Although Indiana has a few bright spots within its emergency care environment, they are overshadowed by numerous problems, including poor Medicaid reimbursement rates for office visits, a shortage of specialists, and inadequate funding for key injury prevention programs.
Strengths. Despite implementing a number of policies to help improve the Quality and Patient Safety Environment, Indiana receives an average grade in this category. The state has mandatory quality reporting and hospital-based infections reporting requirements. Indiana maintains a statewide trauma registry and has a uniform system for providing pre-arrival instructions. In addition, more than half of the state’s hospitals (52.9 percent) use electronic medical records.
In the Disaster Preparedness category, the state has made numerous efforts to increase its capacity to respond to a major public health tragedy or emergency. Indiana has the highest rate of physicians registered in the state-based Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) program, which allows for the advanced screening, credentialing, and registration of volunteer physicians, nurses, and other health professionals. In addition, Indiana has real-time systems in place for surveillance of common emergency department presentations and the ability to notify health care providers of a disaster event.
Challenges. Indiana’s poor performance in Public Health and Injury Prevention reflects low rates of immunization for young children (79.6 percent) and older adults, among whom only 65.3 percent receive an annual influenza vaccine and just 63.8 percent have ever received a pneumococcal vaccine. Indiana also has among the lowest levels of funding for injury prevention programs (ranking 49th) and relatively high rates of fatal occupational injuries and unintentional fatalities. In addition, Indiana’s infant mortality rate (8.0 deaths per 1,000 live births) is significantly higher than the national rate (6.9 per 1,000 live births).
Indiana also fared poorly in the area of Access to Emergency Care. Indiana ranks among the bottom 12 states for its low rates of neurosurgeons; orthopedists and hand surgeons; plastic surgeons; and ear, nose, and throat specialists per 100,000 people. The state also has a low rate of physicians accepting Medicare (2.5 physicians per 100 beneficiaries).
Indiana ranks 29th for its Medical Liability Environment due to the state’s failure to enact a number of liability reforms, such as additional liability protections for EMTALA-mandated emergency care and expert witness rules requiring witnesses to be of the same specialty as the defendant or licensed to practice medicine in the state. Perhaps reflective of this environment, the average malpractice award in the state is significantly higher than the average across the states ($310,430 versus $285,218, respectively).
Recommendations. Indiana’s poor grade for Public Health and Injury Prevention suggests a pressing need for further state investment in programs, activities, or campaigns aimed at promoting immunizations, obesity prevention, injury prevention, and smoking prevention and cessation. By applying tested health promotion strategies and tools more widely, the state could potentially lower rates of injury and illness, improving health outcomes and reducing demand for emergency and acute care services.
The state should seek to encourage more physicians to accept Medicaid patients by increasing reimbursement rates, which for office visits are 69.5 percent of the national average. Additionally, increasing Medicaid payments across the board may be one incentive to help attract more needed specialists to the state.
Emergency physicians in the state also report growing problems with emergency department and hospital crowding. The state’s relatively low hospital occupancy rate (60.4 per 100 staffed beds) may provide an opportunity for addressing this problem. Crowding, however, may also be exacerbated by the lack of specialists to provide timely on-call emergency care. The state needs to focus efforts on improving access to specialty care, as well as primary and preventive care, by decreasing the rate of the uninsured and increasing the rate of physicians who will accept public insurance.
In addition, if Indiana can apply its success in enrolling physicians in the ESAR-VHP system to include nurses and other health professionals and improve its bed surge capacity, this will go far in boosting the state’s level of preparedness for large-scale public health disasters or emergencies.