AMERICA’S EMERGENCY
CARE ENVIRONMENT

California

Category Grades
2009
RankGrade
2014
RankGrade
Overall:
37D+ 23C-
Access to Emergency Care:
51F 42F
Quality/Patient Safety:
44D- 32C-
Medical Liability:
9B- 20C+
Public Health/ Injury Prevention:
6B+ 10B+
Disaster Preparedness:
40D+ 30C-


California continues to rank among the top 10 states for Public Health and Injury Prevention and has improved in three of the other four categories. However, this large and diverse state suffers from poor overall Access to Emergency Care, with an inadequate supply of medical facilities and low rates of health insurance coverage.

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Strengths

California is a national leader in Public Health and Injury Prevention. It has extremely low rates of adult smoking (13.7%) and obesity (23.8%). California's infant mortality rate (4.7 per 1,000 live births) is among the lowest in the nation, and the infant mortality disparity ratio is better than average. California has implemented strong child safety seat and seat belt legislation, primary enforcement of distracted driving laws, and requires motorcycle helmet use for all riders. These state policies, in concert with the provision of outstanding trauma care in a large state where 97.7% of the population lives within 60 minutes of a Level I or II trauma center, contribute to a low overall rate of traffic fatalities (5.3 per 100,000 people).

California continues to support a favorable Medical Liability Environment and has been rewarded with lower-than-average medical liability insurance premiums, which will help recruit physicians to the state and improve Access to Emergency Care. The state encourages physician apologies by preventing them from being admitted as evidence in a trial. California has enacted a $250,000 cap on non-economic damages in medical liability cases, which helps to control health care costs by keeping medical liability insurance premiums affordable.

California has also improved in Disaster Preparedness since the 2009 Report Card. It is one of only 11 states that has a state budget line item for Disaster Preparedness funding specific to health care surge. In 2011, it conducted more than nine emergency drills per hospital involving hospital personnel, equipment, or facilities. California has been accredited by the Emergency Management Accreditation Program.

Challenges

California continues to struggle with provider and facility shortages in Access to Emergency Care. Overcrowding and lack of access to needed medical facilities are critical problems for the state. California has the lowest number of emergency departments (ED) per capita (6.7 per 1 million people) and lacks adequate numbers of staffed inpatient beds (223.8 per 100,000 people) and psychiatric care beds (18.3 per 100,000 people). The state also has extremely low rates of orthopedists and hand surgeon specialists (8.5 per 100,000 people) and registered nurses (664.0 per 100,000 people), and has a shortage of physicians accepting Medicare fee-for-service patients. All these factors contribute to high ED wait times, which average 334 minutes (or 5.6 hours) from ED arrival to ED departure for admitted patients.

Financial barriers to care persist in California, impeding access to care. The state has one of the highest rates of adults with no health insurance (22.7%) and a high rate of children with no health insurance (10.8%). It also has moderately high rates of underinsurance for adults (8.2%) and children (18.9%).

While California has regionalized much of its emergency medical services (EMS), there are some key aspects of the Quality and Patient Safety Environment that the state could support, including funding for quality improvement of the EMS system and the development of state field triage protocols. California lacks a statewide trauma registry and a uniform system for providing pre-arrival instructions.

Recommendations

California must work to address a number of issues in Access to Emergency Care, including a gap in medical facilities, financial barriers to care, and long wait times in the emergency department. It should invest in ensuring that its citizens can afford doctor visits. Without a concentrated effort to increase the health care workforce and support adequate facilities, the problem of overcrowding will worsen.

Despite its improved Disaster Preparedness grade, California should consider developing additional statewide systems and procedures to ensure that all citizens are protected in the event of a disaster. California does not have a statewide patient tracking system or a real-time or near realtime syndromic surveillance system. While this kind of surveillance system has been installed in some counties, the state could work to ensure that all counties have access to this technology.

California could also improve its overall emergency care system by enhancing its Medical Liability Environment, including pretrial screening panels or case certification, which would help discourage frivolous lawsuits. Additional liability protection for care mandated by the Emergency Medical Treatment and Labor Act (EMTALA) would help ensure fairness regarding the liability burden placed on emergency care providers and help encourage specialists to be on call for high-risk patients.

Access to Emergency Care

Title 2009
Report Card
2014
Report Card
Board-certified emergency physicians per 100,000 pop 9.2 10.5
Emergency physicians per 100,000 pop 11.5 12.9
Neurosurgeons per 100,000 pop 1.7 1.8
Orthopedists and hand surgeon specialists per 100,000 pop 8.7 8.5
Plastic surgeons per 100,000 pop 3.0 3.1
ENT specialists per 100,000 pop 3.2 3.3
Registered nurses per 100,000 pop 643.3 664.0
Percent of children able to see provider 93.1
Level I or II trauma centers per 1M pop 1.2 1.2
Percent of population within 60 minutes of Level I or II trauma center 96.7 97.7
Accredited chest pain centers per 1M pop 0.2 0.8
Percent of population with an unmet need for substance abuse treatment 8.5 9.1
Pediatric specialty centers per 1M pop 3.5 3.2
Medicaid fee levels for office visits as a percent of the national average 66.7 123.4
Percent change in Medicaid fees for office visits (2004-05 to 2007/2007 to 2012) 9 108.7
Percent of adults with no health insurance 20.9 22.7
Percent of adults underinsured 8.2
Percent of children with no health insurance 12.8 10.8
Percent of children underinsured 18.9
Percent of adults with Medicaid 10.7 12.9
Hospital closures in 2006/2011 1 0
Staffed inpatient beds per 100,000 pop 237.7 223.8
Hospital occupancy rate per 100 staffed beds 73.9 69.8
Psychiatric care beds per 100,000 pop 16.9 18.3
Median time from ED arrival to ED departure for admitted ED patients 334
State collects data on diversion NR YES

Disaster Preparedness

Title 2009
Report Card
2014
Report Card
Per capita federal disaster preparedness funds $10.28 $6.98
State budget line item health care surge YES
ESF-8 plan is shared with all EMS and essential hospital personnel YES, YES YES
Emergency physician input into the state planning process YES
Public health and emergency physician input during an ESF-8 response YES
Drills, exercises conducted involving hospital personnel, equipment, or facilities per hospital
Accredited by the Emergency Management Accreditation Program (EMAP) NO YES
Special needs patients included in medical response plan YES YES
Patients dependent on medication for chronic conditions in medical response plan NO NO
Medical response plan for supplying dialysis NO NO
Mental health patients included in medical response plan NO
Medical response plan for supplying psychotropic medications NO
Mutual aid agreements in place with behavioral health providers STATE LEVEL
State requires long-term care and nursing home facilities to have a written disaster plan YES
State able to report number of exercises involving long-term care facilities or nursing YES
Just-in-time training systems in place STATEWIDE COUNTY OR CITYWIDE
Statewide medical communication system with one layer of redundancy YES YES
Statewide patient tracking system NO NO
Statewide real-time or near real-time syndromic surveillance system NO NO
Real-time surveillance system in place for common ED presentations NR NO
Bed surge capacity per 1M pop NR 358.8
ICU beds per 1M pop 232.6 236.5
Burn unit beds per 1M pop 6.0 5.3
Verified burn centers per 1M pop 0.164144248 0.2
Physicians registered in ESAR-VHP per 1M pop NR 43.7
Nurses registered in ESAR-VHP per 1M pop NR 180.0
Behavioral health professionals registered in ESAR-VHP per 1M pop 8.3
Strike teams or medical assistance teams YES YES
Disaster training required for essential hospital/EMS personnel YES, YES NR
Percent of RNs that received emergency training 46.4 43.7

Medical Liability Environment

Title 2009
Report Card
2014
Report Card
Lawyers per 10,000 pop 17.8 17.7
Lawyers per physician 0.7 0.6
Lawyers per emergency physician 15.4 13.7
ATRA judicial hellholes (2009 range 0 to -7/2014 range 2 to -6) -2 -2
Malpractice award payments per 100,000 pop 0.2 2.1
Average malpractice award payments $181,782 $143,192
National Practitioner Databank reports per 1,000 physicians 17.0 27.7
Apology laws: Apology is inadmissible as evidence in a court of law YES
State has implemented a patient compensation fund NO NO
Number of insurers writing medical liability policies per 1,000 physicians 0.9 1.1
Average medical liability insurance premiums for primary care physicians $13,391 $9,834
Average medical liability insurance premiums for specialists $53,132 $39,135
Presence of pretrial screening panels NONE NO
Pretrial screening panel's findings admissible as evidence N/A N/A
Periodic payments are: required, granted upon request, at court's discretion UPON REQUEST OR AGREEMENT OF PARTY(IES) UPON REQUEST
Medical liability cap on non-economic damages $250,000 $250,000
Additional liability protection for EMTALA-mandated emergency care NO NO
Joint and several liability abolished YES PARTIALLY
Collateral Source Rule/Provides for Awards to be Offset YES, NO OFFSET
State provides for case certification NO NO
Expert witness required to be of the same specialty as the defendant NO NO
Expert witness must be licensed to practice medicine in the state NO NO

Public Health & Injury Prevention

Title 2009
Report Card
2014
Report Card
Bicyclist fatalities per 100,000 cyclists 3.0
Pedestrian fatalities per 100,000 pedestrians 5.9
Percent of traffic fatalities alcohol-related 42.0 32.0
Percent of front occupants using restraints 94.6 96.6
Child safety seat/seat belt legislation - score out of a possible 10 points 6 8
Helmet use required for all motorcylce riders YES YES
Distracted driving legislation score - out of a possible 4 points 4
Graduated drivers' licenses legislation score -out of a possible 5 points 1
Percentage of children aged 19-35 months who are immunized 80.2 80.4
Percentage of adults aged 65+ who rec’d an influenza vaccine in the last 12 mos 66.9 57.2
Percentage of adults aged 65+ who ever rec’d pneumococcal vaccine 60.0 68.1
Fatal occupational injuries per 1M workers 27.5 19.0
Homicides and suicides (non-motor vehicle)(per 100,000) 15.9 16.1
Unintentional fall-related fatal injuries (per 100,000) 4.6 5.6
Fire/burn related fatal injuries (per 100,000) 0.6 0.4
Rate of unintentional firearm-related fatal injuries (per 100,000) 0.2 0.2
Rate of unintentional poisoning-related deaths (per 100,000) 9.6
Total injury prevention funds per 1,000 persons $286.20 $272.29
Dedicated child injury prevention funding YES
Dedicate elderly injury prevention funding NO
Dedicated occupational injury prevention funding NO
Anti-smoking legislation score - score out of a possible 3 points 0
Infant mortality rate per 1,000 live births 5.3 4.7
Percentage of adults who binge drink 15.4 18.6
Percentage of adults who currently smoke 14.9 13.7
Percentage of adult population who are obese (BMI > 30.0) 23.3 23.8
Percentage of children who are obese 15.1
Cardiovascular disease disparity ratio 2.8
HIV diagnosis disparity ratio 9.6
Infant mortality disparity ratio 2.4

Quality & Patient Safety

Title 2009
Report Card
2014
Report Card
Funding for quality improvement within the EMS system NR NO
Funded state EMS medical director NR YES
Emergency medicine residents per 1M pop 11.6 14.1
Adverse event reporting required YES YES
% of counties with Enhanced 911 capability 100.0 100.0
State has a uniform system for providing pre-arrival instructions NR NO
State uses CDC guidelines for state field triage protocols NO PROTOCOLS
State has or is working on a stroke system of care NR YES
State has triage and destination policy in place for stroke patients YES
State has or is working on a PCI network or a STEMI system of care NR YES
State has triage and destination policy in place for STEMI patients YES
State maintains statewide trauma registry NR NO
State has triage and destination policy in place for trauma patients YES
Prescription drug monitoring program score (range 0-4) 2
% of hospitals with computerized practitioner order entry 15.8 81.9
% of hospitals with electronic medical records 37.3 94.6
% of patients with AMI given PCI within 90 minutes of arrival 55 94
Median time to transfer to another facility for acute coronary intervention 64
% of patients with AMI who received aspirin within 24 hours 99
% of hospitals collecting data on race/ethnicity and primary language 44.4
% of hospitals with or planning to develop a diversity strategy or plan 35.3

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