Overall Results: C-

The results of the 2009 Report Card present a picture of an emergency care system fraught with significant challenges and under more stress than ever before. The overall grade for the nation across all five categories is a C-. This low grade is particularly reflective of the poor score in Access to Emergency Care (D-). Because of its direct impact on emergency services and capacity for patient care, this category of indicators accounts for 30 percent of the Report Card grade, so the poor score is especially relevant. This category also incorporates many of the issues that states have identified as their top areas of concern.²⁴ These include:

• Boarding of patients in emergency departments and hospital crowding
• Lack of adequate access to on-call specialists
• Limited access to primary care services
• Shortages of emergency physicians and nurses
• Ambulance diversion
• Inadequate reimbursement from public and private insurers
• High rates of uninsured individuals

The grades for the other categories are slightly better, but not strong enough to pull up the full national average. Both Disaster Preparedness and Quality and Patient Safety Environment receive a C+, Public Health and Injury Prevention receives a grade of C, and the Medical Liability Environment receives a grade of C-.

National Trends and State Comparisons by Category

Access to Emergency Care

The national grade for Access to Emergency Care is a D-. As noted earlier, the access category includes many of the issues that states are struggling with the most. Unfortunately, there is a critical lack of detailed and consistent state-specific data related to some of these major access issues, such as boarding, ambulance diversion, and on-call specialist shortages. Thus, though these issues are having a serious impact on Access to Emergency Care across the country, it is virtually impossible to craft a meaningful state-by-state comparison of these indicators.

In a 2006 report, nearly three-quarters (73 percent) of emergency department medical directors surveyed the previous year reported inadequate on-call specialist coverage, compared with two-thirds in 2004. The problem was most pervasive in the southern United States, with 81 percent stating that on-call coverage was inadequate. Significant problems were also noted in the northeast (74 percent), the north central (63 percent), and the western regions (72 percent).²⁵  The inability to access an on-call specialist can have devastating results.  For example, 21 percent of patient deaths or permanent injuries related to emergency department treatment delays are attributed to lack of availability of physician specialists.²⁶

The major reasons cited for the deterioration of on-call coverage for emergency departments are declining reimbursement, medical liability concerns, and an increasing number of specialists who practice only in specialty hospitals or surgical centers.¹⁹  According to the data collected for this Report Card, on average, states have access to fewer than 2 neurosurgeons, fewer than 10 orthopedists or hand surgeons, 2 plastic surgeons, and slightly more than 3 ear, nose, and throat specialists for every 100,000 people.²⁷ However, it is important to note that even in states that enjoy fairly high proportions of specialists, such as Massachusetts, emergency departments still struggle with inadequate supplies of those willing to be on call.

As the demand on emergency departments exceeds their capacity to provide immediate care, one common response is to divert incoming ambulances to another emergency department.  The frequency of ambulance diversion is a strong indicator of the stress on the entire emergency care system.  Unfortunately, statistics regarding ambulance diversion are not collected in all 50 states. One recently published national study estimated that more than a half million ambulances are diverted every year – equal to an average of one every minute.²⁸  For this Report Card, ACEP surveyed state health officials about their data collection and estimates regarding ambulance diversions. Twenty-five states reported collecting data on diversions, and 20 provided data on diversion frequency and duration in their state. Of those 20 states, only 4 reported no diversions, while 9 reported having hospitals on diversion an average of 1-4 percent of the time, 1 reported a time on diversion average of 5-9 percent, 3 had hospitals on diversion an average of 10-19 percent of the time, and 3 had a hospital diversion average of 20 percent of the time or more.

Emergency department boarding and hospital crowding are also widely felt across the country. According to the data analyzed for this Report Card, the average state has 20 emergency departments per 1 million people, but this figure ranges from a high of 66 per 1 million people to a low of 7 per 1 million people.²⁹ The average state’s daily hospital occupancy rate is reported to be 67 per 100 staffed beds, but that number goes as high as 85 per 100 in some states. Moreover, the time of day when hospital patients are counted may vary, and may not reflect times of peak occupancy. In addition, a lack of specialty beds (e.g., ICU, burn unit, psychiatric) contributes to hospital crowding and emergency department boarding as patients must wait hours or even days to transfer to appropriate units or facilities.

Most states are experiencing a shortage of primary care physicians as well. Based on data from the U.S. Health Resources and Services Administration’s Bureau of Primary Care, the average state needs a total of an additional 136 full-time equivalent primary care providers to adequately care for its population, but some states need to fill more than 700 full-time equivalent primary care provider positions to do so. Similarly, there is a clear need for mental health specialists. The average number of full-time equivalent mental health positions that need to be filled is 30, though some states need more than 200 additional mental health providers to adequately serve their populations.³⁰  As a result, patients experience longer waits trying to obtain appointments with primary care or mental health care providers. Delayed appointments are more likely to increase demand for services in emergency departments as medical conditions worsen and the need for emergency care increases.

The financial challenges associated with decreasing reimbursement and increasing numbers of uninsured patients also affect emergency service access across the country. Declining reimbursement rates from public programs such as Medicaid and Medicare and decreased and delayed payments from private insurers add to these challenges by further reducing patient access to primary care providers and increasing the amount of uncompensated and undercompensated care demanded of emergency departments.

Based on key indicators that were able to be measured and included in the Access to Emergency Care category, the only A grade went to the District of Columbia, which benefits from being an area with a high population density and high rates of specialists, physicians accepting Medicare, staffed inpatient beds, and Medicaid coverage. The next highest ranked states are Maine, Massachusetts, Nebraska and West Virginia. The majority of states struggle with this category, with almost half receiving a D or an F.

The states receiving a failing grade for access include (by rank in ascending order) California, Florida, New Mexico, Arizona, Texas, Nevada, South Carolina, Georgia, Washington, Idaho, Oregon, and Oklahoma. Interestingly, while all of the failing grades occur in southern or western states, no other single set of factors or negative indicators distinguish them. They represent a mix of economic and urban/rural environments. They face different combinations of challenges in areas such as workforce shortages, lack of medical facilities, large uninsured populations, low Medicaid reimbursement rates for office visits, and short supplies of specialists.

Quality and Patient Safety Environment

It is important to note that this Report Card does not attempt to measure the quality of emergency care provided by any physician or in any particular facility in any given state, but focuses on key factors related to the overall Quality and Patient Safety Environment that has been created in each state. Because many states have made it a priority to improve their Quality and Patient Safety Environments, this is the category in which they receive the best scores.  The national grade for this category is a C+ and seven states receive an A in this area, including Washington, Maryland, Utah, Pennsylvania, North Carolina, Massachusetts, and Rhode Island. Five states also receive an A- in this area. Though the exact combinations of factors vary across these states, their high scores reflect an active investment in quality reporting and improvement systems so that problems can be identified and addressed and errors reduced. Increasingly, hospitals are implementing electronic health records and computerized practitioner order entry to increase consistency and safety. However, it is important to note that the United States lags well behind other industrialized countries, where the use of electronic medical systems is nearly universal.³¹

Three states receive failing grades in this category: South Dakota, Arkansas, and Kentucky. The low grades generally reflect a lack of state investment in enhanced quality systems or improvements for the EMS system. They reveal weaknesses regarding the support for or implementation of quality and patient safety improvement strategies that involve cross-hospital systems or standards (e.g., cardiac care networks, statewide trauma registries) to improve quality and prevent, track, or reduce adverse events. The low grades also occur in states that are less likely to have mandates in place to require quality reporting or the tracking and reporting of negative outcomes such as hospital-based infections and adverse events.

Medical Liability Environment

The role of medical liability in the United States is considerable, a fact that is highlighted by comparisons with other countries. For example, compared to the United Kingdom and Australia, the United States has 50 percent more medical liability claims filed per 1,000 people and a rate that is 350 percent higher than in Canada.³² In two-thirds of the U.S. cases, the claims are dropped, dismissed, or found in favor of the defendant. The rest are settled or judged in favor of the claimant. In Britain and Canada, there is a single national organization that protects physicians from liability litigation and the premiums are subsidized by the government. The Australian government also subsidizes premiums for physicians and reinsures high-cost claims. In contrast, the United States lacks federal policies to subsidize premiums or help protect physicians from litigation, including those providing emergency or EMTALA-mandated care.

States report that the fear of liability claims and the costs of medical liability insurance in the United States are driving more physicians and medical students away from high-risk specialties or from serving as on-call specialists to emergency departments. The consequence is that patients have less access to needed services, potentially compromising their care.

Research suggests that liability reforms can stabilize or reduce medical liability premiums and limit fears of litigation on the part of providers.³³ State-by-state enactment of liability reforms has not succeeded in improving the overall picture of the Medical Liability Environment in our nation. Full reform will require federal measures to protect and support physicians who provide emergency and EMTALA-mandated care and to even out the enormous discrepancies that currently exist across states regarding the costs, risks, and rankings of their liability environments.

The nation receives a C- in this category – barely mediocre –  despite successes in some states to enact and implement liability reforms. The stars in this category are Colorado, Texas, Kansas, Georgia, and South Carolina, which have passed liability reforms and tend to have lower medical liability insurance premiums and malpractice awards. There were nine failing grades in this category: the District of Columbia, New Jersey, Rhode Island, Arizona, Kentucky, North Carolina, Delaware, Vermont, and New York.

Public Health and Injury Prevention

Of all the categories of this Report Card, Public Health and Injury Prevention is the one with the most indicators that can be measured against ideal or international standards. In that light, the data are sobering. Despite proven and economically efficient public health methods for promoting health and reducing morbidity and mortality, the United States does not measure well compared to accepted objectives or the outcomes reached in other industrialized countries. For example, the infant mortality rate across the United States is 6.9 deaths per 1,000 live births, which is twice the rate of six other countries and places our nation in 28th position behind such countries as Cuba, Canada, New Zealand, Australia, Hong Kong, Singapore, Japan, and much of Europe.³⁴  Infant mortality is a valuable indicator, because it reflects disparities in the health status of women before and during pregnancy, as well as the quality and accessibility of primary care for pregnant women and infants.

Several measures can be easily compared to an ideal standard of 100 percent. For example, ideally, to further reduce traffic-related mortality and morbidity, seat belt use by the occupants of front seats would approach 100 percent. However, the average rate, according to data collected for the Report Card, is 83 percent, with some states below 65 percent and a maximum of 98 percent. Similarly, childhood and adult immunization rates would ideally approach 100 percent. However, the proportion of children who have received all of the recommended vaccines is only 80 percent.³⁵ The proportion of adults aged 65 years and over who have received an influenza vaccine in the past 12 months is 69 percent, and the rate of those who have ever received a pneumococcal vaccine is just 67 percent.³⁶

The national grade for this category is a C, which in this case reflects a balance between high and low performing states rather than a cluster of average performances. The top four performers in this category, Massachusetts, Utah, Connecticut, and Washington, receive a grade of A, followed by Hawaii, which receives an A-. These states receive high marks across multiple categories of prevention measures, such as immunization rates, injury prevention funding, seat belt use, or child safety seat and seat belt legislation. They also generally have more positive outcomes in areas such as smoking or obesity rates, binge drinking, traffic fatalities, and deaths from occupational, fire, or firearm-related injuries.

The lowest ranked states in this category are Louisiana, South Carolina, Mississippi, South Dakota, Arkansas, Montana, Wyoming, and Alabama – all of which receive an F. Problems that tend to characterize these states include low rates of seat belt use and high rates of traffic fatalities. Poor immunization and high infant mortality along with high rates of smoking, obesity, or alcohol-related traffic fatalities are also common concerns. Lack of investment in injury prevention and activities to promote greater access to and use of preventive health measures are also reflected.

Disaster Preparedness

The overwhelming effects of Hurricane Katrina on the medical infrastructure and emergency medical response capacity of an entire region highlighted our nation’s vulnerability to major disasters. However, federal funding in this area has been lacking. For example, only 4 percent of funding from the Department of Homeland Security goes to emergency medical system preparedness.^37,38,15 As a result, although numerous states have made considerable investments in infrastructures and systems to respond to the health and emergency medical needs that may arise as a result of a natural or manmade catastrophe, the overall grade in this category is a C+.

The top ranked performers in this category include the District of Columbia, Maryland, Louisiana, Pennsylvania, and North Dakota. All of these states share some commonalities in this area, including having received relatively high rates of federal funding per capita to support disaster preparedness compared to other states. They have written all-hazards medical response or ESF-8 plans, which are shared in most cases with EMS and essential hospital personnel. Some have high bed surge capacity and written plans to address special needs populations and supply medications for chronic conditions in the event of a disaster. They have relatively high rates of nurses and physicians registered in a state-based Emergency System for Advanced Registration of Volunteer Health Professionals. In addition, these states have instituted communications and notification systems, and have held drills and trainings for medical staff, emergency personnel, and essential hospital personnel. The lowest ranked states for Disaster Preparedness include Tennessee, Idaho, Alaska, Arkansas, and Nevada.

State Rankings and Variations

There are wide variations in state scores and rankings across each of the different indicators. Every category includes states that receive grades ranging from A to F, but no state receives either very high or very low marks across all five of the categories. The highest overall grade for a state is a B, a feat achieved by only one state: Massachusetts. Even among the top performing states there are important variations among categories. For example, although Massachusetts scores an A in both Public Health and Injury Prevention and the Quality and Patient Safety Environment, it slips to a B in Disaster Preparedness and Access to Emergency Care and a D for the Medical Liability Environment. Similarly, fourth-ranked Maryland rates an A for both the Quality and Patient Safety Environment and Disaster Preparedness, but gets a C- in Access to Emergency Care and a D- in Medical Liability Environment.

The states with the lowest grades also show wide variations across different indicator categories. Arkansas gets the lowest rank and an overall grade of D-. However, while it has failing grades in three areas (Public Health and Injury Prevention, Disaster Preparedness, and the Quality and Patient Safety Environment), it also gets a C+ for its Medical Liability Environment. Similarly, 49th-ranked New Mexico receives an F for Access to Emergency Care, but also a C- for its Quality and Patient Safety Environment.

Interestingly, there is a fair amount of heterogeneity among states in the top and bottom ranks regarding wealth, geography, and rural or frontier environments. For example, although most of the highest performing states are located in the eastern United States, the list also includes Nebraska, North Dakota, and Utah. Similarly, the lower ranked states are located in several different regions, including the West, Southwest, South, and Midwest.

Rural and Frontier Areas

The states with large rural or frontier areas, including low population densities and large distances to medical facilities, face greater challenges regarding health care access and health status generally. Data confirm that people living in rural areas are more likely than their urban or suburban counterparts to report being in poor health, and are more likely to have higher rates of chronic diseases, poor nutrition, cigarette smoking, and deaths from injuries.  Rural populations, on average, tend to be older than those in urban areas and suffer from greater levels of poverty and unemployment. They are also more likely to be geographically isolated and lack access to transportation, a regular health provider, and health services.³⁹  Many rural areas also face major shortages of health care providers. For example, though 20 percent of America’s population lives in rural areas, those areas are home to only 9 percent of the nation’s practicing physicians,⁴⁰ many of whom are older and increasingly aging out of the system.

On the other hand, rural emergency departments are less likely than their urban counterparts to be crowded or have long wait times, and they are more likely to have greater surge capacity. In many cases, the challenges that rural and frontier areas face regarding access issues are balanced with other indicators in this Report Card that reflect state investments and strengths in such areas as the Quality and Patient Safety Environment, Public Health and Injury Prevention, and the Medical Liability Environment.

The states with the lowest scores overall include a majority characterized by large rural or frontier areas, but there are exceptions. For example, California and Florida are listed among the bottom 10 for access, while North Dakota, Nebraska, and West Virginia fall among the top 10. Similarly, while there is a greater representation of wealthier states among the top 10 and of poorer states among the bottom ranked group, the distinctions are not exclusive.