgent care. With this information, Texas healthcare consumers will have all the information they need to make informed decisions about care.

For a topic that sparks so much confusion, one thing is clear: Freestanding ERs have already started to disrupt the healthcare market in Northeast Texas, and the long-term consequences of the presence of multiple facilities in Texarkana, Tyler, and Longview could have a lasting impact on patient care, availability of doctors, insurance cost and patient pocketbooks for the foreseeable future.

In the meantime, Matt Young and his staff are at their center across from Central Mall waiting for patients right now, and it is very likely that informed consumers who know the price of emergency care will continue to offer high praise for a well-run, customer-centric freestanding ER. But less informed consumers at any freestanding ER could be in for a "real" expensive surprise.

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