Massachusetts leads the nation with regard to the overall emergency care environment. While the state demonstrates leadership in a majority of the categories studied, significant opportunities for improvement exist, particularly within the Medical Liability Environment.
Strengths. Massachusetts consistently ranks among the top four states for numerous Public Health and Injury Prevention measures, including childhood immunizations, fatal unintentional injuries, and traffic fatalities. The state has relatively low rates of obesity (20.3 percent) and smoking among adults (17.8 percent), as well as the fourth lowest infant mortality rate in the nation.
The state’s strong performance with regard to the Quality and Patient Safety Environment reflects the quality control and improvement systems in place or under development, such as a statewide trauma registry, a stroke system of care, and a PCI network or STEMI system of care.
With regard to Disaster Preparedness, Massachusetts earns positive scores in relation to planning, coordination, tracking systems, burn treatment capacity, and surveillance. The state ranks among the top 10 for enrollment of physicians and nurses in the state-based Emergency System for Advance Registration of Volunteer Health Professionals program.
Massachusetts also fared well in the Access to Emergency Care category. The state deserves special acknowledgment with regard to the rates of uninsured. The data presented indicate that 11.4 and 7.0 percent of adults and children, respectively, lack health insurance. However, these rates have dropped even further since implementation of the universal health insurance mandate.
Additionally, state health officials are to be commended for efforts to end ambulance diversion. The state will effectively prohibit diversion as of January 2009. Acknowledging that diversion does not address the causes of hospital crowding, the state is also encouraging hospitals to improve patient flow and to document efforts to reduce patient boarding in emergency departments.
Challenges. Massachusetts’ Medical Liability Environment is in need of reform. The average malpractice award payment is among the highest in the nation: $437,000 compared to the $285,218 average across the states. Massachusetts also has the fourth lowest number of insurers writing medical liability policies (1.9 per 1,000 physicians).
In the Disaster Preparedness category, the state lacks liability protection for alternative standards of care in the event of a disaster and does not have well defined plans for special populations. Although Massachusetts requires some training in disaster management and response to bio- and chemical terrorism for all EMS providers, there is no standardized training requirement for all EMS and essential hospital personnel.
While Massachusetts fared well overall with regard to Access to Emergency Care, the state faces a high hospital occupancy rate (75.4 per 100 staffed beds) and a comparatively low number of emergency departments per capita (9.8 per 1 million people).
Recommendations. Although Massachusetts benefits from a relatively substantial workforce, emergency physicians in the state have reported difficulties in obtaining on-call services from specialists who appear to be moving from in-hospital practice toward more lucrative specialty clinics and hospitals. This move may also be driven by a reluctance to provide on-call services that might entail greater medical liability risks. The decreasing on-call workforce, combined with a high hospital occupancy rate and lack of emergency departments statewide, has also contributed to the practice of emergency department patient boarding and hospital crowding. These practices create the potential for compromised patient care. The state’s recent decision to begin prohibiting ambulance diversion and to encourage hospitals to more effectively address crowding and boarding should be a positive step in helping to address some of these critical issues.
Massachusetts must enact appropriate medical liability reforms to decrease insurance premiums, and, above all, encourage specialists to be available on-call for what are generally high-risk cases in the emergency department. Failure to take action in this area may result in decreased quality and access to care for those presenting in the emergency department.
Of further concern regarding access to services is a growing shortage of primary care physicians, which may lead to increases in the time that it takes patients to obtain primary care appointments. This is an especially important issue given the increasing percentage of the population that now has health insurance coverage.