District of Columbia

The District of Columbia remains at the top of the pack, with one of the strongest emergency care environments in the nation, stellar overall Access to Emergency Care, and a strong commitment to Disaster Preparedness. While the District has improved the Quality and Patient Safety Environment, it continues to struggle with the worst Medical Liability Environment in the nation and excessive emergency department (ED) wait times.

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The District has the top-ranked environment for Access to Emergency Care and is first in the nation for rates of many specialists, such as neurosurgeons; emergency physicians; and ear, nose, and throat specialists. The District has high rates of health insurance among adults and children, with only 4.3% of children and 9.3% of adults lacking health insurance. It also has the second highest per capita rate of physicians accepting Medicare (5.3 per 100 beneficiaries), as well as high Medicaid reimbursement rates for office visits, which realized the largest increase in the nation from 2007 to 2012 (121.7%).

Thanks in part to the availability of medical facilities, an ample health care workforce, and the presence of the federal government, the District continues to boast the best Disaster Preparedness capacity in the nation. Washingtonians have access to the highest rates of burn unit beds, intensive care unit beds, and verified burn centers. The District also has many important plans and systems in place to address the needs of medically fragile populations during an emergency.

The District made significant gains in its Quality and Patient Safety Environment since the 2009 Report Card by funding both quality improvements in the emergency medical services (EMS) system and an EMS medical director. There are also significantly more emergency medicine residents in the District compared with 2009: 107.5 residents per 1 million people, for which it ranks first in the nation.


The District of Columbia struggles with an adverse Medical Liability Environment that is the worst in the country. The District's courts award more malpractice awards than almost any state (4.8 per 100,000 people), and those payments are among the 10 highest ($416,388). Practitioners in the District face sky-high average medical liability insurance premiums for both primary care physicians ($24,010) and specialists ($110,307). The District has enacted few laws that protect practitioners from frivolous lawsuits, and it allows only periodic payments of malpractice awards at the court's discretion.

Access to Emergency Care in the District is a dichotomy. While enjoying few financial barriers to care and an ample supply of specialists, it has some of the highest hospital occupancy rates and longest ED wait times in the nation. At an average of 452 minutes from ED arrival to ED departure, patients can expect to wait nearly 3 hours longer than the national average to be admitted into a hospital. The District also ranks second to last in the nation for its critical need for primary care providers and last for the proportion of the population with an unmet need for substance abuse treatment.

These basic access issues are particularly worrisome when considering the District's challenges in Public Health and Injury Prevention. The District has the highest homicide and suicide rate in the country, at 29.9 per 100,000 people, compared with the national average of 18.8 per 100,000. The District also has the highest proportion of adults engaging in binge drinking (25.0%) and the highest rate of traffic fatalities that are alcohol-related (50.0%).


The District must act to improve its highly unfavorable Medical Liability Environment and rein in high malpractice awards and insurance premiums. A medical liability cap on noneconomic damages, abolishing joint and several liability, and requiring awards to be offset by collateral sources would help lower the costs of malpractice lawsuits. Pretrial screening panels or case certification provisions would help cull frivolous lawsuits before they begin. Finally, additional liability protections for Emergency Medical Treatment and Labor Act-mandated emergency care would go a long way toward protecting emergency care providers as they serve high-risk patients with little or no knowledge of the patient's medical history.

Significant attention should be given to reducing the excessively long ED wait times facing Washingtonians. To address part of the problem, the District should intensify efforts to increase access to primary care.

There is also evidence of severe racial and ethnic health disparities in the District: The infant mortality rate for Black infants (16.5 deaths per 1,000 live births) is 3.8 times the rate for White infants. Similar disparities exist for cardiovascular disease. The District must ensure that all receive the preventive care, education, and treatment that they need, and it must work to increase the number of primary care providers able to meet those needs.

Access to Emergency Care

Title 2009
Report Card
Report Card
Board-certified emergency physicians per 100,000 pop 11.0 18.2
Emergency physicians per 100,000 pop 25.2 35.4
Neurosurgeons per 100,000 pop 5.9 7.6
Orthopedists and hand surgeon specialists per 100,000 pop 18.7 17.9
Plastic surgeons per 100,000 pop 7.1 7.4
ENT specialists per 100,000 pop 7.1 10.1
Registered nurses per 100,000 pop 1,382.2 1,725.3
Percent of children able to see provider 94.8
Level I or II trauma centers per 1M pop 5.1 4.7
Percent of population within 60 minutes of Level I or II trauma center 100.0 100.0
Accredited chest pain centers per 1M pop 0.0 0.0
Percent of population with an unmet need for substance abuse treatment 10.0 11.9
Pediatric specialty centers per 1M pop 8.5 7.9
Medicaid fee levels for office visits as a percent of the national average 71.9 129.7
Percent change in Medicaid fees for office visits (2004-05 to 2007/2007 to 2012) 0 121.7
Percent of adults with no health insurance 12.4 9.3
Percent of adults underinsured 7.4
Percent of children with no health insurance 8.7 4.3
Percent of children underinsured 11.8
Percent of adults with Medicaid 13.7 20.3
Hospital closures in 2006/2011 0 0
Staffed inpatient beds per 100,000 pop 891.9 703.8
Hospital occupancy rate per 100 staffed beds 76.4 72.2
Psychiatric care beds per 100,000 pop 43.9 46.2
Median time from ED arrival to ED departure for admitted ED patients 452
State collects data on diversion YES YES

Disaster Preparedness

Title 2009
Report Card
Report Card
Per capita federal disaster preparedness funds $160.57 $107.37
State budget line item health care surge NR
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) YES, ACCREDITED YES
Special needs patients included in medical response plan NO YES
Patients dependent on medication for chronic conditions in medical response plan NO YES
Medical response plan for supplying dialysis NO 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 YES
Just-in-time training systems in place STATEWIDE 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 YES YES
Real-time surveillance system in place for common ED presentations YES YES, STATEWIDE
Bed surge capacity per 1M pop 425.0 636.2
ICU beds per 1M pop 608.1 687.9
Burn unit beds per 1M pop 28.9 31.6
Verified burn centers per 1M pop 1.699836136 1.6
Physicians registered in ESAR-VHP per 1M pop 6.8 338.4
Nurses registered in ESAR-VHP per 1M pop 30.6 1,069.1
Behavioral health professionals registered in ESAR-VHP per 1M pop 20.6
Strike teams or medical assistance teams YES YES
Disaster training required for essential hospital/EMS personnel NO, NO NO
Percent of RNs that received emergency training 48.1 47.2

Medical Liability Environment

Title 2009
Report Card
Report Card
Lawyers per 10,000 pop 496.4 458.8
Lawyers per physician 6.5 5.7
Lawyers per emergency physician 196.4 129.5
ATRA judicial hellholes (2009 range 0 to -7/2014 range 2 to -6) -1 0
Malpractice award payments per 100,000 pop 8.0 4.8
Average malpractice award payments $366,131 $416,388
National Practitioner Databank reports per 1,000 physicians 24.4 13.5
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 9.4 11.3
Average medical liability insurance premiums for primary care physicians $24,010 $24,010
Average medical liability insurance premiums for specialists $110,307 $110,307
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 COURT'S DESCRETION COURT'S DESCRETION
Medical liability cap on non-economic damages NONE NONE
Additional liability protection for EMTALA-mandated emergency care NO NO
Joint and several liability abolished NO NO
Collateral Source Rule/Provides for Awards to be Offset NO
State provides for case certification NO NO
Expert witness required to be of the same specialty as the defendant NO NO
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 0.5
Pedestrian fatalities per 100,000 pedestrians 2.0
Percent of traffic fatalities alcohol-related 48.0 50.0
Percent of front occupants using restraints 87.1 95.2
Child safety seat/seat belt legislation - score out of a possible 10 points 9 9
Helmet use required for all motorcylce riders YES YES
Distracted driving legislation score - out of a possible 4 points 4
Graduated drivers' licenses legislation score -out of a possible 5 points 1
Percentage of children aged 19-35 months who are immunized 82.8 81.4
Percentage of adults aged 65+ who rec’d an influenza vaccine in the last 12 mos 61.2 56.7
Percentage of adults aged 65+ who ever rec’d pneumococcal vaccine 52.0 63.3
Fatal occupational injuries per 1M workers 34.3 36.4
Homicides and suicides (non-motor vehicle)(per 100,000) 36.6 29.9
Unintentional fall-related fatal injuries (per 100,000) 7.2 9.6
Fire/burn related fatal injuries (per 100,000) 1.4 1.8
Rate of unintentional firearm-related fatal injuries (per 100,000) 0.4 NR
Rate of unintentional poisoning-related deaths (per 100,000) 12.0
Total injury prevention funds per 1,000 persons $849.92 NR
Dedicated child injury prevention funding NR
Dedicate elderly injury prevention funding NR
Dedicated occupational injury prevention funding NR
Anti-smoking legislation score - score out of a possible 3 points 3
Infant mortality rate per 1,000 live births 14.1 7.9
Percentage of adults who binge drink 15.9 25.0
Percentage of adults who currently smoke 17.9 20.8
Percentage of adult population who are obese (BMI > 30.0) 22.5 23.8
Percentage of children who are obese 21.4
Cardiovascular disease disparity ratio 2.7
HIV diagnosis disparity ratio NR
Infant mortality disparity ratio 3.8

Quality & Patient Safety

Title 2009
Report Card
Report Card
Funding for quality improvement within the EMS system NO YES
Funded state EMS medical director NO YES
Emergency medicine residents per 1M pop 62.9 107.5
Adverse event reporting required NO YES
% of counties with Enhanced 911 capability 100.0 100.0
State has a uniform system for providing pre-arrival instructions YES YES
State uses CDC guidelines for state field triage protocols YES (2011)
State has or is working on a stroke system of care YES YES
State has triage and destination policy in place for stroke patients YES
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 YES
State maintains statewide trauma registry YES NO
State has triage and destination policy in place for trauma patients YES
Prescription drug monitoring program score (range 0-4) 1
% of hospitals with computerized practitioner order entry 28.6 70.0
% of hospitals with electronic medical records 85.7 80.0
% of patients with AMI given PCI within 90 minutes of arrival 41 79
Median time to transfer to another facility for acute coronary intervention 77
% of patients with AMI who received aspirin within 24 hours 99
% of hospitals collecting data on race/ethnicity and primary language 60.0
% of hospitals with or planning to develop a diversity strategy or plan 46.7

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