Category Grades
29C 38D+
Access to Emergency Care:
47F 47F
Quality/Patient Safety:
17B- 42F
Medical Liability:
2A 2A
Public Health/ Injury Prevention:
34D 49F
Disaster Preparedness:
41D+ 21C

While Texas continues to provide a model Medical Liability Environment and has made great improvements in Disaster Preparedness, it still struggles with significant threats to Public Health and Injury Prevention, as well as severe financial barriers in Access to Emergency Care.

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Texas continues to be among the nation's leaders with its exemplary Medical Liability Environment. The state has the third lowest average malpractice award payments, and medical liability insurance premiums have continued to decline, especially for specialists whose premiums are on average $11,000 less than in the previous Report Card. Texas placed a $250,000 medical liability cap on non-economic damages, enacted additional liability protections for care mandated by the Emergency Medical Treatment and Labor Act, and passed apology inadmissibility legislation.

Texas has made substantial improvements in Disaster Preparedness since 2009. The state has instituted state or regional strike teams or medical assistance teams and has begun enrolling health care professionals in the Emergency System for Advance Registration of Volunteer Health Professionals. The state has the second highest rate of registered nurses who have received training in emergency preparedness (51.8%) and requires training in disaster management for all emergency medical services (EMS) and hospital personnelóone of only five states to do so. Texas also has strong liability protections in place to protect volunteer health care workers responding to a disaster.


Texas continues to struggle with numerous factors in Access to Emergency Care, including severe financial barriers to care. The state has some of the worst rates of health insurance for adults and children (26.9% and 15.4% uninsured, respectively), for which it ranks last and second to last in the nation. Additionally, Medicaid fee levels for office visits are only 77.3% of the national average, having declined 4.9% since 2007. While hospital capacity is about average on many indicators, the state saw two hospital closures in 2011, which has likely contributed to the overall reduction in staffed inpatient beds from 319.8 to 292.7 per 100,000 people. Additionally, while Texas has been successful in attracting large numbers of emergency physicians and specialists over the past decade, performance on these indicators is overshadowed by the state's large and growing population and has resulted in very low per capita rates of many types of specialists, emergency physicians, and registered nurses. The Texas legislature recently increased graduate medical education funding, which should provide opportunity for increases in future workforce numbers.

Texas' grade in the Quality and Patient Safety Environment has declined, partially due to the inclusion of new indicators, but also due to a lack of funding for quality improvement of the EMS system and not having implemented important statewide policies. A multitude of EMS is necessary to cover this large state; as a result, the state has taken a regionalized approach to various EMS protocols. Nevertheless, Texas could investigate implementation of statewide practices and policies to set a standard of safe and effective care for emergency response, such as field trauma triage protocols; destination policies for stroke, ST-elevation myocardial infarction, or trauma patients; or a system for providing pre-arrival instructions.

Texans suffer from a number of health risk factors and high rates of motor vehicle-related fatalities in the Public Health and Injury Prevention category. Texas has extremely high rates of obesity among adults and children (30.4% and 19.1%, respectively) and the highest cardiovascular disease disparity ratio in the nation: Non-Hispanic American Indians are 4.6 times more likely to have cardiovascular disease than the racial or ethnic group with the lowest likelihood. Texas also has high rates of bicyclist and pedestrian fatalities and the third highest rate of traffic fatalities related to alcohol (46.0%).


Texas must work to improve Access to Emergency Care for its population. Of great importance is lessening the state's severe financial barriers to care by improving access to adequate health insurance for both adults and children. Texas must also act to increase Medicaid fee levels so that they are at least on par with the national average. In addition, Texas must continue to support a strong Medical Liability Environment and attract additional emergency care providers, specialists, and Medicare providers to meet the needs of its growing and aging population.

Texas must address racial and ethnic health disparities in cardiovascular disease rates by improving access to primary health care services. Hospitals have taken an excellent first step in addressing health disparities by collecting data on patients' race and ethnicity and taking steps to implement diversity strategies or plans, but the state must do more to encourage healthy habits and reduce cardiovascular disease risk factors among populations at highest risk. Implementing evidence-based practices to reduce adult and child obesity rates and improving traffic safety may be important first steps in improving state scores.

Access to Emergency Care

Title 2009
Report Card
Report Card
Board-certified emergency physicians per 100,000 pop 5.7 6.9
Emergency physicians per 100,000 pop 8.2 10.1
Neurosurgeons per 100,000 pop 1.5 1.6
Orthopedists and hand surgeon specialists per 100,000 pop 7.3 7.3
Plastic surgeons per 100,000 pop 2.3 2.4
ENT specialists per 100,000 pop 2.9 3
Registered nurses per 100,000 pop 674.4 721.3
Percent of children able to see provider 94.6
Level I or II trauma centers per 1M pop 0.9 0.9
Percent of population within 60 minutes of Level I or II trauma center 78.6 82.4
Accredited chest pain centers per 1M pop 2.6 5.4
Percent of population with an unmet need for substance abuse treatment 7.9 8.5
Pediatric specialty centers per 1M pop 4.4 4.2
Medicaid fee levels for office visits as a percent of the national average NR 77.3
Percent change in Medicaid fees for office visits (2004-05 to 2007/2007 to 2012) 34 -4.9
Percent of adults with no health insurance 25.8 26.9
Percent of adults underinsured 8.1
Percent of children with no health insurance 21.2 15.4
Percent of children underinsured 18.8
Percent of adults with Medicaid 6.4 7.2
Hospital closures in 2006/2011 0 2
Staffed inpatient beds per 100,000 pop 319.8 292.7
Hospital occupancy rate per 100 staffed beds 62.3 61
Psychiatric care beds per 100,000 pop 26.5 27.1
Median time from ED arrival to ED departure for admitted ED patients 274
State collects data on diversion NO NR

Disaster Preparedness

Title 2009
Report Card
Report Card
Per capita federal disaster preparedness funds $6.24 $5.32
State budget line item health care surge NO
ESF-8 plan is shared with all EMS and essential hospital personnel YES YES
Emergency physician input into the state planning process YES, YES 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 NO
Special needs patients included in medical response plan YES YES
Patients dependent on medication for chronic conditions in medical response plan YES YES
Medical response plan for supplying dialysis YES YES
Mental health patients included in medical response plan YES
Medical response plan for supplying psychotropic medications YES
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 NO
Just-in-time training systems in place NR STATEWIDE
Statewide medical communication system with one layer of redundancy YES YES
Statewide patient tracking system YES YES
Statewide real-time or near real-time syndromic surveillance system NO NO
Real-time surveillance system in place for common ED presentations NR YES, STATEWIDE
Bed surge capacity per 1M pop NR 549.1
ICU beds per 1M pop 351.3 340.5
Burn unit beds per 1M pop 5.4 4.7
Verified burn centers per 1M pop 0.209166688 0.2
Physicians registered in ESAR-VHP per 1M pop 0 2.1
Nurses registered in ESAR-VHP per 1M pop 0 10.1
Behavioral health professionals registered in ESAR-VHP per 1M pop 0.4
Strike teams or medical assistance teams NO YES
Disaster training required for essential hospital/EMS personnel YES, YES YES
Percent of RNs that received emergency training 45.8 51.8

Medical Liability Environment

Title 2009
Report Card
Report Card
Lawyers per 10,000 pop 14.6 13.3
Lawyers per physician 0.7 0.6
Lawyers per emergency physician 17.4 13.1
ATRA judicial hellholes (2009 range 0 to -7/2014 range 2 to -6) -3 1
Malpractice award payments per 100,000 pop 0.4 1.7
Average malpractice award payments $148,495 $140,441
National Practitioner Databank reports per 1,000 physicians 16.1 17.3
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 1.7 1.8
Average medical liability insurance premiums for primary care physicians $17,597 $16,656
Average medical liability insurance premiums for specialists $65,313 $54,176
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 REQUIRED BY STATE REQUIRED
Medical liability cap on non-economic damages $250,000 $250,000
Additional liability protection for EMTALA-mandated emergency care YES YES
Joint and several liability abolished YES YES
Collateral Source Rule/Provides for Awards to be Offset NO
State provides for case certification YES YES
Expert witness required to be of the same specialty as the defendant YES YES
Expert witness must be licensed to practice medicine in the state NO NO

Public Health & Injury Prevention

Title 2009
Report Card
Report Card
Bicyclist fatalities per 100,000 cyclists 7.9
Pedestrian fatalities per 100,000 pedestrians 9.1
Percent of traffic fatalities alcohol-related 48 46
Percent of front occupants using restraints 91.8 93.7
Child safety seat/seat belt legislation - score out of a possible 10 points 4 8
Helmet use required for all motorcylce riders NO NO
Distracted driving legislation score - out of a possible 4 points 0
Graduated drivers' licenses legislation score -out of a possible 5 points 0
Percentage of children aged 19-35 months who are immunized 76.7 76.3
Percentage of adults aged 65+ who rec’d an influenza vaccine in the last 12 mos 66.4 59.1
Percentage of adults aged 65+ who ever rec’d pneumococcal vaccine 63.7 70.4
Fatal occupational injuries per 1M workers 46.6 36.4
Homicides and suicides (non-motor vehicle)(per 100,000) 17.1 17
Unintentional fall-related fatal injuries (per 100,000) 5.1 6.1
Fire/burn related fatal injuries (per 100,000) 1.1 0.9
Rate of unintentional firearm-related fatal injuries (per 100,000) 0.3 0.2
Rate of unintentional poisoning-related deaths (per 100,000) 8.7
Total injury prevention funds per 1,000 persons $14.96 $63.63
Dedicated child injury prevention funding NO
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 6.6 6.1
Percentage of adults who binge drink 14.7 18.9
Percentage of adults who currently smoke 17.9 19.2
Percentage of adult population who are obese (BMI > 30.0) 26.1 30.4
Percentage of children who are obese 19.1
Cardiovascular disease disparity ratio 4.6
HIV diagnosis disparity ratio 11.5
Infant mortality disparity ratio 2.7

Quality & Patient Safety

Title 2009
Report Card
Report Card
Funding for quality improvement within the EMS system YES NO
Funded state EMS medical director NO NO
Emergency medicine residents per 1M pop 8.2 13.2
Adverse event reporting required YES NO
% of counties with Enhanced 911 capability 100 100
State has a uniform system for providing pre-arrival instructions NO NO
State uses CDC guidelines for state field triage protocols NO PROTOCOLS
State has or is working on a stroke system of care YES YES
State has triage and destination policy in place for stroke patients NO
State has or is working on a PCI network or a STEMI system of care YES YES
State has triage and destination policy in place for STEMI patients NO
State maintains statewide trauma registry YES YES
State has triage and destination policy in place for trauma patients NO
Prescription drug monitoring program score (range 0-4) 3
% of hospitals with computerized practitioner order entry 20.4 71.8
% of hospitals with electronic medical records 39.4 88.6
% of patients with AMI given PCI within 90 minutes of arrival 51 94
Median time to transfer to another facility for acute coronary intervention 63
% of patients with AMI who received aspirin within 24 hours 99
% of hospitals collecting data on race/ethnicity and primary language 85.5
% of hospitals with or planning to develop a diversity strategy or plan 60.6

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