Understanding the Report Card

The Report Card is based on 116 objective measures, using the most recent comparable data available from high-quality sources such as the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Centers for Medicare & Medicaid Services, and the American Medical Association. Additional data were gathered from a survey of state health officials, specifically conducted to obtain information for which no reliable, comparable sources were available. The goal of the Report Card is to show how individual states, and our nation as a whole, measure up in supporting the ability of the nation’s emergency departments to care for patients.

Puerto Rico and Government Services present special cases.  Since data for these areas are not comparable to the 50 states and District of Columbia, no grades were awarded.  The report for Puerto Rico is based on a limited set of indicators for which comparable data were available and the Government Services report is based upon in-depth interviews with topic experts.

The indicators and categories included in the 2006 Report Card served as a starting point for discussions regarding indicators and categories that should be included in the 2009 Report Card. However, the final set of indicators and categories for the 2009 Report Card was ultimately selected by the Report Card Task Force, a panel of experts in emergency medicine (and other relevant topics), using a Modified Delphi Technique. Factors such as feedback received on the 2006 Report Card and the Task Force members’ knowledge of issues most relevant to emergency medicine at the present time strongly influenced these decisions.  In total, 116 different indicators were selected because they represent factors that are vital to the provision of lifesaving emergency care. Each indicator also met several key criteria: relevance, reliability, validity, consistency across all of the states, and currency (collected within the past 3 years). A more detailed description of the Report Card data, the selection of Report Card Task Force members, the Modified Delphi Technique, and the grading methodology is presented in the appendix.

The 2009 Report Card includes a wide range of indicators that represent both direct measures of emergency medical services and indirect measures that have an important effect on the ability to provide quality and timely emergency care. They are classified according to five categories: Access to Emergency Care, the Quality and Patient Safety Environment, the Medical Liability Environment, Public Health and Injury Prevention, and Disaster Preparedness. For each state and the nation as a whole, the Report Card presents one grade for each of the five categories of indicators and an overall grade.

Access to Emergency Care
(30 percent of total grade)
Subcategories: Access to Providers (25 percent of the category), Access to Treatment Centers (25 percent), Financial Barriers (25 percent), Hospital Capacity (25 percent)

Access to emergency care is both fundamental and complex. Emergency departments are a vital part of the health care system in each community and region. They deliver emergency care day in and day out, and serve as the health care safety net for anyone, insured or not, who cannot otherwise obtain the timely health care services they need. Access to emergency care is complex because the demand for emergency services often is related to the capacity of the broader health care system to deliver services. Thus, measures of Access to Emergency Care must include multiple elements that compose that broader system.

This category measures the availability of emergency care resources, such as numbers of emergency physicians, emergency departments, registered nurses, and Level I or II trauma centers per person, along with proximity to Level I or II trauma centers. Because emergency department capacity is also a function of the broader health care system, the access category includes key measures of that system’s capacity, such as the availability of primary care, mental health, and substance abuse providers. It also includes the numbers of available staffed inpatient hospital beds, psychiatric beds, and designated pediatric specialty centers, because greater capacity in those areas can alleviate the crowding and pressure within emergency departments. Since one of the most commonly cited concerns in emergency departments across the country is the lack of access to on-call specialists, this category also includes measures of the total supply of commonly requested specialists, including neurosurgeons, orthopedists, hand surgeons, plastic surgeons, and ear, nose, and throat specialists (ENTs). As an example of the complexity of the access issue, it should be noted that while the number of specific specialists is measurable, many of these specialists have curtailed their availability for emergency services for any number of reasons, including the cost of obtaining medical liability insurance.

Finally, another critical issue that affects the demand for and access to emergency care is the ability of patients to pay for needed health services. Emergency departments are obligated under the unfunded government mandate of EMTALA to screen and stabilize individuals with emergency medical conditions. Therefore, the percentage of uninsured individuals, the number of people relying on public health insurance such as Medicaid and Medicare, and the percentage of physicians who will accept those patients are included as important measures of the demand for care that must be absorbed by the emergency medical system.

Comments from Emergency Physicians "We are unable to control whether our patients will have a space to lie down in the emergency department. Obviously, this situation leads to unsatisfactory patient care and no surge capacity. If the future inevitably will mean more patients using the emergency department - because of inadequate primary care providers or too many uninsured patients using the emergency department - we must have more staff, more beds, and more efficient systems to do the job."

Quality and Patient Safety Environment
(20 percent of total grade)
Subcategories: State Systems (66.7 percent of the category), Institutions (33.3 percent)

One of the critical concerns regarding the increasing pressures on our emergency medical system is the effect they may have on the quality and patient safety environment. Therefore, it is important to be able to measure that environment and how improved systems and technologies can contribute to its enhancement.

While there exists a wealth of national data on the Quality and Patient Safety Environment, state-specific data are largely unavailable or imperfect. Despite these limitations, multiple measures are included in this Report Card. Some of these look at direct state investments in quality and safety improvements – for example, whether a state provides funding for quality improvements to EMS or for a state EMS medical director. In addition, there are key measures of systems and standards designed to track and improve service quality. The importance of these measures was outlined nearly a decade ago in a seminal report from the Institute of Medicine, which noted that a major barrier to improving the quality and patient safety environment was a lack of awareness of the problem due to inadequate reporting of errors.¹⁶  As a result, an important measure of the Quality and Patient Safety Environment in this Report Card relates to whether or not states have requirements regarding the reporting of quality measures, adverse events, or hospital-based infections since the ability to recognize these problems is a key step in applying strategies to address them effectively.

Additional measures of state investments in the quality and patient safety arena include the percentage of counties that have Enhanced 911 capability and the number of emergency medicine resident physicians in the state relative to the population. The latter number is important because research shows that investment in emergency medicine residency programs helps increase the numbers of emergency physicians, since most choose to stay and practice in or near the state where they are trained. Further measures of quality improvement systems include systems of care for specific conditions, such as stroke or myocardial infarction; systems for providing pre-arrival instructions; and the use of electronic medical records or computerized practitioner order entry, which may help reduce medical errors.

This section also includes two other outcomes-based measures of the Quality and Patient Safety Environment. The first concerns the percentage of patients presenting with acute myocardial infarction who receive percutaneous coronary intervention (PCI) within 90 minutes of arriving in the emergency department. The second includes the number of sentinel events reviewed by The Joint Commission (TJC).  TJC defines a sentinel event as any unanticipated event in a health care setting resulting in death or serious physical or psychological injury that is not related to the natural course of the patient’s illness. The point of reporting sentinel events is to identify their causes and assist in developing measures to prevent their recurrence.

Comments from Emergency Physicians "While at times it all seems to be about money and resources, there have to be systems and policies that we can develop to change the course we are set upon."

Medical Liability Environment
(20 percent of total grade)
Subcategories: Legal Atmosphere (25 percent of the category), Insurance Availability (20 percent), Tort Reform (55 percent)

According to the U.S. Department of Health and Human Services, the medical liability system in our nation is “broken.”¹⁷ There are wide variations in rates and policies across states. In some states, high liability insurance rates have forced physicians to curtail their practices, stop performing high-risk procedures or move to other states with more favorable liability environments. Physicians may practice “defensive medicine” – providing extra medical treatments or tests solely out of concern to avoid litigation. The result for patients is greater costs, longer waits, and more difficulty accessing care. For our nation, the result is increased health care expenditures. The U.S. Department of Health and Human Services has estimated that medical liability costs add between $60 billion and $108 billion to the total cost of health care each year.17

In 2007, the average state’s medical liability insurance premium for internal medicine was $16,042, with the highest average premium reaching $71,467. For obstetrician/gynecologists and general surgery specialists, the insurance premium in the average state was $65,489 per year, but reached as high as $171,231.¹⁸  High medical liability insurance rates and fear of lawsuits, particularly in the higher risk environment of the emergency department, may lead to reductions in the numbers of specialists willing to offer on-call services to emergency departments.  High insurance costs also discourage medical students from going into high-risk specialties, such as emergency medicine, surgery, neurosurgery, orthopedics, and obstetrics.

Further aggravating the situation is evidence that the lack of access to on-call specialists contributes to adverse patient outcomes because of delayed treatment or the need to transfer patients long distances to obtain the care they need.¹⁹  Two-thirds of emergency department directors in Level I and II trauma centers surveyed by ACEP in 2006 reported that more than half of the patient transfers that they received were referred there because of a lack of timely access to specialty physicians in the emergency department of origin.²⁰ The unfortunate result of this situation is that pressures from a medical liability environment in crisis may result in a greater risk of adverse outcomes for patients. Ironically, some medical liability laws designed to protect patients are now possibly contributing to patient harm.

In the face of rising medical liability insurance costs and physician shortages, many states have introduced some type of medical liability reform legislation in recent years, including 24 states in 2007.²¹ However, many of the reforms have not passed, and in some cases have been reversed by state judicial systems. In addition, the range of degrees of liability reforms across different states is quite varied.

To assess the status and variation of these measures, this Report Card category includes data on numerous types of liability reforms, based on a detailed survey of information regarding the liability environment in each state. Examples of reform indicators include medical liability caps on non-economic damages, pretrial screening panels, periodic payments, the presence or absence of a state-funded patient compensation fund, health court pilot programs, and additional liability protection for EMTALA-mandated care. There are several indicators of reforms regarding expert witnesses and a measure of whether or not the state has abolished joint and several liability.

Further measures of the liability environment in this category include information on the numbers of awards in medical malpractice cases, average value of such awards, and average medical liability insurance costs.

Public Health and Injury Prevention
(15 percent of total grade)
Subcategories: Traffic Safety and Drunk Driving (27.8 percent of the category), Immunization (16.7 percent), Injury (16.7 percent), State Injury Prevention Efforts (22.2 percent), Health Risk Factors (16.7 percent)

More than one-third (35.6 percent) of emergency visits are for injury-related causes.²² In addition, more than half of the causes of death and disability are due to preventable and behavior-related factors, such as smoking, poor diet, lack of physical activity, alcohol consumption, motor vehicle crashes, firearms, and illicit drug use.²³ Consequently, the impact of public health and injury prevention on the need for emergency care and other health care services is considerable, and state investments in these areas are important.

The public health measures in this Report Card include indicators such as state rates of obesity, cigarette smoking, and binge drinking. They also include infant mortality rates as well as adult and child immunization rates, each of which is an important measure of access to primary care services that are proven to greatly reduce morbidity and mortality.

The rates of traffic fatalities, including those that are alcohol-related, are represented, as are fatal injuries from falls, fires, firearms, and occupational incidents. Regarding injury prevention, there are measures of seat belt use, state policies regarding seat belts and child safety seats, and state investments in various forms of injury prevention. Wherever possible, the indicators in this section were designed to measure the outcomes of prevention efforts - such as rates of seat belt use and traffic fatalities - in addition to the policies, such as seat belt laws, that may influence these outcomes.

Comments from Emergency Physicians "The lack of on-call specialists affects the numbers of patients referred to tertiary care facilities even for basic specialty related diseases (like orthopedics). This adds to emergency department crowding in some facilities, and it means that patients have to travel across town or greater distances for a relatively simple problem that could have been resolved if the specialist had been on call at the initial facility."

Disaster Preparedness
(15 percent of total grade)
Subcategories: Financial Resources (13.3 percent of the category), State Coordination (40 percent), Hospital Capacity (20 percent), Personnel (27.6 percent)

Threats of terrorism and the number of natural and manmade disasters in the United States have increased over the past two decades, highlighting the fact that at no time in our history has the need for disaster preparedness been more urgent or pronounced. Several factors, such as population growth, greater urbanization, population migration to states at higher risk of natural disasters, and decreased health care access and capacity, have magnified the potential effects of disasters on individuals and infrastructure. For example, the devastating consequences of Hurricane Katrina on the medical and emergency response systems of a whole region of the country dramatically underscored the need for greater coordination and resources to contend with large-scale catastrophes.

Emergency physicians have training and experience in managing mass casualty events and delivering lifesaving care to the sick and injured. As such, they play an integral role in local and national disaster preparedness and response. However, while there has been increased state and federal focus on disaster preparedness, there is great variability among states in terms of planning and response capacity. In addition, there is increasing concern regarding the fact that the emergency care system in many communities is already stretched to the limit, and that surge capacity, staffing, and resources are inadequate to deal with the extraordinary demands of a major disaster.

To measure support for disaster preparedness and response, this category includes numerous measures of disaster planning, capacity, and systems associated with emergency medical service capacity and response. Examples of those measures range from levels of federal funding received by each state for disaster preparedness to training, drills, and numbers of available surge capacity staffed beds, burn beds, and intensive care unit beds per capita. There are several indicators associated with medical response plans and the degree to which they incorporate physician input, special health care needs, and communication with emergency and hospital staff. Further indicators measure multiple systems regarding such issues as emergency notification, “just-in-time” training, communications, patient and victim tracking, and syndromic surveillance. The presence or absence of medical strike teams and liability protection for health care workers during a disaster event are included, as is the level of participation by physicians and nurses in state-based Emergency System for Advanced Registration of Volunteer Health Care Professionals programs.

Comments from Emergency Physicians "Boarding, lack of surge capacity, liability concerns, nursing shortages, and on-call shortages may create a perfect storm that will potentially funnel even more patients into the emergency medicine system. This affects both urban and rural facilities, which have scarce resources to begin with and are losing the ability to refer patients elsewhere."

Comparing the 2006 and 2009 Report Cards

Highlights of the 2006 Report Card

ACEP’s original Report Card on the State of Emergency Medicine, published in January 2006, provided the first national snapshot of the environment for emergency services in our nation. The first Report Card gathered and analyzed existing statistics and graded the results from 50 different measures across all 50 states and the District of Columbia. There were four categories of measures, including: Access to Emergency Care, the Quality and Patient Safety Environment, Public Health and Injury Prevention, and the Medical Liability Environment. 

The nation’s overall grade for support of emergency care in 2006 was a C–. While there were wide variations across different states and categories, there was a notable absence of high or low performers. No state obtained straight A’s across all or most of the categories, nor did any state receive a majority of F’s.

The overarching message of the 2006 Report Card was that our nation’s emergency medicine system was struggling and that emergency patients were in jeopardy. In the face of multiple pressures, such as hospital closures, uncompensated care from EMTALA requirements, crowding, medical liability costs and pressures, shortages of on-call specialists, and low reimbursement rates, the system clearly needed remedial attention in the form of policy reforms and increased federal and state investments.

Some of the recommendations of the 2006 Report Card were to:

• Foster state and federal policies to strengthen support for emergency patient care
• Call for all states and the federal government to systematically study and monitor patient boarding and ambulance diversion in order to understand the full dimension of the gridlock in emergencydepartments
• Enact medical liability reforms to help states retain medical specialists and protect access to on-call physicians who provide EMTALA-mandated care
• Increase support for emergency medicine residency programs to help increase the supply of emergency physicians

Environment of the 2009 Report Card

The 2009 Report Card measures the state of the American emergency medicine system at a time when emergency departments are increasingly in demand to save lives and offer services to patients who find it more difficult to access the health care system. It also is a time when emergency physicians are taking on additional critical roles, such as responding to disasters, while facing greater pressures including increased demand, crowding, boarding, ambulance diversion, low reimbursement, liability concerns, and lack of access to on-call specialists. In response, many states have instituted activities, policies, and systems to try to alleviate some of the pressures on emergency departments. This Report Card measures those efforts to institute better systems and policies for ensuring quality, safety, capacity, response, and liability reforms.

Differences between the Report Cards

There are several critical differences between the 2006 and 2009 Report Cards. First, the 2009 Report Card includes an entirely new category of indicators in the area of Disaster Preparedness. The importance of this category has become increasingly apparent, particularly following the devastating impact of Hurricane Katrina. In recent years, major floods, tornados, storms, and wildfires have occurred in multiple regions of the United States, highlighting the role of emergency physicians in preparing for and responding to disasters.

An additional important difference between the two Report Cards is that the 2009 version includes more than twice as many indicators as the earlier version, which results in a very different weighting and grading system. The disadvantage of this difference is that it eliminates the possibility of direct one-to-one comparisons between the two Report Cards. However, it also means that the 2009 Report Card presents a much fuller portrait of the state of emergency medicine in our nation today at a time when it faces greater challenges than ever before. The greater detail is critically important for identifying where the many complex factors affecting the emergency health system and broader health care environment stand.  It is also important for better identifying gaps and needs as well as effective policies, areas of strength or promise, and innovative strategies.

Some of the metrics used in the 2006 Report Card were retained for use in the 2009 Report Card. In those areas where direct comparisons are possible, the 2009 Report Card indicates improvement or deterioration compared with the 2006 Report Card.  These comparisons are found on the state data pages.

The 2006 Report Card presented an important foundation from which to measure the status of emergency medicine nationwide. The 2009 Report Card, while not directly comparable, presents a new, even richer evaluation, within which the portrait of the emergency and broader health care environment is even more clearly presented.