Executive Summary

For millions of Americans who experience sudden, serious illness or injury every year—and in the increasing scores of communities that must respond to disasters and mass casualty events—immediate access to quality emergency care is essential to saving life and limb. But the availability of that care is threatened by a wide range of factors, including shrinking capacity and an ever-increasing demand for services. Even as more and more Americans come to rely on emergency departments for their acute care needs, particularly aging and sick Boomers and people newly enrolled in Medicaid, such care will increasingly become harder to access.

This national Report Card rates the overall environment in which the emergency care system operates with a near-failing grade of D+.  

This is a poorer grade than the one earned in 2009, a C-. Overall state rankings have changed since the 2009 Report Card, with the District of Columbia now ranking first and Wyoming ranking last in the nation.

These findings are the result of a comprehensive and focused study of the emergency care environment nationwide and state-by-state. The American College of Emergency Physicians (ACEP) convened a blue-ribbon task force of experts to produce this third edition of a national report card. It builds on previous work to provide a comprehensive look at the nation’s emergency medical system in five categories. Despite hoped-for changes and improvements, the environment has not improved; it has, in fact, gotten worse.

The five categories are based on 136 objective measures that reflect the most current data available from reliable public sources, including the U.S. Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, and the Centers for Medicare and Medicaid Services, as well as other sources, such as the American Medical Association. 
The 136 measures were selected because they represent factors vital to life-saving emergency care and meet the key criteria of relevance, reliability, validity, reproducibility, and consistency across all states.

Access to Emergency Care: D-

This important category represents 30% of the total grade and includes four subcategories: access to providers, access to treatment centers, financial barriers, and hospital capacity. It also includes access to specialists, such as neurosurgeons, orthopedists, and plastic surgeons.

Access to emergency care is fundamental and complex—and essential. Several factors affect people’s access, such as the availability of emergency departments, the capacity of those departments, and the workforce available to staff those departments.

In addition, the environment is affected by an unfunded government mandate, the Emergency Medical Treatment and Labor Act (EMTALA), that requires emergency departments to screen and stabilize anyone who presents with an emergency medical condition, which means that all patients are seen, regardless of ability to pay.

This failing grade reflects trouble for a nation that has too few emergency departments to meet the needs of a growing, aging population, and of the increasing number of people now insured as a result of the Affordable Care Act. For more than 20 years, emergency visit rates have increased at twice the rate of the growth of the U.S. population, totaling 130 million in 2010. And that growth in demand is poised to continue.

Quality & Patient Safety Environment: C

This category represents 20% of the total grade and includes subcategories reflecting state systems and institutions that can support the emergency care environment. Measuring this environment is essential, as is examining how better-quality systems and technologies can help improve care and prevent injuries.

Federal agencies, state governments, and private institutions have made advancements in developing and implementing indicators of health care quality. ACEP continues to monitor direct state investments in improving quality and safety, such as funding for emergency medical services (EMS) medical directors and development and implementation of destination and triage policies that allow EMS to bypass local hospitals to take patients to appropriate hospital specialty centers. Institutional improvements include advances, such as the use of computerized practitioner order entry and attention to addressing racial and ethnic disparities in care.

Medical Liability Environment: C-

This category represents 20% of the total grade and includes subcategories that describe the legal atmosphere, insurance availability, and tort reform across the states.

The U.S. Department of Health and Human Services characterizes the medical liability environment as a broken system, one that features wide variations in policies and practices across states. In some cases, high liability insurance rates have forced physicians to curtail their practices, stop performing high-risk but critically necessary procedures, such as delivering babies, or move to states with more favorable liability environments.

And the country pays for it: studies estimate that liability costs, including those associated with the practice of defensive medicine, add as much as $108 billion to the annual total cost of health care, resulting in patients experiencing higher costs, longer waits, and more challenges in accessing care. This category includes data on numerous types of liability reforms, such as medical liability caps on non-economic damages, pretrial screening panels, periodic payments of malpractice awards, the presence of state-funded patient compensation funds, and additional liability protections for care mandated by EMTALA.

Public Health & Injury Prevention: C

This category represents 15% of the total grade and includes measures of traffic safety and drunk driving, immunization, fatal injury, state health and injury prevention efforts, and health risk factors.

Injuries account for nearly one-third of emergency visits. And preventable and behavior-related factors, such as smoking, poor diet, alcohol consumption, and drug abuse, contribute to many more. States can positively impact all of these factors through life-saving policies, such as those requiring seat belt use in vehicles and helmet use while riding motorcycles, as well as education and outreach to increase healthy choices among the general population, including vaccination. Failure to adopt effective measures at the state-level can negatively impact public health and have a considerable effect on the need for emergency services.

Disaster Preparedness: C-

This category represents 15% of the total grade and includes financial resources, state coordination, hospital capacity, and personnel data related to the capacity to respond to disasters. The ever-present threat and reality of natural disasters and man-made catastrophes require an effective response capability. Disaster preparedness efforts rely on ongoing collaboration of many entities at all levels of government and in all economic sectors. In this process, emergency physicians, who have training and experience in managing mass casualty events and delivering lifesaving care, are integral to this process. Despite real and present threats, states continue to experience great variability in planning and response capacities. In many communities, capacity is already stretched to the limit, and hospital bed surge capacity, staffing, and resources are inadequate to respond to the extraordinary demands precipitated by any disaster.


In response to these findings, the American College of Emergency Physicians makes the following recommendations, each aimed at improving care in terms of access, safety and quality, medical liability, public health and injury prevention, and disaster preparedness.
  1. Protect access to emergency care as health care reforms are implemented.
  2. Support programs that recognize the pivotal role emergency medicine plays in care coordination and transitions of care.
  3. Reduce the incidence of hospital crowding and boarding of admitted patients in the emergency department.
  4. Enact federal and state medical liability reforms that enhance timely access to quality care, particularly those that provide appropriate liability protections for EMTALA-mandated care.
  5. Increase coordination and regionalization of specialized emergency services and support funding of federally authorized regional pilot programs.
  6. Devote consistent federal and state funding to ensure adequate and sustainable local and regional disaster preparedness.
  7. Continue to increase the use of systems, standards, and information technologies to track and enhance the quality and patient safety environment.
  8. Continue pursuit of state laws that help reduce the number of preventable deaths and injuries, particularly those that address traffic-related injuries and fatalities. 
  9. Expand access to standardized and user-friendly state and/or federal prescription drug monitoring programs to decrease unintentional deaths by drug overdose.
  10. Fund graduate medical education programs that support emergency care, especially those related to addressing physician shortages in disadvantaged areas and in rural areas.
  11. Support emergency medicine research, including basic, clinical, and translational research into improving the delivery of emergency care services.
Emergency physicians today mobilize resources to diagnose and treat every kind of medical emergency. They also play a pivotal role in setting the health care course for their patients by coordinating care with on-call specialists and other clinicians in the hospital and in communities. Care that once was provided in inpatient settings is now being done in emergency departments.

Yet emergency physicians work in a stressed system that operates in a near-crisis situation. This Report Card points to shortcomings and challenges in the emergency care environment, but it does not attempt to grade the care provided by dedicated emergency physicians and staff, nor does it underestimate the day-today commitment and concern that emergency physicians demonstrate in caring for millions of patients each year.


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