Iowa scores well for its relatively high rate of emergency departments and Level I and II trauma centers, as well as the substantial efforts it has put forth in planning for effective disaster response. However, a significant shortage of some critical specialists and a severe lack of medical liability reforms leave plenty of room for improvement.
Strengths. Iowa receives an above average grade for Access to Emergency Care, reflecting both strengths and weaknesses in this area. Among the strengths are high proportions of specialty facilities per capita. Iowa ranks 12th for the rate of Level I or II trauma centers (2.3 per 1 million people) and has the 6th highest rates of emergency departments and pediatric specialty centers (40.0 and 6.4 per 1 million people, respectively). In addition, while having a moderate number of staffed inpatient beds, Iowa has the fifth lowest hospital occupancy rate (59.9 per 100 staffed beds).
Iowa’s grade in Disaster Preparedness was helped by the statewide infrastructure that has been developed in case of disaster events. Iowa supports statewide victim and patient tracking systems and has a statewide medical communication system with one layer of redundancy. The state has an all-hazards medical response plan, as well as a written plan specifically for special needs patients. Iowa requires training in disaster preparedness and response to bio- and chemical terrorism for all EMS and essential hospital personnel. In addition, medical assistance teams or strike teams are in place in case of an event.
Challenges. Iowa fell short with regard to the Medical Liability Environment, largely due to a failure to enact many of the liability reforms reviewed in this Report Card. The state lacks a medical liability cap on non-economic damages, expert witness rules providing for case certification or requiring the witness to be of the same specialty as the defendant, and additional liability protection for EMTALA-mandated emergency care.
The state also has the potential to significantly improve its grade with regard to the Quality and Patient Safety Environment. Iowa has relatively low percentages of hospitals participating in electronic networking, ranking 41st in the country for electronic medical records (29.9 percent of hospitals) and 37th with regard to computerized practitioner order entry (14.6 percent of hospitals). Iowa also has a relatively low number of emergency medicine residents (6.4 per 1 million people), compared to the average across the states (12.9 per 1 million).
Recommendations. Iowa is facing a workforce shortage. Despite the relatively high rate of nurses reported as compared with other states, emergency physicians in Iowa have identified the nursing workforce shortage as a primary concern. In addition, the state lacks primary care and specialty physicians generally, as well as on-call specialists. This is highlighted by the state’s low rates of neurosurgeons and emergency physicians (1.1 and 6.3 per 100,000 people, respectively), for which it ranks 50th. The state should take steps to draw additional specialists to the state through medical liability reforms and other efforts. To encourage specialists to provide on-call services to emergency patients, the state could start by enacting additional liability protections for EMTALA-mandated emergency care and instituting a $250,000 medical liability cap on non-economic damages.
The state also might encourage workforce development through increases in Medicaid reimbursement rates across all medical and surgical specialties in Iowa. While the state’s Medicaid fee level for office visits is 116.3 percent of the national average, this rate increased only 3.0 percent from 2004 to 2007, an increase that did not keep up with medical inflation. In order to draw and maintain a stronger workforce in the state, it is imperative that Medicaid reimbursement rates reflect the real costs of the medical care being provided.
While Iowa has a low hospital occupancy rate overall, this may be largely due to the low occupancy rate in many of its rural hospitals which are required to transfer patients with stays longer than three days to one of the larger urban hospitals. As such, emergency physicians have noted that hospital crowding and emergency department boarding of admitted patients is a burden on emergency departments in urban areas. Steps must be taken to ensure that boarding problems are addressed and that Access to Emergency Care in these hospitals is not compromised.